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Klute L, Esser M, Henssler L, Riedl M, Schindler M, Rupp M, Alt V, Kerschbaum M, Lang S. Anterior Column Reconstruction of Destructive Vertebral Osteomyelitis at the Thoracolumbar Spine with an Expandable Vertebral Body Replacement Implant: A Retrospective, Monocentric Radiological Cohort Analysis of 24 Cases. J Clin Med 2024; 13:296. [PMID: 38202303 PMCID: PMC10780050 DOI: 10.3390/jcm13010296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/21/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Vertebral osteomyelitis (VO) often necessitates surgical intervention due to bone loss-induced spinal instability. Anterior column reconstruction, utilizing expandable vertebral body replacement (VBR) implants, is a recognized approach to restore stability and prevent neurological compromise. Despite various techniques, clinical evidence regarding the safety and efficacy of these implants in VO remains limited. METHODS A retrospective cohort analysis, spanning 2000 to 2020, was conducted on 24 destructive VO cases at a Level 1 orthopedic trauma center. Diagnosis relied on clinical, radiological, and microbiological criteria. Patient demographics, clinical presentation, surgical interventions, and radiological outcomes were assessed. RESULTS The study included 24 patients (62.5% male; mean age 65.6 ± 35.0 years), with 58% having healthcare-associated infections (HAVO). The mean radiological follow-up was 137.2 ± 161.7 weeks. Surgical intervention significantly improved the bi-segmental kyphotic endplate angle (BKA) postoperatively (mean -1.4° ± 13.6°). However, a noticeable loss of correction was observed over time. The study reported a mortality rate of 1/24. CONCLUSIONS Anterior column reconstruction using expandable VBR effectively improved local spinal alignment in destructive VO. However, the study underscores the necessity for prolonged follow-up and continuous research to refine surgical techniques and postoperative care. Addressing long-term complications and refining surgical approaches will be pivotal as the field progresses.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Siegmund Lang
- Clinic of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
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Brooks CA, Mahajan S, Beresford R, Damodaran O, Pope R. Thoracic spondylodiscitis secondary to Klebsiella oxytoca urosepsis-a case report. JOURNAL OF SPINE SURGERY (HONG KONG) 2022; 8:54-61. [PMID: 35441097 PMCID: PMC8990402 DOI: 10.21037/jss-21-124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 01/27/2022] [Indexed: 06/14/2023]
Abstract
Spondylodiscitis is an insidious and infectious pathology of the spinal column attributable to pathogenic micro-organisms and occurs in a variety of contexts. These micro-organisms can be inoculated surgically or can metastasise from distant sites of infection. Klebsiella species are important community-acquired and nosocomial pathogens but are uncommonly implicated in spinal infection. Klebsiella oxytoca is more obscure than its generic relative Klebsiella pneumoniae and has only five times previously been reported in spondylodiscitis. It possesses the ability to acquire inducible and recombinant antibiotic resistance, especially in the hospital setting. We describe the case of an elderly man with complex urology and this rare sequela due to incomplete treatment of a K. oxytoca urinary infection. He developed sepsis that recurred after incomplete antibiosis and seeded to his thoracic spine causing overt spondylodiscitis. The infection fulminated and his spinal lesion deteriorated into acute spinal cord compression with neurological compromise, requiring surgical decompression, fixation and long-term antibiotics. This is a sixth documented instance of a rare spinal bacterial infection. We describe the relevant microbiology and pathology, neurosurgical considerations, and general practice points for clinicians. Our report is a novel illustration of the potentially catastrophic consequences of inadequately treated urosepsis and is a stark reminder of the importance of antimicrobial stewardship.
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Affiliation(s)
| | - Sameer Mahajan
- Department of Neurosurgery, Concord Repatriation General Hospital, Concord, Australia
| | - Rohan Beresford
- Department of Microbiology and Infectious Diseases, Concord Repatriation General Hospital, Concord, Australia
| | - Omprakash Damodaran
- Department of Neurosurgery, Concord Repatriation General Hospital, Concord, Australia
- Department of Neurosurgery, Nepean Hospital, Kingswood, Australia
| | - Raoul Pope
- Department of Neurosurgery, Concord Repatriation General Hospital, Concord, Australia
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Moreno-Gómez LM, Esteban-Sinovas O, García-Pérez D, García-Posadas G, Delgado-Fernández J, Paredes I. Case Report: SARS-CoV-2 Infection-Are We Redeemed? A Report of Candida Spondylodiscitis as a Late Complication. Front Med (Lausanne) 2021; 8:751101. [PMID: 34901064 PMCID: PMC8664247 DOI: 10.3389/fmed.2021.751101] [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: 07/31/2021] [Accepted: 10/22/2021] [Indexed: 12/12/2022] Open
Abstract
Background: We describe a case of candida spondylodiscitis secondary to coronavirus disease (COVID-19). Case report: A 47-year-old man diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) required prolonged admission to the intensive care unit (ICU). Four months later, he was diagnosed with thoracic candida spondylodiscitis. Medical management was insufficient, so he eventually underwent surgery. Discussions: Fungal infections seem to be more likely in patients with COVID-19, but it is unknown whether they are directly attributed to COVID-19 or other surrounding factors. Regardless of the answer, the diagnosis is complicated, and the mortality rate is high. Lessons: COVID-19 is posing a challenge to the society, and new and unexpected diseases that had once disappeared have risen again. It is our duty to suspect them and to treat them in the most effective way possible.
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[Infections of the spine : Pyogenic spondylodiscitis and implant-associated vertebral osteomyelitis]. Unfallchirurg 2021; 124:489-504. [PMID: 33970304 DOI: 10.1007/s00113-021-01002-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2021] [Indexed: 10/21/2022]
Abstract
Pyogenic (unspecific) spondylodiscitis and implant-associated vertebral osteomyelitis (IAVO) are important diseases with the risk of neurological and septic complications. An early diagnosis is essential in which magnetic resonance imaging (MRI), histopathology and microbiological identification of the pathogen play key roles. The goals of conservative treatment in uncomplicated spondylodiscitis are antibiotic infection control and pain management. In the case of sepsis, neurological deficits, segmental instability or epidural abscesses surgical treatment of the infection with stabilization of the spine should be considered. In IAVO the formation of a mature biofilm represents the transition from acute to chronic infection. Acute infections can be treated by extensive debridement in combination with biofilm-active antibiotic treatment while retaining the implant. In chronic infections implant removal or exchange in combination with several weeks of antibiotic treatment is often necessary.
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Maurya VP, Elangovan D, Mourougayan V, Ranjini M. Severe Spinal Infection after Vertebral Fracture Stabilization: A Narrow Escape. INDIAN JOURNAL OF NEUROTRAUMA 2020. [DOI: 10.1055/s-0040-1713307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractSpinal cord injury is typical following fall from height. The thoracolumbar vertebra undergoes maximum fracture following trauma. A 26-year-old man was brought to the emergency department with a history of fall from height. Clinical examination showed weakness in lower limbs with the inability to pass urine. Magnetic resonance imaging (MRI) of spine done elsewhere was suggestive of loss of second lumbar (L2) vertebral body height with compression over the lower end of the cord. Computed tomography (CT) scan of the spine revealed a burst fracture of L2 vertebra with bone fragments protruding into the spinal canal. The patient was taken up for spinal decompression with stabilization. His hospital stay was uneventful, and two weeks after discharge he was readmitted with wound bulge over the operative site. We started him on intravenous antibiotics and did regular debridement of the wound. Later on, he underwent wound closure with flap rotation.At last follow-up, he was ambulant with bladder and bowel control. During treatment, the titanium implants were left in situ. The decision for implant removal in early wound infection is at the discretion of the operating surgeon, along with the timing and nature of the disease.
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Affiliation(s)
- Ved Prakash Maurya
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Uttar Pradesh, India
| | - D. Elangovan
- Department of Neurosurgery, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India
| | - V. Mourougayan
- Department of Plastic Surgery, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India
| | - M. Ranjini
- Department of Neurosurgery, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India
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Bettag C, Abboud T, von der Brelie C, Melich P, Rohde V, Schatlo B. Do we underdiagnose osteoporosis in patients with pyogenic spondylodiscitis? Neurosurg Focus 2020; 49:E16. [DOI: 10.3171/2020.5.focus20267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 05/14/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVEPyogenic spondylodiscitis affects a fragile patient population. Surgical treatment in cases of instability entails instrumentation, and loosening of this instrumentation is a frequent occurrence in pyogenic spondylodiscitis. The authors therefore attempted to investigate whether low bone mineral density (BMD)—which is compatible with the diagnosis of osteoporosis—is underdiagnosed in patients with pyogenic spondylodiscitis. How osteoporosis was treated and how it affected implant stability were further analyzed.METHODSCharts of patients who underwent operations for pyogenic spondylodiscitis were retrospectively reviewed for clinical data, prior medical history of osteoporosis, and preoperative CT scans of the thoracolumbar spine. In accordance with a previously validated high-fidelity opportunistic CT assessment, average Hounsfield units (HUs) in vertebral bodies of L1 and L4 were measured. Based on the validation study, the authors opted for a conservative cutoff value for low BMD, being compatible with osteoporosis ≤ 110 HUs. Baseline and outcome variables, including implant failure and osteoporosis interventions, were entered into a multivariate logistic model for statistical analysis.RESULTSOf 200 consecutive patients who underwent fusion surgery for pyogenic spondylodiscitis, 64% (n = 127) were male and 66% (n = 132) were older than 65 years. Seven percent (n = 14) had previously been diagnosed with osteoporosis. The attenuation analysis revealed HU values compatible with osteoporosis in 48% (95/200). The need for subsequent revision surgery due to implant failure showed a trend toward an association with estimated low BMD (OR 2.11, 95% CI 0.95–4.68, p = 0.067). Estimated low BMD was associated with subsequent implant loosening (p < 0.001). Only 5% of the patients with estimated low BMD received a diagnosis and pharmacological treatment of osteoporosis within 1 year after spinal instrumentation.CONCLUSIONSRelying on past medical history of osteoporosis is insufficient in the management of patients with pyogenic spondylodiscitis. This is the first study to identify a substantially missed opportunity to detect osteoporosis and to start pharmacological treatment after surgery for prevention of implant failure. The authors advocate for routine opportunistic CT evaluation for a better estimation of bone quality to initiate diagnosis and treatment for osteoporosis in these patients.
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Affiliation(s)
- Christoph Bettag
- 1Department of Neurosurgery, Georg-August University of Göttingen; and
| | - Tammam Abboud
- 1Department of Neurosurgery, Georg-August University of Göttingen; and
| | | | - Patrick Melich
- 1Department of Neurosurgery, Georg-August University of Göttingen; and
- 2Department of Neurosurgery, University Hospital Cologne, Germany
| | - Veit Rohde
- 1Department of Neurosurgery, Georg-August University of Göttingen; and
| | - Bawarjan Schatlo
- 1Department of Neurosurgery, Georg-August University of Göttingen; and
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Ramey WL, von Glinski A, Jack A, Blecher R, Oskouian RJ, Chapman JR. Antibiotic-impregnated polymethylmethacrylate strut graft as a treatment of spinal osteomyelitis: case series and description of novel technique. J Neurosurg Spine 2020; 33:415-420. [PMID: 32384277 DOI: 10.3171/2020.3.spine191313] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 03/06/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The surgical treatment of osteomyelitis and discitis of the spine often represents a challenging clinical entity for a multitude of reasons, including progression of infection despite debridement, development of spinal deformity and instability, bony destruction, and seeding of hardware. Despite advancement in spinal hardware and implantation techniques, these aforementioned challenges not uncommonly result in treatment failure, especially in instances of heavy disease burden with enough bony endplate destruction as to not allow support of a modern titanium cage implant. While antibiotic-infused polymethylmethacrylate (aPMMA) has been used in orthopedic surgery in joints of the extremities, its use has not been extensively described in the spine literature. Herein, the authors describe for the first time a series of patients treated with a novel surgical technique for the treatment of spinal osteomyelitis and discitis using aPMMA strut grafts with posterior segmental fusion. METHODS Over the course of 3 years, all patients with spinal osteomyelitis and discitis at a single institution were identified and included in the retrospective cohort if they were surgically treated with spinal fusion and implantation of an aPMMA strut graft at the nidus of infection. Basic demographics, surgical techniques, levels treated, complications, and return to the operating room for removal of the aPMMA strut graft and placement of a traditional cage were examined. The surgical technique consisted of performing a discectomy and/or corpectomy at the level of osteomyelitis and discitis followed by placement of aPMMA impregnated with vancomycin and/or tobramycin into the cavity. Depending on the patient's condition during follow-up and other deciding clinical and radiographic factors, the patient may return to the operating room nonurgently for removal of the PMMA spacer and implantation of a permanent cage with allograft to ultimately promote fusion. RESULTS Fifteen patients were identified who were treated with an aPMMA strut graft for spinal osteomyelitis and discitis. Of these, 9 patients returned to the operating room for aPMMA strut graft removal and insertion of a cage with allograft at an average of 19 weeks following the index procedure. The most common infections were methicillin-sensitive Staphylococcus aureus (n = 6) and methicillin-resistant S. aureus (n = 5). There were 13 lumbosacral infections and 1 each of cervical and thoracic infection. Eleven patients were cured of their infection, while 2 had recurrence of their infection; 2 patients were lost to follow-up. Three patients required unplanned return trips to the operating room, two of which were for wound complications, with the third being for recurrent infection. CONCLUSIONS In cases of severe infection with considerable bony destruction, insertion of an aPMMA strut graft is a novel technique that should be considered in order to provide strong anterior-column support while directly delivering antibiotics to the infection bed. While the active infection is being treated medically, this structural aPMMA support bridges the time it takes for the patient to be converted from a catabolic to an anabolic state, when it is ultimately safe to perform a definitive, curative fusion surgery.
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Affiliation(s)
- Wyatt L Ramey
- 1Swedish Neuroscience Institute, Swedish Medical Center, Seattle
| | - Alexander von Glinski
- 1Swedish Neuroscience Institute, Swedish Medical Center, Seattle
- 2Seattle Science Foundation, Seattle, Washington
- 3Department of Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Germany; and
- 4Hansjoerg Wyss Hip and Pelvic Center, Swedish Hospital, Seattle, Washington
| | - Andrew Jack
- 1Swedish Neuroscience Institute, Swedish Medical Center, Seattle
| | - Ronen Blecher
- 1Swedish Neuroscience Institute, Swedish Medical Center, Seattle
| | - Rod J Oskouian
- 1Swedish Neuroscience Institute, Swedish Medical Center, Seattle
- 2Seattle Science Foundation, Seattle, Washington
| | - Jens R Chapman
- 1Swedish Neuroscience Institute, Swedish Medical Center, Seattle
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Adjacent Segment Infection after Lumbar Fusion: A Case Report and the Literature Review. Case Rep Orthop 2020; 2020:2163909. [PMID: 32395359 PMCID: PMC7201821 DOI: 10.1155/2020/2163909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 01/02/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Adjacent segment infective spondylodiscitis is a rare type of surgical spinal infection after lumbar fusion with few reports. We report a further case of adjacent segment infection after three-level lumbar fusion managed successfully with anti-infective therapy and revision surgery. Case Description. A clinical case of a 69-year-old female with multilevel lumbar degenerative disease received three-level fusion. The leading preoperative symptoms were relieved after decompression surgery. However, severe back pain recurred and prompted her to be rehospitalized 2 months later. The signal of spondylitis and discitis at the adjacent segment was detected by magnetic resonance imaging (MRI). No bacteria were identified despite blood cultures being taken before antibiotic treatment. After a long-term anti-infective therapy with vancomycin, the patient gained symptom relief and was discharged home. However, the patient complained of severe back pain again after long-term oral antibiotic treatment and was rehospitalized 6 months after surgery. The computed tomography (CT) scan showed obvious bony endplate destruction at the adjacent segment space. The patient received a debridement operation and autologous iliac bone graft. The infective inflammatory markers were controlled, and the infective space achieved fusion finally. Conclusion Adjacent segment space infection is a rare reported complication that occurs after spinal fusion surgery. Conservative antibiotic therapy may not control the infection completely, and disc space debridement and autologous iliac bone graft can achieve ultimate fusion and a satisfactory outcome.
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Zhou B, Kang YJ, Chen WH. Continuous Epidural Irrigation and Drainage Combined with Posterior Debridement and Posterior Lumbar Inter-Body Fusion for the Management of Single-Segment Lumbar Pyogenic Spondylodiscitis. Surg Infect (Larchmt) 2019; 21:262-267. [PMID: 31647391 DOI: 10.1089/sur.2019.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Purpose: To observe the clinical curative effect of continuous epidural irrigation combined with posterior debridement and posterior lumbar inter-body fusion with instrumentation for the therapy of single-segment lumbar pyogenic spongdylodiscitis. Methods: From June 2010 to November 2013, surgical treatment was performed in 18 patients with pyogenic spondylodiscitis. The surgical indications were progressive biomechanical instability, epidural abscesses, deterioration of neurologic status, and intractable back pain. All these patients received posterior decompression with posterior instrumentation, debridement of infected tissue, and inter-body fusion. Visual Analogue Scale (VAS) scores were used to assess clinical outcomes. The neural function was evaluated by the Frankel grading system. Laboratory and radiologic results were recorded during clinical follow-up for at least one year. Results: The average follow-up period was 18 months after the operation. The VAS scores decreased from an average of 7.1 points before the procedure to 2.6 points after operation. The neurologic deficits of all the patients were recovered to Frankel grade E. All of the examined laboratory parameters were normalized gradually. Imaging-documented fusion was achieved in each patient, and no implants failure was noted. No patients showed any evidence of recurrence or persistence of infection. Conclusion: In carefully selected patients, single-segment lumbar pyogenic spondylodiscitis can be cured successfully with continuous epidural irrigation and drainage combined with posterior debridement and posterior lumbar inter-body fusion. Instrumentation could provide immediate stability and reconstruction of the spine column, and the presence of instrumentation did not result in any persistence or recurrence of infection. Continuous epidural irrigation and drainage is an effective method facilitating the elimination of residual infection.
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Affiliation(s)
- Bin Zhou
- Spine Surgery Department, Second Xiangya Hospital of Central South University, Hunan Province, People's Republic of China
| | - Yi-Jun Kang
- Spine Surgery Department, Second Xiangya Hospital of Central South University, Hunan Province, People's Republic of China
| | - Wei-Hua Chen
- Spine Surgery Department, Second Xiangya Hospital of Central South University, Hunan Province, People's Republic of China
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Fu TS, Wang YC, Lin TY, Chang CW, Wong CB, Su JY. Comparison of Percutaneous Endoscopic Surgery and Traditional Anterior Open Surgery for Treating Lumbar Infectious Spondylitis. J Clin Med 2019; 8:jcm8091356. [PMID: 31480610 PMCID: PMC6780224 DOI: 10.3390/jcm8091356] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 08/28/2019] [Accepted: 08/30/2019] [Indexed: 12/02/2022] Open
Abstract
Minimally invasive surgery is becoming popular for treating spinal disorders. The advantages of percutaneous endoscopic debridement and drainage (PEDD) for infectious spondylitis include direct observation of the lesion, direct pus drainage, and earlier pain relief. We retrospectively reviewed 37 patients who underwent PEDD and 31 who underwent traditional anterior open debridement and interbody fusion with bone grafting from 2004 to 2012. The causative organisms were isolated from 30 patients (81.1%) following PEDD, and from 25 patients (80.6%) following open surgery (p = 0.48). Staphylococcus aureus was the most common pathogen (38.2%). In the PEDD group, blood loss (<50 mL versus 585 ± 428 mL, p < 0.001) was significantly lesser and the duration of hospitalization (24.4 ± 12.5 days versus 31.5 ± 14.6 days, p = 0.03) was shorter than that in the open surgery group. Serologically, there were significantly faster C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) normalization rates in the PEDD group (p < 0.001, p = 0.009, respectively). In the two-year follow-up radiographs, 26 out of 30 (86.7%) open surgery patients showed bony fusions of the infected segments. On the contrary, sclerotic change of the destructive endplates was observed and the motion of infected spinal segments was still preserved in the PEDD group. There was no significant difference in the change of sagittal profile, including primary correction gain, correction loss, and actual correction gain/loss. PEDD is an effective alternative option and should be considered prior to traditional extensive spinal surgery—particularly for patients with early-stage spinal infection or serious complicated medical conditions.
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Affiliation(s)
- Tsai-Sheng Fu
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung branch 20401, Taiwan.
| | - Ying-Chih Wang
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung branch 20401, Taiwan
| | - Tung-Yi Lin
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung branch 20401, Taiwan
| | - Chia-Wei Chang
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung branch 20401, Taiwan
| | - Chak-Bor Wong
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung branch 20401, Taiwan
| | - Juin-Yih Su
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung branch 20401, Taiwan
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Nagashima H, Tanishima S, Tanida A. Diagnosis and management of spinal infections. J Orthop Sci 2018; 23:8-13. [PMID: 29066036 DOI: 10.1016/j.jos.2017.09.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 08/16/2017] [Accepted: 09/05/2017] [Indexed: 12/24/2022]
Abstract
The number of spinal infections has been increasing due to aging populations and larger numbers of immunocompromised hosts and intravenous drug users. Magnetic resonance imaging is a useful tool for the early diagnosis of spinal infections, and can yield positive findings just 3-5 days after disease onset. Before antibiotic administration, cultures must be initiated from blood and from specimens collected from the locus of infection. Based on the pathogens identified by culture, appropriate antibiotics should be selected with careful consideration of antimicrobial susceptibility and spinal tissue penetration. Antibiotic treatment of spinal infections should be continued for longer than for most other types of infections, although the optimal duration remains unknown. The indications for surgical treatment include progressive neurologic deficits, progressive deformity, spinal instability, persistent or recurrent infection, and unbearable pain. In most patients with spinal infection, the gold standard surgical treatment is anterior radical debridement followed by autologous strut bone grafting. The addition of posterior instrumentation has recently become popular. This procedure may be performed alone as an alternative surgical option in patients in poor condition, and if it dramatically reduces pain, subsequent observation may be reasonable. If progressive deformity is observed or pain relief is inadequate after posterior instrumentation, additional anterior debridement and bone grafting should be scheduled.
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Affiliation(s)
- Hideki Nagashima
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, 36-1 Nishi-cho, Yonago, Tottori 683-8504, Japan.
| | - Shinji Tanishima
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, 36-1 Nishi-cho, Yonago, Tottori 683-8504, Japan
| | - Atsushi Tanida
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, 36-1 Nishi-cho, Yonago, Tottori 683-8504, Japan
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Herren C, Jung N, Pishnamaz M, Breuninger M, Siewe J, Sobottke R. Spondylodiscitis: Diagnosis and Treatment Options. DEUTSCHES ARZTEBLATT INTERNATIONAL 2017; 114:875-882. [PMID: 29321098 PMCID: PMC5769318 DOI: 10.3238/arztebl.2017.0875] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 05/19/2017] [Accepted: 10/16/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND A recent population-based study from Denmark showed that the incidence of spondylodiscitis rose from 2.2 to 5.8 per 100 000 persons per year over the period 1995-2008; the age-standardized incidence in Germany has been estimated at 30 per 250 000 per year on the basis of data from the Federal Statistical Office (2015). The early diagnosis and treatment of this condition are essential to give the patient the best chance of a good outcome, but these are often delayed because it tends to present with nonspecific manifestations, and fever is often absent. METHODS This article is based on a systematic search of Medline and the Cochrane Library for the period January 2009 to March 2017. Of the 788 articles identified, 30 publications were considered. RESULTS The goals of treatment for spondylodiscitis are to eliminate infection, restore functionality of the spine, and relieve pain. Magnetic resonance imaging (MRI) remains the gold standard for the radiological demonstration of this condition, with 92% sensitivity and 96% specificity. It also enables visualization of the spatial extent of the infection and of abscess formation (if present). The most common bacterial cause of spondylodiscitis in Europe is Staphylococcus aureus, but tuberculous spondylodiscitis is the most common type worldwide. Antibiotic therapy is a pillar of treatment for spondylodiscitis and should be a part of the treatment in all cases. Neurologic deficits, sepsis, an intraspinal empyema, the failure of conservative treatment, and spinal instability are all indications for surgical treatment. CONCLUSION The quality of life of patients who have been appropriately treated for spondylodiscitis has been found to be highly satisfactory in general, although back pain often persists. The risk of recurrence increases in the presence of accompanying illnesses such as diabetes mellitus, renal failure, or undrained epidural abscesses.
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Affiliation(s)
- Christian Herren
- Department for Trauma and Reconstructive Surgery, University Hospital RWTH Aachen
| | - Norma Jung
- Department I for Internal Medicine, University Hospital Cologne
| | - Miguel Pishnamaz
- Department for Trauma and Reconstructive Surgery, University Hospital RWTH Aachen
| | | | - Jan Siewe
- Center of Orthopedic and Trauma Surgery, University Hospital Cologne
| | - Rolf Sobottke
- Center of Orthopedic and Trauma Surgery, University Hospital Cologne
- Center for Orthopaedics and Trauma Surgery, Rhein-Maas Klinikum GmbH, Würselen
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13
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Yang SC, Chen HS, Kao YH, Tu YK. Single-stage anterior debridement and reconstruction with tantalum mesh cage for complicated infectious spondylitis. World J Orthop 2017; 8:710-718. [PMID: 28979855 PMCID: PMC5605357 DOI: 10.5312/wjo.v8.i9.710] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 05/02/2017] [Accepted: 05/31/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the clinical and radiographic results of patients with complicated infectious spondylitis treated with single-stage anterior debridement and reconstruction using tantalum mesh cage (TaMC) followed by immediate instrumentation.
METHODS Single-stage radical debridement and subsequent reconstruction with TaMC instead of autograft or allograft were performed to treat 20 patients with spinal deformity or instability due to complicated infectious spondylitis. Clinical outcomes were assessed by careful physical examination and regular serological tests to determine the infection control. In addition, the visual analog score (VAS), neurologic status, length of vertebral body reconstruction, and the correction of sagittal Cobb angle on radiography were recorded and compared before and after surgery. The conditions of the patients were evaluated based on the modified Brodsky’s criteria.
RESULTS The average VAS score significantly decreased after the surgery (from 7.4 ± 0.8 to 3.3 ± 0.8, P < 0.001). The average Cobb angle correction was 14.9 degrees. The neurologic status was significantly improved after the surgery (P = 0.003). One patient experienced refractory infection and underwent additional debridement. Eighteen patients achieved good outcome based on the modified Brodsky’s criteria and significant improvement after the surgery (P < 0.001). No implant breakage or TaMC dislodgement was found during at least 24 mo of follow-up.
CONCLUSION Single-stage anterior debridement and reconstruction with TaMC followed by immediate instrumentation could be an alternative method to manage the patients with spinal deformity or instability due to complicated infectious spondylitis.
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Affiliation(s)
- Shih-Chieh Yang
- Department of Orthopedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung 82445, Taiwan
| | - Hung-Shu Chen
- Department of Orthopedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung 82445, Taiwan
| | - Yu-Hsien Kao
- Department of Orthopedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung 82445, Taiwan
| | - Yuan-Kun Tu
- Department of Orthopedic Surgery, E-Da Hospital, I-Shou University, Kaohsiung 82445, Taiwan
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Prognostic Factors for Failure of Antibiotic Treatment in Patients With Osteomyelitis of the Spine. Spine (Phila Pa 1976) 2017; 42:1339-1346. [PMID: 28134749 DOI: 10.1097/brs.0000000000002084] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of this study was to identify factors independently associated with antibiotic treatment failure in patients with spinal osteomyelitis. SUMMARY OF BACKGROUND DATA There are few studies that have identified risk factors for antibiotic treatment failure in medically managed spinal osteomyelitis. Identifying such factors could help to identify patients who can be treated solely with antibiotics. METHODS All patients who underwent antibiotic treatment for spinal osteomyelitis in one of our institutions between January 1, 2001 and January 1, 2015 were identified. Patients who underwent surgery before the start of the antibiotic treatment were excluded. RESULTS We included 215 patients with a mean age of 58 years; 63 (29%) patients had failure of antibiotic treatment. Diabetes (hazard ratio [HR] 1.69, 95% confidence interval [CI] 1.03-2.79, P = 0.037), fever (HR 1.61, 95% CI 0.93-2.79, P = 0.088), osteomyelitis at an additional site (HR 5.17, 95% CI 2.63-27.9, P = 0.001), and the presence of an epidural abscess (HR 1.91, 95% CI 1.05-3.45, P = 0.033) were associated with failure of antibiotic treatment. In the multivariate Cox regression analysis, diabetes (HR 1.69, 95% CI 1.03-2.79, P = 0.019), osteomyelitis at an additional site (HR 8.26, 95% CI 2.51-27.2, P = 0.001), fever (HR 1.77, 95% CI 1.00-3.12, P = 0.050), and the presence of an epidural abscess (HR 1.82, 95% CI 1.06-3.13, P = 0.030) were independently associated with failure of antibiotic treatment. CONCLUSION Antibiotic treatment failed in 29% of patients; diabetes, current other osteomyelitis, and having an epidural abscess were independently associated with failure of antibiotic treatment. LEVEL OF EVIDENCE 3.
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Mastoraki A, Mastoraki S, Papanikolaou IS, Tsikala-Vafea M, Tsigou V, Lazaris A, Arkadopoulos N. Spondylodiscitis Associated with Major Abdominal Surgical Intervention: Challenging Diagnostic and Therapeutic Modalities. Indian J Surg Oncol 2017; 8:274-278. [DOI: 10.1007/s13193-017-0641-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 02/27/2017] [Indexed: 11/28/2022] Open
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Park KH, Cho OH, Lee YM, Moon C, Park SY, Moon SM, Lee JH, Park JS, Ryu KN, Kim SH, Lee SO, Choi SH, Lee MS, Kim YS, Woo JH, Bae IG. Therapeutic outcomes of hematogenous vertebral osteomyelitis with instrumented surgery. Clin Infect Dis 2015; 60:1330-8. [PMID: 25663159 DOI: 10.1093/cid/civ066] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 01/24/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Patients with hematogenous vertebral osteomyelitis (HVO) occasionally require instrumentation for spinal stabilization. However, placing instrumentation in the setting of spinal infection raises concerns about recurrent infection due to bacteria adhering to the foreign material. In this study, we evaluated the therapeutic outcomes of patients with HVO who underwent instrumented surgery. METHODS We conducted a retrospective chart review of adult patients with microbiologically diagnosed HVO who underwent surgical intervention in 5 tertiary care hospitals over an 8-year period. RESULTS A total of 153 patients with HVO underwent surgical management for their infections. Of these 153 patients, 94 (61.4%) underwent surgical debridement alone (noninstrumented surgery) and 59 (38.6%) underwent surgical debridement and instrumentation (instrumented surgery). The median durations of antibiotic therapy were 66 and 80 days for the noninstrumentation and instrumentation groups, respectively (P = .22). Clinical outcomes were similar between the groups, including rates of infection-related death (2.1% vs 0%; P = .52), primary failure (1.1% vs 5.1%; P = .30), and recurrence (4.8% vs 6.8%; P = .72). Among the instrumentation group, there was a significant decreasing trend for recurrence according to total duration of antibiotic therapy: 22.2% (4-6 weeks), 9.1% (6-8 weeks), and 2.6% (≥ 8 weeks; P = .04). Duration of pre-instrumentation antibiotic therapy and single-stage operation (vs 2-stage operation) were not risk factors for recurrence. CONCLUSIONS Spinal instrumentation in patients with HVO may be safe with pathogen-directed prolonged antibiotic therapy and should not be abandoned or delayed solely because of the risk of recurrence.
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Affiliation(s)
- Ki-Ho Park
- Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul
| | - Oh-Hyun Cho
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju
| | - Yu-Mi Lee
- Department of Infectious Diseases, Busan Paik Hospital, Inje University College of Medicine, Busan
| | - Chisook Moon
- Department of Infectious Diseases, Busan Paik Hospital, Inje University College of Medicine, Busan
| | - Seong Yeon Park
- Department of Internal Medicine, Dongguk University Ilsan Hospital, University of Dongguk College of Medicine, Goyang-si
| | - Song Mi Moon
- Department of Infectious Diseases, Gachon University Gil Medical Center, Incheon
| | | | - Ji Seon Park
- Department of Radiology, Kyung Hee University Hospital, Kyung Hee University School of Medicine
| | - Kyung Nam Ryu
- Department of Radiology, Kyung Hee University Hospital, Kyung Hee University School of Medicine
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Ho Choi
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Mi Suk Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul
| | - Yang Soo Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jun Hee Woo
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - In-Gyu Bae
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju
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Chung TC, Yang SC, Chen HS, Kao YH, Tu YK, Chen WJ. Single-stage anterior debridement and fibular allograft implantation followed by posterior instrumentation for complicated infectious spondylitis: report of 20 cases and review of the literature. Medicine (Baltimore) 2014; 93:e190. [PMID: 25501067 PMCID: PMC4602818 DOI: 10.1097/md.0000000000000190] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Complicated infectious spondylitis is an infrequent infection with severe spinal destruction, and is indicated for combined anterior and posterior surgeries. Staged debridement and subsequent reconstruction is advocated in the literature. The purpose of this study is to evaluate the feasibility and clinical outcome of patients who underwent single-stage combined anterior debridement and fibular allograft implantation followed by supplemental posterior fixation for complicated infectious spondylitis. We retrospectively reviewed the medical records of 20 patients who underwent single-stage combined anterior and posterior surgeries for complicated infectious spondylitis from January 2005 to December 2010. Complicated infectious spondylitis was defined as at least 1 vertebral osteomyelitis with pathological fracture or severe bony destruction and adjacent discitis, based on imaging studies. The severity of the neurological status was evaluated using the Frankel scale. The clinical outcomes were assessed by careful physical examination and regular serological tests to determine the visual analog scale (VAS) score and Macnab criteria. Correction of the sagittal Cobb angle on radiography was also compared before and after surgery. The Wilcoxon signed-rank test was used to analyze patient surgical prognosis and radiological findings. All patients with complicated infectious spondylitis were successfully treated by single-stage combined anterior and posterior surgeries. No patients experienced neurologic deterioration. The average VAS score was 7.8 before surgery and significantly decreased to 2.1 at discharge. Three patients had excellent outcomes and 17 had good outcomes, based on Macnab criteria. The average length of the allograft for reconstruction was 64.0 mm. Kyphotic deformity improved in all patients, with an average correction angle of 13.4°. There was no implant breakage or allograft dislodgement during at least 36 months of follow-up. Single-stage anterior debridement and fibular allograft implantation followed by posterior pedicle screw instrumentation provide immediate stability, satisfactory alignment, and successful infection control. Fibular allograft implantation seems to be a good alternative for anterior reconstruction; it can proceed to bony incorporation and avoids donor site morbidity.
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Affiliation(s)
- Tzu-Chun Chung
- From the Department of Orthopaedic Surgery and Anesthesiology (T-CC, S-CY, H-SC, Y-HK, Y-KT), E-Da Hospital, I-Shou University, Kaohsiung; and Department of Orthopaedic Surgery (W-JC), Chang Gung Memorial Hospital, Taoyuan, Taiwan
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Calvert G, May LA, Theiss S. Use of permanently placed metal expandable cages for vertebral body reconstruction in the surgical treatment of spondylodiscitis. Orthopedics 2014; 37:e536-42. [PMID: 24972434 DOI: 10.3928/01477447-20140528-53] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Accepted: 11/25/2013] [Indexed: 02/03/2023]
Abstract
This is a retrospective study of 15 patients treated for spondylodiscitis with implanted metal cages. The purpose of this study is to investigate the outcomes of patients treated with permanently placed metal hardware in vertebral body reconstruction for spondylodiscitis. The use of metal implants in the face of infection has classically been discouraged in orthopedic literature because of the ability of bacteria to form biofilms on metal surfaces. Traditional treatment of spondylodiscitis has been aggressive debridement followed by reconstruction with bone grafts. Expandable metallic cages made reconstruction of these defects significantly easier. However, concern exists that metallic implants affect the resolution of infection. A search of the authors' patient database from 2005 to 2009 revealed 21 patients with spondylodiscitis treated with anterior debridement and reconstruction with an expandable metallic cage. Fourteen patients (15 cases) had sufficient documented clinical follow-up and were available for review. Resolution of infection was determined by evaluating symptoms, laboratory data, and final radiographic result. Of the 15 cases, all had clinical resolution of infection with an average follow-up time of 25 months. An average loss of 1.9° of correction was observed when comparing final follow-up radiographs with initial postoperative radiographs. Radiograph review revealed no extensive osteolysis around the hardware or progressive collapse. These results suggest that the use of expandable metal cages maintains alignment while not perpetuating infection. The spine appears to provide a unique environment that permits the use of metal implants in the setting of infection.
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20
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Pyogenic osteomyelitis of the spine. CURRENT ORTHOPAEDIC PRACTICE 2014. [DOI: 10.1097/bco.0000000000000070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lee BH, Park JO, Kim HS, Lee HM, Cho BW, Moon SH. Transpedicular curettage and drainage versus combined anterior and posterior surgery in infectious spondylodiscitis. Indian J Orthop 2014; 48:74-80. [PMID: 24600067 PMCID: PMC3931157 DOI: 10.4103/0019-5413.125508] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Hematogeneous infectious spondylodiscitis usually occurs in older immunocompromised patients with other comorbidities. They are usually unable to undergo reconstructive anterior and posterior surgeries. Therefore, an alternative, less aggressive surgical method of transpedicular curettage and drainage was suggested. This study was designed to compare the surgical outcomes for the treatment of hematogeneous infectious spondylodiscitis between transpedicular curettage and drainage technique and conventional combined anterior and posterior surgery. MATERIALS AND METHODS Between January 2002 and July 2011, 26 patients underwent surgical treatment for hematogeneous infectious spondylodiscitis. The patients were classified into two groups depending on surgical modality: a transpedicular curettage and drainage (TCD) group and a combined anterior and posterior surgery (CAPS) group. RESULTS The TCD group consisted of 10 patients (mean age 68.0 years), and the CAPS group consisted of 16 patients (mean age 58.4 years). The mean postoperative followup periods were 36.9 (months) in the TCD group and 69.9 (months) in the CAPS group. The operation time was 180.6 ± 33.6 minutes in the TCD group and 332.7 ± 74.5 minutes in the CAPS group (P < 0.05). Postoperative independent ambulation began at postoperative 4.9 ± 2.4 days in the TCD group but at postoperative 15.1 ± 15.3 days in the CAPS group (P < 0.05). The postoperative hospital stays were 19.9 ± 7.8 days in the TCD group and 35.4 ± 33.3 days in the CAPS group (P < 0.05). The level of C-reactive proteins decreased significantly in both groups after surgery (P < 0.05). CONCLUSION Transpedicular curettage and drainage technique proved to be a useful technique for treating hematogeneous infectious spondylodiscitis in patients who were in poor heath with multiple comorbidities unable to undergo the conventional combined anterior and posterior surgery in a single day in terms of earlier ambulation, shorter hospitalization and similar clinical success rate.
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Affiliation(s)
- Byung Ho Lee
- Department of Orthopaedic Surgery, International St. Mary's Hospital, Incheon, Korea
| | - Jin-Oh Park
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Hak-Sun Kim
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Hwan-Mo Lee
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Byung-Woo Cho
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Seong-Hwan Moon
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Korea,Address for correspondence: Dr. Seong-Hwan Moon, Department of Orthopaedic Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul - 120752, Korea. E-mail:
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Chen CH, Chen WL, Yen HC. Candida albicans lumbar spondylodiscitis in an intravenous drug user: a case report. BMC Res Notes 2013; 6:529. [PMID: 24325945 PMCID: PMC3878824 DOI: 10.1186/1756-0500-6-529] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 12/04/2013] [Indexed: 11/29/2022] Open
Abstract
Background Spondylodiscitis leads to debility, and few data exist on Candida spondylodiscitis in patients with intravenous drug use. Case presentation We present a case of Candida albicans lumbar spondylodiscitis in a patient with intravenous drug use. This patient was treated with surgical debridement and 9 months of fluconazole therapy, and the neurological deficits resolved completely. The infection did not recur clinically or radiologically during 9 months of follow-up. Conclusion Although Candida albicans lumbar spondylodiscitis is rare, Candida should be suspected as a causative pathogen in patients with intravenous drug use except for Staphylococcus aureus, Pseudomonas aeruginosa, and Mycobacterium tuberculosis. As soon as Candida albicans lumbar spondylodiscitis is suspected, magnetic resonance imaging and percutaneous biopsy should be performed. Surgical intervention combined with treatment with antifungal medications can successfully eradicate the infection and resolve the neurological deficits.
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Affiliation(s)
| | | | - Hua-Cheng Yen
- Department of Neurosurgery, Changhua Christian Hospital, Changhua, Taiwan.
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The management gram-negative bacterial haematogenous vertebral osteomyelitis: a case series of diagnosis, treatment and therapeutic outcomes. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2013; 22:1845-53. [PMID: 23543389 DOI: 10.1007/s00586-013-2750-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Revised: 01/28/2013] [Accepted: 03/15/2013] [Indexed: 12/17/2022]
Abstract
PURPOSE The incidence of gram-negative bacterial haematogenous vertebral osteomyelitis (GNB HVO) is increasing. We performed a retrospective cohort study of patients with this type of infection in an effort to gain an improved understanding of the current clinical presentation, management and outcome. METHODS Between May 2007 and May 2010, all patients, over the age of 18 years, suffering from GNB HVO were identified and their microbiological diagnoses were evaluated. RESULTS This study identified seventy-nine patients with haematogenous vertebral osteomyelitis (HVO). Of these seventy-nine patients, 10 patients (12.66%) had Gram-negative organisms isolated. These organisms included Escherichia coli (4), Pseudomonas aeruginosa (3), Klebsiella pneumonia (1), Haemophilus influenza (1) and Enterobacter cloacae (1). Eight patients were successfully treated with antibiotics and/or surgery. Of the eight patients whose HVO was cured, five had Ciprofloxacin as part of their definitive antibiotic regime. CONCLUSION The treatment of GNB HVO is often challenging because of unpredictable resistance patterns and limited published data on effective treatment regimens. Our study has highlighted the need for prompt microbiological sampling and initiation of early appropriate antibiotic regime. The most effective treatment for GNB HVO was with oral Ciprofloxacin over a period of 6-8 weeks.
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Kshettry VR, Hardy S, Weil RJ, Angelov L, Barnett GH. Immediate titanium cranioplasty after debridement and craniectomy for postcraniotomy surgical site infection. Neurosurgery 2012; 70:8-14; discussion 14-5. [PMID: 22343833 DOI: 10.1227/neu.0b013e31822fef2c] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND For postcraniotomy surgical site infection (SSI) involving the bone, typical management involves craniectomy, debridement, and delayed cranioplasty. Disadvantages to delayed cranioplasty include cosmetic deformity, vulnerability of unprotected brain, and risks and costs associated with an additional operation. Many authors have attempted bone flap salvage by using various techniques. OBJECTIVE We evaluate our experience with immediate titanium mesh cranioplasty at the time of craniectomy and debridement. METHODS We retrospectively reviewed SSIs in patients that underwent craniotomy for treatment of a brain tumor. These patients were treated with craniectomy, debridement, and immediate titanium mesh cranioplasty followed by antibiotics. The primary outcome was recurrent infection. RESULTS Twelve patients met the inclusion criteria. Risk factors for infection included preoperative radiation therapy (33%), prior craniotomy (33%), and postoperative CSF leak (25%). Median follow-up was 14 months. Ten (83%) patients had long-term resolution without recurrent infection. One patient required additional surgical debridement for persistent infection with successful placement of new titanium mesh. Another patient developed recurrent infection but opted for hospice care because of tumor progression. CONCLUSION This series demonstrates the safety and feasibility of performing immediate titanium cranioplasty at the time of craniectomy and debridement in patients with postcraniotomy infections. This has been shown in patients with risk factors for poor wound healing. Immediate cranioplasty avoids the drawbacks, risks, and costs of delayed cranioplasty.
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Affiliation(s)
- Varun R Kshettry
- The Brain Tumor and Neuro-Oncology Center, Department of Neurosurgery, The Neurological Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
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Abstract
As a result of reading this article, physicians should be able to:1.Understand the importance of early diagnosis and treatment of spinal infection in an effort to avoid devastating and crippling complications such as paralysis, painful deformity, and death.2.Understand current perceptions in the ongoing debate of whether operative or conventional treatment should be preferred and in which cases.3.Understand the latest advances in the surgical treatment of spinal infection, their indications, and their effectiveness.4.Understand the change in the traditionally held belief that in the presence of infection, the use of metal implants or grafts is not indicated. Controversy exists regarding optimal treatment for pyogenic spinal infection. The authors systematically reviewed peer-reviewed published clinical trials in the English language through 2009 on the clinical presentation, complications, and conservative and operative treatments of pyogenic spinal infection. The cornerstone of therapy for uncomplicated spondylodiskitis is intravenous antibiotics followed by oral antibiotics and bracing. Surgery is effective in complicated cases and improves sagittal balance, restores neurological impairment, and relieves severe pain. In cases of delayed diagnosis or surgery, potential early devastating and late crippling complications may occur. To the authors' knowledge, no Level I studies compare operative vs conservative treatment of pyogenic spinal infection.
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Lee BH, Lee HM, Kim TH, Kim HS, Moon ES, Park JO, Chong HS, Moon SH. Transpedicular curettage and drainage of infective lumbar spondylodiscitis: technique and clinical results. Clin Orthop Surg 2012; 4:200-8. [PMID: 22949951 PMCID: PMC3425650 DOI: 10.4055/cios.2012.4.3.200] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Accepted: 04/04/2012] [Indexed: 12/03/2022] Open
Abstract
Background Infective spondylodiscitis usually occurs in patients of older age, immunocompromisation, co-morbidity, and individuals suffering from an overall poor general condition unable to undergo reconstructive anterior and posterior surgeries. Therefore, an alternative, less aggressive surgical method is needed for these select cases of infective spondylodiscitis. This retrospective clinical case series reports our novel surgical technique for the treatment of infective spondylodiscitis. Methods Between January 2005 and July 2011, among 48 patients who were diagnosed with pyogenic lumbar spondylodiscitis or tuberculosis lumbar spondylodiscitis, 10 patients (7 males and 3 females; 68 years and 48 to 78 years, respectively) underwent transpedicular curettage and drainage. The mean postoperative follow-up period was 29 months (range, 7 to 61 months). The pedicle screws were inserted to the adjacent healthy vertebrae in the usual manner. After insertion of pedicle screws, the drainage pedicle holes were made through pedicles of infected vertebra(e) in order to prevent possible seeding of infective emboli to the healthy vertebra, as the same instruments and utensils are used for both pedicle screws and the drainage holes. A minimum of 15,000 mL of sterilized normal saline was used for continuous irrigation through the pedicular pathways until the drained fluid looked clear. Results All patients' symptoms and inflammatory markers significantly improved clinically between postoperative 2 weeks and postoperative 3 months, and they were satisfied with their clinical results. Radiologically, all patients reached the spontaneous fusion between infected vertebrae and 3 patients had the screw pulled-out but they were clinically tolerable. Conclusions We suggest that our method of transpedicular curettage and drainage is a useful technique in regards to the treatment of infectious spondylodiscitic patients, who could not tolerate conventional combined anterior and posterior surgery due to multiple co-morbidities, multiple level infectious lesions and poor general condition.
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Affiliation(s)
- Byung Ho Lee
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
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Hamdan TA. Postoperative disc space infection after discectomy: a report on thirty-five patients. INTERNATIONAL ORTHOPAEDICS 2012; 36:445-50. [PMID: 22159658 PMCID: PMC3282847 DOI: 10.1007/s00264-011-1430-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Accepted: 11/12/2011] [Indexed: 12/19/2022]
Abstract
PURPOSE The focus of this study was to analyse the patient with disc space infection and the need for re-exploration. METHOD Thirty-five patients were analysed within the period from April 1992 and May 2011. The diagnosis was confirmed by the cardinal clinical features, raised erythrocyte sedimentation rate [ESR], raised C-reactive protein and MRI findings. All received 500-mg intravenous amikacin and one gram ceftriaxone at the time of anaesthetic induction and six hours after surgery. RESULTS Age range was between 25-62 years. The appearance of symptoms was between four days and three weeks. Nine patients had silent chronic urinary tract infection. Twenty-nine patients had re-exploration while the others did well on conservative treatment. Neurological deficit was not recorded. All recovered well within six to nine months. CONCLUSION Re-exploration is recommended if no response is achieved after four day's conservative treatment for or if the patient's condition is critical.
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Spinal epidural abscess following epidural cannulation for flail chest analgesia: a case report. Neurol Neurochir Pol 2011; 45:80-3. [DOI: 10.1016/s0028-3843(14)60064-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Skaf GS, Kanafani ZA, Araj GF, Kanj SS. Non-pyogenic infections of the spine. Int J Antimicrob Agents 2010; 36:99-105. [DOI: 10.1016/j.ijantimicag.2010.03.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Revised: 03/16/2010] [Accepted: 03/19/2010] [Indexed: 10/19/2022]
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Posterior transdiscal three-column shortening in the surgical treatment of vertebral discitis/osteomyelitis with collapse. Spine (Phila Pa 1976) 2010; 35:1316-22. [PMID: 20354475 DOI: 10.1097/brs.0b013e3181c0a158] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review of consecutive case series. OBJECTIVE To evaluate the early surgical results and complications of thoracic transdiscal osteotomies and vertebral shortening for the treatment of thoracic discitis/osteomyelitis. SUMMARY OF BACKGROUND DATA Thoracic discitis/osteomyelitis leads to collapse of the disc space and/or vertebral body. We propose a novel technique to achieve the same goals as anterior column reconstruction through an entirely posterior approach. Shortening of the vertebral column provides structural support without the morbidity of an anterior approach. METHODS Following REB approval, retrospective review of the charts of five patients that underwent posterior only thoracic transdiscal osteotomies and vertebral shortening for discitis/osteomyelitis was carried out. Posterior only surgery was performed in these patients with excision of the affected disc space and corresponding posterior elements. Instrumented fusion was performed across the segment spanning multiple vertebral levels. Clinical outcome, radiographic correction, and perioperative complications were analyzed. RESULTS Three patients had bacterial discitis, and 2 had tuberculosis. Mean age at the time of surgery was 61 years (50-76). Mean follow-up was 45 months (25-63). There was no neurologic deterioration; 2 patients with Frankel grade B improved to grade D and E, respectively. Mean kyphosis corrected from 36 degrees (14-90) to 4 degrees (0-8), and the mean construct spanned 9 levels (6-15). No major complications were encountered during surgery. Two patients underwent revision surgeries, 1 patient died of unrelated causes at 6 months. All patients were treated with a full course of postoperative antibiotic treatment. No cases of recurrent infection were recorded. CONCLUSION Thoracic transdiscal osteotomy with vertebral shortening is a safe and effective option for the treatment of infectious discitis/osteomyelitis with associated kyphosis. With adjuvant antibiotics, it effectively eradicates the infection through a posterior only approach, avoiding the need for anterior procedures and long anterior struts.
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Septic hematogenous lumbar spondylodiscitis in elderly patients with multiple risk factors: efficacy of posterior stabilization and interbody fusion with iliac crest bone graft. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2010; 19:1720-7. [PMID: 20495933 DOI: 10.1007/s00586-010-1448-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Revised: 02/27/2010] [Accepted: 05/09/2010] [Indexed: 12/19/2022]
Abstract
The conservative and operative treatment strategies of hematogenous spondylodiscitis in septic patients with multiple risk factors are controversial. The present series demonstrates the outcome of 18 elderly patients (median age, 72 years) with septic hematogenous spondylodiscitis and intraspinal abscess treated with microsurgical decompression and debridement of the infective tissue, followed by posterior stabilization and interbody fusion with iliac crest bone graft in one or two lumbar segments. The majority of the patients were unsuccessfully treated with intravenous antibiotics prior to the operation. Antibiotic therapy was continued for more than 6 weeks postoperatively. Morbidity and early mortality amounted to 50 and 17%, respectively. Three patients died in the hospital from internal complications after an initial postoperative improvement of the inflammatory clinical signs and laboratory parameters. Fifteen patients recovered from the spinal infection. Three of them died several months after discharge (cerebral hemorrhage, malignancy and unknown cause). Twelve patients had excellent or good outcomes during the follow-up period of at least 1 year. The series shows that operative decompression and eradication of the intraspinal and intervertebral infective tissue with fusion and stabilization via a posterior approach is possible in septic patients with multiple risk factors and leads to good results in those patients, who survive the initial severe stage of the septic disease. However, the morbidity and mortality suggest that this surgical treatment is not the therapy of first choice in high-risk septic patients, but may be considered in patients when conservative management has failed.
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Skaf G, Domloj N, Fehlings M, Bouclaous C, Sabbagh A, Kanafani Z, Kanj S. Pyogenic spondylodiscitis: An overview. J Infect Public Health 2010; 3:5-16. [DOI: 10.1016/j.jiph.2010.01.001] [Citation(s) in RCA: 144] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2009] [Revised: 12/27/2009] [Accepted: 01/01/2010] [Indexed: 11/24/2022] Open
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Garcia-Vidal C, Cabellos C, Ayats J, Font F, Ferran E, Fernandez-Viladrich P. Fungal postoperative spondylodiscitis due to Scedosporium prolificans. Spine J 2009; 9:e1-7. [PMID: 19447683 DOI: 10.1016/j.spinee.2009.03.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2008] [Revised: 03/19/2009] [Accepted: 03/28/2009] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Postoperative fungal spondylodiscitis is a rare infectious disease. PURPOSE We report the first case of postoperative spondylodiscitis because of Scedosporium prolificans and review postoperative vertebral infection caused by fungi. STUDY DESIGN/SETTING Medline search. METHODS Case report and literature review. RESULTS On reviewing the cases of postoperative fungal spondylodiscitis reported so far in the literature, we found eight were caused by mold, and five by yeast. Clinically, the disease presents similar to postoperative vertebral osteomyelitis caused by bacteria, and a high clinical index of suspicion may be required to perform appropriate cultures to establish a diagnosis. Our review revealed a significant number of cases that were cured after surgical debridement and/or antifungal therapy. CONCLUSIONS On the basis of this limited assessment, it appears that the clinical course and prognosis of postoperative fungal spondylodiscitis is similar to that reported for postoperative pyogenic spondylodiscitis.
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Affiliation(s)
- Carolina Garcia-Vidal
- Infectious Disease Service, IDIBELL-Hospital Universitary de Bellvitge, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain.
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Percutaneous curettage and continuous irrigation for MRSA lumbar spondylodiscitis: a report of three cases. Case Rep Med 2009; 2009:253868. [PMID: 19718264 PMCID: PMC2729424 DOI: 10.1155/2009/253868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2009] [Accepted: 04/14/2009] [Indexed: 11/18/2022] Open
Abstract
There has been a recent increase in pyogenic spondylitis caused by methicillin-resistant Staphylococcus aureus (MRSA) associated with an increasing number of compromised patients. As long as serious paralysis is absent, we recommend percutaneous curettage and continuous irrigation as an effective treatment for MRSA lumbar spondylodiscitis. Under local anesthesia, the affected lumbar discs were curetted using percutaneous nucleotomy, and tubes were placed for continuous irrigation. The period of continuous irrigation was generally 2 weeks. Infection was controlled after one procedure in two cases and after two procedures in one case. Postoperative radiography and magnetic resonance imaging (MRI) showed callus formation, normalized signal intensity in vertebral bodies, and regression of abscesses. Open surgery under general anesthesia has been considered risky in patients with poor performance status or old age. The present method, which is an application of needle biopsy, can be performed under local anesthesia and is minimally invasive.
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Surgical treatment of lumbar tuberculous spondylodiscitis by transforaminal lumbar interbody fusion (TLIF) and posterior instrumentation. ACTA ACUST UNITED AC 2009; 22:257-62. [PMID: 19494745 DOI: 10.1097/bsd.0b013e31818859d0] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Retrospective case study. OBJECTIVE We present a retrospective clinical study of 15 patients with lumbar and lumbosacral tuberculosis treated by transforaminal lumbar interbody fusion and posterior instrumentation. The purpose is to determine the clinical efficacy of such surgical treatment for lumbar tuberculosis. SUMMARY OF BACKGROUND DATA The goals of management of tuberculous spondylodiscitis are to eradicate infection and to prevent or treat deformity, instability, and neurologic deficit. Various methods of surgical debridement and fusion have been described for the lumbar spine. However, there have been few reports on the treatment of patients with peridiscal type of lumbar tuberculosis by transforaminal debridement and interbody fusion along with posterior stabilization using pedicle screw fixation. METHODS Our study comprises 9 males and 6 females with an average age of 47 years treated with the above given surgical procedure. All patients had single motion segment involvement. The average follow-up is 41 months. We have evaluated the following parameters: healing of disease, deformity correction and its maintenance, improvement in neurology, fusion of affected segment, and functional outcome. RESULTS The mean preoperative local lordotic angle of -3.7 degrees was corrected surgically to a mean of 5 degrees immediately postoperatively. The mean local lordosis at final follow-up (mean 41 mo, 26 to 69 mo) was 4 degrees. Using the modified radiologic criteria of Lee et al, we found that 13 patients had definitive fusion and 2 patients had probable fusion. All patients had healing of disease and there was no recurrence at final follow-up. Using the criteria of Kirkaldy-Willis et al, the functional outcome was found to be excellent in 8, good in 5, and fair in 2 patients. CONCLUSIONS Transforaminal lumbar interbody fusion with pedicle screw fixation is a simple, safe, and effective procedure for treatment of selected patients suffering from lumbar and lumbosacral tuberculosis.
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Fang WK, Chen SH, Huang DW, Huang KC. Post-traumatic osteomyelitis with spinal epidural abscess of cervical spine in a young man with no predisposing factor. J Chin Med Assoc 2009; 72:210-3. [PMID: 19372079 DOI: 10.1016/s1726-4901(09)70057-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Spinal osteomyelitis with epidural abscess is a rare disease. Most patients have 1 or more predisposing factors, such as impaired immune system secondary to diabetes mellitus, chemotherapy for cancer, immunological compromised disease, and chronic renal or hepatic impairment. We present a case of a physically steady young man without any predisposing risk factor who suffered from cervical osteomyelitis with epidural abscess after neck blunt injury. This patient recovered well after one-stage anterior surgical debridement with implant instrumentation and proper antibiotics treatment. The initial accurate diagnosis rate of spinal epidural abscess is low, even in patients with predisposing factor(s). We present this case to raise the attention of medical staff to this disease in patients with or without any predisposing factor(s) in order to establish early diagnosis and treatment. Our case report also indicates that with adequate debridement and antibiotic coverage, one-stage surgery is a safe and efficacious method to treat patients with cervical spinal epidural abscess.
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Affiliation(s)
- Wen-Kuei Fang
- Department of Neurosurgery, Chiayi Christian Hospital, Chiayi, Taiwan, R.O.C.
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Dai LY, Chen WH, Jiang LS. Anterior instrumentation for the treatment of pyogenic vertebral osteomyelitis of thoracic and lumbar spine. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2008; 17:1027-34. [PMID: 18575900 DOI: 10.1007/s00586-008-0661-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2007] [Revised: 03/13/2008] [Accepted: 03/14/2008] [Indexed: 11/26/2022]
Abstract
Anterior radical debridement and bone grafting is popular in the treatment of pyogenic infection of the spine, but there remains great concern of placing instrumentation in the presence of infection because of the potentiality of infection recurrence after surgery. The objective of this study was to prospectively evaluate the efficacy and safety of anterior instrumentation in patients who underwent simultaneous anterior debridement and autogenous bone grafting for the treatment of pyogenic vertebral osteomyelitis. The series consisted of 22 consecutive patients who were treated with anterior debridement, interbody fusion with autogenous bone grafting and anterior instrumentation for pyogenic vertebral osteomyelitis of thoracic and lumbar spine. The patients were prospectively followed up for a minimum of 3 years (average 46.1 months; range 36-74 months). Data were obtained for assessing clinically the neurological function and pain and radiologically the spinal alignment and fusion progress as well as recurrence of the infection. All the patients experienced complete or significant relief of back pain with rapid improvement of neurological function. Kyphosis was improved with an average correction rate of 93.1% (range 84-100%). Solid fusion and healing of the infection was achieved in all the patients without any evidence of recurrent or residual infection. The study shows that combined with perioperative antibiotic regimen, anterior instrumentation is effective and safe in the treatment of pyogenic vertebral osteomyelitis of thoracic and lumbar spine directly following radical debridement and autogenous bone grafting.
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Affiliation(s)
- Li-Yang Dai
- Department of Orthopaedic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, 200092, Shanghai, China.
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Surgical treatment of severe angular kyphosis with myelopathy: anterior and posterior approach with pedicle screw instrumentation. Spine (Phila Pa 1976) 2008; 33:1229-35. [PMID: 18469697 DOI: 10.1097/brs.0b013e31817152b3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE To evaluate the outcomes of anterior decompression and fusion followed by posterior instrumented fusion using pedicle screws without intentional correction of severe angular kyphosis deformity with myelopathy. SUMMARY OF BACKGROUND DATA Treatment of severe angular kyphosis with myelopathy is extremely difficult and dangerous. Although surgical circumferential spinal osteotomy via a single posterior approach has been reported in several studies, serious neurologic complications are a possible outcome. MATERIALS AND METHODS Among 51 patients surgically treated for angular kyphosis from 1988 to 2004, 16 patients (follow-up period, 32-168 months; mean, 72 months) with severe (>70 degrees ) angular kyphosis with progressive myelopathic symptoms underwent anterior decompression and fusion, followed by posterior pedicle screw instrumentation and bone graft without attempted correction of the deformity. Radiologic assessment, clinical findings including pain and daily activity scores, and neurologic status using the modified Frankel grade were analyzed before surgery and at the last follow-up. RESULTS Curve progression or nonunion did not occur in any of the cases. The mean pain and daily activity score were 3.1 and 2.3 before surgery and 4.7 and 4.2 after surgery, respectively. The modified Frankel grade indicated that every patient but one had improved neurologic function by one or more grades. Nine (75%) of 12 patients with ankle clonus, 10 (71%) of 14 patients with Babinski sign, and 6 (55%) of 11 patients with bowel and bladder dysfunction showed full improvement at the last follow-up. Postoperative complications included 1 screw pullout case and 2 infection cases which resolved without incidence. CONCLUSION Anterior decompression and fusion followed by posterior pedicle screw instrumentation and fusion without correction effectively improved neurologic symptoms and halted progression of kyphotic deformity in cases of severe angular kyphosis with myelopathy.
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Amini A, Beisse R, Schmidt MH. Thoracoscopic Debridement and Stabilization of Pyogenic Vertebral Osteomyelitis. Surg Laparosc Endosc Percutan Tech 2007; 17:354-7. [PMID: 17710069 DOI: 10.1097/sle.0b013e31811ea2b9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The role of surgical debridement and internal fixation in treatment of vertebral osteomyelitis has been evolving. The standard surgical approach to thoracolumbar vertebral osteomyelitis requiring extensive thoracotomy or retroperitoneal exposure carries significant associated morbidity and postoperative pain. Minimally invasive thoracoscopic spine surgery is designed to improve postoperative morbidity associated with the traditional open surgery. We report a case of a 70-year-old man who developed T11-T12 pyogenic vertebral osteomyelitis 3 months after undergoing posterior laminectomy and microsurgical excision of a herniated thoracic disc. The patient underwent minimally invasive thoracoscopic radical debridement and anterior spinal reconstruction and fusion. Patients with vertebral osteomyelitis may benefit from the decreased postoperative morbidity that is associated with minimally invasive thoracoscopic spinal surgery.
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Affiliation(s)
- Amin Amini
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
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Frangen TM, Kälicke T, Gottwald M, Andereya S, Andress HJ, Russe OJ, Müller EJ, Muhr G, Schinkel C. [Surgical management of spondylodiscitis. An analysis of 78 cases]. Unfallchirurg 2007; 109:743-53. [PMID: 16897028 DOI: 10.1007/s00113-006-1084-7] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Spondylodiscitis is a rare bacterial infection of the spine with an inflammatory, destructive course. To obtain further information on the therapeutic management and clinical course of spondylodiscitis, we retrospectively investigated 78 patients after surgical intervention. Mean age was 64 years (+/-4.6 years; range 21-80 years), the mean length of stay 49 days (+/-8.2 days; 3-121 days) including 24 days (+/-4.7 days; 0-112 days) in ICU. In hospital mortality was 9%. The cervical spine was affected in 10%, the thoracic spine in 35% and the lumbar/sacral spine in 55% of patients. Abscess formation occurred in 65% and destruction of the vertebral body in 74%. A total of 75% of patients presented with neurological deficits which could be improved by surgical intervention in 82% of cases. 24 patients were treated by ventral debridement and stabilization alone, 20 patients with a combined dorsoventral method. Most patients (n=34) were stabilized via dorsal bridging instrumentation without ventral debridement of the focus. Of this group, 23 patients were initially scheduled for secondary ventral debridement but complete healing was achieved prior to this, so further surgical therapy was unnecessary. Successful cure was obtained in 92% of cases. Based on our findings, we favor a split surgical approach: initially with dorsal internal fixation only. Abscesses can be drained percutaneously. Ventral debridement and stabilization is only recommended if insufficient stability can be obtained by dorsal fixation alone, as shown by the persistence of infection or pain.
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Affiliation(s)
- T M Frangen
- Chirurgische Klinik und Poliklinik, BG-Kliniken Bergmannsheil, Ruhr-Universität Bochum, Bürkle-de-la-Camp-Platz 1, 44789 Bochum.
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Muzii VF, Mariottini A, Zalaffi A, Carangelo BR, Palma L. Cervical spine epidural abscess: experience with microsurgical treatment in eight cases. J Neurosurg Spine 2006; 5:392-7. [PMID: 17120887 DOI: 10.3171/spi.2006.5.5.392] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECT The authors report a series of eight consecutive cases in which epidural abscesses in the cervical spine were treated by microsurgery without arthrodesis, including two cases of concomitant pyogenic and tubercular infection. METHODS The authors used a minimally invasive surgical approach consisting of single-level anterior microsurgical discectomy and drainage of the epidural abscess via a silicone catheter, and then initiated antibiotic therapy. At follow-up examination (mean duration 39 months), six patients exhibited complete recovery and two suffered from minor residual deficits. In all cases, spontaneous vertebral fusion occurred. Sagittal alignment was maintained in seven patients, and in one there was slight asymptomatic kyphosis. In two patients, tubercular and pyogenic infections were found. Prior intervention for dental infection was recorded in four cases. CONCLUSIONS In the absence of preoperative spinal instability, microsurgical drainage of the abscess followed by specific antibiotic therapy resulted in spinal cord decompression and neurological recovery, thereby facilitating spontaneous fusion and vertebral stability. The presence of combined tubercular and pyogenic infections of the cervical spine should be considered, especially in patients whose immune systems are depressed.
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Hodges FS, McAtee S, Kirkpatrick JS, Theiss SM. The Ability of MRI to Predict Failure of Nonoperative Treatment of Pyogenic Vertebral Osteomyelitis. ACTA ACUST UNITED AC 2006; 19:566-70. [PMID: 17146299 DOI: 10.1097/01.bsd.0000210118.40015.07] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pyogenic vertebral osteomyelitis (PVO) can be treated most often by medical management. For those failing with medical management, surgical delay can result in increased morbidity. Therefore, the ability to predict failure of medical management on presentation would greatly improve the outcome. This study determines the ability of the presenting magnetic resonance imaging scan to predict failure of nonoperative management at the onset of treatment. A cohort of patients with PVO, initially treated medically, was reviewed. Imaging, demographics, and clinical data of patients successfully treated medically were compared with those ultimately requiring surgical treatment. The extent of signal change on the T1-weighted sagittal images of the affected motion segment was determined for each group. Twenty-two patients were included in the study. Patients successfully treated medically averaged 57%+/-19% of motion segment involvement, whereas those failing conservative treatment averaged 89%+/-18%. Using 90% involvement as an indication for initial surgery would have a sensitivity of 78% and specificity of 93%. Patients with thoracolumbar PVO who have 90% or higher involvement of an affected motion segment should be considered for early operative management.
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Affiliation(s)
- Frank S Hodges
- Department of Surgery, Division of Orthopaedic Surgery, University of Alabama at Birmingham Medical Center, Alabama, USA
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Chen WH, Jiang LS, Dai LY. Surgical treatment of pyogenic vertebral osteomyelitis with spinal instrumentation. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2006; 16:1307-16. [PMID: 17106664 PMCID: PMC2200751 DOI: 10.1007/s00586-006-0251-4] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/24/2006] [Revised: 08/17/2006] [Accepted: 10/15/2006] [Indexed: 10/23/2022]
Abstract
Pyogenic vertebral osteomyelitis responds well to conservative treatment at early stage, but more complicated and advanced conditions, including mechanical spinal instability, epidural abscess formation, neurologic deficits, and refractoriness to antibiotic therapy, usually require surgical intervention. The subject of using metallic implants in the setting of infection remains controversial, although more and more surgeons acknowledge that instrumentation can help the body to combat the infection rather than to interfere with it. The combination of radical debridement and instrumentation has lots of merits such as, restoration and maintenance of the sagittal alignment of the spine, stabilization of the spinal column and reduction of bed rest period. This issue must be viewed in the context of the overall and detailed health conditions of the subjecting patient. We think the culprit for the recurrence of infection is not the implants itself, but is the compromised general health condition of the patients. In this review, we focus on surgical treatment of pyogenic vertebral osteomyelitis with special attention to the role of spinal instrumentation in the presence of pyogenic infection.
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Affiliation(s)
- Wei-Hua Chen
- Department of Orthopaedic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092 China
| | - Lei-Sheng Jiang
- Department of Orthopaedic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092 China
| | - Li-Yang Dai
- Department of Orthopaedic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, 200092 China
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Labler L, Keel M, Trentz O, Heinzelmann M. Wound conditioning by vacuum assisted closure (V.A.C.) in postoperative infections after dorsal spine surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2006; 15:1388-96. [PMID: 16835734 PMCID: PMC2438567 DOI: 10.1007/s00586-006-0164-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2005] [Revised: 02/28/2006] [Accepted: 05/28/2006] [Indexed: 01/13/2023]
Abstract
The use of vacuum assisted closure (V.A.C.) therapy in postoperative infections after dorsal spinal surgery was studied retrospectively. Successful treatment was defined as a stable healed wound that showed no signs of acute or chronic infection. The treatment of the infected back wounds consisted of repeated debridement, irrigation and open wound treatment with temporary closure by V.A.C. The instrumentation was exchanged or removed if necessary. Fifteen patients with deep subfascial infections after posterior spinal surgery were treated. The implants were exchanged in seven cases, removed completely in five cases and left without changing in one case. In two cases spinal surgery consisted of laminectomy without instrumentation. In two cases only the wound defects were closed by muscle flap, the remaining ones were closed by delayed suturing. Antibiotic treatment was necessary in all cases. Follow up was possible in 14 patients. One patient showed a new infection after treatment. The study illustrates the usefulness of V.A.C. therapy as a new alternative management for wound conditioning of complex back wounds after deep subfascial infection.
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Affiliation(s)
- Ludwig Labler
- Universitätsspital, Klinik für Unfallchirurgie, Zürich, Switzerland.
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Brodke DS, Klimo P, Bachus KN, Braun JT, Dailey AT. Anterior cervical fixation: analysis of load-sharing and stability with use of static and dynamic plates. J Bone Joint Surg Am 2006; 88:1566-73. [PMID: 16818983 DOI: 10.2106/jbjs.e.00305] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Anterior plates provide stability following decompression and fusion of the cervical spine. Various plate designs have emerged, and they include static plates with fixed-angle screws, rotationally dynamic plates that allow the screws to toggle in the plate, and translationally dynamic plates that allow the screws to both toggle and translate vertically. The goal of this study was to document the effects of plate design following a single-level corpectomy and placement of a full-length strut graft and the effects following 10% subsidence of the graft. METHODS A total of twenty-one cadaveric cervical spines (C2-T1) were randomized into three treatment groups and were tested for initial range of motion. A C5 corpectomy was performed, reconstruction was done with a full-length interbody spacer containing a load-cell, and an anterior cervical plate was applied. Load-sharing data were recorded with incremental axial loads. The range of motion was measured with +/- 2.5 Nm of torque in flexion-extension, lateral bending, and axial rotation. Then, the total length of the interbody spacer was reduced by 10% to simulate subsidence, and load-sharing and the range of motion were retested. RESULTS With the full-length interbody spacer, there were no significant differences in the abilities of the constructs to share load or limit motion. Following shortening of the interbody spacer, the static plate construct lost nearly 70% of its load-sharing capability, while neither of the dynamic plate constructs lost load-sharing capabilities. Also, the static plate construct allowed significantly more motion in flexion-extension following simulated subsidence than did either of the dynamic plate constructs (p < 0.05). CONCLUSIONS Although all of the tested anterior cervical plating systems provide similar load-sharing and stiffness following initial placement of the interbody spacer, the static plate system lost its ability to share load and limit motion following simulated subsidence of the interbody spacer. Both dynamic plate systems maintained load-sharing and stiffness despite simulated subsidence. CLINICAL RELEVANCE This study provides an improved understanding of the immediate performance of anterior cervical fusion surgery with plate fixation.
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Affiliation(s)
- Darrel S Brodke
- Department of Orthopaedics and the Orthopaedic Research Laboratory, University of Utah Orthopaedic Center, Salt Lake City, UT 84108, USA
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Chen JF, Lee ST. Antibiotic–polymethylmethacrylate strut: an option for treating cervical pyogenic spondylitis. J Neurosurg Spine 2006; 5:90-5. [PMID: 16850966 DOI: 10.3171/spi.2006.5.1.90] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
✓ Antibiotic–polymethylmethacrylate (PMMA) cement and beads constitute an effective system of local drug delivery of antibiotic agents in patients with bone and soft-tissue infections. Debridement followed by implantation of antibiotic–PMMA beads and systemic administration of antibiotic agents has achieved a 100% success rate in treating chronic osteomyelitis; however, there have been no reports of an antibiotic–PMMA strut for treating spinal pyogenic spondylitis. In this case report we describe a 57-year-old woman with C5–6 pyogenic spondylitis, progressive kyphotic deformity, and neurological deficits. The patient underwent anterior C-5 and C-6 corpectomy and spinal reconstruction in which we used an antibiotic–PMMA strut. The strut was 14 mm in diameter and contained PMMA and vancomycin powder. The operation was technically successful, and no complication related to anesthesia or the surgical procedure occurred. At the 12-month follow-up examination, dynamic radiographs revealed cervical spine stabilization. The patient’s neck pain subsided and she recovered neurologically with no residual infection. No antibiotic–PMMA strut dislodgment or failure was identified; however, 9.8% subsidence of the strut into the vertebrae was observed. The long-term outcome in this case requires further evaluation.
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Affiliation(s)
- Jyi-Feng Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan, Republic of China.
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Abstract
Vertebral osteomyelitis (VO) is an infectious disease of the vertebral body that requires early diagnosis with identification of the infecting organism to direct antibiotic therapy. Most VO can be treated nonsurgically, but 10% to 20% of cases require open surgical treatment. Excellent clinical outcomes can be achieved with appropriate medical and surgical treatment.
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Affiliation(s)
- Jorge J Jaramillo-de la Torre
- The Neuroscience Institute, Department of Neurosurgery, University of Cincinnati College of Medicine, Mayfield Clinic and Spine Institute, 222 Piedmont Avenue, Suite 3100, Cincinnati, OH 45267-0515, USA
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Cunningham ME, Girardi F, Papadopoulos EC, Cammisa FP. Spinal infections in patients with compromised immune systems. Clin Orthop Relat Res 2006; 444:73-82. [PMID: 16523130 DOI: 10.1097/01.blo.0000201176.87635.f3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
UNLABELLED Spinal infections are relatively uncommon but have potentially devastating consequences if not diagnosed and treated correctly. Compromised immunologic responsiveness, either transient or permanent, predisposes patients to more frequent and more severe infections. Through a Medline review of the English-language literature from 1990 to 2005, we examined the current understanding of the etiology of common immunocompromising conditions, how these diagnoses impact the relative spine infection rates including diagnosis and therapeutic monitoring, and practice trends regarding surgical intervention. LEVEL OF EVIDENCE Level V (expert opinion). Please see Guidelines for Authors for a complete description of the levels of evidence.
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Khazim RM, Debnath UK, Fares Y. Candida albicans osteomyelitis of the spine: progressive clinical and radiological features and surgical management in three cases. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2006; 15:1404-10. [PMID: 16429290 PMCID: PMC2438560 DOI: 10.1007/s00586-005-0038-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2005] [Revised: 11/01/2005] [Accepted: 11/30/2005] [Indexed: 10/25/2022]
Abstract
Candida albicans vertebral osteomyelitis is rare. Three cases are presented. Without antifungal treatment, they developed spinal collapse and neurological deterioration within 3-6 months from the onset of symptoms. There was a delay of 4.5 and 7.5 months between the onset of symptoms and surgery. All patients were managed with surgical debridement and reconstruction and 12-week fluconazole treatment. The neurological deficits resolved completely. The infection has not recurred clinically or radiologically at 5-6 years follow-up. Although rare, Candida should be suspected as a causative pathogen in cases of spinal osteomyelitis. Without treatment the disease is progressive. As soon as osteomyelitis is suspected, investigations with MRI and percutaneous biopsy should be performed followed by medical therapy. This may prevent the need for surgery. However, if vertebral collapse and spinal cord compression occurs, surgical debridement, fusion and stabilisation combined with antifungal medications can successfully eradicate the infection and resolve the neurological deficits.
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Affiliation(s)
- Rabi M Khazim
- Orthopaedics, Southend Hospital, Westcliff on sea, Essex, United Kingdom.
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