Tag: vertebral osteomyelitis

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Management of spinal infection: a review of the literature

Acta Neurochirurgica (2018) 160:487–496

Spinal infection (SI) is defined as an infectious disease affecting the vertebral body, the intervertebral disc, and/or adjacent paraspinal tissue and represents 2–7% of all musculoskeletal infections. There are numerous factors, which may facilitate the development of SI including not only advanced patient age and comorbidities but also spinal surgery. Due to the low specificity of signs, the delay in diagnosis of SI remains an important issue and poor outcome is frequently seen. Diagnosis should always be supported by clinical, laboratory, and imaging findings, magnetic resonance imaging (MRI) remaining the most reliable method. Management of SI depends on the location of the infection (i.e., intraspinal, intervertebral, paraspinal), on the disease progression, and of course on the patient’s general condition, considering age and comorbidities. Conservative treatment mostly is reasonable in early stages with no or minor neurologic deficits and in case of severe comorbidities, which limit surgical options. Nevertheless, solely medical treatment often fails. Therefore, in case of doubt, surgical treatment should be considered. The final result in conservative as well as in surgical treatment always is bony fusion. Furthermore, both options require a concomitant antimicrobial therapy, initially applied intravenously and administered orally thereafter. The optimal duration of antibiotic therapy remains controversial, but should never undercut 6 weeks. Due to a heterogeneous and often comorbid patient population and the wide variety of treatment options, no generally applicable guidelines for SI exist and management remains a challenge. Thus, future prospective randomized trials are necessary to substantiate treatment strategies.

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Lateral retroperitoneal approach for discitis and osteomyelitis

Direct lateral retroperitoneal approach for the surgical treatment of lumbar discitis and osteomyelitis

Neurosurg Focus 37 (2):E5, 2014

The medical management of discitis and osteomyelitis with long-term antibiotic therapy and bracing usually results in eradicated infection. Surgical management is appropriate when medical management fails and in some cases with pyogenic deformity or neurological deficit. The success of surgery depends on adequate debridement of the necrotic infected disc and vertebral body, along with anterior column reconstruction and vertebral stabilization. Debridement is typically performed via an anterior retroperitoneal approach, which can necessitate mobilization of the great vessels for proper exposure. Mobilization can be technically difficult and lead to vascular injury. The purpose of this study was to evaluate an alternative technique for the surgical treatment of lumbar discitis and osteomyelitis using a direct lateral retroperitoneal approach, which allows for thorough debridement and anterior column reconstruction while avoiding the need to mobilize the great vessels.

Methods. A retrospective chart analysis was performed for all patients who had presented with lumbar discitis and osteomyelitis and had undergone surgical management via the direct lateral retroperitoneal approach in the period from 2006 to 2013. Collected data included surgical blood loss, perioperative complications (wound infection, vascular injury, approach-related complications, and neurological injury), need for secondary procedures, microbiological and laboratory results, and efficacy of infection eradication. Imaging studies were reviewed as well.

Results. Ten patients, 7 male and 3 female, underwent this procedure at the authors’ institution in the defined period. Average blood loss was 272 ml (range 150–800 ml, with 800 ml in the only 2-level case). There were no vascular injuries. Average follow-up was 680 days, although 4 patients did not complete the follow-up beyond 6 months. Eight patients underwent immediate posterior pedicle screw instrumentation. Two patients did not undergo posterior instrumentation, and one of these developed a kyphotic deformity that required a secondary posterior procedure. Infection was eradicated in all patients according to a history, physical examination, imaging studies, and laboratory parameters (complete blood count, erythrocyte sedimentation rate, and C-reactive protein). One patient developed a painful neuroma at the iliac crest harvest site, and one patient had a retroperitoneal hematoma. Otherwise, there were no approach-related neurological injuries or complications. Neither was there any postoperative surgical site infection.

Conclusions. The direct lateral approach for the surgical treatment of lumbar discitis and osteomyelitis allows for thorough debridement and spinal reconstruction without the need to mobilize the great vessels. This technique effectively eradicated infection in all cases, with reasonable blood loss and no vascular injuries. This approach should be considered as an alternative to the open anterior approach. The authors recommend posterior instrumentation to prevent the development of kyphosis.

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