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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 102-109

Single-level lumbar pyogenic discitis treated with combined minimally invasive posterior and mini-open anterior approach: Functional outcome analysis


Department of Spine Surgery, MIOT International Hospital, Chennai, Tamil Nadu, India

Date of Submission27-Feb-2019
Date of Decision26-Jul-2019
Date of Acceptance29-Oct-2019
Date of Web Publication05-Feb-2020

Correspondence Address:
Dr. Narendra R Medagam
Dr. Narendra R. Medagam, Department of Spine Surgery MIOT International, Manappakam, Chennai 600089, Tamil Nadu.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/isj.isj_12_19

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  Abstract 

Study Design: This was a retrospective study. Objective: The objective of this study was to evaluate the clinico-radiological outcome in single-level lumbar pyogenic discitis treated with single-stage combined percutaneous posterior stabilization with mini-open anterior debridement and fusion under single anesthesia. Materials and Methods: We retrospectively reviewed 27 patients with single-level lumbar pyogenic discitis who presented to our institute from January 2010 to August 2015. All the patients underwent preoperative evaluation with blood parameters including complete blood count, erythrocyte sedimentation rate, C-reactive protein, blood and urine cultures, and imaging studies. They underwent single-stage combined posterior percutaneous stabilization with mini-open anterior debridement and fusion with tricortical iliac crest graft under the same anesthesia. They were followed up at regular intervals with clinical and radiological assessment with minimum follow-up of 24 months. Preoperative and postoperative final follow-up assessments of neurological status, pain, and disability were conducted using the Frankel Grade scoring, visual analog scale (VAS) score, and Oswestry Disability Index (ODI), respectively. Results: This study included 10 women and 17 men (n = 27) with average age of 57 years (range: 45–73 years). The mean operative time was 194min (range: 150–230min). The mean intraoperative blood loss was 212mL (range: 100–350mL). The mean VAS score (0.56) at final follow-up was significantly lower than the mean preoperative VAS score (7.30) with P < 0.001. The ODI scores at final follow-up (mean, 13.48) were significantly lower than preoperative ODI scores (mean, 83.70) with P < 0.001. Conclusion: Single-stage combined posterior percutaneous stabilization with mini-open anterior debridement and fusion under one anesthesia is an effective alternative to conventional open technique as it allows thorough debridement and rigid fixation, and results in minimal blood loss and lesser postoperative complications.

Keywords: Combined approach, lumbar pyogenic discitis, mini-open anterior approach, percutaneous pedicle screw, single stage


How to cite this article:
Dhillon CS, Medagam NR, Ega S, Tantry R, Chhasatia NP. Single-level lumbar pyogenic discitis treated with combined minimally invasive posterior and mini-open anterior approach: Functional outcome analysis. Indian Spine J 2020;3:102-9

How to cite this URL:
Dhillon CS, Medagam NR, Ega S, Tantry R, Chhasatia NP. Single-level lumbar pyogenic discitis treated with combined minimally invasive posterior and mini-open anterior approach: Functional outcome analysis. Indian Spine J [serial online] 2020 [cited 2020 Feb 27];3:102-9. Available from: http://www.isjonline.com/text.asp?2020/3/1/102/277796




  Introduction Top


Lumbar pyogenic spondylodiscitis has a low incidence rate, but its onset is typically acute and is accompanied by severe pain and constitutional symptoms.[1] It commonly results from primary hematogenous infection[2] or occurs after lumbar disc surgery or invasive procedures.[3] The failure of conservative measures, compression of neural elements, mechanical instability, and intractable pain make surgery imperative in most cases.[4] Nonetheless, surgical approaches and techniques for spondylodiscitis are still a matter of controversy.[5],[6],[7],[8],[9],[10],[11],[12]

Currently, anterior debridement and fusion in combination with posterior stabilization is widely used for the treatment of pyogenic spondylodiscitis.[1],[5],[8], [13,[14],[15] However, conventional lumbar anterior debridement and the posterior midline approach entail more surgical trauma, bleeding, and longer stay in hospital.[8], [13,[14],[15]

The purpose of our study was to evaluate the clinico-radiological outcome in single-level lumbar pyogenic spondylodiscitis treated with single-stage combined percutaneous posterior stabilization with mini-open anterior debridement and fusion under single anesthesia.


  Materials and Methods Top


We retrospectively reviewed 27 patients with single-level lumbar pyogenic spondylodiscitis who presented to our institute from January 2010 to August 2015. Patients with single-level lumbar discitis at L2-3, L3-4, and L4-5 were included in this study. Those with L5-S1 discitis, extensive vertebral destruction, and multiple-level discitis were excluded from the study as they require more extensile anterior approach. The indications for surgery in our study were compression of neural elements, mechanical instability, and intractable pain not responding to conservative management.

All the patients underwent thorough clinical and neurological examination. Of 27 patients, six patients presented with Frankel Grade D neurological deficit, whereas the remaining had intact neurology. They underwent preoperative evaluation with blood parameters such as total count (TC), differential count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), blood and urine culture, and imaging studies including X-rays, computed tomography (CT) scans, and magnetic resonance imaging. They were diagnosed with lumbar spondylodiscitis based on clinical presentation such as rest pain, severe mechanical low backache on slightest spine movements, constitutional symptoms, and laboratory parameters such as raised TC, ESR, CRP, and positive blood and urine cultures. Imaging studies were correlated with positive findings for the signs of intervertebral infection [Figure 1]. All the patients underwent single-stage combined posterior minimally invasive stabilization with mini-open anterior debridement and fusion using tricortical iliac crest graft under single anesthesia.
Figure 1: Preoperative computed tomography and magnetic resonance imaging showing L4-5 end plates erosion with discitis

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Postoperatively, broad-spectrum antibiotics were started empirically, and specific antibiotics were reinstated according to the results of the bacterial culture and drug sensitivity tests. Antibiotics were continued for minimum six weeks or until the symptoms and signs disappeared and TC, ESR, and CRP levels returned to normal. For patients with a negative bacterial culture, broad-spectrum antibiotics were empirically used for six weeks.

All the patients were followed up at regular intervals with clinical assessment, blood parameters, and imaging studies. White blood cell count, ESR, and CRP were reviewed weekly until the results returned to normal. Lumbar X-rays were taken at 1, 3, 6, 12, and 24 months to assess intervertebral fusion. Preoperative and postoperative final follow-up assessment of neurological status was carried out using Frankel Grade scoring system. Pain and disability assessment was conducted using the visual analog scale (VAS) score and Oswestry Disability Index (ODI), respectively. Postoperative complications were recorded. Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) software, version 20.0 (IBM, Armonk, New York); paired sample t test was used for the comparison of mean values.


  Surgical Procedure Top


All the patients underwent percutaneous posterior stabilization followed by mini-open anterior debridement and fusion under single anesthesia. They were initially positioned prone under general anesthesia. Percutaneous insertions of pedicle screws were carried out in the infected motion segment by using CD Horizon Longitude (Medtronic, Minneapolis, Minnesota) system [Figure 2]. Every attempt was made to step away from intraosseous cavities by careful analysis of preoperative CT scan. Appropriate size titanium rods were contoured to required lordotic curvature and connected to the screws in distraction.
Figure 2: Intraoperative picture showing percutaneous posterior stabilization being performed

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The patients were then log rolled to the right lateral position, and the affected level was marked by image intensifier. A mini-open incision of ≤6cm was used for anterior approach. External oblique, internal oblique, and transverse abdominal muscles were dissected to expose retroperitoneal space [Figure 3]. The retroperitoneal fat was pushed forward and psoas muscle was directly visualized. After reconfirming the discitis level with image intensifier, the psoas muscle was retracted posteriorly to expose the infected disc space. All infected tissues were thoroughly debrided and the samples were sent for bacterial, tuberculous, and fungal culture and antibiotic sensitivity and histopathological examination. Debrided disc space was grafted with appropriate size tricortical bone graft harvested from the left iliac crest. Wound was closed in layers with drain in the retroperitoneal space.
Figure 3: Intraoperative pictures showing the mini-open anterior approach. (A) Patient positioning in right lateral position. (B) Incision site identified with image intensifier and marked with skin marker. (C) Mini-open anterior approach exposing L4-5 disc space

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  Results Top


This study included 10 women and 17 men (n = 27) with average age of 57 years (range: 45–73 years). Of 27 patients, 10 patients had previous spine intervention in the form of discectomy performed 2–15 months (average, 6 months) before presentation with discitis. All the 27 patients included in this study underwent combined posterior minimally invasive stabilization with mini-open anterior debridement and fusion under single anesthesia. The mean operative time was 194min (range: 150–230min). The mean intraoperative blood loss was 212mL (range: 100–350mL) [Table 1]. Involved levels were L2-3 in 5 patients, L3-4 in 7 patients, and L4-5 in 15 patients [Figure 4].
Table 1: Patient demographic data and other variables

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,
Figure 4: Bar chart showing distribution of discitis across various disc levels

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Of the 27 patients, 11 patients had either positive blood or urine bacterial cultures preoperatively [Figure 5]. All the patients with preoperative positive blood or urine culture had grown the same organism in operative tissue culture. Tissue culture was positive in 21 patients, which included 11 with Staphylococcus aureus (40.7%), 5 with Escherichia coli (18.5%), 2 with Pseudomonas (7.4%), 2 with Enterobacter cloacae (7.4%), and 1 with S. equorum (3.7%). Remaining six patients (22.2%) had negative bacterial culture results but their histopathology showed acute inflammatory tissue, suggestive of pyogenic spondylodiscitis [Figure 6].
Figure 5: Pie chart showing distribution of patients with positive blood or urine culture

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Figure 6: Bar chart showing various organisms isolated from intraoperative tissue culture

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In all the patients, back pain improved immediately after the surgery. They were mobilized on first postoperative day with the help of a lumbosacral corset. The blood parameters such as TC, ESR, and CRP showed gradually reducing trend and attained normal levels at 4–6 weeks follow-up after surgery. Postoperative complications were urinary retention in three patients and deep vein thrombosis (DVT) in two patients. However, no wound-related complications were observed. Urinary retention was treated with Foley catheter for two weeks followed by intermittent self catheterization till urinary symptoms resolved. DVT was confirmed by venous Doppler study and was treated with subcutaneous low-molecular-weight heparin for three weeks followed by oral anticoagulants for six weeks with good overall response.

All the patients underwent follow-up for average 29 months (range: 24–36 months). Radiographic bony fusion, as defined by bridging bony trabeculae across the entire length of the graft and adjacent vertebral body, was achieved in all the 27 patients within 12 months postoperatively [Figure 7]. Lumbar radiographs taken at 24-month follow-up following surgery showed no signs of recurrence of infection, pseudarthrosis, or implant breakage. Six patients who had Frankel Grade D neurology preoperatively improved to Frankel Grade E at the final follow-up. The mean VAS score (0.56) at final follow-up was significantly lower than the mean preoperative VAS score (7.30) with P < 0.001. The ODI scores at final follow-up (mean, 13.48) were significantly lower than preoperative ODI scores (mean, 83.70) with P < 0.001 [Table 2].
Figure 7: X-ray lumbosacral spine anteroposterior and lateral view at 12-month follow-up showing bony trabeculae crossed the entire length of the graft and adjacent end plates suggestive of bony fusion

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Table 2: Preoperative and final follow-up mean visual analog scale and Oswestry Disability Index scores

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  Discussion Top


Lumbar pyogenic spondylodiscitis is one of the challenging spine conditions to diagnose and treat. Surgical approaches and techniques for spondylodiscitis are still a matter of controversy.[5],[6],[7],[8],[9],[10],[11],[12] Iatrogenic implantation of organism during previous discectomy was the cause of discitis in 10 of 27 (37%) patients in our study. Jimenez-Mejias et al.[6] documented that postoperative spondylodiscitis represented 30.1% of all cases of pyogenic spondylodiscitis in their study.

The most common causative organism cultured in our study was S. aureus (40.7%), which was similar to the findings reported in literature by multiple authors [Table 3].[7],[10],[12],[13],[14]
Table 3: Comparison of various studies on treatment of pyogenic discitis by various approaches

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Several surgical approaches have been described in the literature to treat lumbar pyogenic spondylodiscitis, including posterior-only approach,[9],[12] anterior-only approach,[10] and combined anterior and posterior approaches.[5],[13],[14]

A study conducted by Meng-Ling et al.[9] showed satisfactory clinical outcome, adequate infection control, and good fusion rate with posterior transforaminal lumbar debridement and fusion with pedicle screw instrumentation. In our view, even though posterior-only approach can provide stable three-column spine fixation, it is difficult to thoroughly debride the infected disc space through posterior approach alone. Pawar et al.[16] reported that with posterior transforaminal approach in discitis, intraoperative manipulation to attain optimum cage position resulted in its dislodgement anteriorly and vessel injury with torrential hemorrhage. They attributed this complication to inflammation of major vessels with friable vessel walls anterior to the vertebrae in discitis.[16]

In anterior-only approach, infected tissue can be thoroughly debrided under direct vision, thus reducing bacterial load and chances of recurrence. D’Aliberti et al.[10] concluded that anterior stand-alone approach with spine reconstruction during the acute infection phase was safe and effective. On the contrary, Emery et al.[11] documented poor sagittal correction with anterior-alone debridement and fusion. Our experience espouses the view that stand-alone anterior fusion does not provide as rigid fixation compared to that augmented by posterior pedicle screw fixation.

The literature documenting experience with combined anterior and posterior approach is widely in favor of its use in surgical management of lumbar pyogenic spondylodiscitis.[1],[5],[8], [13,[14],[15] Conventional open combined posterior and anterior surgery for lumbar pyogenic spondylodiscitis was associated with large incision, extensive tissue damage, more intraoperative blood loss, reduced lumbar muscle strength, and long recovery.[8],[13],[14] In this study, we performed combined posterior percutaneous stabilization with mini-open anterior debridement and fusion for single-level lumbar pyogenic spondylodiscitis. Posterior percutaneous pedicle screw fixation provides three-column stable spine fixation and also allows intraoperative distraction of the collapsed inflamed disc space, allowing better anterior debridement and bone grafting.

In this study, we used autogenous tricortical iliac crest graft for fusion following debridement. This decision was supported by previous studies that showed that the use of tricortical iliac autograft as an anterior strut was superior in the face of infection.[14]

A single-stage combined anterior and posterior approach under one anesthesia allows earlier mobilization with a shorter hospitalization with added advantage of fewer complications. This was documented by Korovessis et al.[15] in their study of 14 patients treated with combined anterior and posterior approach as single-stage procedure under one anesthesia. Our study echoed similar findings.

In our study, the mean blood loss was 212mL (range: 100–350mL) with a mean operative time of 194min (range: 150–230min). These results were comparable to the results of a study by Lin et al.[5] In all the patients, VAS and ODI scores improved significantly at final follow-up in comparison to preoperative status (P < 0.001). Lin et al.[5] reported functional outcomes comparable to our study.

This study had some inherent limitations because of its retrospective nature. It is, however, a consecutive series of patients who were treated in a uniform manner. The combined mini-open approach requires surgeons to have enough experience and a thorough knowledge of the anatomy and they might require help of an access surgeon. Longer follow-up periods to assess outcome measures in long term would have fortified the findings of this report. Moreover, this surgical procedure is indicated only for patients with single-level lumbar pyogenic spondylodiscitis and it is not helpful in case of L5-S1 spondylodiscitis due to the overhang of iliac crest laterally. As a result of overhang of iliac crest, anterior midline or paramedian larger incision is required to access L5-S1 discitis through anterior retroperitoneal approach.


  Conclusion Top


Single-stage combined posterior percutaneous stabilization with mini-open anterior debridement and fusion under one anesthesia is an effective alternative to conventional open technique as it allows thorough debridement and rigid fixation and it results in minimal blood loss and lesser postoperative complications for the treatment of single-level lumbar pyogenic spondylodiscitis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lin Y, Chen WJ, Zhu WT, Li F, Fang H, Chen AM,et al. Single-level lumbar pyogenic spondylodiscitis treated with minimally invasive anterior debridement and fusion combined with posterior fixation via Wiltse approach. Huazhong Univ Sci Technol Med Sci 2013;33:707-12.  Back to cited text no. 1
    
2.
Friedman JA, Maher CO, Quast LM, McClelland RL, Ebersold MJ. Spontaneous disc space infections in adults. Surg Neurol 2002;57:81-6.  Back to cited text no. 2
    
3.
Ford LT. Postoperative infection of lumbar intervertebral disc space. South Med J 1976;69:1477-81.  Back to cited text no. 3
    
4.
Valancius K, Hansen ES, Høy K, Helmig P, Niedermann B, Bünger C. Failure modes in conservative and surgical management of infectious spondylodiscitis. Eur Spine J 2013;22:1837-44.  Back to cited text no. 4
    
5.
Lin Y, Li F, Chen W, Zeng H, Chen A, Xiong W. Single-level lumbar pyogenic spondylodiscitis treated with mini-open anterior debridement and fusion in combination with posterior percutaneous fixation via a modified anterior lumbar interbody fusion approach. J Neurosurg Spine 2015;23:747-53.  Back to cited text no. 5
    
6.
Jiménez-Mejías ME, de Dios Colmenero J, Sánchez-Lora FJ, Palomino-Nicás J, Reguera JM, García de la Heras J, et al. Postoperative spondylodiskitis: Etiology, clinical findings, prognosis, and comparison with nonoperative pyogenic spondylodiskitis. Clin Infect Dis 1999;29:339-45.  Back to cited text no. 6
    
7.
Hadjipavlou AG, Mader JT, Necessary JT, Muffoletto AJ. Hematogenous pyogenic spinal infections and their surgical management. Spine 2000;25:1668-79.  Back to cited text no. 7
    
8.
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 2008;8:405-12.  Back to cited text no. 8
    
9.
Lu ML, Niu CC, Tsai TT, Fu TS, Chen LH, Chen WJ. Transforaminal lumbar interbody debridement and fusion for the treatment of infective spondylodiscitis in the lumbar spine. Eur Spine J 2015;24:555-60.  Back to cited text no. 9
    
10.
D’Aliberti G, Talamonti G, Villa F, Debernardi A. The anterior stand-alone approach (ASAA) during the acute phase of spondylodiscitis: Results in 40 consecutively treated patients. Eur Spine J 2012;21:S75-82.  Back to cited text no. 10
    
11.
Emery SE, Chan DP, Woodward HR. Treatment of hematogenous pyogenic vertebral osteomyelitis with anterior debridement and primary bone grafting. Spine 1989;14:284-91.  Back to cited text no. 11
    
12.
Gonzalvo A, Abdulla I, Riazi A, De La Harpe D. Single-level/single-stage debridement and posterior instrumented fusion in the treatment of spontaneous pyogenic osteomyelitis/discitis: Long-term functional outcome and health-related quality of life. J Spinal Disord Tech 2011;24:110-5.  Back to cited text no. 12
    
13.
Sundararaj GD, Babu N, Amritanand R, Venkatesh K, Nithyananth M, Cherian VM, et al. Treatment of haematogenous pyogenic vertebral osteomyelitis by single-stage anterior debridement, grafting of the defect and posterior instrumentation. J Bone Joint Surg Br 2007;89:1201-5.  Back to cited text no. 13
    
14.
Dimar JR, Carreon LY. Treatment of pyogenic vertebral osteomyelitis with anterior debridement and fusion followed by delayed posterior spinal fusion. Spine 2004;29:326-32.  Back to cited text no. 14
    
15.
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 2006;31:1014-9.  Back to cited text no. 15
    
16.
Pawar UM, Kundnani V, Nene A. Major vessel injury with cage migration surgical complication in a case of spondylodiscitis. Spine 2010;35:E663-6.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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