Limits...
Fatal outcome after insufficient spine fixation for pyogenic thoracic spondylodiscitis: an imperative for 360 degrees fusion of the infected spine.

Flierl MA, Beauchamp KM, Bolles GE, Moore EE, Stahel PF - Patient Saf Surg (2009)

Bottom Line: An emergent MRI revealed a kyphotic wedge compression fracture at T7/T8 with significant spinal cord compression, paravertebral and epidural abscess, and signs of myelopathy.The patient recovered well under adjunctive antibiotic treatment.Despite the successful salvage procedure, the patient deteriorated in the postoperative phase, when she developed multiple complications including pneumonia, acute respiratory distress syndrome, bacterial meningitis, abdominal compartment syndrome, followed by septic shock with multiple organ failure and a lethal outcome within two weeks after revision surgery.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock Street, Denver, CO 80204, USA. philip.stahel@dhha.org.

ABSTRACT

Background: Pyogenic spondylodiscitis represents a potentially life-threatening condition. Due to the low incidence, evidence-based surgical recommendations in the literature are equivocal, and the treatment modalities remain controversial.

Case presentation: A 59 year-old patient presented with a history of thoracic spondylodiscitis resistant to antibiotic treatment for 6 weeks, progressive severe back pain, and a new onset of bilateral lower extremity weakness. Clinically, the patient showed a deteriorating spastic paraparesis of her lower extremities. An emergent MRI revealed a kyphotic wedge compression fracture at T7/T8 with significant spinal cord compression, paravertebral and epidural abscess, and signs of myelopathy. The patient underwent surgical debridement with stabilization of the anterior column from T6-T9 using an expandable titanium cage, autologous bone graft, and an anterolateral locking plate. The patient recovered well under adjunctive antibiotic treatment. She presented again to the emergency department 6 months later, secondary to a repeat fall, with acute paraplegia of the lower extremities and radiographic evidence of failure of fixation of the anterior T-spine. She underwent antero-posterior revision fixation with hardware removal, correction of kyphotic malunion, evacuation of a recurrent epidural abscess, decompression of the spinal canal, and 360 degrees fusion from T2-T11. Despite the successful salvage procedure, the patient deteriorated in the postoperative phase, when she developed multiple complications including pneumonia, acute respiratory distress syndrome, bacterial meningitis, abdominal compartment syndrome, followed by septic shock with multiple organ failure and a lethal outcome within two weeks after revision surgery.

Conclusion: This catastrophic example of a lethal outcome secondary to failure of anterior column fixation for pyogenic thoracic spondylodiscitis underlines the notion that surgical strategies for the infected spine must be aimed at achieving absolute stability by a 360 degrees fusion. This aggressive - albeit controversial - concept allows for an adequate infection control by adjunctive antibiotics and reduces the imminent risk of a secondary loss of fixation due to compromises in initial fixation techniques.

No MeSH data available.


Related in: MedlinePlus

Initial MRI obtained on the first day in the emergency department. STIR sagittal views show the extent of kyphosis at T7/T8 with vertebral body destruction due to pyogenic thoracic spondylodiscitis, spinal canal compression, anterior paravertebral and epidural abscess, and evidence of myelopathy at the T7/T8 level.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC2654872&req=5

Figure 1: Initial MRI obtained on the first day in the emergency department. STIR sagittal views show the extent of kyphosis at T7/T8 with vertebral body destruction due to pyogenic thoracic spondylodiscitis, spinal canal compression, anterior paravertebral and epidural abscess, and evidence of myelopathy at the T7/T8 level.

Mentions: A 59-year-old lady with a known history of intravenous heroin abuse, arterial hypertension, and chronic hepatitis C, presented to our emergency department with severe thoracic back pain and progressive spastic paraparesis of her lower extremities. The patient had a past history of aT7/T8 spondylodiscitis with epidural abscess, and failed conservative treatment by intravenous antibiotics at an outside institution, where the patient had been initially treated with nafcillin 10 g i.v. for 6 weeks. Due to unsuccessful eradication, the antibiotic regimen was then adapted changed to cefazolin 1 g i.v. twice daily for 6 weeks. An emergent MRI on the day of admission to our emergency departments showed a kyphotic wedge compression fracture at T7/T8 with significant spinal cord compression and myelopathy (Figure 1). She was taken to surgery the same day for a right-side anterolateral thoracotomy, radical surgical debridement, anterior corpectomy T7 and T8, discectomy T6/T7, T7/T8 and T8/T9 and anterior spinal canal decompression, prevertebral and epidural abscess evacuation. Spinal stabilization from T6 through T9 (Figure 2) was performed by vertebral body replacement using an expandable titanium cage (Synthes Synex® cage), autologous bone graft, and an anterolateral locking plate system (Synthes). There were no intra-/perioperative complications and the patient tolerated the surgical procedure well. Her postoperative course was uneventful, and the neurological impairment recovered within two weeks. She was fitted in an adjunctive TLSO brace and discharged on day 12 after clearance by physical and occupational therapy. Intravenous antibiotics were adjusted according to the intraoperative culture results and continued through a Hohn catheter on an outpatient basis with vancomycin 1 g i.v. per day for 6 weeks The patient followed up in clinic at regular intervals, showing an uneventful recovery with progressive ambulation, decreased back pain, and well-healed surgical wounds without any signs of a residual infection.


Fatal outcome after insufficient spine fixation for pyogenic thoracic spondylodiscitis: an imperative for 360 degrees fusion of the infected spine.

Flierl MA, Beauchamp KM, Bolles GE, Moore EE, Stahel PF - Patient Saf Surg (2009)

Initial MRI obtained on the first day in the emergency department. STIR sagittal views show the extent of kyphosis at T7/T8 with vertebral body destruction due to pyogenic thoracic spondylodiscitis, spinal canal compression, anterior paravertebral and epidural abscess, and evidence of myelopathy at the T7/T8 level.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2654872&req=5

Figure 1: Initial MRI obtained on the first day in the emergency department. STIR sagittal views show the extent of kyphosis at T7/T8 with vertebral body destruction due to pyogenic thoracic spondylodiscitis, spinal canal compression, anterior paravertebral and epidural abscess, and evidence of myelopathy at the T7/T8 level.
Mentions: A 59-year-old lady with a known history of intravenous heroin abuse, arterial hypertension, and chronic hepatitis C, presented to our emergency department with severe thoracic back pain and progressive spastic paraparesis of her lower extremities. The patient had a past history of aT7/T8 spondylodiscitis with epidural abscess, and failed conservative treatment by intravenous antibiotics at an outside institution, where the patient had been initially treated with nafcillin 10 g i.v. for 6 weeks. Due to unsuccessful eradication, the antibiotic regimen was then adapted changed to cefazolin 1 g i.v. twice daily for 6 weeks. An emergent MRI on the day of admission to our emergency departments showed a kyphotic wedge compression fracture at T7/T8 with significant spinal cord compression and myelopathy (Figure 1). She was taken to surgery the same day for a right-side anterolateral thoracotomy, radical surgical debridement, anterior corpectomy T7 and T8, discectomy T6/T7, T7/T8 and T8/T9 and anterior spinal canal decompression, prevertebral and epidural abscess evacuation. Spinal stabilization from T6 through T9 (Figure 2) was performed by vertebral body replacement using an expandable titanium cage (Synthes Synex® cage), autologous bone graft, and an anterolateral locking plate system (Synthes). There were no intra-/perioperative complications and the patient tolerated the surgical procedure well. Her postoperative course was uneventful, and the neurological impairment recovered within two weeks. She was fitted in an adjunctive TLSO brace and discharged on day 12 after clearance by physical and occupational therapy. Intravenous antibiotics were adjusted according to the intraoperative culture results and continued through a Hohn catheter on an outpatient basis with vancomycin 1 g i.v. per day for 6 weeks The patient followed up in clinic at regular intervals, showing an uneventful recovery with progressive ambulation, decreased back pain, and well-healed surgical wounds without any signs of a residual infection.

Bottom Line: An emergent MRI revealed a kyphotic wedge compression fracture at T7/T8 with significant spinal cord compression, paravertebral and epidural abscess, and signs of myelopathy.The patient recovered well under adjunctive antibiotic treatment.Despite the successful salvage procedure, the patient deteriorated in the postoperative phase, when she developed multiple complications including pneumonia, acute respiratory distress syndrome, bacterial meningitis, abdominal compartment syndrome, followed by septic shock with multiple organ failure and a lethal outcome within two weeks after revision surgery.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock Street, Denver, CO 80204, USA. philip.stahel@dhha.org.

ABSTRACT

Background: Pyogenic spondylodiscitis represents a potentially life-threatening condition. Due to the low incidence, evidence-based surgical recommendations in the literature are equivocal, and the treatment modalities remain controversial.

Case presentation: A 59 year-old patient presented with a history of thoracic spondylodiscitis resistant to antibiotic treatment for 6 weeks, progressive severe back pain, and a new onset of bilateral lower extremity weakness. Clinically, the patient showed a deteriorating spastic paraparesis of her lower extremities. An emergent MRI revealed a kyphotic wedge compression fracture at T7/T8 with significant spinal cord compression, paravertebral and epidural abscess, and signs of myelopathy. The patient underwent surgical debridement with stabilization of the anterior column from T6-T9 using an expandable titanium cage, autologous bone graft, and an anterolateral locking plate. The patient recovered well under adjunctive antibiotic treatment. She presented again to the emergency department 6 months later, secondary to a repeat fall, with acute paraplegia of the lower extremities and radiographic evidence of failure of fixation of the anterior T-spine. She underwent antero-posterior revision fixation with hardware removal, correction of kyphotic malunion, evacuation of a recurrent epidural abscess, decompression of the spinal canal, and 360 degrees fusion from T2-T11. Despite the successful salvage procedure, the patient deteriorated in the postoperative phase, when she developed multiple complications including pneumonia, acute respiratory distress syndrome, bacterial meningitis, abdominal compartment syndrome, followed by septic shock with multiple organ failure and a lethal outcome within two weeks after revision surgery.

Conclusion: This catastrophic example of a lethal outcome secondary to failure of anterior column fixation for pyogenic thoracic spondylodiscitis underlines the notion that surgical strategies for the infected spine must be aimed at achieving absolute stability by a 360 degrees fusion. This aggressive - albeit controversial - concept allows for an adequate infection control by adjunctive antibiotics and reduces the imminent risk of a secondary loss of fixation due to compromises in initial fixation techniques.

No MeSH data available.


Related in: MedlinePlus