A unilateral less invasive posterolateral approach for disc debridement and titanium cage insertion supplemented by contralateral transfascial screw fixation for high-morbidity patients suffering from septic thoracolumbosacral spondylodiscitis
- 3 Downloads
This case series reports on the efficacy and safety of a less invasive posterolateral approach for septic thoracolumbosacral spondylodiscitis in high-morbidity patients.
Twenty consecutive severe sick (ASA > III) patients (14 men and 6 women), with an average age of 64 ± 14 years, suffering from septic subacute and chronic thoracolumbosacral spondylodiscitis were selected to undergo a one-stage less invasive unilateral posterolateral disc space debridement, supplemented by an ipsilateral titanium cage implantation and pedicle screw fixation plus a contralateral transfascial pedicle screw fixation.
Two high-risk patients with severe comorbidities (ASA stage IV and V, respectively) died on days 1 and 8 postoperatively because of non-surgical complications such as massive lung embolism and acute myocardial infract, respectively. Three patients with incomplete paraplegia (ASIA C) preoperatively were improved after the surgery to ASIA D (two patients) and E (one patient), respectively, while there was no neurological deterioration in any patient postoperatively. From the 18 patients that survived, ten patients were available for the final follow-up 8.8 ± 2.7 years postoperatively. In two patients with spondylodiscitis caused by gram(−) bacteria, the posterior instrumentation was finally removed because of asymptomatic fistula emerging from posterior instrumentation solely, 15 and 19 months after surgery. The survivals at 2.5 and 10 years with revision as end point was 87.4% (95% CI 58.1–96.7); while in the “worst case scenario” the survivals at 2.5 and 10 years were: 66.7% (95% CI 40.4–83.4%); 47.7% (95% CI 23.2–68.8%) and 47.7% (95% CI 23.2–68.8%), respectively.
The less invasive posterolateral approach for disc debridement and titanium cage insertion seems to be an alternative surgery for severe sick adult immunosuppressed patients with septic thoracolumbosacral spondylodiscitis that cannot tolerate traditional open transthoracic, thoracolumbar, retroperitoneal or combined approaches.
The study has been registered in the Public Registry ClinicalTrials.gov PRS with the ID: NCT03472131.
KeywordsSpondylodiscitis Titanium cage Posterolateral debridement Immunosuppressed Less invasive Spine infection
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
All authors declare that all procedures performed in these series were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
- 2.Gasbarrini AL, Bertoldi E, Mazzetti M et al (2005) Clinical features, diagnostic and therapeutic approaches to haematogenous vertebral osteomyelitis. Eur Rev Med Pharmacol Sci 9:53–66Google Scholar
- 4.Fantoni M, Trecarichi EM, Rossi B et al (2012) Epidemiological and clinical features of pyogenic spondylodiscitis. Eur Rev Med Pharmacol Sci 16(Suppl 2):2–7Google Scholar
- 5.Emery SE, Chan DK, Woodward HR (1989) Treatment of hematogenous pyogenic vertebral osteomyelitis with anterior debridement and primary bone grafting. Spine 14:284–291Google Scholar
- 8.Korovessis P, Petsinis G, Koureas G et al (2006) Anterior surgery with insertion of titanium mesh cage and posterior instrumented fusion performed sequentially on the same day under one anesthesia for septic spondylitis of thoracolumbar spine: is the use of titanium mesh cages safe? Spine 20(31):1014–1019CrossRefGoogle Scholar
- 14.Horton WC, Bridwell KH, Glassman SD et al (2005) The morbidity of anterior exposure for spinal deformity in adults: an analysis of patient-based outcomes and complications in 112 consecutive cases. Presented at: Scoliosis Research Society 40th Annual Meeting; October; Miami, Paper 32Google Scholar
- 23.Jayaswal A, Upendra B, Ahmed A et al (2007) Video-assisted thoracoscopic anterior surgery for tuberculous spondylitis. Clin Orthop Relat Res 460:100–107Google Scholar
- 26.Korovessis P, Vardakastanis K, Fennema P, Syrimpeis V (2016) Mesh cage for treatment of hematogenous spondylitis and spondylodiskitis. How safe and successful is its use in acute and chronic complicated cases? A systematic review of literature over a decade. Eur J Orthop Surg Traumatol 26(7):753–761CrossRefGoogle Scholar
- 29.Wang LJ, Zhang HQ, Tang MX et al (2016) Comparison of three surgical approaches for thoracic spinal tuberculosis in adult: minimum 5-year follow-up. Spine. https://doi.org/10.1097/brs.0000000000001955
- 33.Javernick MA, Kuklo TR, Polly DW Jr (2003) Transforaminal lumbar interbody fusion: unilateral versus bilateral disk removal—an in vivo study. Am J Orthop (Belle Mead NJ) 32:344–348Google Scholar