The Use of Titanium Mesh Cages in the Reconstruction of Anterior Column Defects in Active Spinal Infections: Can We Rest the Crest?

Abstract

Study DesignRetrospective clinical series.PurposeTo assess whether titanium cages are an effective alternative to tricortical iliac crest bone graft for anterior column reconstruction in patients with active pyogenic and tuberculous spondylodiscitis.Overview of LiteratureThe use of metal cages for anterior column reconstruction in patients with active spinal infections, though described, is not without controversy.MethodsSeventy patients with either tuberculous or pyogenic vertebral osteomyelitis underwent a single staged anterior debridement, reconstruction of the anterior column with titanium mesh cage and adjuvant posterior instrumentation. The lumbar spine was the predominant level of involvement. Medical co-morbidities were seen in 18 (25.7%) patients. A significant neurological deficit was seen in 32 (45.7%) patients. At follow up patients were assessed for healing of disease, bony fuson, and clinical outcome was assessed using Macnab's criteria.ResultsFinal follow up was done on 64 (91.4%) patients at a mean average of 25 months (range, 12 to 110 months). Pathologic organisms could be identified in 42 (60%) patients. Forty two (60%) patients had histopathological findings consistent with tuberculosis. Thirty of 32 (93.7%) patients showed neurological recovery. The surgical wound healed uneventfully in 67 (95.7%) patients. Bony fusion was seen in 60 (93.7%) patients. At final follow up healing of infection was seen in all patients. As per Macnab's criteria 61 (95.3%) patients reported a good to excellent outcome.ConclusionsInspite of the theoretical risks, titanium cages are a suitable alternative to autologous tricortical iliac crest bone graft in patients with active spinal infections.

When and how to operate on spondylodiscitis: a report of 13 patients

“…The 10-year rate of spinal fusion using spinal instrumentation is 97 % compared to 90 % with debridement alone; the respective rate of conservative treatment with antibiotics alone ranges from 65 to 79 % [12,15,16,[41][42][43]. However, there is still controversy regarding the use of spinal instrumentation and infection recurrence rates in patients with spondylodiscitis [12,15,16,41].…”

Pyogenic lumbar spondylodiscitis treated with transforaminal lumbar interbody fusion: safety and outcomes

“…Sundararaj et al concluded that titanium cages may be safely used in place of iliac crest graft for treating active spinal infection. Their series included cases of tuberculosis as well as pyogenic spondylodiscitis [14]. Brase et al, in their review of nine prospective cases of purulent spondylodiscitis including cervical and lumbar infections, showed satisfactory clearance of infection with the use of polyetheretherketone (PEEK) cages [22].…”

“…Tubercle bacilli have reduced propensity to form biofilm, and thus risk of recurrences with titanium implants is low [11,[14][15][16]. A posterior approach allows for a single-stage surgical procedure, offering satisfactory lesion debridement and simultaneous placement of instrumentation to provide stability and deformity correction, which is well maintained [11][12][13].…”

“…However, there has been a recent surge in the literature showing satisfactory results in spondylodiscitis management with a single-stage posterior approach, especially with spinal tuberculosis [11][12][13]. Metallic implants have been safely used i n tuberculosis spondylodiscitis due to poor biofilm formation; however, metallic implants in the setting of pyogenic infections cause concern due to the the risk of biofilm formation and recurrences [14][15][16]. There are few reports documenting posterior lumbar interbody fusion with instrumentation and its feasibility for treating pyogenic lumbar spondylodiscitis.…”

Intervertebral focal surgery for the treatment of non-contiguous multifocal spinal tuberculosis

“…For complete debridement, the foci should neither undergo over excision of normal bone, nor overlook infected material that could cause the disease to recur [20]. For the procedure of intervertebral focal graft union, the best graft is autologous iliac bone followed by titanium mesh cage filled with autologous iliac bone [21]. The drawback of the former is chronic pain and cosmetic defect while the latter can undergo mesh subsidence [14].…”