Journal of Korean Neurosurgical Society

The Korean Neurosurgical Society (대한신경외과학회)
권호 표지
DOI QR코드

DOI QR Code

Laminotomy with Continuous Irrigation in Patients with Pyogenic Spondylitis in Thoracic and Lumbar Spine

  • Kim, Sung-Hyun (Department of Neurosurgery, Chonnam National University Medical School & Research Institute of Medical Sciences) ;
  • Lee, Jung-Kil (Department of Neurosurgery, Chonnam National University Medical School & Research Institute of Medical Sciences) ;
  • Jang, Jae-Won (Department of Neurosurgery, Chonnam National University Medical School & Research Institute of Medical Sciences) ;
  • Seo, Bo-Ra (Department of Neurosurgery, Chonnam National University Medical School & Research Institute of Medical Sciences) ;
  • Kim, Tae-Sun (Department of Neurosurgery, Chonnam National University Medical School & Research Institute of Medical Sciences) ;
  • Kim, Soo-Han (Department of Neurosurgery, Chonnam National University Medical School & Research Institute of Medical Sciences)
  • Received : 2011.03.10
  • Accepted : 2011.10.10
  • Published : 2011.10.28
Download PDF
⟨ Previous Next ⟩

Abstract

Objective : Pyogenic spondylitis often results in acute neurological deterioration requiring adequate surgical intervention and appropriate antibiotic treatment. The purpose of this study was to conduct an analysis of the clinical effect of continuous irrigation via laminotomy in a series of patients with pyogenic spondylitis in thoracic and lumbar spine. Methods : The authors conducted a retrospective investigation of 31 consecutive patients with pyogenic thoracic and lumbar spondylitis who underwent continuous irrigation through laminotomy from 2004 to 2008. The study included 22 men and 9 women, ranging in age from 38 to 78 years (mean 58.1 years). The average follow-up duration was 13.4 months (range, 8-34 months). We performed debridement and abscess removal after simple laminotomy, and then washed out epidural and disc space using a continuous irrigation system. Broad spectrum antibiotics were administered empirically and changed according to the subsequent culture result. Clinical outcomes were based on the low back outcome scale (LBOS), visual analogue scale (VAS) score, and Frankel grade at the last follow-up. Radiological assessment involved plain radiographs, including functional views. Results : Common predisposing factors included local injection for pain therapy, diabetes mellitus, chronic renal failure, and liver cirrhosis. Causative microorganisms were identified in 22 cases (70.9%) : Staphylococcus aureus and Streptococcus spp. were the main organisms. After surgery, LBOS, VAS score, and Frankel grade showed significant improvement in most patients. Spinal stability was maintained during the follow-up period, making secondary reconstructive surgery unnecessary for all patients, except one. Conclusion : Simple laminotomy with continuous irrigation by insertion of a catheter into intervertebral disc space or epidural space was minimally invasive and effective in the treatment of pyogenic spondylitis. This procedure could be a beneficial treatment option in patients with thoracolumbar spondylitis combined with minimal or moderate destructive change of vertebrae.

Keywords

References

  1. Barth E, Myrvik QM, Wagner W, Gristina AG : In vitro and in vivo comparative colonization of Staphylococcus aureus and Staphylococcus epidermidis on orthopaedic implant materials. Biomaterials 10 : 325-328, 1989 https://doi.org/10.1016/0142-9612(89)90073-2
  2. Calderone RR, Larsen JM : Overview and classification of spinal infections. Orthop Clin North Am 27 : 1-8, 1996
  3. Carragee EJ : Instrumentation of the infected and unstable spine : a review of 17 cases from the thoracic and lumbar spine with pyogenic infections. J Spinal Disord 10 : 317-324, 1997
  4. Carragee EJ : Pyogenic vertebral osteomyelitis. J Bone Joint Surg Am 79 : 874-880, 1997 https://doi.org/10.1302/0301-620X.79B5.8078
  5. Emery SE, Chan DP, Woodward HR : Treatment of hematogenous pyogenic vertebral osteomyelitis with anterior debridement and primary bone grafting. Spine (Phila Pa 1976) 14 : 284-291, 1989
  6. Fayazi AH, Ludwig SC, Dabbah M, Bryan Butler R, Gelb DE : Preliminary results of staged anterior debridement and reconstruction using titanium mesh cages in the treatment of thoracolumbar vertebral osteomyelitis. Spine J 4 : 388-395, 2004 https://doi.org/10.1016/j.spinee.2004.01.004
  7. Fu TS, Yang SC, Tsai TT, Chen LH, Lai PL, Niu CC, et al. : Percutaneous endoscopic debridement and drainage in immunocompromised patients with complicated infectious spondylitis. Minim Invasive Ther Allied Technol 19 : 42-47, 2010 https://doi.org/10.3109/13645700903384450
  8. Fukuta S, Miyamoto K, Masuda T, Hosoe H, Kodama H, Nishimoto H, et al. : Two-stage (posterior and anterior) surgical treatment using posterior spinal instrumentation for pyogenic and tuberculotic spondylitis. Spine (Phila Pa 1976) 28 : E302-E308, 2003
  9. Garrido E, Rosenwasser RH : Experience with the suction-irrigation technique in the management of spinal epidural infection. Neurosurgery 12 : 678-679, 1983 https://doi.org/10.1227/00006123-198306000-00015
  10. Gebhard JS, Brugman JL : Percutaneous discectomy for the treatment of bacterial discitis. Spine (Phila Pa 1976) 19 : 855-857, 1994 https://doi.org/10.1097/00007632-199404000-00025
  11. Hadjipavlou AG, Mader JT, Necessary JT, Muffoletto AJ : Hematogenous pyogenic spinal infections and their surgical management. Spine (Phila Pa 1976) 25 : 1668-1679, 2000 https://doi.org/10.1097/00007632-200007010-00010
  12. Hanaoka N, Kawasaki Y, Sakai T, Nakamura T, Nanamori K, Nakamura E, et al. : Percutaneous drainage and continuous irrigation in patients with severe pyogenic spondylitis, abscess formation, and marked bone destruction. J Neurosurg Spine 4 : 374-379, 2006 https://doi.org/10.3171/spi.2006.4.5.374
  13. Hanigan WC, Asner NG, Elwood PW : Magnetic resonance imaging and the nonoperative treatment of spinal epidural abscess. Surg Neurol 34 : 408-413, 1990 https://doi.org/10.1016/0090-3019(90)90245-K
  14. Hlavin ML, Kaminski HJ, Ross JS, Ganz E : Spinal epidural abscess : a ten-year perspective. Neurosurgery 27 : 177-184, 1990 https://doi.org/10.1227/00006123-199008000-00001
  15. Ito M, Abumi K, Kotani Y, Kadoya K, Minami A : Clinical outcome of posterolateral endoscopic surgery for pyogenic spondylodiscitis : results of 15 patients with serious comorbid conditions. Spine (Phila Pa 1976) 32 : 200-206, 2007 https://doi.org/10.1097/01.brs.0000251645.58076.96
  16. Jensen AG, Espersen F, Skinhoj P, Frimodt-Moller N : Bacteremic Staphylococcus aureus spondylitis. Arch Intern Med 158 : 509-517, 1998 https://doi.org/10.1001/archinte.158.5.509
  17. Jensen AG, Espersen F, Skinhoj P, Rosdahl VT, Frimodt-Moller N : Increasing frequency of vertebral osteomyelitis following Staphylococcus aureus bacteraemia in Denmark 1980-1990. J Infect 34 : 113-118, 1997 https://doi.org/10.1016/S0163-4453(97)92395-1
  18. Karadimas EJ, Bunger C, Lindblad BE, Hansen ES, Hoy K, Helmig P, et al. : Spondylodiscitis. A retrospective study of 163 patients. Acta Orthop 79 : 650-659, 2008 https://doi.org/10.1080/17453670810016678
  19. Komatsubara S, Shibuya S, Arima N, Yamamoto T, Oka S : Clinical outcomes of percutaneous curettage and continuous irrigation for pyogenic spondylitis. Surg Neurol 72 : 545-547; discussion 547, 2009 https://doi.org/10.1016/j.surneu.2008.12.009
  20. Korovessis P, Petsinis G, Koureas G, Iliopoulos P, Zacharatos S : 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 (Phila Pa 1976) 31 : 1014-1019, 2006 https://doi.org/10.1097/01.brs.0000215049.08622.9d
  21. Lange M, Tiecks F, Schielke E, Yousry T, Haberl R, Oeckler R : Diagnosis and results of different treatment regimens in patients with spinal abscesses. Acta Neurochir (Wien) 125 : 105-114, 1993 https://doi.org/10.1007/BF01401836
  22. Legrand E, Flipo RM, Guggenbuhl P, Masson C, Maillefert JF, Soubrier M, et al. : Management of nontuberculous infectious discitis. treatments used in 110 patients admitted to 12 teaching hospitals in France. Joint Bone Spine 68 : 504-509, 2001 https://doi.org/10.1016/S1297-319X(01)00315-3
  23. Lifeso RM : Pyogenic spinal sepsis in adults. Spine (Phila Pa 1976) 15 : 1265-1271, 1990 https://doi.org/10.1097/00007632-199012000-00007
  24. Martin RJ, Yuan HA : Neurosurgical care of spinal epidural, subdural, and intramedullary abscesses and arachnoiditis. Orthop Clin North Am 27 : 125-136, 1996
  25. Martinez Hernandez PL, Amer Lopez M, Zamora Vargas F, Garcia de Paso P, Navarro San Francisco C, Perez Fernandez E, et al. : [Spontaneous infectious spondylodiscitis in an internal medicine department : epidemiological and clinical study in 41 cases]. Rev Clin Esp 208 : 347-352, 2008 https://doi.org/10.1157/13124314
  26. McGee-Collett M, Johnston IH : Spinal epidural abscess : presentation and treatment. A report of 21 cases. Med J Aust 155 : 14-17, 1991
  27. Nagata K, Ohashi T, Ariyoshi M, Sonoda K, Imoto H, Inoue A : Percutaneous suction aspiration and drainage for pyogenic spondylitis. Spine (Phila Pa 1976) 23 : 1600-1606, 1998 https://doi.org/10.1097/00007632-199807150-00018
  28. Nussbaum ES, Rigamonti D, Standiford H, Numaguchi Y, Wolf AL, Robinson WL : Spinal epidural abscess : a report of 40 cases and review. Surg Neurol 38 : 225-231, 1992 https://doi.org/10.1016/0090-3019(92)90173-K
  29. Pee YH, Park JD, Choi YG, Lee SH : Anterior debridement and fusion followed by posterior pedicle screw fixation in pyogenic spondylodiscitis : autologous iliac bone strut versus cage. J Neurosurg Spine 8 : 405-412, 2008 https://doi.org/10.3171/SPI/2008/8/5/405
  30. Phillips JM, Stedeford JC, Hartsilver E, Roberts C : Epidural abscess complicating insertion of epidural catheters. Br J Anaesth 89 : 778-782, 2002 https://doi.org/10.1093/bja/89.5.778
  31. Picada R, Winter RB, Lonstein JE, Denis F, Pinto MR, Smith MD, et al. : Postoperative deep wound infection in adults after posterior lumbosacral spine fusion with instrumentation : incidence and management. J Spinal Disord 13 : 42-45, 2000 https://doi.org/10.1097/00002517-200002000-00009
  32. Rath SA, Neff U, Schneider O, Richter HP : Neurosurgical management of thoracic and lumbar vertebral osteomyelitis and discitis in adults : a review of 43 consecutive surgically treated patients. Neurosurgery 38 : 926-933, 1996 https://doi.org/10.1097/00006123-199605000-00013
  33. Rayes M, Colen CB, Bahgat DA, Higashida T, Guthikonda M, Rengachary S, et al. : Safety of instrumentation in patients with spinal infection. J Neurosurg Spine 12 : 647-659, 2010 https://doi.org/10.3171/2009.12.SPINE09428
  34. Rea GL, McGregor JM, Miller CA, Miner ME : Surgical treatment of the spontaneous spinal epidural abscess. Surg Neurol 37 : 274-279, 1992 https://doi.org/10.1016/0090-3019(92)90152-D
  35. Reihsaus E, Waldbaur H, Seeling W : Spinal epidural abscess : a meta-analysis of 915 patients. Neurosurg Rev 23 : 175-204; discussion 205, 2000 https://doi.org/10.1007/PL00011954
  36. Rigamonti D, Liem L, Sampath P, Knoller N, Namaguchi Y, Schreibman DL, et al. : Spinal epidural abscess : contemporary trends in etiology, evaluation, and management. Surg Neurol 52 : 189-196; discussion 197, 1999 https://doi.org/10.1016/S0090-3019(99)00055-5
  37. Taylor AR, Maudsley RH : Instillation-suction technique in chronic osteomyelitis. J Bone Joint Surg Br 52 : 88-92, 1970
  38. Tofuku K, Koga H, Yone K, Komiya S : Continuous irrigation in pyogenic spondylitis accompanied by iliopsoas abscess. Spine (Phila Pa 1976) 32 : E382-E387, 2007 https://doi.org/10.1097/BRS.0b013e318067e35e
  39. Vakharia SB, Thomas PS, Rosenbaum AE, Wasenko JJ, Fellows DG : Magnetic resonance imaging of cerebrospinal fluid leak and tamponade effect of blood patch in postdural puncture headache. Anesth Analg 84 : 585-590, 1997
  40. Vender JR, Hester S, Houle PJ, Choudhri HF, Rekito A, McDonnell DE : The use of closed-suction irrigation systems to manage spinal infections. J Neurosurg Spine 3 : 276-282, 2005 https://doi.org/10.3171/spi.2005.3.4.0276
  41. Wisneski RJ : Infectious disease of the spine. Diagnostic and treatment considerations. Orthop Clin North Am 22 : 491-501, 1991
  42. Yoon SH, Chung SK, Kim KJ, Kim HJ, Jin YJ, Kim HB : Pyogenic vertebral osteomyelitis : identification of microorganism and laboratory markers used to predict clinical outcome. Eur Spine J 19 : 575-582, 2010 https://doi.org/10.1007/s00586-009-1216-1
  43. Yu WY, Siu C, Wing PC, Schweigel JF, Jetha N : Percutaneous suction aspiration for osteomyelitis. Report of two cases. Spine (Phila Pa 1976) 16 : 198-202, 1991

Cited by

  1. Delayed Spondylodiscitis Presenting as a Skip Lesion vol.14, pp.1, 2011, https://doi.org/10.14245/kjs.2017.14.1.14
  2. Thoracic Epidural Abscesses: A Systematic Review vol.8, pp.4, 2018, https://doi.org/10.1177/2192568218763324
  3. Continuous Epidural Irrigation and Drainage Combined with Posterior Debridement and Posterior Lumbar Inter-Body Fusion for the Management of Single-Segment Lumbar Pyogenic Spondylodiscitis vol.21, pp.3, 2020, https://doi.org/10.1089/sur.2019.038