Treatment of haematogenous pyogenic vertebral osteomyelitis by single-stage anterior debridement, grafting of the defect and posterior instrumentation

Abstract

Anterior debridement, grafting of the defect and posterior instrumentation as a single-stage procedure is a controversial method of managing pyogenic vertebral osteomyelitis. Between 1994 and 2005, 37 patients underwent this procedure at our hospital, of which two died and three had inadequate follow-up. The remaining 32 were reviewed for a mean of 36 months (12 to 66). Their mean age was 48 years (17 to 68). A significant pre-operative neurological deficit was present in 13 patients (41%). The mean duration of surgery was 285 minutes (240 to 360) and the mean blood loss was 900 ml (300 to 1600). Pyogenic organisms were isolated in 21 patients (66%). All patients began to mobilise on the second post-operative day. The mean hospital stay was 13.6 days (10 to 20). Appropriate antibiotics were administered for 10 to 12 weeks. Early wound infection occurred in four patients (12.5%), and late infection in two (6.3%). At final follow-up, the infection had resolved in all patients, neurological recovery was seen in ten of 13 (76.9%) and interbody fusion had occurred in 30 (94%). The clinical outcome was excellent or good in 30 patients according to Macnab's criteria. This surgical protocol can be used to good effect in patients with pyogenic vertebral osteomyelitis when combined with appropriate antibiotic therapy.

Single-level lumbar pyogenic spondylodiscitis treated with mini-open anterior debridement and fusion in combination with posterior percutaneous fixation via a modified anterior lumbar interbody fusion approach

“…8,21,22 For the posterior approach, pedicle screws can provide stable 3-column spine fixation, but it is difficult to thoroughly debride the affected lesions and thus there is a high risk of the spread of bacteria to the screws and muscles posterior to the vertebrae. For the anterior approach, the intervertebral lesions can be completely removed under direct vision, 25 thus reducing surgical interference with the spinal canal and avoiding bacterial spread.…”

“…Because of these considerations, anterior debridement in combination with posterior fixation is widely used for the treatment of lumbar pyogenic spondylodiscitis. 8,21,22 Yet, conventional open surgery using this approach is associated with disadvantages such as a large incision, excessive tissue damage, cles, leading to postoperative back pain, reduced lumbar muscle strength, and slow recovery time. 24 The Wiltse approach is another choice, but still causes a certain amount of muscle trauma and skin incision.…”

“…8,21,22 This approach can result in thorough debridement and stable internal fixation, improving the rates of inflammation resolution and bony fusion. 8 However, conventional open surgery is associated with several disadvantages, including large surgical trauma, severe intraoperative blood loss, high postoperative complication rates, and a slow recov- reSultS The mean operative time was 181.1 ± 22.6 minutes (range 155-240 minutes).…”

“…The advantages of this approach over open surgery include minimizing intraoperative retraction of the paraspinal muscles and ligaments, shortening the surgical time, reducing intraoperative blood loss, and promoting the postoperative recovery of lumbar muscle strength. 10 Conventional anterior open surgery can achieve good debridement and bone implantation, 8,21,22 but often results in an incision longer than 15 cm, extensive dissection of the muscles, severe blood loss, and a high risk of injury to the major blood vessels, ureter, lumbar plexus, and peritoneum. In the present study, we adopted the mini-open modified ALIF 16 approach by establishing a working channel directly to the surgical area, which was about 5 mm behind the anterior edge of the psoas major muscle.…”

Management of postoperative spondylodiscitis with and without internal fixation

“…There are also reports of spondylodiscitis/pyogenic vertebral osteomyelitis being treated by anterior debridement and fusion with/without anterior instrumentation (8, 9, 11, 14). Additionally, anterior debridement combined with onestage/staged posterior internal fixation has been used to treat patients with primary pyogenic vertebral osteomyelitis (10,15,36,40,43). There are few studies on anterior debridement for the treatment of postoperative spondylodiscitis, however.…”