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Bilateral Portal Percutaneous Endoscopic Debridement and Lavage for Lumbar Pyogenic Spondylitis Li-Chen Hsu, MD; Tzu-Ming Tseng, MD; Shih-Chieh Yang, MD, PhD; Hung-Shu Chen, MD, PhD; Cheng-Yo Yen, MD, PhD; Yuan-Kun Tu, MD, PhD
abstract Common management approaches for spinal infections include conservative administration of antibiotics and aggressive surgical debridement. Minimally invasive endoscopic treatment has been reported and is gaining widespread attention because of its simplicity and effectiveness. This study retrospectively evaluated the clinical outcomes of bilateral portal percutaneous endoscopic debridement and lavage with dilute povidone-iodine solution in the treatment of patients with lumbar pyogenic spondylitis. From January 2007 to December 2011, a total of 22 patients diagnosed with single-level lumbar pyogenic spondylitis underwent bilateral portal percutaneous endoscopic debridement and lavage with dilute povidone-iodine solution at the authors’ institution. Clinical outcomes were assessed by careful physical examination, visual analog scale pain score, modified MacNab criteria functional score, regular serologic testing, and imaging studies to determine whether percutaneous endoscopic debridement and lavage treatment was successful or if surgical intervention was required. Causative bacteria were identified in 19 (86.4%) of 22 biopsy specimens. Eighteen patients had satisfactory relief of back pain and uneventful recovery after this treatment. The success rate was 81.8% (18 of 22). Both visual analog scale and modified MacNab criteria scores improved significantly in successfully treated patients. No major surgical complications were noted, except for 3 patients who had residual or subsequent paresthesia in the affected lumbar segment. Percutaneous endoscopic debridement and lavage is a minimally invasive procedure that can yield a higher bacterial diagnosis, relieve back pain, and help to eradicate lumbar pyogenic spondylitis. It is an effective alternative treatment for patients with spinal infection before extensive open surgery. [Orthopedics. 2015; 38(10):e856-e863.] The authors are from the Department of Orthopaedic Surgery and Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan. Drs Hsu and Tseng contributed equally to this work and should be considered as equal first authors. The authors have no relevant financial relationships to disclose. Correspondence should be addressed to: Shih-Chieh Yang, MD, PhD, Department of Orthopaedic Surgery and Anesthesiology, E-Da Hospital, I-Shou University, No. 1, E-Da Rd, Kaohsiung City 82445, Taiwan, ROC (
[email protected]). Received: August, 1, 2014; Accepted: January 16, 2015. doi: 10.3928/01477447-20151002-50
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he aging population and the increased number of immunocompromised individuals in recent decades has contributed to the increasing number of spinal infections.1,2 Pyogenic spondylitis is the most common spinal infection and is generally believed to start in one endplate, spread to the avascular disk, and then extend to the adjacent vertebral body.3 A delay in the diagnosis of all types of spinal infections is common because of their early indolent course and variable presentation.4-6 The advent of imaging studies, especially magnetic resonance imaging, has made early diagnosis of spinal infections possible.7 Identifying the offending pathogen is a critical step in providing appropriate medical treatment with antimicrobial therapy. In the past, computed tomography– guided needle biopsy was recommended to isolate causative pathogens.8-10 However, the aspirate is often inadequate, and sometimes no organisms can be cultured. The reported accuracy of spinal biopsy varies from 26% to 91%, according to the organism isolated.8-13 Failure of prompt, effective treatment for spinal infections can lead to structural instability, spinal deformity, sepsis, neurologic deficits, and even death. Percutaneous endoscopic diskectomy was first used in the early 1980s to treat uncomplicated herniated disks. Numerous minimally invasive endoscopic procedures for lumbar disk herniation have been developed, with clinical results comparable to those reported with conventional open surgery.14-16 The authors used this simple, minimally invasive technique for the management of pyogenic spondylitis. In this study, bilateral portal percutaneous endoscopic debridement and lavage with dilute povidone-iodine solution was used to treat 22 patients with pyogenic spondylitis. The clinical outcomes of these patients were retrospectively reviewed to evaluate the diagnostic and therapeutic value of this method.
Materials and Methods With the approval (EMRP-101-027) of the institutional review board at the au-
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thors’ institution, 22 patients with pyogenic spondylitis who underwent bilateral portal percutaneous endoscopic debridement and lavage with dilute povidone-iodine solution between January 2007 and December 2011 were enrolled in the study. There were 6 women and 16 men, with an average age of 57.8 years (range, 35-73 years). Patient medical records, including outpatient and emergency room notes, admission notes, inpatient progress and nursing notes, discharge summaries, procedure notes, surgical reports, radiology reports, pathology reports, and microbiology laboratory results, were reviewed. Microbiology reports included microscopy and culture findings and any specific pathogens identified by either method. In 17 patients, comorbid medical problems were present, such as diabetes mellitus, hypertension, rheumatoid arthritis, coronary artery disease, chronic obstructive pulmonary disease, end-stage renal disease, cancer, and acquired immune deficiency syndrome. All patients presented with intractable back pain requiring narcotic pain control and bed rest. The duration of severe back pain before the diagnosis was made was 2 weeks to 9 weeks, with a mean of 4.6 weeks. Pyogenic spondylitis was diagnosed on the basis of clinical examination, including elevated erythrocyte sedimentation rate and Creactive protein level, and radiographic and magnetic resonance imaging confirmation. The surgical indication in these 22 patients was single-level pyogenic spondylitis, with or without paraspinal abscess, and none of their infections were treated effectively by conservative administration of antibiotics. Patients who had a history of spinal surgery and those who had severe infections that caused severe structural deformity or significant neurologic deficits were excluded from the study. Surgical Technique The patient was placed prone on a radiolucent frame suitable for fluoroscopy. All procedures were performed under local anesthesia with conscious sedation
similar to that used for standard lumbar diskography. Conscious sedation was administered with an intravenous bolus dose of 50 μg of fentanyl and 0.5 mg·kg-1 of propofol. Under fluoroscopic guidance, the target site was located and the entry site was marked on the skin at a point 8 to 12 cm from the midline. After sterile preparation, draping, and local anesthesia, a spinal needle was inserted directly into the center of the target disk. A guidewire was introduced through the spinal needle into the central disk space, and the spinal needle was withdrawn. After a small stab wound incision (approximately 1 cm) was created, a dilator and a cannulated sleeve were guided over the wire and progressed sequentially into the center of the disk. An additional intravenous bolus dose of 0.5 mg·kg-1 of propofol was administered if the patient had pain during the procedure. Fluoroscopy was repeated in 2 orthogonal planes to verify the correct position of the tip of the endoscope. The tissue dilator was then removed, and the cutting tool was inserted. The cutting tool, a cylindric sleeve with a serrated edge at its distal end, was used to harvest a core of the biopsy specimen. Diskectomy forceps were then inserted through the cannulated sleeve to extract additional tissue from the infected disk. Percutaneous debridement was performed piecemeal by manipulating the biopsy forceps, flexible rongeurs, and shaver into different positions to withdraw as much tissue as possible under fluoroscopic monitoring. The same procedures were repeated on the other side. The 2 working sheaths were left in place on both sides for sufficient removal and extensive debridement of the infected intervertebral disk and even some endplate from different endoscopic directions. After the biopsy and debridement procedures, at least 10,000 mL of dilute povidone-iodine solution was used for irrigation. Approximately 35 mL of povidone-iodine was diluted with 1000 mL of normal saline to achieve a 3.5% povidone-iodine solution for use during
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year, and after 2 years with the Wilcoxon signed-rank test. Nonparametric statistics were used because some variables were not normally distributed. All data analysis was performed with SPSS version 13.0 software (SPSS Inc, Chicago, Illinois). P
