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Single-stage debridement and spinal fusion using PEEK cages through a posterior approach for eradication of lumbar pyogenic spondylodiscitis: a safe treatment strategy for a detrimental condition.

Tschöke SK, Fuchs H, Schmidt O, Gulow J, von der Hoeh NH, Heyde CE - Patient Saf Surg (2015)

Bottom Line: Oral antibiotics were continued for 12 weeks postoperatively and clinical and radiological results recorded throughout a minimum 1-year clinical follow-up.Furthermore, two-plane conventional X-rays showed no significant implant subsidence or failure at any of the given time-points in up to 5 years postoperatively.In patients meeting the criteria for surgical treatment of lumbar pyogenic spondylodiscitis, the implantation of PEEK cages using a single-step TLIF approach is a safe and feasible procedure.

View Article: PubMed Central - PubMed

Affiliation: Department of Spine Surgery, HELIOS Park Hospital Leipzig, Leipzig, Germany.

ABSTRACT

Background: Pyogenic infections of the lumbar spine are a rare but critical pathology, yet with considerably high mortality rates. In cases indicating surgical therapy, the implantation of titanium cages or autologous bone grafts represent today's gold standard. Although non-metallic implants such as poly-ether-ether-ketone (PEEK) have proven to be advantageous in diverse degenerative conditions, their saftey and practicability in lumbar spine infection remains questionable. Moreover, the efficacy of a single-step radical debridement of the infected disc space with subsequent fusion from a strictly posterior approach continues to be an issue of debate. We therefore sought to evaluate the feasibility, clinical and radiological outcome of a single-step TLIF procedure using oblique PEEK cages in the surgical management of patients with lumbar pyogenic spondylodiscitis.

Methods: From January 2009 through December 2013, all patients meeting the indication for surgical treatment of lumbar pyogenic spondylodiscitis were included. Patients demonstrating intact cortical bone on preoperative CT received a single-step radical debridement of the infected intervertebral disc space, posterior screw-and-rod instrumentation and implantation of an oblique PEEK cage using the TLIF technique. Oral antibiotics were continued for 12 weeks postoperatively and clinical and radiological results recorded throughout a minimum 1-year clinical follow-up.

Results: A total of 104 patients were admitted to receive surgical therapy for lumbar pyogenic spondylodiscitis. Within this patient population, 18 patients met the diagnostic criteria to receive the implantation of an oblique PEEK cage. Pathogens were detected in 13 cases with Staph. aureus being the predominant causative organism. All patients were discharged to recover in their domestic environment. Throughout the first year of clinical and radiological follow-up and beyond, none of the 18 patients demonstrated any signs of residual neurologic deficits or recurrent infection. Furthermore, two-plane conventional X-rays showed no significant implant subsidence or failure at any of the given time-points in up to 5 years postoperatively.

Conclusions: In patients meeting the criteria for surgical treatment of lumbar pyogenic spondylodiscitis, the implantation of PEEK cages using a single-step TLIF approach is a safe and feasible procedure. Based on our experience, the concern of a recurrent infection when implanting non-metallic cages may be refuted in carefully selected patients.

No MeSH data available.


Related in: MedlinePlus

Pre- and post-operative conventional X-rays in the a.p. view (upright standing) throughout the 3 year follow-up
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Fig5: Pre- and post-operative conventional X-rays in the a.p. view (upright standing) throughout the 3 year follow-up

Mentions: From January 2009 through December 2013 a total number of 104 patients (62 male and 42 female patients) with a mean age of 75.0 ± 8.3 years presented with lumbar pyogenic spondylodiscitis requiring surgical therapy. Eighteen of these patients (4 male and 14 female patients, mean age 74.3 ± 7.2 years) were prospectively enrolled into the study by means of the above mentioned criteria (Table 1), and subsequently received the TLIF procedure with PEEK cage implantation as described. Upon admission, these 18 patients presented with an average VAS of 9.0 ± 0.5 and an ODI (%) of 77.0 ± 5.7. Laboratory results demonstrated mean baseline CRP serum level concentrations of 159.4 mg/l ± 53.9 mg/l and a mild leucocytosis with an average of 11.1/nl ± 4.8/nl. The most common comorbidity was a coronary heart disease with or without cardiomyopathy, respectively (Table 2). All 18 patients (n = 18) had a past medical history of acute bacterial infection involving either the nasopharynx or the respiratory tract but none of the patients presented with sepsis. Neurologic impairment was evident in two cases (n = 2), demonstrating lumbar radiculopathy with mild unilateral sensomotoric dysfunction. The average postoperative stay on the intensive care unit was 1.9 days (0–3 days). One patient (n = 1) demonstrated immobilizing pain (VAS 8/10) despite appropriate conservative treatment and an additional abscess formation within the right psoas muscle at the level of infection. The surgical procedure included drainage of the abscess via the ipslateral disc space by perforating the lateral anulus and carefully advancing a soft infant feeding tube into the respective area under fluorscopic guidance (Figs. 1, 2, 3). A second patient (n = 1) presented with a suspected bisegmental infection at the L3/4 and L4/5 level with secondary kyphosis and immobilizing pain (VAS 10/10). The surgical procedure consisted of a two level posterior decompression, removal of the purulent L3/4 disc, debridement of L4/5 and bisegemental fusion of L3-5 in TLIF technique (Figs. 4, 5, 6). However, only the L3/4 level resulted positive in the subsequent microbiological analysis.Table 1


Single-stage debridement and spinal fusion using PEEK cages through a posterior approach for eradication of lumbar pyogenic spondylodiscitis: a safe treatment strategy for a detrimental condition.

Tschöke SK, Fuchs H, Schmidt O, Gulow J, von der Hoeh NH, Heyde CE - Patient Saf Surg (2015)

Pre- and post-operative conventional X-rays in the a.p. view (upright standing) throughout the 3 year follow-up
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4641346&req=5

Fig5: Pre- and post-operative conventional X-rays in the a.p. view (upright standing) throughout the 3 year follow-up
Mentions: From January 2009 through December 2013 a total number of 104 patients (62 male and 42 female patients) with a mean age of 75.0 ± 8.3 years presented with lumbar pyogenic spondylodiscitis requiring surgical therapy. Eighteen of these patients (4 male and 14 female patients, mean age 74.3 ± 7.2 years) were prospectively enrolled into the study by means of the above mentioned criteria (Table 1), and subsequently received the TLIF procedure with PEEK cage implantation as described. Upon admission, these 18 patients presented with an average VAS of 9.0 ± 0.5 and an ODI (%) of 77.0 ± 5.7. Laboratory results demonstrated mean baseline CRP serum level concentrations of 159.4 mg/l ± 53.9 mg/l and a mild leucocytosis with an average of 11.1/nl ± 4.8/nl. The most common comorbidity was a coronary heart disease with or without cardiomyopathy, respectively (Table 2). All 18 patients (n = 18) had a past medical history of acute bacterial infection involving either the nasopharynx or the respiratory tract but none of the patients presented with sepsis. Neurologic impairment was evident in two cases (n = 2), demonstrating lumbar radiculopathy with mild unilateral sensomotoric dysfunction. The average postoperative stay on the intensive care unit was 1.9 days (0–3 days). One patient (n = 1) demonstrated immobilizing pain (VAS 8/10) despite appropriate conservative treatment and an additional abscess formation within the right psoas muscle at the level of infection. The surgical procedure included drainage of the abscess via the ipslateral disc space by perforating the lateral anulus and carefully advancing a soft infant feeding tube into the respective area under fluorscopic guidance (Figs. 1, 2, 3). A second patient (n = 1) presented with a suspected bisegmental infection at the L3/4 and L4/5 level with secondary kyphosis and immobilizing pain (VAS 10/10). The surgical procedure consisted of a two level posterior decompression, removal of the purulent L3/4 disc, debridement of L4/5 and bisegemental fusion of L3-5 in TLIF technique (Figs. 4, 5, 6). However, only the L3/4 level resulted positive in the subsequent microbiological analysis.Table 1

Bottom Line: Oral antibiotics were continued for 12 weeks postoperatively and clinical and radiological results recorded throughout a minimum 1-year clinical follow-up.Furthermore, two-plane conventional X-rays showed no significant implant subsidence or failure at any of the given time-points in up to 5 years postoperatively.In patients meeting the criteria for surgical treatment of lumbar pyogenic spondylodiscitis, the implantation of PEEK cages using a single-step TLIF approach is a safe and feasible procedure.

View Article: PubMed Central - PubMed

Affiliation: Department of Spine Surgery, HELIOS Park Hospital Leipzig, Leipzig, Germany.

ABSTRACT

Background: Pyogenic infections of the lumbar spine are a rare but critical pathology, yet with considerably high mortality rates. In cases indicating surgical therapy, the implantation of titanium cages or autologous bone grafts represent today's gold standard. Although non-metallic implants such as poly-ether-ether-ketone (PEEK) have proven to be advantageous in diverse degenerative conditions, their saftey and practicability in lumbar spine infection remains questionable. Moreover, the efficacy of a single-step radical debridement of the infected disc space with subsequent fusion from a strictly posterior approach continues to be an issue of debate. We therefore sought to evaluate the feasibility, clinical and radiological outcome of a single-step TLIF procedure using oblique PEEK cages in the surgical management of patients with lumbar pyogenic spondylodiscitis.

Methods: From January 2009 through December 2013, all patients meeting the indication for surgical treatment of lumbar pyogenic spondylodiscitis were included. Patients demonstrating intact cortical bone on preoperative CT received a single-step radical debridement of the infected intervertebral disc space, posterior screw-and-rod instrumentation and implantation of an oblique PEEK cage using the TLIF technique. Oral antibiotics were continued for 12 weeks postoperatively and clinical and radiological results recorded throughout a minimum 1-year clinical follow-up.

Results: A total of 104 patients were admitted to receive surgical therapy for lumbar pyogenic spondylodiscitis. Within this patient population, 18 patients met the diagnostic criteria to receive the implantation of an oblique PEEK cage. Pathogens were detected in 13 cases with Staph. aureus being the predominant causative organism. All patients were discharged to recover in their domestic environment. Throughout the first year of clinical and radiological follow-up and beyond, none of the 18 patients demonstrated any signs of residual neurologic deficits or recurrent infection. Furthermore, two-plane conventional X-rays showed no significant implant subsidence or failure at any of the given time-points in up to 5 years postoperatively.

Conclusions: In patients meeting the criteria for surgical treatment of lumbar pyogenic spondylodiscitis, the implantation of PEEK cages using a single-step TLIF approach is a safe and feasible procedure. Based on our experience, the concern of a recurrent infection when implanting non-metallic cages may be refuted in carefully selected patients.

No MeSH data available.


Related in: MedlinePlus