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Anterior spinal infection (prevertebral abscess and/or discitis) after posterior instrumentation for vertebral fractures is a challenging complication, since a new implant may become necessary anteriorly, in a septic environment. Generally accepted management guidelines are yet to be established. The authors present a case of posterior instrumentat...
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Context 1
... on holidays abroad, a 29-year-old woman, on antiepileptic medication, fell and sustained fractures of T12 and L1. A skin laceration made imme- diate surgery impossible. Two weeks later a posterior T11-L2 instrumentation was performed. The postoperative period was complicated with a urinary tract infection, which was treated with antibiotics. Nine months later, the patient was seen again with pain, a discharging wound and kyphosis. Plain radiographs showed loosening of the proximal pedicle screws T11 with recurring kyphosis ( fig 1a). Cultures showed Escherichia coli . In a first stage, posterior débridement and implant removal (fig 1b) were carried out, followed by intravenous anti biot- ic treatment using a third generation cephalosporin (ceftriaxone). However, a gadolinium enhanced MRI scan, performed two weeks after surgery, showed evidence of prevertebral abscess formation and two-level discitis (fig 2). Bone densitometry showed osteoporosis and the patient was thus started on a biphosphonate treatment in view of the pending stabilization procedure. In a second stage, six weeks after implant removal, anterior débridement using a left sided thoraco-abdominal approach was performed. At the same occasion reconstruc- tion was carried out from T9 to L2, using titanium mesh cages filled with autologous iliac crest grafts, along with an anterior dual rod fixation system (DePuy Spine, Inc., Raynham, MA, USA) (fig 3a & 3b). Satisfactory sagittal alignment was achieved. Unfortunately, specimens taken from the T10-T11 and T11-T12 discs during the aforementioned reconstructive procedure tested positive for extended-spectrum beta-lactamase (ESBL) ...
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In unstable thoracolumbar fractures T11-L2, exaggerated kyphosis at the end of treatment may predispose to late back pain and poor functional outcome. Short-segment (SS) (3 vertebrae) pedicle instrumentation has become a popular method of treatment. However the question to add a fusion or not is still under debate. The authors retrospectively evalu...
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Objective: To explore the efficacy of an intracorporeal bone grafting technique in the treatment of type A thoracolumbar fracture. Methods: From Feb 2010 to March 2012, a series of 28 patients type A thoracolumbar fracture with moderate to severe osteoporosis who met our inclusion criteria were treated by a combination of percuta-neous pedicle scre...
Objectives Although there is an agreement of using long-level construct than short-level construct to correct the kyphosis, no literature mentioned the success of this treatment based on timing of surgery after the injury. Objective of this paper was to study the effect of ligamentotaxis on preventing the development of postoperative kyphosis in un...
Citations
... The number of pyogenic spinal infections has increased during the past decades in relation to the greater number of older patients and also immunocompromised patients (chronic renal failure, diabetes type 1, long-term steroid intake, HIV, chronic immunosuppression). 1 The spine accounts for about 0.15% to 3.90% of all cases of osteomyelitis, but despite this relatively low rate, its consequences may be devastating, resulting in severe back pain, kyphotic deformity, and neurological impairment. 2 Secondary kyphosis after infection has been widely described in the literature for tuberculosis cases 3,4 but rarely for pyogenic microorganisms. 5,6 Staphylococcus aureus is the most common organism identified with postoper-ative spinal infections, followed by Streptococcus. Pseudomonas aeruginosa is a relatively uncommon cause, as it accounts for about 5% of the cases. ...
Background:
Kyphosis secondary to pyogenic spondylodiscitis is rare and its management can be very challenging.
Methods:
In this report, we present the case of a 28-year-old woman, with past history of type 1 diabetes and kidney failure on hemodialysis. Her current complaint is chronic middle and low back pain with kyphotic attitude. She had undergone posterior fixation for T12 fracture 3 years earlier, which was complicated by surgical site infection to Pseudomonas aeruginosa, with secondary kyphosis proximally. X-ray showed a 64° kyphosis with complete fusion between T8 and T10, and MRI showed persistent infection foci.
Results:
The patient underwent a pedicle subtraction osteotomy at the level of T9 with instrumentation from T5 to L1. Thoracic kyphosis was corrected to 39°. Samples taken from the remaining collections returned positive for multidrug-resistant Pseudomonas aeruginosa, and the patient was kept on intravenous antibiotic (Colistine) for 2 months. She could walk on day 1, with a satisfactory clinical and radiological result at 3 years.
Conclusions:
Literature is sparse on the management of post-pyogenic infection kyphosis in immunocompromised patients. The current case shows that aggressive correction techniques such as pedicle subtraction osteotomy can be performed in such cases but within a multidisciplinary team to deal simultaneously with the different issues of the fragile patient.
... Spondylodiscitis by drug-multiresistant bacteria is hardly rare any more. Methicillin-resistant S. aureus spondylodiscitis accounts for 10% to 30% of all S. aureus spinal infections [4,8], and more recently, few case reports of gram-negative drug-multiresistant bacteria have also been published [9,10]. ...
Though the incidence of pyogenic spinal infections is increasing the ideal treatment of spondylodiscitis is still a controversially discussed issue. Furthermore, the proportion of multiresistant bacteria in spondylodiscitis is increasing and treatment recommendations or reported results are missing for this especially difficult subset of patients.
Aim of this study is to evaluate the surgical outcome as well as the postoperative antibacterial treatment regime.
Retrospective case series.
Patients treated for a spondylodiscitis from multiresistant bacteria at our department between 2006 and 2011.
Data were gathered through review of patients' case notes, relevant imaging, and electronic patients' records. MR imaging of the whole spine including Gd-enhanced T1 sequences and CT scans of the affected regions were obtained in all cases. There were no funding sources or potential conflicts of interest to disclose.
C-reactive protein (CRP) and complete blood cell count was analyzed in all cases using routine laboratory techniques. Neurological deficits were classified according to the ASIA impairment scale.
25 patients were identified (15 gram-positive and 10 gram-negative drug-multiresistant bacteria). The mean age at presentation was 66 years, 14 patients were male (56%). All patients presented with pain, a neurological deficit was present in 11 (44%) cases. An epidural abscess was found in 11 (44%) cases. At admission C-reactive protein (CRP) was elevated in all cases with a mean of 13 ± 9.2 mg/dl. The main source of infection was previous spine surgery (36%). All patients in this series underwent surgical debridement of the infection and instrumentation of the spine. Postoperative intravenous antibiotics were administered for 19 ± 8.6 days followed by 3 ± 0.3 months of oral antibiotic therapy. Eradication of the infection was achieved ultimately in all surviving patients. Out of 11 patients with neurological deficits, four had a full recovery, four improved incompletely and three remained unchanged after surgery.
Staged surgical immobilization and instrumentation and optimal debridement at the interdiscal space and spinal canal is a reliable approach to achieve complete healing of spinal inflammation with multiresistant bacteria. A period of intravenous antibiotic therapy of 2-3 weeks followed by a three months oral antibiotic therapy seems appropriate for most cases.
Postoperative spondylodiscitis is relatively uncommon. This complication is associated with increased cost, and long-term of inability to work, and even morbidity. Although the majority of postoperative spondylodiscitis cases can be well managed by conservative treatment, postoperative spondylodiscitis after internal fixation and those cases that are unresponsive to the conservative treatment present challenges to the surgeon. Here, a review was done to analyze the treatment of postoperative spondylodiscitis with/without internal fixation. This review article suggested that majority of postoperative spondylodiscitis without internal fixation could be cured by conservative treatment. Either posterior or anterior debridement can be used to treat postoperative spondylodiscitis without internal fixation when conservative treatment fails. In addition, minimally invasive debridement and drainage may also be an alternative treatment. In case of postoperative spondylodiscitis after internal fixation, surgical treatment was required. In the cervical spine, it can be well managed by anterior debridement, removal of internal fixation, and reconstruction of the spinal stability by using bone grafting/cage/anterior plate. Postoperative spondylodiscitis after internal fixation is successfully managed by combined anterior debridement, fusion with posterior approach and removal of pedicle screw or extension of pedicle screw beyond the lesion site, in the thoracic and lumbar spine.
