Percutaneous discectomy and drainage for postoperative intervertebral discitis

Noncontiguous Multifocal Spondylodiscitis in 3 Regions of the Spine

Spondylodiscitis is an uncommon infectious disease of the spine, usually presenting in 1 or 2 contiguous levels, associated with risk factors such as diabetes, intravenous drugs, corticosteroids, and invasive procedures. The most common presentation is pain with nonspecific systemic manifestations. Diagnosis relies on clinical suspicion, laboratories, and imaging studies. Urgent treatment is important due to the high morbid mortality associated with sepsis or a fulminant disease course. We report the case of a 39-year-old female diagnosed with noncontiguous multifocal spondylodiscitis, in the cervical, thoracic, and lumbar spine. The patient initially presented with back pain, inability to walk and severe neurological deficit in the upper and lower extremities, upon diagnosis broad-spectrum antibiotics were initiated. A staged surgical approach was performed in the 3 spine segments. During the 6 month follow-up, the patient presented walking with assistance, with the recovery of strength in the upper and lower extremities.

Full-endoscopic debridement and drainage treating spine infection and psoas muscle abscess

Background

In recent years, full-endoscopic debridement and drainage (FEDD) is gaining popularity treating spondylodiscitis. Comparing to tradition open surgery, FEDD possess many advantages including lower anesthesia risk and minimally invasiveness. In this study, we report our surgical technique of FEDD and preliminary clinical outcome in 34 consecutive patients with minimum 12 months follow-up.

Methods

In our institute, "early intervention and minimally invasive surgery" is our primary strategy to treat spine infection. Surgical approaches of FEDD include transforaminal and interlaminar technique. Selection of surgical approach depends on the location of spine infection. "Trocar-rotating technique" is a novel method to treat psoas muscle abscess. Additional instrumentation is suggested in complicated patients with unstable spinal segment.

Results

Since June 2016 to June 2018, 34 patients including 22 males and 12 females with average aged 62.3 years (21 to 82 years old) sustained spine infection were treated by FEDD. Twenty-eight patients belong to primary spondylodiscitis and 15 patients among them sustained concomitant psoas abscess. Five patients was post-operative infection and one patient was mixed infection including lumbar spondylodiscitis, psoas abscess and multi-level posterior epidural abscess. Positive culture was obtained in 27 patients (27/34=79%) while gram-positive cocci (Staphyloccocci and Streptoccoi) are the most frequent pathogen (67%). Infection was controlled in 28 patients (28/34=82%). Six patients were defined as treatment failure with infection recurrence, they underwent repeat FEDD surgery or open revision surgeries. There was no major intra-operative complications expect two patients sustained transient paresthesia and one instrument broken. Superficial wound infection was encountered in 2 patients and healed after local debridement.

Conclusions

FEDD is a safe and effective procedure. We hope that, FEDD surgery will be the first-line surgery method to treat lumbar spine infection globally in the near future.

Percutaneous suction and irrigation for the treatment of recalcitrant pyogenic spondylodiscitis

BACKGROUND

The primary management of pyogenic spondylodiscitis is conservative. Once the causative organism has been identified, by blood culture or biopsy, administration of appropriate intravenous antibiotics is started. Occasionally patients do not respond to antibiotics and surgical irrigation and debridement is needed. The treatment of these cases is challenging and controversial. Furthermore, many affected patients have significant comorbidities often precluding more extensive surgical intervention. The aim of this study is to describe early results of a novel, minimally invasive percutaneous technique for disc irrigation and debridement in pyogenic spondylodiscitis.

MATERIALS AND METHODS

A series of 10 consecutive patients diagnosed with pyogenic spondylodiscitis received percutaneous disc irrigation and debridement. The procedure was performed by inserting two Jamshidi needles percutaneously into the disc space. Indications for surgery were poor response to antibiotic therapy (8 patients) and the need for more extensive biopsy (2 patients). Pre- and postoperative white blood cell count (WBC), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), Oswestry disability index (ODI), and visual analogue score (VAS) for back pain were collected. Minimum follow-up was 18 months, with regular interval assessments.

RESULTS

There were 7 males and 3 females with a mean age of 67 years. The mean WBC before surgery was 14.63 × 109/L (10.9-26.4) and dropped to 7.48 × 109/L (5.6-9.8) after surgery. The mean preoperative CRP was 188 mg/L (111-250) and decreased to 13.83 mg/L (5-21) after surgery. Similar improvements were seen with ESR. All patients reported significant improvements in ODI and VAS scores after surgery. The average hospital stay after surgery was 8.17 days. All patients had resolution of the infection, and there were no complications associated with the procedure.

CONCLUSIONS

Our study confirms the feasibility and safety of our percutaneous technique for irrigation and debridement of pyogenic spondylodiscitis. Percutaneous irrigation and suction offers a truly minimally invasive option for managing recalcitrant spondylodiscitis or for diagnostic purposes. The approach used is very similar to discography and can be easily adapted to different hospital settings.

LEVEL OF EVIDENCE

Level III.

Vertebral osteomyelitis in adults: an update

INTRODUCTION

The incidence of vertebral osteomyelitis is increasing, attributed to an ageing population with inherent co-morbidities and improved case ascertainment.

SOURCES OF DATA

References were retrieved from the PubMed database using the terms 'vertebral osteomyelitis' and 'spondylodiscitis' between January 1, 2009 and April 30, 2014 published in English as checked in May 2014 (>1000 abstracts checked).

AREAS OF AGREEMENT

Blood cultures and whole spine imaging with magnetic resonance imaging are essential investigations. Thorough debridement is the mainstay of surgical management, although placing metalwork in active infection is becoming increasingly common.

AREAS OF CONTROVERSY

The extent of pursuing spinal biopsies to determine aetiology, antimicrobial choices and duration, monitoring the response to treatment, and surgical techniques and timing all vary widely in clinical practice with heterogeneous studies limiting comparisons. Surgery, rather than conservative approaches, is being proposed as the default management choice, because it can, in carefully selected patients, offer faster reduction in pain scores and improved quality of life.

AREAS TIMELY FOR DEVELOPING RESEARCH

Further studies are needed to define the most effective technique for spinal biopsies to maximize determining aetiology. High-quality trials are required to provide an evidence base for both the medical and surgical management of vertebral osteomyelitis, including challenging medical management as the default option.

Antibiotic penetration into rabbit nucleus pulposus with discitis

OBJECTIVE

To assess the penetration into nucleus pulposus (NP) of cephazolin and clindamycin in a discitis model.

MATERIALS AND METHODS

Twenty New Zealand white rabbits were inoculated with 103 Staphylococcus aureus at lumbar disc space. The rabbits with discitis confirmed by MRI 10 days after inoculation were divided into two groups. One was given cephazolin by intravenous (IV) at 80 mg/kg/day at 1.5 h interval for 5 half-lives; the other was given clindamycin by IV at 30 mg/kg/day at 2.5-h interval for 5 half-lives. Thirty minutes after completion of the last dose, NP and serum were sent to measure antibiotic concentration.

RESULTS

Two rabbits died during inoculation. After 10 days, 18 rabbits were confirmed discitis in the inoculated levels. The cephazolin and clindamycin can diffuse throughout the infected, sham-infected and normal NP. The serum concentration of cephazolin and clindamycin was 251.3 ± 40.5 and 21.6 ± 4.71 mg/l, respectively. The cephazolin concentration in infected NP (1.93 ± 0.84 mg/l) was higher than that in sham-infected (1.73 ± 0.61 mg/l) and normal NP (1.68 ± 0.65 mg/l), but the difference showed no statistically significant (P > 0.05). The cephazolin penetration into NP averaged 0.68-0.77 % of serum level. The clindamycin concentration in infected NP (4.32 ± 1.54 mg/l) was higher than that in sham-infected NP (2.63 ± 1.26 mg/l) and normal NP (2.59 ± 1.01 mg/l) (P < 0.05). The penetration into NP averaged 11.9-20 % of serum level. There was no significance difference between sham-infected and normal NP in clindamycin and cephazolin concentration (P > 0.05).

CONCLUSIONS

This study demonstrates cephazolin and clindamycin can penetrate the infected and normal NP. The antibiotics charge influences the delivery. Furthermore, infection condition selectively promotes antibiotic distribution within NP.

Postoperative spondilodiscitis

INTRODUCTION

Postoperative spondylodiscitis is a primary infection of the nucleus pulposus with secondary involvement of the cartilaginous endplate and vertebral bone. Although uncommon, postoperative spondylodiscitis causes major morbidity and may be associated with serious long-term sequelae. Several risk factors had been identified, including immunosuppression, obesity, alcohol, smoking, diabetes and malnutrition.

MATERIALS AND METHODS

A review of the literature was done to analyse the diagnosis, treatment and prevention of postoperative spondylodiscitis.

RESULTS

We found that the principles of conservative treatment are to establish an accurate microbiological diagnosis, treat with appropriate antibiotics, immobilise the spine, and closely monitor for spinal instability and neurological deterioration. The purpose of surgical treatment is to obtain multiple cultures of bone and soft tissue, perform a thorough debridement of infected tissue, decompress neural structures, and reconstruct the unstable spinal column with bone graft with or without concomitant instrumentation.

CONCLUSIONS

Appropriate management requires aggressive medical treatment and, at times, surgical intervention. If recognised early and treated appropriately, a full recovery can often be expected. Therefore, clinicians should be aware of the clinical presentation of such infections to improve patient outcome. A review of the literature was done to advance our understanding of the diagnosis, treatment, prevention and outcome of these infections.