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Cheng L, Feng Z, Jon TG, Chen Z, Wang Y. Remove the infected interbody cage using endoscopy in lumbar spine revision surgery: A case series and technique report. J Orthop Sci 2024; 29:423-427. [PMID: 35871062 DOI: 10.1016/j.jos.2022.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 05/22/2022] [Accepted: 06/20/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Current revision surgery to remove the infected interbody cage following transforaminal lumbar interbody fusion (TLIF) surgery is challenging and traumatic. The purpose of this study is to introduce a novel surgical technique to remove the infected interbody cage for chronic infection. METHODS Three patients with chronic infection following TLIF surgery underwent revision surgery. Instrumentations were removed and a spinal endoscope was obliquely inserted to the disc space through the initial annular breach. Under endoscope, the cage was found, released, turned around, and dragged to the posterior edge of the disc space. The cage was then removed without distracting the dural sac and nerve roots. For two cases, appropriately sized structural iliac bone grafts were used for interbody fusion without extra instrumentations. RESULTS Using endoscope, the interbody cage was easy to identify and expose without disrupting the dural sac and nerve roots. With various endoscopic tools, the cage was easily released and removed. In this case series, the infected interbody cage was removed within thirty minutes without dural sac rupture and nerve root injury. The infection was controlled after the surgery, and the patients obtained good clinical outcomes. At 6-month follow-up, bony fusion was achieved in two patients who underwent interbody fusion. CONCLUSIONS This endoscopy assisted technique simplified the revision surgery for chronic infection followed TLIF surgery, with the advantages of no disruption of the neural tissues, bright surgical field and complete disc debridement.
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Affiliation(s)
- Linxiang Cheng
- Spine lab, Department of Orthopedic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Zhiyun Feng
- Spine lab, Department of Orthopedic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Tae Gyong Jon
- Spine lab, Department of Orthopedic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Zhong Chen
- Spine lab, Department of Orthopedic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Yue Wang
- Spine lab, Department of Orthopedic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China.
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Benavent E, Kortajarena X, Sobrino-Diaz B, Gasch O, Rodríguez-Pardo D, Escudero-Sanchez R, Bahamonde A, Rodriguez-Montserrat D, García-País MJ, Del Toro López MD, Sorli L, Nodar A, Vilchez HH, Muñez E, Iribarren JA, Ariza J, Murillo O. Vertebral osteomyelitis after spine instrumentation surgery: risk factors and management. J Hosp Infect 2023; 140:102-109. [PMID: 37482096 DOI: 10.1016/j.jhin.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 06/30/2023] [Accepted: 07/06/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND Vertebral osteomyelitis after spine instrumentation surgery (pVOM) is a rare complication. Most cases of infection occur early after surgery that involve skin and soft tissue and can be managed with debridement, antibiotics, and implant retention (DAIR). AIM To identify pVOM risk factors and evaluate management strategies. METHODS From a multicentre cohort of deep infection after spine instrumentation (IASI) cases (2010-2016), pVOM cases were compared with those without vertebral involvement. Early and late infections were defined (<60 days and >60 days after surgery, respectively). Multivariate analysis was used to explore risk factors. FINDINGS Among 410 IASI cases, 19 (4.6%) presented with pVOM, ranging from 2% (7/347) in early to 19.1% (12/63) in late IASIs. After multivariate analysis, age (adjusted odds ratio (aOR): 1.10; 95% confidence interval (CI): 1.03-1.18), interbody fusion (aOR: 6.96; 95% CI: 2-24.18) and coagulase-negative staphylococci (CoNS) infection (aOR: 3.83; 95% CI: 1.01-14.53) remained independent risk factors for pVOM. Cases with pVOM had worse prognoses than those without (failure rate; 26.3% vs 10.8%; P = 0.038). Material removal was the preferred strategy (57.9%), mainly in early cases, without better outcomes (failure rate; 33.3% vs 50% compared with DAIR). Late cases managed with removal had greater success compared with DAIR (failure rate; 0% vs 40%; P = 0.067). CONCLUSION Risk factors for pVOM are old age, use of interbody fusion devices and CoNS aetiology. Although the diagnosis leads to a worse prognosis, material withdrawn should be reserved for late cases or when spinal fusion is achieved.
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Affiliation(s)
- E Benavent
- Infectious Diseases Department, Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain; Study Group on Osteoarticular Infections of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain
| | - X Kortajarena
- Infectious Diseases Department, Hospital Universitario Donostia, Gipuzkoa, Spain
| | - B Sobrino-Diaz
- Study Group on Osteoarticular Infections of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain; Department of Infectious Diseases, Hospital Regional Universitario Málaga - Instituto de investigacion biomedica de Málaga (IBIMA), Málaga, Spain
| | - O Gasch
- Infectious Diseases Department, Hospital Parc Tauli de Sabadell, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - D Rodríguez-Pardo
- Study Group on Osteoarticular Infections of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain; Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - R Escudero-Sanchez
- Study Group on Osteoarticular Infections of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain; Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; Infectious Disease Department, University Hospital Ramón y Cajal, Madrid, Spain
| | - A Bahamonde
- Study Group on Osteoarticular Infections of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain; Department of Internal Medicine-Infectious Diseases, Hospital Universitario del Bierzo, León, Spain
| | - D Rodriguez-Montserrat
- Orthopedic Surgery Department, Germans Trias i Pujol University Hospital, Badalona, Spain
| | - M J García-País
- Infectious Disease Unit and Microbiology Departments, Hospital Universitario Lucus Augusti, Lugo, Spain
| | - M D Del Toro López
- Study Group on Osteoarticular Infections of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain; Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; Division of Infectious Diseases and Microbiology, University Hospital Virgen Macarena, Seville, Spain; Biomedicine Institute of Sevilla/Department of Medicine, University of Seville/CSIC, Seville, Spain
| | - L Sorli
- Study Group on Osteoarticular Infections of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain; Infectious Diseases Department, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona (UAB), CEXS-Universitat Pompeu Fabra, Barcelona, Spain
| | - A Nodar
- Study Group on Osteoarticular Infections of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain; Infectious Diseases Unit, Internal Medicine Department and Instituto de Investigación Biomédica Galicia Sur, Hospital Álvaro Cunqueiro, Vigo, Spain
| | - H H Vilchez
- Study Group on Osteoarticular Infections of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain; Infectious Diseases Unit, Internal Medicine Department, Hospital Universitari Son Espases, Fundació Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma de Mallorca, Spain
| | - E Muñez
- Study Group on Osteoarticular Infections of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain; Infectious Diseases Unit, Internal Medicine Department, Universitary Hospital Puerta de Hierro-Majadahonda - Research Institute Puerta de Hierro-Segovia de Arana (IDPHISA), Madrid, Spain
| | - J A Iribarren
- Study Group on Osteoarticular Infections of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain; Infectious Diseases Department, Hospital Universitario Donostia, Gipuzkoa, Spain; Biodonostia Health Research Institute, Gipuzkoa, Spain
| | - J Ariza
- Infectious Diseases Department, Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain; Study Group on Osteoarticular Infections of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain; Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - O Murillo
- Infectious Diseases Department, Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain; Study Group on Osteoarticular Infections of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIO-SEIMC), Spain; Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain.
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Fernández-Maza B, Sánchez-Márquez JM, Talavera-Buedo G, Sánchez J, Fernández-Baíllo N. Total en bloc spondylectomy in the treatment of postoperative chronic osteomyelitis: a case report. JOURNAL OF SPINE SURGERY (HONG KONG) 2022; 8:288-295. [PMID: 35875627 PMCID: PMC9263736 DOI: 10.21037/jss-22-14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Infection of the spine after surgical procedures is one of the most dreaded complications of spinal fusion surgery. Treatment goals are to eradicate the necrotic and infected tissue and to obtain a correct spinal profile. Traditionally many authors have recommended the posterolateral or double approach, anterior and posterior. Total en bloc spondylectomy is a surgical procedure traditionally used to treat primary and metastatic tumors. The use of this surgical procedure in treatment of chronic vertebral osteomyelitis is not clearly defined in literature. CASE DESCRIPTION This case involved a 66-year-old female patient with a history of T9-S1 instrumentation after several surgeries, who developed chronic osteomyelitis of T8-T9 with extensive destruction of the vertebral body and severe thoracic kyphosis. After targeted antibiotic therapy, total en bloc spondylectomy of T8-T9 was performed according to the Tomita technique. Necrotic and infected tissues were removed proceeding as if it were chronic osteomyelitis of long bones and performing en bloc resection with clear margins, that is, applying the criteria of oncological surgery to this chronic infection. After resection, the sagittal plane is reconstructed in the affected segment, restoring the normal distance between the two healthy vertebrae and the mechanical stability of the spine. CONCLUSIONS Total en bloc spondylectomy in the treatment of extensive infectious lesions with a mechanical component allows performing en bloc resection of infected and necrotic tissue along with biological and mechanical reconstruction. In our case, the complete resection of the infected bone and soft tissues achieved good outcome without complications. We propose total en bloc spondylectomy as a reasonable treatment option in complicated spondylodiscitis progressing to extensive chronic osteomyelitis and compromising spinal stability due to a significant loss of bone material.
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Affiliation(s)
| | - José Miguel Sánchez-Márquez
- Section of Spine and Spinal Cord Surgery, Department of Orthopedic Surgery, HM Sanchinarro University Hospital, Madrid, Spain
| | - Gloria Talavera-Buedo
- Section of Spine and Spinal Cord Surgery, Department of Orthopedic Surgery, HM Sanchinarro University Hospital, Madrid, Spain
| | - Javier Sánchez
- Section of Spine and Spinal Cord Surgery, Department of Orthopedic Surgery, Asepeyo Hospital, Madrid, Spain
| | - Nicomedes Fernández-Baíllo
- Section of Spine and Spinal Cord Surgery, Department of Orthopedic Surgery, HM Sanchinarro University Hospital, Madrid, Spain
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Nakamura S, Nakai T, Hayashi J, Hosozawa K, Tanaka Y, Kishimoto K, Sakata K, Iwata H. Treatment strategy for surgical site infection post posterior lumbar interbody fusion: A retrospective study. J Orthop 2022; 31:40-44. [PMID: 35368734 PMCID: PMC8967701 DOI: 10.1016/j.jor.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/10/2022] [Accepted: 03/16/2022] [Indexed: 10/18/2022] Open
Abstract
Introduction Posterior lumbar interbody fusion (PLIF) has been widely used to treat various degenerative spinal diseases. However, surgical site infection (SSI) post-PLIF is often difficult to cure. This study aimed to clarify the difference in clinical course due to the causative organism and develop a treatment strategy for SSI post-PLIF. Methods Between January 2011 and March 2019, 581 PLIF surgeries were performed at our hospital. Deep SSI occurred in 14 patients who were followed up for more than 2 years. Causative bacterial species were diagnosed by preoperative puncture and/or intraoperative drainage or by tissue culture in 13 patients and by intradiscal puncture in one patient who underwent conservative treatment. Of the 13 patients who underwent surgeries for infection, 10 had Propionibacterium acnes (Group A; n = 4) or coagulase-negative Staphylococcus (CNS) (Group B; n = 6) as the causative bacterial species. Groups A and B were retrospectively compared in terms of age, sex, number of segments, presence of diabetes mellitus, operation time, blood loss, C-reactive protein on hematological examination, the elapsed time to diagnosis (ETD), the presence of clinical findings such as heat, redness, swelling, and discharge from the wound and healing time. Results All infections were eradicated with surgery except in one patient whose causative bacteria was CNS; cages were finally removed in 11 patients. There was a significant difference (P = 0.0105) in the ETD and clinical findings (P = 0.0476) between Groups A and B. Posterior one-stage simultaneous revision (POSSR) was performed in nine patients, of whom eight were cured and one required additional surgery. Conclusions The ETD and clinical findings were significantly different in SSI cases caused by different bacteria, which will be useful in predicting the causative bacteria in future cases. For the treatment of deep SSI post-PLIF, POSSR was effective.
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Xará-Leite F, Ribau A, Lopes Guerra MD, Abreu MA, Rodrigues-Pinto R. Multidisciplinary Approach to Multiple Multiresistant Agent Infection of Instrumented Spine Surgery: A Case Report. JBJS Case Connect 2022; 12:01709767-202203000-00029. [PMID: 35081062 DOI: 10.2106/jbjs.cc.21.00472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We report the case of a patient with consecutive infections with several multidrug-resistant agents-including carbapenem-resistant strains of Klebsiella pneumoniae among others-from a surgical wound infection after lumbar spine fusion, only successfully treated after the resort to novel antibiotics (ceftazidime-avibactam) in combination therapy. CONCLUSIONS Multidrug resistance has become a major challenge in today's medicine. Care should be taken to avoid their emergence, but when present, a multidisciplinary approach is mandatory to ensure clinically up-to-date treatment choices. Multimodal antibiotic schemes tend to show the most promising results, with which successful infection resolution can still be achieved.
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Affiliation(s)
- Francisco Xará-Leite
- Spinal Unit (UVM), Department of Orthopaedics, Centro Hospitalar Universitário do Porto, Porto, Portugal.,Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal.,School of Medicine, University of Minho, Braga, Portugal
| | - Ana Ribau
- Spinal Unit (UVM), Department of Orthopaedics, Centro Hospitalar Universitário do Porto, Porto, Portugal.,Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal
| | | | - Miguel Araújo Abreu
- Department of Infectious Diseases, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Ricardo Rodrigues-Pinto
- Spinal Unit (UVM), Department of Orthopaedics, Centro Hospitalar Universitário do Porto, Porto, Portugal.,Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal
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Hersh A, Young R, Pennington Z, Ehresman J, Ding A, Kopparapu S, Cottrill E, Sciubba DM, Theodore N. Removal of instrumentation for postoperative spine infection: systematic review. J Neurosurg Spine 2021:1-13. [PMID: 34243152 DOI: 10.3171/2020.12.spine201300] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 12/14/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Currently, no consensus exists as to whether patients who develop infection of the surgical site after undergoing instrumented fusion should have their implants removed at the time of wound debridement. Instrumentation removal may eliminate a potential infection nidus, but removal may also destabilize the patient's spine. The authors sought to summarize the existing evidence by systematically reviewing published studies that compare outcomes between patients undergoing wound washout and instrumentation removal with outcomes of patients undergoing wound washout alone. The primary objectives were to determine 1) whether instrumentation removal from an infected wound facilitates infection clearance and lowers morbidity, and 2) whether the chronicity of the underlying infection affects the decision to remove instrumentation. METHODS PRISMA guidelines were used to review the PubMed/MEDLINE, Embase, Cochrane Library, Scopus, Web of Science, and ClinicalTrials.gov databases to identify studies that compared patients with implants removed and patients with implants retained. Outcomes of interest included mortality, rate of repeat wound washout, and loss of correction. RESULTS Fifteen articles were included. Of 878 patients examined in these studies, 292 (33%) had instrumentation removed. Patient populations were highly heterogeneous, and outcome data were limited. Available data suggested that rates of reoperation, pseudarthrosis, and death were higher in patients who underwent instrumentation removal at the time of initial washout. Three studies recommended that instrumentation be uniformly removed at the time of wound washout. Five studies favored retaining the original instrumentation. Six studies favored retention in early infections but removal in late infections. CONCLUSIONS The data on this topic remain heterogeneous and low in quality. Retention may be preferred in the setting of early infection, when the risk of underlying spine instability is still high and the risk of mature biofilm formation on the implants is low. However, late infections likely favor instrumentation removal. Higher-quality evidence from large, multicenter, prospective studies is needed to reach generalizable conclusions capable of guiding clinical practice.
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Neal MT, Curley KL, Richards AE, Kalani MA, Lyons MK, Davila VJ. An unusual case of a persistent, infected retroperitoneal fluid collection 5 years after anterior lumbar fusion surgery: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE20107. [PMID: 36033916 PMCID: PMC9394109 DOI: 10.3171/case20107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 11/20/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUNDAnterior lumbar fusion procedures have many benefits and continue to grow in popularity. The technique has many potential approach- and procedure-related complications. Symptomatic retroperitoneal fluid collections are uncommon but potentially serious complications after anterior lumbar procedures. Collection types include hematomas, urinomas, chyloperitoneum, cerebrospinal fluid collections, and deep infections.OBSERVATIONSThe authors present an unusual case of a patient with persistent symptoms related to a retroperitoneal collection over a 5-year period following anterior lumbar fusion surgery. To the authors’ knowledge, no similar case with such extensive symptom duration has been described. The patient had an infected encapsulated fluid collection. The collection was presumed to be a postoperative lymphocele that was secondarily infected after serial percutaneous drainage procedures.LESSONSWhen retroperitoneal collections occur after anterior retroperitoneal approaches, clinical clues, such as timing of symptoms, hypotension, acute anemia, urinary tract infection, hydronephrosis, elevated serum creatinine and blood urea nitrogen, low-pressure headaches, anorexia, or systemic signs of infection, can help narrow the differential. Retroperitoneal collections may continue to be symptomatic many years after anterior lumbar surgery. The collections may become infected after serial percutaneous drainage or prolonged continuous drainage. Encapsulated, infected fluid collections typically require surgical debridement of the capsule and its contents.
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Revision Surgery for Postoperative Spondylodiscitis at Cage Level after Posterior Instrumented Fusion in the Lumbar Spine-Anterior Approach Is Not Absolutely Indicated. J Clin Med 2020; 9:jcm9123833. [PMID: 33256126 PMCID: PMC7760829 DOI: 10.3390/jcm9123833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 11/17/2022] Open
Abstract
Spondylodiscitis at the cage level is rare but remains a challenge for spine surgeons. In this study, the safety and efficacy of revision surgery by a posterior approach to spondylodiscitis developed at the cage level were evaluated, and these data were compared to those of patients treated with revision surgeries using the traditional anterior plus posterior approach for their infections. Twenty-eight patients with postoperative spondylodiscitis underwent revision surgeries to salvage their infections, including 15 patients in the study group (posterior only) and 13 patients in the control group (combined anterior and posterior). Staphylococcus aureus was the most common pathogen in both groups. L4-L5 was the most common infection site in both groups. The operation time (229.5 vs. 449.5 min, p < 0.001) and blood loss (427.7 vs. 1106.9 mL, p < 0.001) were the only two data points that were statistically significantly different between the two groups. In conclusion, a single posterior approach with ipsilateral or contralateral transforaminal lumbar interbody debridement and fusion plus extending instrumentation was safe and effective for spondylodiscitis developed at the cage level. This strategy can decrease the operation time and blood loss.
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