Circumferential Decompression with Posterior Instrumentation and Fusion by Lateral Extracavitary Approach – Effective Solution Aiding the Treatment of Infectious Spondylodiscitis

Abstract:

The goal of this study is to assess the efficacy of one-stage surgical management for infectious spondylodiscitis by circumferential decompression with posterior instrumentation and fusion by lateral extracavitary approach. Between March 2010 and June 2012, 7 cases with bacterial spondylodiscitis were treated with one-stage circumferential decompression with posterior instrumentation and fusion. All cases were followed-up for an average of 11.3 months (range 6-18 months). The average preoperative kyphosis was 13° (range 9-29°), and the average postoperative kyphosis was 8° (range 3-18°). At final follow-up, minimal progression of kyphosis was seen, with an average kyphosis of 12° (range 4-22°). An average loss of correction of 4° was seen at final follow-up. One-stage surgical management for spondylodiscitis by circumferential decompression with posterior instrumentation and fusion was feasible and effective.

• Periodical: Key Engineering Materials (Volume 614)
• Pages: 173-177
• DOI: https://doi.org/10.4028/www.scientific.net/KEM.614.173
• Online since: June 2014
• Authors: Iulian Popa*, Dan Negoescu, Dan Poenaru, Manuel Oprea
• Keywords: Circumferential Decompression, Lateral Extracavitary Approach, Spondylodiscitis, Vertebral Body Replacement

References

[17] Most cases of spondylodiscitis heal with antibiotic therapy, but large defects may be an indication for surgery.

[1] After radical debridement of the affected vertebra, some authors prefer to fill the defect with autologous or allogeneic cancellous bone [18, 19], while others use titanium cages filled with bone grafts [20, 21], as was done in this series. Well-fitting spacers leading to evenly distributed load transmission between the spacer and the supporting vertebrae can provide immediate stability. PMMA cylinders provide such an equal load transmission, but they bear a high risk of dislocation. Harms cages achieve close contact between grafts and supporting bone, but anterior distraction is necessary before implant insertion, imposing an unfavourable load on the vertebral screws.

[22] On the contrary, the Obelisc system is distractible in situ, and does not require the use of a supplementary distraction device. In situ distractibility was also seen as an advantage by Knop et al.

[23] Moreover, the Obelisc cage has spikes, the importance of which was stressed by Morlock et al.

[24] in a study on human cadaver specimens. Conclusions. One-stage surgical treatment for spondylodiscitis by antero-posterior surgical approach with posterior instrumentation and anterior reconstruction with vertebral body replacement device filled with composite antibiotic carrier is a feasible and effective method. In situ distractible vertebral body replacement systems allow for a stable customised restoration of the anterior column of the spine. Spikes prevent loosening of the cage. Bibliography.

DOI: 10.1055/b-0034-75898

[1] M.C. McHenry, K.A. Easley, G.A. Locker, Vertebral osteomyelitis: long-term outcome for 253 patients from 7 Cleveland-area hospitals, Clin Infect Dis 34 (2002) 1342–50.

DOI: 10.1086/340102

[2] O. Safran, N. Rand, L. Kaplan, S. Sagiv, Y. Floman, Sequential or simultaneous, same-day anterior decompression and posterior stabilization in the management of vertebral osteomyelitis of the lumbar spine, Spine (Phila Pa 1976) 23 (1998) 1885–90.

DOI: 10.1097/00007632-199809010-00018

[3] F.L. Sapico, J.Z. Montgomerie, Pyogenic vertebral osteomyelitis: report of nine cases and review of the literature, Rev Infect Dis 1 (1979) 754–76.

DOI: 10.1093/clinids/1.5.754

[4] S. Endres, A. Wilke, Posterior interbody grafting and instrumentation for spondylodiscitis, J Orthop Surg (Hong Kong) 20 (2012) 1-6.

DOI: 10.1177/230949901202000101

[5] E.J. Carragee, Instrumentation of the infected and unstable spine: a review of 17 cases from the thoracic and lumbar spine with pyogenic infections, J Spinal Disord 10 (1997) 317–24.

DOI: 10.1097/00002517-199708000-00007

[6] F. Grados, F.X. Lescure, E. Senneville, R.M. Flipo, J.L. Schmit, P. Fardellone, Suggestions for managing pyogenic (non-tuberculous) discitis in adults, Joint Bone Spine 74 (2007) 133–9.

DOI: 10.1016/j.jbspin.2006.11.002

[7] M. Soehle, T. Wallenfang, Spinal epidural abscesses: clinical manifestations, prognostic factors, and outcomes, Neurosurgery 51 (2002) 79–87.

DOI: 10.1097/00006123-200207000-00013

[8] A.G. Chacko, R.K. Moorthy, N.J. Chandy, The transpedicular approach in the management of thoracic spine tuberculosis: a short-term follow up study, Spine 29 (2004) 363-367.

DOI: 10.1097/01.brs.0000137063.64650.e1

[9] J.R. Dimar, L.Y. Carreon, S.D. Glassman, M.J. Campbell, M.J. Hartman, J.R. Johnson, Treatment of pyogenic vertebral osteomyelitis with anterior debridement and fusion followed by delayed posterior spinal fusion, Spine 29 (2004) 326–32.

DOI: 10.1097/01.brs.0000109410.46538.74

[10] R.M. Ozuna, R.B. Delamarter, Pyogenic vertebral osteomyelitis and postsurgical disc space infections, Orthop Clin North Am 27 (1996) 87–94.

DOI: 10.1016/s0030-5898(20)32053-8

[11] S.E. Emery, D.P. Chan, H.R. Woodward, Treatment of hematogenous pyogenic vertebral osteomyelitis with anterior debridement and primary bone grafting, Spine (Phila Pa 1976) 14 (1989) 284–91.

[12] D. Fang, K.M. Cheung, I.D. Dos Remedios, Y.K. Lee, J.C. Leong, Pyogenic vertebral osteomyelitis: treatment by anterior spinal debridement and fusion, J Spinal Disord 7 (1994) 173–80.

DOI: 10.1097/00002517-199407020-00012

[13] R.A. McGuire, F.J. Eismont, The fate of autogenous bone graft in surgically treated pyogenic vertebral osteomyelitis, J Spinal Disord 7 (1994) 206–15.

DOI: 10.1097/00002517-199407030-00002

[14] A.G. Hadjipavlou, J.T. Mader, J.T. Necessary, A.J. Muffoletto, Hematogenous pyogenic spinal infections and their surgical management, Spine (Phila Pa 1976) 25 (2000) 1668–79.

DOI: 10.1097/00007632-200007010-00010

[15] R.K. Osenbach, P.W. Hitchon, A.H. Menezes, Diagnosis and management of pyogenic vertebral osteomyelitis in adults. Surg Neurol, 33 (1990) 266–75.

DOI: 10.1016/0090-3019(90)90047-s

[16] C.E. Heyde, H. Boehm, H. El Saghir, S.K. Tschoke, R. Kayser, Surgical treatment of spondylodiscitis in the cervical spine: a minimum 2-year follow-up, Eur Spine J 15 (2006) 1380–7.

DOI: 10.1007/s00586-006-0191-z

[17] A.H. Fayazi, S.C. Ludwig, M. Dabbah, R. Bryan Butler, D.E. Gelb, Preliminary results of staged anterior debridement and reconstruction using titanium mesh cages in the treatment of thoracolumbar vertebral osteomyelitis, Spine J 4 (2004) 388–95.

DOI: 10.1016/j.spinee.2004.01.004

[18] J.S. Lee, K.T. Suh, Posterior lumbar interbody fusion with an autogenous iliac crest bone graft in the treatment of pyogenic spondylodiscitis, J Bone Joint Surg Br 88 (2006) 765–70.

DOI: 10.1302/0301-620x.88b6.17270

[19] C. Hopf, A. Meurer, P. Eysel, J.D. Rompe, Operative treatment of spondylodiscitis—what is the most effective approach? Neurosurg Rev 21 (1998) 217–25.

DOI: 10.1007/bf01105775

[20] U. Liljenqvist, T. Lerner, V. Bullmann, L. Hackenberg, H. Halm, W. Winkelmann, Titanium cages in the surgical treatment of severe vertebral osteomyelitis, Eur Spine J 12 (2003) 606–12.

DOI: 10.1007/s00586-003-0614-z

[21] O. Suess, L. Weise, M. Brock, T. Kombos, Debridement and spinal instrumentation as a single-stage procedure in bacterial spondylitis/spondylodiscitis, Zentralbl Neurochir 68 (2007) 123–32.

DOI: 10.1055/s-2007-984461

[22] Z. Klezl, C.A. Bagley, M.J. Bookland, J.P. Wolinsky, Z. Rezek, Z.L. Gokaslan, Harms titanium mesh cage fracture, Eur Spine J. 16 (2007) 306-10.

DOI: 10.1007/s00586-007-0377-z

[23] C. Knop, U. Lange, L. Bastian et al., Vergleichende biomechanische Kompressionsversuche mit einem neuen Wirbelkörperersatzimplantat, Unfallchirurg 104 (2001) 25-33.

DOI: 10.1007/s001130050684

[24] M. Morlock, J. Strandborg, K. Sellenschloh et al., Migration Characteristics and primary stability of vertebral body replacement systems in combination with dorso lumbar spondylodeses, Orthopäde 31 (2002) 514-521.

DOI: 10.1007/s00132-001-0294-5