|SYMPOSIUM – POST SURGICAL SPINE INFECTION
|Year : 2018 | Volume
| Issue : 1 | Page : 17-23
The scope of minimally invasive techniques in spinal infections
Arvind Gopalrao Kulkarni, Navin Geralal Mewara
Departments of Orthopedics and Spine Surgery and Mumbai Spine Scoliosis and Disc Replacement Centre, Bombay Hospital and Medical Research Center, Mumbai, Maharashtra, India
|Date of Web Publication||17-Jan-2018|
Dr. Arvind Gopalrao Kulkarni
Department of Orthopedics and Spine Surgery, Room Number-206, Bombay Hospital and Medical Research Center, Marine Lines, Mumbai - 400 002, Maharashtra
Source of Support: None, Conflict of Interest: None
The primary goals for treating infectious spinal conditions are to make an accurate diagnosis, isolate the causative organism, and prescribe effective antibiotic therapy based on the culture reports. A positive culture is extremely important for successful treatment and prevention of further morbidity. Surgically collected samples have shown to have a greater chance of demonstrating growth of organism on culture as compared to computed tomography-guided fine-needle samples. Surgical drainage and/or reconstruction with/or without fixation is usually indicated when there is no or poor response to antibiotic therapy, systemic toxicity with evidence of large collections, progressive spinal deformity, or instability or neurological impairment. However, the incidence of perioperative morbidity is particularly increased in elderly patients or in those with a poor general condition. With improved instrumentation and techniques in minimally invasive spine surgery, spinal infections can be successfully treated by minimally invasive debridement followed by pharmacological treatment, without causing any destabilization to spine. Where major reconstruction and fixation procedures are deemed mandatory, various MIS techniques can be utilized to decrease the surgery related morbidity and allow for faster rehabilitation. These procedures are associated with steep learning curve. With the advent of intraoperative navigation, the exposure to radiations can be significantly reduced.
Keywords: Immunocompromised, minimally invasive spine surgery, percutaneous endoscopic discectomy and drainage, spinal infection
|How to cite this article:|
Kulkarni AG, Mewara NG. The scope of minimally invasive techniques in spinal infections. Indian Spine J 2018;1:17-23
| Introduction|| |
Infectious spinal conditions are becoming increasingly prevalent, especially in elderly or immune compromised patients or those with medical comorbidities. This increase has been due to vast improvements in medical care and prolonged life expectancies. Identifying the offending pathogen is critical to administration of the correct antibiotics for nonoperative treatment. To procure a sample of tissue for biopsy and culture, many techniques have been employed with pathogen identification rate from 36% to 92%.,,,, Debridement and reconstruction with or without posterior instrumentation are the traditional gold standard surgical procedures for cases that require surgical treatment; however, this is associated with high rates of postoperative complications, especially in immunocompromised patients with many comorbid diseases or in the elderly.
Over the last few decades, minimally invasive spinal surgery has been increasingly used. In degenerative spinal disorders, minimally invasive spine surgery (MISS) has proven to reduce blood loss, muscular trauma, and the hospital stays. MISS also helps to decrease the overall rate of surgical-site infections. With an increase in the experience with MISS, it is gaining popularity for patients with spinal infections. The innovations in techniques such as intraoperative navigation systems have helped to increase the accuracy of these procedures and reduce the overall exposure to radiations. MIS techniques that can be employed in spinal infections can be broadly categorized as: needle based, tubular retractor based, endoscopic techniques, and thoracoscopic techniques. The scope of MISS in spinal infections includes the following: to obtain specimens for culture, drainage of epidural abscesses, percutaneous debridement of infected disc in early stage, anterior debridement and reconstruction followed by posterior MIS screw fixation, utilization of MIS direct lateral interbody fusion/extreme lateral interbody fusion (DLIF/XLIF) techniques, transforaminal debridement with interbody fusion and percutaneous pedicle screw fixation, and integration of MISS techniques with intraoperative navigation. The advantages of using MISS techniques include lesser blood loss, lesser use of blood products, shorter hospital stays, quicker rehabilitation (which is extremely important in these patients), and reduced overall cost.
| Percutaneous Transpedicular Biopsy|| |
Obtaining biopsy specimen from the affected vertebral body and disc space is extremely important for initiation of proper antibiotics. In cases of spinal infections, the reported accuracy of spinal biopsy varies from 36% to 92%., Computed tomography (CT) guided needle biopsies can have accuracy up to 90%, but is associated with an increased risk of exposure to radiations. Minimally invasive percutaneous transpedicular biopsy (PTB) has shown to yield high cultures in both pyogenic and granulomatous conditions, with accuracy up to 92%. PTB can avoid the complications associated with paraspinal needle biopsy of vertebral lesions. The advantages of PTB are: (1) Can be performed under local anaesthesia (2) The needle can be positioned real time under fluoroscopic guidance (3) Through one pedicle more than 50% of body and disc tissue can be accessed. Since the technique is similar to vertebroplasty, thus it is familiar to most spinal surgeons.
The procedure is usually performed under local anesthesia. Intravenous sedation may be given. The chosen vertebral level and the pedicle are marked and probed in the anteroposterior (AP) view with a Jamshedi needle, after a stab incision. With the fluoroscopy now brought into lateral view, the needle is tapped gently with a mallet through the pedicle into the intended area of the vertebral body [Figure 1]. Core biopsy samples are sent for histopathological examination in a sterile container. The procedure may be repeated on the opposite side if required. The integrity of the pedicle margins must be preserved at all times, especially the medial and inferior borders. This is to prevent the spread of hematoma, infection, or tumor into the spinal canal. No drain is needed.
|Figure 1: (a) A true anteroposterior view with entry site for the Jamshedi needle. (b) Lateral view showing the needle entering the vertebral body|
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| Percutaneous Endoscopic Discectomy and Drainage|| |
Numerous minimally invasive, percutaneous, endoscopic procedures for lumbar disc herniation have been developed for spinal surgery, with clinical outcomes comparable to those of conventional open surgery., The minimal invasiveness and acceptance of this technique for lumbar disc herniation has led the authors to apply it in treating infectious spondylitis in select cases. Obtaining a sufficient amount of material for microbiological examination directly from the infected region is possible. In addition, eradication and irrigation of infected and necrotic tissues from a disc and even an epidural space facilitate a fenestration similar to open debridement.
Yang et al. evaluated 15 patients with infectious spondylitis treated by percutaneous endoscopic discectomy and drainage (PEDD) and appropriate parenteral antibiotics. The patients had presented with intractable back pain requiring narcotic pain control and bed rest. The inclusion criteria were (1) early-stage spondylitis (clinical, pathological, and radiological) and (2) complicated spondylitis in patients of advanced age and/or with a compromising medical condition. Patients with an infection associated with epidural abscess resulting in the neurological deficit were excluded. Thirteen patients (86.7%) reported immediate relief of back pain following PEDD. The remaining two patients, who had persistent infection and severe back pain, underwent anterior debridement with accompanied autograft interbody fusion 1 and 2 weeks after PEDD, respectively. The causative bacteria were identified in 13 (86.7%) specimens. Eleven patients responded to PEDD and were successfully treated with at least a 6 week course of parenteral antibiotics therapy or full-course antimicrobial chemotherapy. However, no surgery related complications or side effects were noted during at least 12 months of follow up. Remaining four of the 15 patients underwent anterior debridement and fusion with autograft because the pathogens or progressive infection had not been identified. These four developed extensive osteolytic destruction of the vertebral body with spinal instability and/or kyphotic deformity. The authors concluded that PEDD is an effective alternative to spinal biopsy and should be considered prior to extensive anterior surgery for infectious spondylitis in carefully selected cases. It is especially recommended for patients with early stage spinal infection or serious medical problems.
Hsu et al. retrospectively evaluated the clinical outcomes of bilateral PEDD in the treatment of patients with single level lumbar pyogenic spondylitis, in 22 patients. The causative bacteria were identified in 19 (86.4%) of the 22 biopsy specimens. Chen et al. demonstrated the safety and effectiveness of CT-assisted PEDD in the treatment of infectious spondylodiscitis of the thoracic and upper lumbar spines.
Under local anesthesia and conscious sedation, the target site is localized with a spinal needle that passed 8–10 cm away from the midline under fluoroscopic guidance. A guide wire is inserted through the spinal needle into the central disc space and the spinal needle is withdrawn. A small stab incision (about 1 cm) is placed; a dilator and the cannulated sleeve are passed. The dilator is withdrawn and a cutting tool is used to harvest a core of impacted biopsy specimen. Percutaneous debridement using the biopsy forceps and shaver is followed by normal saline irrigation. Finally, a drainage tube is inserted into the debrided disc space and connected to a negative-pressure Hemovac. The biopsy specimen containing disc material and parts of vertebral endplates of adjacent vertebrae is examined histopathologically for microorganisms.
| Tubular Decompression|| |
While percutaneous endoscopic techniques are not widely used by all surgeons, surgery through a tubular retractor is a familiar technique to many spine surgeons. With regard to spinal epidural abscess (SEA), Reihsaus et al. determined that laminectomy was the procedure recommended by most authors and should be performed emergently following its diagnosis. However, laminectomy over several levels, especially in the cervicothoracic spine, and particularly in children and young adults, carries the risk of development of spinal deformity., Extensive SEA decompressed through conventional surgical approach is also associated with high rates of morbidity and mortality such as increased blood loss, increased pain, delayed mobilization, and longer hospital stay and recovery time.
The patient is placed prone on two horizontal bolsters under general anesthesia. The level and extent of involvement are carefully evaluated on preoperative magnetic resonance imaging studies. The entry site is then marked about 1 cm paramedial and a spinal needle is inserted at the disc level with the help of fluoroscopy. The sequential tubular dilators (METRx ®, Medtronic Sofamor Danek) are used after incising skin and fascia and 18-mm-diameter retractor tube is docked on the inferior part of the superior lamina [Figure 2]a. A hemilaminectomy is completed under the microscope [Figure 2]b using high-speed drilling and Kerrison rongeurs. The infectious material is drained once ligamentum flavum is cut. The small-angled pituitary suction tips can be connected to Silastic ® tubing and placed down into the epidural space once spontaneous drainage ends. Copious irrigation is performed through these tubes until all infectious materials are evacuated. No drain is required once procedure is completed. Cultures are taken during the evacuation for postoperative adjustment of the patient's antibiotic regimen.
|Figure 2: (a) Docking of an 18-mm tubular retractor, (b) Microscopic view|
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| Posterior Transforaminal Lumbar Decompression and Interbody Fusion|| |
Lumbar pedicle screw fixation with transforaminal lumbar interbody fusion (TLIF) is an established, safe, and effective surgical technique in patients with infective spondylodiscitis. It provides adequate surgical debridement and enables immediate stabilization, if necessary. Nevertheless, open pedicle screw fixation with TLIF is an invasive surgical intervention that may be associated with several risks. Therefore, minimally invasive techniques developed for degenerative diseases have been applied in infected cases to minimize tissue damage, reduce narcotic requirements, decrease blood loss, and potentially avoid prolonged immobilization. This is of great interest, especially in spondylodiscitis patients who frequently suffer from severe comorbidities. Viezens et al. retrospectively evaluated 148 patients comparing the safety and efficacy of minimally invasive and open surgeries over a period of 9 years. The patients were divided into two groups: 75 underwent MISS and 73 open surgery. The two groups did not differ in terms of age, body mass index, American Society of Anesthesiologists score, comorbidities, septic disease, or preoperative neurologic deficit. The two methods were associated with similar postoperative stays in the intensive care unit, overall hospital stays, complication rates, and postoperative survival. However, MISS was associated with a significantly shorter operating time, a lower perioperative need for blood products, and, as expected, increased intraoperative fluoroscopy duration. They concluded that MISS is safe and effective for spontaneous pyogenic thoracic and lumbar spondylodiscitis.
Under general anesthesia, the patient is placed prone on two vertical bolsters. Two 3-cm incisions are placed approximately 4 cm paraspinal at the involved level for passage of guide wires into the pedicles of the involved segment. The 22-mm-diameter tube is docked at the ipsilateral facets over the sequential dilators [Figure 3]. Facetectomy and hemilaminectomy are done to decompress the ipsilateral side of the spinal canal. Furthermore, the contralateral side of the spinal canal can also be reached if required by tilting the tube and the table toward the contralateral side. After adequate decompression, interbody fusion is performed. Ipsilateral and contralateral pedicle screws are passed over the guide wires. A rod is introduced with the help of a zig assembly. When using intraoperative navigation, an extra 2-cm midline incision is placed at one or two level above the affected segment in order to fix the reference frame to the spinous process.
|Figure 3: (a-d) X-ray and magnetic resonance imaging showing L4 L5 spondylodiscitis, in a 50-year-old male, 6 weeks post-discectomy, (e) Intraoperative images showing a reference frame for the navigation at the spinous process of L2 with guide wires inserted into all the four pedicles and use of a navigable probe to guide for the tubular decompression and interbody fusion (f and g) Immediate postoperative X-rays. (h) Postoperative wound healing|
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| Lateral Transpoas Lumbar Interbody Decompression and Fusion|| |
The lateral retroperitoneal transpsoas approach has demonstrated utility in providing an adequate surgical corridor for interbody fusion in patients with degenerative back pain, scoliosis, spondylolisthesis, trauma, and tumor, among other indications. Although the lateral transpsoas approach has been effectively studied for these indications, there have been very few dedicated reports of its utility in the treatment of spinal infections.
Lateral lumbar interbody fusion (LLIF) may provide an ideal treatment option because it provides a direct surgical corridor to the anterior and middle columns without disrupting the unaffected posterior elements or traversing the neural elements and risking injury. The great vessels do not have to be mobilized, as is necessary with a true anterior approach. The other advantages of LLIF include decreased tissue trauma, blood loss, and operative time, which are further valued in the treatment of this patient population who generally present in a poor medical condition. In the obese population, the lateral positioning tends to decreases the working distance to reach the vertebral bodies, as the pannus often falls forward. The lateral positioning is more tolerable for obese patients, as opposed to the more traditional posterior approach where they may experience decreased oxygenation and/or ventilation. It is important to educate patients prior to surgery of the possibility of transient sensory and motor symptoms related to this approach. The majority of the symptoms are thought to be related to psoas muscle inflammation and/or stretch injury to the genitofemoral nerve due to the surgical corridor traversed during the operation. No major injuries to the lumbar plexus are usually encountered.
Under general anesthesia, the patient is positioned in the standard lateral decubitus position. The level is identified under fluoroscopy. After an oblique incision, blunt dissection is used to dissect down to the level of the psoas muscle, at which point sequential dilator tubes are used to traverse the psoas [Figure 4]. After ensuring adequate safe placement, the tubular retractor system is docked and fixed with the table mount. The disc space and vertebral bodies are then exposed and derided extensively. Multiple cultures and specimens are sent for pathological analysis. After complete debridement and end plate preparation, interbody fusion is completed with a cage and graft. This is followed by anterior ± posterior fixation.
|Figure 4: (a) Intraoperative lateral position with a break in the table at the level of greater trochanter. (b and c) Use of tubular retractor and the transpsoas corridor used to access the disc space through a retroperitoneal approach|
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Patel et al. presented a series of six patients with discitis and osteomyelitis who were surgically treated through a minimally invasive lateral transpsoas approach to the lumbar spine (DLIF/XLIF). The patients underwent debridement with a discectomy and partial or complete corpectomy, with polyetheretherketone or titanium cage placement, with only two patients requiring additional posterior fixation with percutaneous pedicle screws. The author reported satisfactory debridement and hardware placement on CT scan. The patients experienced significant pain relief and were ambulatory within few days of surgery. At one year followup stable hardware with good fusion was demonstrated and the patients continued to have pain improvement. They concluded that due to the significant comorbidities in this patient population, a minimally invasive approach is a suitable surgical technique.
Wang et al. described the application of minimally invasive XLIF in combination with percutaneous pedicle screw fixation in the treatment of lumbar tuberculosis (TB) in an elderly patient. They concluded that satisfying results can be obtained with this procedure in terms of correcting spinal deformity, eradicating infection, achieving spinal decompression, and obtaining functional improvement in the treatment of lumbar TB if proper surgical indications are correctly followed.
| Video-Assisted Thoracoscopic Surgery|| |
In the early 1990s, video-assisted thoracoscopic surgery (VATS) techniques were applied to the treatment of spinal diseases simultaneously by both Rosenthal and Dickman in Germany and Mack et al. in the United States., VATS techniques have been used for the management of thoracic and thoracolumbar junction pathologies, including thoracic disc herniation, fractures, TB spondylitis, idiopathic scoliosis, neuromuscular spinal deformity, congenital scoliosis, and tumors.,,
A retrospective analysis comparing VATS with MISTLIF, in patients with TB of dorsal and lumbar spines, was reported by Kandwal et al. The indications of surgery in both the groups were neurological deficits not responding to antituberculous chemotherapy for 4–6 weeks or instability (AP or lateral translation; kyphosis). Good surgical decompression and interbody fusion were achieved by both the groups. Postoperative improvement in the Oswestry Disability Index (ODI) and visual analog scale (VAS) scores was significantly achieved. In VATS group, the most common complication was conversion to open thoracotomy, seen in three patients. Two had prolonged (5 days) intercostal drainage tube in situ due to a persistent air leak. One patient had a superficial wound infection. In MISTLIF group, one patient reported pseudoarthrosis with screw loosening and clinico radiological evidence of persistent disease at 6 months of follow up; she later improved clinically with the second line of antitubercular chemotherapy with good fusion status.
VATS , provides excellent direct intraoperative visualization of the abnormality, anterior and anterolateral reconstruction can be performed to provide effective anterior load bearing, and multisegmental abnormality can be dealt with or without the need for additional rib resection. VATS avoids division of the diaphragm and significantly reduces injury to the chest wall. In addition, there is lesser postoperative pain, better cosmetic effect, lower perioperative morbidity, and an earlier return to normal activity. On the contrary,, VATS involves an extremely steep learning curve, the costs for thoracoscopic instrumentation are high, and the posterior elements, the contralateral pedicle, or contralateral transverse process cannot be exposed. The associated complications  include intraoperative bleeding due to damage of the segmental vessels and intercostal vessels. It is important to identify the segmental vessels during the procedure at the midportion of the vertebral body. Although ligation of the segmental vessels is a time-consuming procedure, it eliminates catastrophic intra- or postoperative bleeding. Transient intercostal neuralgia is the second most common complication, but it usually resolves spontaneously in 1–2 weeks. Other complications include pulmonary atelectasis or pleural effusions and postoperative chylothorax.
| Minimally Invasive Spine Surgery Coupled With Intraoperative Navigation|| |
In order to improve the identification of anatomic structure and the accuracy of pedicle screw placement, the intraoperative fluoroscopy and intraoperative computed tomography (iCT) guided navigation has been developed and may play a significant role in MISS. In their study, Wu et al. aimed to evaluate the safety and efficacy of using iCT-guided navigation in simultaneous minimally invasive anterior and posterior surgery for infectious spondylitis. With the patient in lateral decubitus position and the reference array fixed to the iliac crest, pedicle screws were first inserted with the aid of iCT-guided navigation. This is followed by minimal access anterior decompression and reconstruction. The anterior spine lesions localized by iCT-guided navigation is peroperatively targeted, followed by curettage and debridement of the lesion, obtaining tissue specimens, decompression of the epidural space, and placement of autogenous bone struts from the ileum or excised rib into the intervertebral space. Finally, the connecting rods are inserted and anchored in pedicle screw heads to achieve stabilization. Out of 54 pedicle screws employed, 53 screws were placed correctly. There was a significant improvement in terms of clinical (ODI and VAS scores), neurological (ASIA impairment scale), and radiological (Cobb's angle) parameters. They concluded that iCT-guided navigation approach can provide a good intraoperative orientation and visualization of anatomic structures and also high pedicle screw placement accuracy. The author regularly uses intraoperative navigation for the routine MISTLIF.
| Conclusion|| |
MIS in conjugation with intraoperative navigation has proven the test of time. A transpedicular biopsy is safe and a low morbid procedure that can be performed under local anesthesia with high rates of tissue yield. PEDD can be safely performed for early stage spinal infections without any evidence for instability with high changes of positive cultures and effective irrigation of the infected segments. Tubular decompression of the epidural abscess can be performed at multiple levels without causing instability of the involved segments. MISTLIF and LLIF  can be employed in conditions demanding stabilization. VATS can be used for decompression and fixation of the affected segments, but has its own set of advantages and disadvantages. MIS provides a less morbid opportunity to the already compromised individuals with the added advantages of less blood loss, lesser hospital stay, and early mobilization that are essential in this group of patients. Each procedure is associated with steep learning curve and surgeon can choose any of these according to his/her training and the demand of the situation.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]