Journal of Orthopaedic Surgery 2012;20(1):1-6
Posterior interbody grafting and instrumentation for spondylodiscitis Stefan Endres, Axel Wilke
Department of Orthopaedic Surgery, Elisabeth-Klinik Bigge/Olsberg, Olsberg, Germany
ABSTRACT Purpose. To report outcomes of 7 patients with bacterial spondylodiscitis treated through a posterior approach. Methods. Five men and 2 women aged 40 to 80 years underwent one-stage posterior interbody debridement and instrumentation for single-segment bacterial spondylodiscitis of lumbar (n=5) or thoracic (n=2) vertebrae. The Oswestry Disability Score, the Frankel classification, the Cobb angle, and the visual analogue scale (VAS) for pain as well as bone union on radiographs were assessed. Results. Patients were followed up for 19 to 36 months. None had relapses or complications. Postoperatively, 5 patients had no pain or used analgesics only occasionally; their VAS scores varied from 0 to 20. The remaining 2 patients had residual symptoms and received regular peripheral pain medication and opiates; their VAS scores ranged from 30 to 50. The mean Oswestry Disability Score improved to 21 (range, 12–38). The mean Cobb angle
improved from 13.1º to 11.1º. The segments were probably fused in 5 patients and questionable in 2. Conclusion. Posterior debridement and instrumentation was adequate for single-segment spondylodiscitis and achieved good outcomes. Key words: discitis; spine
INTRODUCTION Bacterial spondylodiscitis is rare; its incidence in Germany is approximately one in 250 000 persons per year.1 It can be fatal in up to 9% of patients,2,3 and results in permanent neurological deficits in up to 33% of them.3,4 Most patients can be treated with immobilisation (bed arrest, orthosis) combined with empirical antibiotics.3,5,6 Surgical intervention is indicated when there is (1) any interspinal space-occupying mass (e.g. epidural abscess), (2) bacteriological and/or histopathological diagnosis but negative percutaneous biopsies, (3) advanced destruction of vertebral bodies together with kyphosis, (4) rapid neurological deterioration, and (5)
Address correspondence and reprint requests to: Dr S Endres, Department of orthopaedic surgery Elisabeth-Klinik Bigge/Olsberg, Heinrich-Sommer-Str. 4, 59939 Olsberg, Germany. E-mail:
[email protected]
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septic progression. The optimal operating strategies and approaches remain controversial.7–9 Some recommend (anterior or posterior) debridement, bed rest, and immobilisation (with a brace or through posterior instrumentation).10,11 Anterior debridement combined with bone grafting using oneor 2-stage posterior instrumentation is the standard approach.3–5,12–16 In our clinic, posterior lumbar interbody fixation has been performed for patients with a small abscess in the anterior portion of the vertebral body connected to a disc, so that drainage can be accomplished through the posterior approach. It has also been performed for those with spinal stenosis and those with an abscess in the posterior portion of the dura. We report outcomes of 7 patients with bacterial spondylodiscitis treated through a posterior approach. MATERIALS AND METHODS From January 2006 to June 2007, 5 men and 2 women aged 40 to 80 years underwent one-stage posterior interbody debridement and instrumentation for single-segment bacterial spondylodiscitis of lumbar (n=5) or thoracic (n=2) vertebrae (Table 1). This approach enabled immediate ambulation/ rehabilitation. Ideal candidates are those with limited vertebral body destruction, single-segment involvement, epidural abscesses in the posterior dura, and spinal stenosis. Diagnosis was based on radiography, contrast magnetic resonance imaging, and elevated levels of
infection markers. The interval from presentation to diagnosis was 7 to 10 weeks. All patients presented with increased white blood cell count (range, 12.5–14.8 g/dl), erythrocyte sedimentation rate (range, 40–100 mm/h), and C-reactive protein level (range, 56–204 mg/l). Only 2 patients were febrile. No patient had a history of operations or injections near the spine, and thus the spondylodiscitis was endogenous. Two of the patients had urogenital infection, and 3 had diabetes mellitus. The posterior elements were exposed. The entire posterior complex up to the base of the pedicles (including the transverse processes, facet joints, and lamina) was excised. This exposed the dura, the exiting and the descending nerve roots on both sides. These neural structures were carefully dissected and lifted off the posterior longitudinal ligament using a bipolar cautery. The affected intervertebral disc was exposed and curetted out on one side, followed by the other. All visible inflammatory tissues were debrided. The interbody was fused with 2 tricortical iliac crest grafts positioned between the vertebral bodies as posterior lumbar interbody fusion. Deformity was corrected by positioning the patient on the table. Posterior instrumentation was carried out with pedicle screws and rods.17 Two vertebral bodies above and below the affected segment were included. Intra-operative smears and tissue samples were taken for histological and microbiological assessment. Antibiotics were administered intravenously for 12 to 20 days. When inflammatory marker levels declined to normal values, oral antibiotics were given for a further 12 weeks.
Table 1 Neurological status and outcome of patients Patient Sex/age Segment no. (years) involved 1 2
M/62 M/40
T6/7 L4/5
3 5
F/73 M/80
L3/4 L2/3
6
W/67
T12/L1
6 7
M/63 M/48
L3/4 T11/12
Neurological status (Frankel grade) Preop
Postop
Incomplete paraparesis of both legs (C) Complete resolution (E) Incomplete L5 lesion unilaterally (D) Incomplete resolution, persistent L5 lesion, muscle strength of 3/5 (D) Incomplete L4 lesion unilaterally (D) Complete resolution (E) Complete paraparesis of both legs and Incomplete resolution, recovery bladder-colon disturbances (B) bladder-colon disturbances, both quadriceps strength of 4/5, dysanaesthesia of the genital area (D) Incomplete paraparesis of both legs (C) Incomplete resolution, recovery of walking ability, quadriceps and iliopsoas strength of 4/5, dysanaesthesia of the genital area and light bladder-colon disturbances (D) Complete L4 unilaterally (C) Complete resolution (E) Incomplete paraplegia T12 (C) Complete resolution (E)
Cobb angle Preop Postop 15° 10°
13° 8°
14° 12°
12° 11°
16°
13°
13° 12º
12° 9º
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Posterior interbody grafting and instrumentation for spondylodiscitis
Postoperatively, physiotherapy was given for 6 weeks with a semi-elastic lumbar bandage for 3 months. The Oswestry Disability Score, the Frankel classification, the Cobb angle, and visual analogue scale (VAS) for pain, as well as bone union on radiographs18 were assessed. Patients were followed up at weeks 6, 12, and months 6 and 24. RESULTS Patients were followed up for 19 to 36 months; none had relapses or complications (Table 1). Organisms were identified in 5 of the patients only. The most common was Staphylococcus aureus (n=3), followed by coagulase-negative Staphylococcus (n=1) and Enterococcus (n=1). Postoperatively, 5 patients had no pain or used analgesics only occasionally; their VAS scores varied from 0 to 20. The remaining 2 patients had residual symptoms and received regular peripheral pain medication and opiates; their VAS scores ranged from 30 to 50. The mean Oswestry Disability Score improved to 21 (range, 12–38). The mean Cobb angle improved from 13.1º to 11.1º. The segments were probably fused in 5 patients and questionable in 2 (Fig.).18
(a)
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DISCUSSION Intervertebral fusion and instrumentation for spondylodiscitis can be performed through the anterior-posterior approach (in one or 2 stages),19–25 anterior fusion and grafting only (with or without anterior instrumentation)26,27 or a posterior approach combined with interbody bone grafting, with or without posterior instrumentation (Table 2).28 It is important to debride inflammatory and necrotic tissue, correct or prevent deformity by fusion, and decompress neural structures.15,29,30 Anterior fusion and bone grafting combined with posterior instrumentation is considered the standard procedure. Patients with titanium cages or those with posterior instrumentation have greater improvement in sagittal alignment than those without.19,31 Most patients can be treated by immobilisation and antibiotic treatment.3,5,6 Surgery should be performed when there are epidural abscesses and neurological symptoms, kyphosis, and persistent pain, or when conservative treatment is ineffective. Decompression by laminectomy only may result in instability and failure.6,32 It should be combined with posterior instrumentation and fusion using autologous bone grafts. This achieves a fusion rate
(b)
Figure A 60-year-old man with pyogenic spondylodiscitis of L2-3: (a) destructive change and space narrowing in L2-3, and (b) questionable bony fusion 22 months after interbody bone grafting and posterior transpedicular stabilisation from L1 to L4.
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S Endres et al. Table 2 Review of the literature19–28,33,34
Study
No. of Mean Pathogen Antipapabiotic tients tient treatage ment (years) (months)
Fayazi et al.,19 2004
11
-
Korovessis et al.,20 2006
14
54
Mostly S aureus
Lerner et al,21 2005
46
66
Mostly S aureus
4
Ruf et al.,22 2007
70
62
Mostly S aureus
3–6
Krodel et al.,24 1991
24
50.2
Tuberculous spondylitis
Pee et al.,25 2008
60
58
53.2 vs. 51.2
Hopf et al.,26 34 1998 vs. 38
-
Treatment*
Followup (months)
Outcome
Radiographic outcome
Chronic APF with titanium suppres- cage sive therapy
17
No recurrence; one died, 7 pain-free
One pseudoarthrosis
4.4±0.8 APF with titanium cage
45
No recurrence; a mean of 1.5 Frankel grade improvement
100% fusion
APF with titanium cage vs. iliac bone grafts
31
76% recovered from neurological 100% fusion impairment; a mean Roland for iliac bone Morris Score of 6.6 grafts; 53% fusion for titanium cages
APF with titanium cage
41
No recurrence; neurologic status unchanged in 37 patients, 26 patients improved 1 Frankel grade, 7 patients improved 2 Frankel grades, one patient worsened 1 Frankel grade.
100% fusion
-
AF with autologous bone grafts
36
No recurrence
100% fusion
Mostly S epidermidis
3
APF with titanium cage vs. iliac bone grafts
36
No recurrence; improved 5 visual analogue scores for pain; 50% improvement in Oswestry Disability Score; of 16 patients with neurological impairment, 11 improved and 5 unchanged
56 of 60 patients showed solid fusion
Mostly M tuberculosis and S epidermidis
-
AF vs. APF with autologous and homologous bone grafts
48 vs. 29
No recurrence; group 1: 24 patients pain-free and 10 slight pain; group 2: 31 patients painfree, 5 slight local pain, and 3 painful sensations
100% fusion in both groups
Lim et al.,27 2008
13
51
Mostly Staphylococcus species
-
AF with autologous bone grafts
11
No recurrence
96% fusion rate
Lee and Suh,28 2006
18
57.7
Mostly S Aureus
3.8
PF with autologous bone grafts
32
2 patients improved by 2 Frankel grades (C to E), 11 improved by one grade, and 5 showed no change; Kirkaldy-Willis criteria was excellent in 5 patients, good in 10, and fair in 3
Bony union in 17 patients
Suess et al.,34 2007
21
65
Mostly S Aureus
3
AF for lumbar spine and APF with titanium cage for thoracic spine
18
No recurrence; median Denis Pain Scale improved from P4 to P2; 2 patients with neurological impairment improved
Liljenqvist et al.,31 2003
20
68
3
APF with titanium cage
23
No recurrence; a median 100% Roland-Morris score of 6.5; all 5 incorporation patients with neurological deficits improved to Frankel grade D or E
-
* AF denotes anterior fusion, PF posterior fusion, and APF anterior-posterior fusion
-
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Posterior interbody grafting and instrumentation for spondylodiscitis
of 93 to 96% and excellent clinical outcomes.14–16 The clinical outcome is the most relevant criterion for success of the procedure. The correlation between intervertebral fusion and the clinical symptoms is weak.33 Advantages of the one-stage posterior approach include avoidance of a chest tube, decreased operating time and blood loss, as well as decreased hospitalisation, rehabilitation, and postoperative morbidity. It provides immediate postoperative stability and enables patients to sit and stand for chest physiotherapy and physical activities.31,34 Nonetheless, exposure and visualisation of the
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affected vertebral body may be limited. It allows only piecemeal removal of the affected vertebral body/disc. It is technically difficult, and there is a risk of inadvertent injury to the parietal pleura at the thoracic level, bleeding from segmental vessels, and difficulty in graft bed preparation (if the vertebral body is eroded asymmetrically). This leads to difficult interbody cage or graft placement (necessitating the anterior approach), and injury to neural structures (dura, nerve roots) and vessels.17 In cases with large psoas abscesses, multi-segmental involvement, or severe kyphosis, anterior debridement and reconstruction becomes necessary.
REFERENCES 1. Sobottke R, Seifert H, Fatkenheuer G, Schmidt M, Gossmann A, Eysel P. Current diagnosis and treatment of spondylodiscitis. Dtsch Arztebl Int 2008;105:181–7. 2. Frangen TM, Kalicke T, Gottwald M, Andereya S, Andress HJ, Russe OJ, et al. Surgical management of spondylodiscitis. An analysis of 78 cases [in German]. Unfallchirurg 2006;109:743–53. 3. McHenry MC, Easley KA, Locker GA. Vertebral osteomyelitis: long-term outcome for 253 patients from 7 Cleveland-area hospitals. Clin Infect Dis 2002;34:1342–50. 4. Hadjipavlou AG, Mader JT, Necessary JT, Muffoletto AJ. Hematogenous pyogenic spinal infections and their surgical management. Spine (Phila Pa 1976) 2000;25:1668–79. 5. Safran O, Rand N, Kaplan L, Sagiv S, Floman Y. Sequential or simultaneous, same-day anterior decompression and posterior stabilization in the management of vertebral osteomyelitis of the lumbar spine. Spine (Phila Pa 1976) 1998;23:1885–90. 6. Sapico FL, Montgomerie JZ. Pyogenic vertebral osteomyelitis: report of nine cases and review of the literature. Rev Infect Dis 1979;1:754–76. 7. Carragee EJ. Instrumentation of the infected and unstable spine: a review of 17 cases from the thoracic and lumbar spine with pyogenic infections. J Spinal Disord 1997;10:317–24. 8. Grados F, Lescure FX, Senneville E, Flipo RM, Schmit JL, Fardellone P. Suggestions for managing pyogenic (non-tuberculous) discitis in adults. Joint Bone Spine 2007;74:133–9. 9. Soehle M, Wallenfang T. Spinal epidural abscesses: clinical manifestations, prognostic factors, and outcomes. Neurosurgery 2002;51:79–87. 10. Asamoto S, Doi H, Kobayashi N, Endoh T, Sakagawa H, Iwanaga Y, et al. Spondylodiscitis: diagnosis and treatment. Surg Neurol 2005;64:103–8. 11. Krodel A, Sturz H. Differentiated surgical and conservative treatment of spondylitis and spondylodiscitis [in German]. Z Orthop Ihre Grenzgeb 1989;127:587–96. 12. Dimar JR, Carreon LY, Glassman SD, Campbell MJ, Hartman MJ, Johnson JR. Treatment of pyogenic vertebral osteomyelitis with anterior debridement and fusion followed by delayed posterior spinal fusion. Spine (Phila Pa 1976) 2004;29:326–32. 13. Ozuna RM, Delamarter RB. Pyogenic vertebral osteomyelitis and postsurgical disc space infections. Orthop Clin North Am 1996;27:87–94. 14. Emery SE, Chan DP, Woodward HR. Treatment of hematogenous pyogenic vertebral osteomyelitis with anterior debridement and primary bone grafting. Spine (Phila Pa 1976) 1989;14:284–91. 15. Fang D, Cheung KM, Dos Remedios ID, Lee YK, Leong JC. Pyogenic vertebral osteomyelitis: treatment by anterior spinal debridement and fusion. J Spinal Disord 1994;7:173–80. 16. McGuire RA, Eismont FJ. The fate of autogenous bone graft in surgically treated pyogenic vertebral osteomyelitis. J Spinal Disord 1994;7:206–15. 17. Sundararaj GD, Venkatesh K, Babu PN, Amritanand R. Extended posterior circumferential approach to thoracic and thoracolumbar spine. Oper Orthop Traumatol 2009;21:323–34. 18. Christensen FB, Laursen M, Gelineck J, Eiskjaer SP, Thomsen K, Bunger CE. Interobserver and intraobserver agreement of radiograph interpretation with and without pedicle screw implants: the need for a detailed classification system in posterolateral spinal fusion. Spine (Phila Pa 1976) 2001;26:538–44. 19. Fayazi AH, Ludwig SC, Dabbah M, Bryan Butler R, Gelb DE. Preliminary results of staged anterior debridement and reconstruction using titanium mesh cages in the treatment of thoracolumbar vertebral osteomyelitis. Spine J 2004;4:388– 95. 20. Korovessis P, Petsinis G, Koureas G, Iliopoulos P, Zacharatos S. Anterior surgery with insertion of titanium mesh cage and posterior instrumented fusion performed sequentially on the same day under one anesthesia for septic spondylitis of
6
S Endres et al.
Journal of Orthopaedic Surgery
thoracolumbar spine: is the use of titanium mesh cages safe? Spine (Phila Pa 1976) 2006;31:1014–9. 21. Lerner T, Hackenberg L, Rosler S, Joosten U, Halm H, Liljenqvist U. Surgical therapy of unspecific and specific spondylodiscitis [in German]. Z Orthop Ihre Grenzgeb 2005;143:204–12. 22. Ruf M, Stoltze D, Merk HR, Ames M, Harms J. Treatment of vertebral osteomyelitis by radical debridement and stabilization using titanium mesh cages. Spine (Phila Pa 1976) 2007;32:E275–80. 23. Robinson Y, Reinke M, Kayser R, Ertel W, Heyde CE. Postoperative multisegmental lumbar discitis treated by staged ventrodorsoventral intervention. Surg Infect (Larchmt) 2007;8:529–34. 24. Krodel A, Sturz H, Siebert CH. Indications for and results of operative treatment of spondylitis and spondylodiscitis. Arch Orthop Trauma Surg 1991;110:78–82. 25. Pee YH, Park JD, Choi YG, Lee SH. Anterior debridement and fusion followed by posterior pedicle screw fixation in pyogenic spondylodiscitis: autologous iliac bone strut versus cage. J Neurosurg Spine 2008;8:405–12. 26. Hopf C, Meurer A, Eysel P, Rompe JD. Operative treatment of spondylodiscitis—what is the most effective approach? Neurosurg Rev 1998;21:217–25. 27. Lim JK, Kim SM, Jo DJ, Lee TO. Anterior interbody grafting and instrumentation for advanced spondylodiscitis. J Korean Neurosurg Soc 2008;43:5–10. 28. Lee JS, Suh KT. Posterior lumbar interbody fusion with an autogenous iliac crest bone graft in the treatment of pyogenic spondylodiscitis. J Bone Joint Surg Br 2006;88:765–70. 29. Osenbach RK, Hitchon PW, Menezes AH. Diagnosis and management of pyogenic vertebral osteomyelitis in adults. Surg Neurol 1990;33:266–75. 30. Heyde CE, Boehm H, El Saghir H, Tschoke SK, Kayser R. Surgical treatment of spondylodiscitis in the cervical spine: a minimum 2-year follow-up. Eur Spine J 2006;15:1380–7. 31. Liljenqvist U, Lerner T, Bullmann V, Hackenberg L, Halm H, Winkelmann W. Titanium cages in the surgical treatment of severe vertebral osteomyelitis. Eur Spine J 2003;12:606–12. 32. Eismont FJ, Bohlman HH, Soni PL, Goldberg VM, Freehafer AA. Pyogenic and fungal vertebral osteomyelitis with paralysis. J Bone Joint Surg Am 1983;65:19–29. 33. Pfeiffer M, Griss P, Haake M, Kienapfel H, Billion M. Standardized evaluation of long-term results after anterior lumbar interbody fusion. Eur Spine J 1996;5:299–307. 34. Suess O, Weise L, Brock M, Kombos T. Debridement and spinal instrumentation as a single-stage procedure in bacterial spondylitis/spondylodiscitis. Zentralbl Neurochir 2007;68:123–32.
