Single-level lumbar pyogenic spondylodiscitis treated with minimally invasive anterior debridement and fusion combined with posterior fixation via Wiltse approach

Abstract

The effect and safety of anterior debridement and fusion with a minimally invasive approach combined with posterior fixation via the Wiltse approach were assessed in the single-level lumbar pyogenic spondylodiscitis. Seventeen patients from 2007 to 2009 underwent anterior debridement and fusion with a minimally invasive approach combined with posterior fixation via the Wiltse approach. Postoperative follow-up time was 24–41 months. Data included the patients’ general information, microbiology, operative time, intraoperative blood loss, postoperative complications, intervertebral fusion rate, and preoperative and final follow-up scores for American Spinal Injury Association (ASIA) impairment, visual analogue scale (VAS), and Oswestry Disability Index (ODI). Ten patients had undergone a prior spinal invasive procedure, and 7 had hematogenous infection. The infected segments included L_1–2, L_2–3, L_3–4, and L_4–5 in 1, 2, 5, and 9 cases, respectively. Thirteen bacterial cultures were positive for Staphylococcus aureus (5 cases), Staphylococcus epidermidis (4), Streptococcus (3), and Escherichia coli (1). The operative time was 213.8±45.6 min, and the intraoperative blood loss was 180.6±88.1 mL. Postoperative complications consisted of urinary retention (2 cases), constipation (3), and deep vein thrombosis (2). On the final follow-up, VAS scores and ODIs were significantly lower than those of preoperation, while the ASIA grades improved. All the cases achieved good intervertebral bony fusion. Anterior debridement and fusion with a minimally invasive approach combined with posterior fixation via the Wiltse approach can successfully treat single-level lumbar pyogenic spondylodiscitis, with less trauma and reliable immobilization. It is a viable option for clinical application.

Keywords

lumbar pyogenic spondylodiscitis / minimal invasion / Wiltse approach / curative effect

References

[1] FordLT. Postoperative infection of lumbar intervertebral disk space. South Med J, 1976, 69(11): 1477-1481

[2] FriedmanJA, MaherCO, QuastLM, et al.. Spontaneous disc space infections in adults. Surg Neurol, 2002, 57(2): 81-86

[3] AsamotoS, DoiH, KobayashiN, et al.. Spondylodiscitis: diagnosis and treatment. Surg Neurol, 2005, 64(2): 103-108

[4] Cebrian ParraJL, Saez-Arenillas MartinA, Urda Martinez-AedoAL, et al.. Management of infectious discitis. Outcome in one hundred and eight patients in a university hospital. Int Orthop, 2012, 36(2): 239-244

[5] SilberJS, AndersonDG, VaccaroAR, et al.. Management of postprocedural discitis. Spine J, 2002, 2(4): 279-287

[6] TylerKL. Acute pyogenic diskitis (spondylodiskitis) in adults. Rev Neurol Dis, 2008, 5(1): 8-13

[7] BettiniN, GirardoM, DemaE, et al.. Evaluation of conservative treatment of non specific spondylodiscitis. Eur Spine J, 2009, 18(Suppl1): 143-150

[8] PeeYH, ParkJD, ChoiYG, et al.. Anterior debridement and fusion followed by posterior pedicle screw fixation in pyogenic spondylodiscitis: autologous iliac bone strut versus cage. J Neurosurg Spine, 2008, 8(5): 405-412

[9] GonzalvoA, AbdullaI, RiaziA, et al.. Single-level/singlestage debridement and posterior instrumented fusion in the treatment of spontaneous pyogenic osteomyelitis/discitis: long-term functional outcome and healthrelated quality of life. J Spinal Disord Tech, 2011, 24(2): 110-115

[10] SundararajGD, BabuN, AmritanandR, et al.. Treatment of haematogenous pyogenic vertebral osteomyelitis by single-stage anterior debridement, grafting of the defect and posterior instrumentation. J Bone Joint Surg Br, 2007, 89(9): 1201-1205

[11] WiltseLL, BatemanJG, HutchinsonRH, et al.. The paraspinal sacrospinalis-splitting approach to the lumbar spine. J Bone Joint Surg Am, 1968, 50(5): 919-926

[12] KirshblumSC, BurnsSP, Biering-SorensenF, et al.. International standards for neurological classification of spinal cord injury (revised 2011). J Spinal Cord Med, 2011, 34(6): 535-546

[13] KnopC, OeserM, BastianL, et al.. Development and validation of the Visual Analogue Scale (VAS) Spine Score. Unfallchirurg (German), 2001, 104(6): 488-497

[14] FairbankJ. Use of Oswestry Disability Index (ODI). Spine, 1995, 20(13): 1535-1537

[15] HadjipavlouAG, MaderJT, NecessaryJT, et al.. Hematogenous pyogenic spinal infections and their surgical management. Spine, 2000, 25(13): 1668-1679

[16] WisneskiRJ. Infectious disease of the spine. Diagnostic and treatment considerations. Orthop Clin North Am, 1991, 22(3): 491-501

[17] CahillDW, LoveLC, RechtineGR. Pyogenic osteomyelitis of the spine in the elderly. J Neurosurg, 1991, 74(6): 878-886

[18] RigamontiD, LiemL, SampathP, et al.. Spinal epidural abscess: contemporary trends in etiology, evaluation, and management. Surg Neurol, 1999, 52(2): 189-196

[19] EnochDA, CargillJS, LaingR, et al.. Value of CT-guided biopsy in the diagnosis of septic discitis. J Clin Pathol, 2008, 61(6): 750-753

[20] ChewFS, KlineMJ. Diagnostic yield of CT-guided percutaneous aspiration procedures in suspected spontaneous infectious diskitis. Radiology, 2001, 218(1): 211-214

[21] ArmstrongP, ChalmersAH, GreenG, et al.. Needle aspiration/biopsy of the spine in suspected disc infection. Br J Radiol, 1978, 51(605): 333-337

[22] El-GindiS, ArefS, SalamaM, et al.. Infection of intervertebral discs after operation. J Bone Joint Surg Br, 1976, 58(1): 114-116

[23] Jimenez-MejiasME, de Dios ColmeneroJ, Sanchez-LoraFJ, et al.. Postoperative spondylodiskitis: etiology, clinical findings, prognosis, and comparison with nonoperative pyogenic spondylodiskitis. Clin Infect Dis, 1999, 29(2): 339-345

[24] HoelscherGL, GruberHE, ColdhamG, et al.. Effects of very high antibiotic concentrations on human intervertebral disc cell proliferation, viability, and metabolism in vitro. Spine, 2000, 25(15): 1871-1877

[25] WirtzDC, GeniusI, WildbergerJE, et al.. Diagnostic and therapeutic management of lumbar and thoracic spondylodiscitis—an evaluation of 59 cases. Arch Orthop Trauma Surg, 2000, 120(5-6): 245-251

[26] PrzybylskiGJ, SharanAD. Single-stage autogenous bone grafting and internal fixation in the surgical management of pyogenic discitis and vertebral osteomyelitis. J Neurosurg, 2001, 94(1Suppl): 1-7

[27] WangX, ZhouJ, ZhangC, et al.. Single-stage anterior debridement and fusion with autografting and internal fixation for pyogenic lumbar spondylodiscitis. Arch Orthop Trauma Surg, 2012, 132(4): 487-493

[28] FukutaS, MiyamotoK, MasudaT, et al.. Two-stage (posterior and anterior) surgical treatment using posterior spinal instrumentation for pyogenic and tuberculotic spondylitis. Spine, 2003, 28(15): E302-308

[29] DimarJR, CarreonLY. Glas Diagnostic and therapeutic management of lumbar and thoracic spondylodiscitis—an evaluation of 59 cases sman SD, et al. Treatment of pyogenic vertebral osteomyelitis with anterior debridement and fusion followed by delayed posterior spinal fusion. Spine, 2004, 29(3): 326-332

[30] VialleR, WicartP, DrainO, et al.. The Wiltse paraspinal approach to the lumbar spine revisited: an anatomic study. Clin Orthop Relat Res, 2006, 445: 175-180

[31] DaiLY, ChenWH, JiangLS. Anterior instrumentation for the treatment of pyogenic vertebral osteomyelitis of thoracic and lumbar spine. Eur Spine J, 2008, 17(8): 1027-1034