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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

Postoperative CT scout (A) and chest X-ray (B) after 360° revision fixation by posterior instrumentation T2–T11 and anterior PMMA/Tobramycin mesh cage placement.
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Figure 4: Postoperative CT scout (A) and chest X-ray (B) after 360° revision fixation by posterior instrumentation T2–T11 and anterior PMMA/Tobramycin mesh cage placement.

Mentions: A posterior instrumentation was performed from T2 through T11 (Stryker Xia® polyaxial internal fixator system) with correction of the kyphotic malunion and posterolateral bone grafting. The failed anterior fixation was revised through the previous right-side anterolateral thoracotomy, by removal of the failed expandable cage and anterolateral locking plate, revision debridement of a recurrent epidural abscess, and revision fixation from T4 through T9 using a titanium mesh cage (Stryker, V-Boss® cage) filled with PMMA/Tobramycin cement (Figure 4). Despite the successful salvage procedure, the patient deteriorated in the postoperative phase in the surgical intensive care unit (SICU). She developed bacteremia, meningitis, sepsis and eventually a septic shock. Blood cultures were positive for Methicillin-sensitive S. aureus, and the patient developed a P. aeruginosa pneumonia, leading to acute respiratory distress syndrome (ARDS). A spinal tap further revealed positive cerebrospinal fluid (CSF) cultures for E. coli, implying a gram-negative bacterial meningitis. Intravenous antibiotic therapy was continued and modified according to the culture sensitivity testing with vancomycin 1 g i.v. per day Standard supportive SICU care was continued for management of ARDS and septic complications. Ultimatively, the patient developed a secondary abdominal compartment syndrome which led to impaired ventilatory capacity and the requirement for an emergent decompressive laparotomy. Within two weeks of spinal revision surgery, the patient succumbed to these postoperative complications, as a consequence of refractory septic shock with multiple organ failure.


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)

Postoperative CT scout (A) and chest X-ray (B) after 360° revision fixation by posterior instrumentation T2–T11 and anterior PMMA/Tobramycin mesh cage placement.
© Copyright Policy - open-access
Related In: Results  -  Collection

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

Figure 4: Postoperative CT scout (A) and chest X-ray (B) after 360° revision fixation by posterior instrumentation T2–T11 and anterior PMMA/Tobramycin mesh cage placement.
Mentions: A posterior instrumentation was performed from T2 through T11 (Stryker Xia® polyaxial internal fixator system) with correction of the kyphotic malunion and posterolateral bone grafting. The failed anterior fixation was revised through the previous right-side anterolateral thoracotomy, by removal of the failed expandable cage and anterolateral locking plate, revision debridement of a recurrent epidural abscess, and revision fixation from T4 through T9 using a titanium mesh cage (Stryker, V-Boss® cage) filled with PMMA/Tobramycin cement (Figure 4). Despite the successful salvage procedure, the patient deteriorated in the postoperative phase in the surgical intensive care unit (SICU). She developed bacteremia, meningitis, sepsis and eventually a septic shock. Blood cultures were positive for Methicillin-sensitive S. aureus, and the patient developed a P. aeruginosa pneumonia, leading to acute respiratory distress syndrome (ARDS). A spinal tap further revealed positive cerebrospinal fluid (CSF) cultures for E. coli, implying a gram-negative bacterial meningitis. Intravenous antibiotic therapy was continued and modified according to the culture sensitivity testing with vancomycin 1 g i.v. per day Standard supportive SICU care was continued for management of ARDS and septic complications. Ultimatively, the patient developed a secondary abdominal compartment syndrome which led to impaired ventilatory capacity and the requirement for an emergent decompressive laparotomy. Within two weeks of spinal revision surgery, the patient succumbed to these postoperative complications, as a consequence of refractory septic shock with multiple organ failure.

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