Percutaneous transpedicular discectomy and drainage in pyogenic spondylodiscitis

Abstract

The natural history of uncomplicated hematogenous pyogenic spondylodiscitis is self-limiting healing. However, a variable degree of bone destruction frequently occurs, predisposing the spine to painful kyphosis. Delayed treatment may result in serious neurologic complications. Early debridement of these infections by percutaneous transpedicular discectomy can accelerate the natural process of healing and prevent progression to bone destruction and epidural abscess. The purpose of this manuscript is to present our technique of percutaneous transpedicular discectomy (PTD), to revisit this minimally invasive surgical technique with stricter patient selection, and to exclude cases of extensive vertebral body destruction with kyphosis and neurocompression by epidural abscess, infected disc herniation, and foraminal stenosis. In a previously published report of 28 unselected patients with primary hematogenous pyogenic spondylodiscitis, the immediate relief of pain after PTD was 75%, and in the long-term follow-up, the success rate was 68%. Applying stricter patient selection criteria in a second series of six patients (five with primary hematogenous spondylodiscitis and one with secondary postlaminectomy-discectomy spondylodiscitis), all patients with primary hematogenous spondylodiskitis (5/5) experienced immediate relief of pain that remained sustained at 12-18 months follow-up. This procedure was not very effective, however, in the patient who suffered from postlaminectomy infection. This lack of response was attributed to postlaminectomy-discitis instability. The immediate success rate after surgery for unselected patients in this combined series of 34 patients was 76%. This technique can be impressively effective and the results sustained when applied in the early stages of uncomplicated spondylodiscitis and contraindicated in the presence of instability, kyphosis from bone destruction, and neurological deficit. The special point of this procedure is a minimally invasive technique with high diagnostic and therapeutic effectiveness.

Surgical treatment of spondylodiscitis. An update

“…LIS are technically demanding but offer good results when applied early [28]. Percutaneous transpedicular discectomy and drainage also result in immediate pain relief [27].…”

Failure modes in conservative and surgical management of infectious spondylodiscitis

“…However, surgeons still discuss staging, surgical access, and usage of instrumentation or cages [3,14,15,20]. Furthermore, minimally invasive and endoscopic surgeries are being promoted [9,11]. Treatment of infectious spondylodiscitis in children, geriatric patients, and patients with multiple risk factors can be very challenging and gives cause for intense discussions [10,13,19].…”

Easy drainage of presacral abscess

“…A similar approach has been previously described for biopsy of a presacral mass [10] and for the treatment of pyogenic spondylodiscitis [1,5]. But this is the first time in the world literature that this approach is being described for the drainage of presacral abscess, which is such a common complication of a common disease in developing countries.…”

“…Interventional radiology has reported several innovative low morbidity approaches like transgluteal, transrectal, transvaginal and precoccygeal routes followed by placement of catheter for drainage [9,11]. Transpedicular approach has been reported in the literature for the management of pyogenic discitis [1,5] and for taking a biopsy from a presacral mass [10]. Here, a simple method of early drainage of presacral abscess through transpedicular approach is described.…”