Percutaneous transforaminal endoscopic discectomy and drainage for spondylodiscitis: A technical note and review of literature

Treatment of Refractory Multilevel Thoracic Spondylodiscitis Using Ultra-Minimally Invasive Endoscopic Approach for Debridement and Drainage: A Technical Note, Intraoperative Video, and Literature Review

OBJECTIVE/BACKGROUND

Spondylodiscitis is an infection of the spinal column which can result in pain, deformity, instability, and/or neurologic deficits. When surgical treatment is required for thoracic spondylodiscitis, invasive open approaches are often utilized due to the ventral location of the pathology.

METHODS

We describe the use of a spinal endoscope to perform drainage and debridement of infected tissue through a transforaminal/intradiscal approach in a patient with multilevel thoracic spondylodiscitis refractory to antibiotic therapy. Illustrative videos are provided, as well as a review of the relevant literature.

RESULTS

A total of 188 patients were included in the systematic review. The mean positive reported culture rate was 76% (117/154 patients). The mean preoperative visual analog scale score was 6.8 (n = 114), and the mean postoperative visual analog scale score was 1.8 at 1 week postoperatively (n = 56) and 1.01 at the final follow-up (n = 114). The most common surgical approach was transforaminal/intradiscal (103/188 patients, 54.8%). The mean reoperation rate was 9.1%. The mean complication rate was 5.25%, with complications including increased transient radicular pain, infection, hardware failure, and new unspecified neurological deficits.

CONCLUSION

This case and those highlighted in our literature review demonstrate that endoscopic treatment for thoracic spondylodiscitis is a viable alternative to traditional open surgery in many cases.

Transpedicular vertebral biopsy under O-arm navigation: a technical note

Background

Despite emerging techniques, sample inadequacy remains the most important factor that necessitates need for repeat biopsy. Transpedicular Biopsy has diagnostic accuracy ranging from 75 to 90% in both computed tomography guided or percutaneous C-arm guided biopsy. Presenting in this article is an add on technique as a modification to enhance quality and quantity of sample obtained using a self designed trocar cannula with computed tomography-based Navigation.

Main body

We have used transpedicular biopsy technique under C Arm fluoroscopy, previously, where we used a self-designed trocar and cannula in our study of 71 cases & reported an accuracy of 88.7% with no reported complications. This is add on modification of same technique where under 3D navigation, we introduce a pituitary forceps through a correctly positioned cannula. This helps for biopsy of soft lesions/ discal level pathologies. Also, multi-planar adjustment of cannula after initial Stealth O-Arm navigation helps in sampling of different regions of vertebral body by reinsertion of pituitary forceps with simple manipulation of cannula without withdrawal. This minimizes risk of fracturing pedicle. With our technical modification, cannulated drill bit with core opening can be drilled through cannula to retrieve a sample. Our technique has limitations being experience driven and also enabling technology dependent. However, same method can be applied using 2-dimensional fluoroscopy without navigation.

Conclusion

Our technique of using pituitary forceps through cannula is highly effective in getting adequate representative sample with spectrum ranging from hard sclerotic lesions to soft lesions and discal pathologies. This procedure can be used with traditional 2-dimensional fluoroscopy as well as with 3-dimensional navigated precision.

Endoscopic treatment of spondylodiscitis: systematic review

BACKGROUND

Spondylodiscitis is a severe condition where standalone antibiotic therapy resolves most cases. In refractory infections, open surgery may aid with infection debulking. However, significant morbidity can occur. Nowadays, endoscopic approaches are emerging as an alternative. However, until now, only small-scale studies exist. Being so, we carried the first systematic review on spondylodiscitis endoscopic debridement indications, technique details, and outcomes.

METHODS

Search for all English written original studies approaching the spondylodiscitis endoscopic treatment was performed using PubMed and EBSCO host. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and a pre-specified protocol was registered at PROSPERO (CRD42020183657).

RESULTS

Fourteen studies involving 342 participants were included for analysis. Data overall quality was fair. Indications for the endoscopic approach were poorly defined. The most consensual indication was refractory infection to conservative treatment. Spinal instability or neurological deficits were common exclusion criteria. All authors described similar techniques, and despite the frequent severe co-morbidities, procedure morbidity was low. Re-interventions were common. Microorganism identification varied from 54.2 to 90.4%. Treatment failure among studies ranged from 0 to 33%. Pain, functional status, and neurological deficits had satisfactory improvement after procedures.

CONCLUSIONS

The endoscopic debridement of spondylodiscitis seems to be an effective and safe approach for refractory spondylodiscitis. A novel approach with initial endoscopic infection debulking and antibiotic therapy could improve the success of spondylodiscitis treatment.

Percutaneous wide bore needle biopsy for spinal lesions using the kyphoplasty cannula-a technical note

PURPOSE

Management of vertebral and discovertebral lesions depends on highly specific modalities like biopsy and histopathology. The transpedicular and transforaminal routes have gained popularity for obtaining samples for diagnosing these lesions. Sample inadequacy plays an important part in lowering the diagnostic accuracy. Present study introduces a technical modification by using a kyphoplasty cannula and pituitary forceps through it thus improving sample adequacy and diagnostic accuracy.

METHODS

Seventy-one patients with radiological evidence of spinal lesions from T1 to S1 were included. After obtaining samples via the transpedicular route they were sent for aerobic, anaerobic, acid fast bacilli & fungal cultures, Mycobacterium Tuberculosis/Radio Immuno Frequency (MTB/RIF) Assay and histopathological examination. In lesions with minimal vertebral erosions the transforaminal route was used to obtain samples from the disc space.

RESULTS

Sixty-eight patients (95.8%) had a definite diagnosis of which 37 patients (54.4%) tested positive for vertebral osteomyelitis/discitis. All the samples were found to be adequate on histopathological examination. The remaining 3 patients showed chronic inflammation and responded to oral and intravenous antibiotics. None of the patients underwent repeat biopsy. There were no perioperative complications.

CONCLUSIONS

Percutaneous transpedicular biopsy has evolved as the intervention of choice in diagnosing radiologically proven vertebral body lesions. Our technique of using a pituitary forceps through a cannula is highly effective in getting an adequate representative sample with excellent accuracy in diagnosis. This procedure is beneficial for soft tissue lesions and for infective pathology especially discitis.

Outcome of Transforminal Lumbar Thorough Debridement, Decompression, and Spondylodesis Technique in Treatment of 25 Patients with Pyogenic Spondylodiscitis

BACKGROUND

Lumbar pyogenic spondylodiscitis (LPS) is still a tangled problem in its management, especially with increasing rates of cases who underwent different spinal procedures and in patients with chronic medical disease. One-stage posterior direct transforminal lumbar thorough debridement of septic lesion, decompression, and spondylodesis (TLTDDS) are the main goals in treatment of complicated LPS without additional morbidity of anterior surgery. This is a retrospective assessment of the clinical, laboratory, functional, and radiologic outcomes in 25 patients with LPS who underwent the TLTDDS procedure.

METHODS

Twenty-nine patients with complicated LPS were treated surgically by TLTDDS surgery from January 2014 to August 2017. Complete records of 25 patients were available for evaluation. All patients were examined clinically for back or leg pain using a visual analog scale (VAS) and neurological assessment by the American Spine Injury Association. Perioperative outcome and complications were documented. All patients were serially followed up between 12 and 32 months as regard pain (VAS), functional status by Kirkaldy Willis criteria, and Oswestry disability index, laboratory, and radiologic outcomes (angle of segmental kyphosis, lumbar lordosis correction, and fusion criteria).

RESULTS

Definitive solid bony fusion was seen between 6 and 14 months, except in 3 cases, which showed probable fusion. There was significant improvement in VAS, American Spine Injury Association index, laboratory investigations, and Oswestry disability index. One patient (5%) had transient neurological deficit, which resolved completely within 2 months.

CONCLUSIONS

TLTDDS surgery is an effective procedure in the treatment of symptomatic LPS and allows abscess evacuation with adequate neural decompression, segmental kyphosis correction, and functional improvement.