A New Treatment Algorithm That Incorporates Minimally Invasive Surgery for Pyogenic Spondylodiscitis in the Thoracic and Lumbar Spines: The Results of Its Clinical Application to a Series of 34 Patients

Abstract

Background and Objectives: Spinal minimally invasive surgery (MIS) experts at the university hospital worked as a team to develop a new treatment algorithm for pyogenic spondylodiscitis in lumbar and thoracic spines. They modified a flow chart introduced for this condition in a pre-MIS era to incorporate MIS techniques based on their extensive experiences accumulated over the years, both in MIS for degenerative lumbar diseases and in the treatment of spine infections. The MIS procedures incorporated in this algorithm consisted of percutaneous pedicle screw (PPS)–rod fixation and transpsoas lateral lumbar interbody fusion (LLIF). The current study analyzed a series of 34 patients treated with prospective selection of the methods according to this new algorithm. Materials and Methods: The algorithm first divided the patients into those who had escaped complicated disease conditions, such as neurologic impairment, extensive bone destruction, and the need to be mobilized without delay (Group 1) (19), and those with complicated pyogenic spondylodiscitis (Group 2) (15). Group 1 had image-guided needle biopsy followed by conservative treatment alone with antibiotics and a spinal brace (12) (Group 1-A) or a subsequent addition of non-fused PPS–rod fixation (7) (Group 1-B). Group 2 underwent an immediate single-stage MIS with non-fused PPS–rod fixation followed by posterior exposure for decompression and debridement through a small midline incision (12) (Group 2-A) or an additional LLIF procedure after an interval of 3 weeks (3) (Group 2-B). Results: All patients, except four, who either died from causes unrelated to the spondylodiscitis (2) or became lost to follow up (2), were cured of infection with normalized CRP at an average follow up of 606 days (105–1522 days). A solid interbody fusion occurred at the affected vertebrae in 15 patients (50%). Of the patients in Group 2, all but two regained a nearly normal function. Despite concerns about non-fused PPS–rod instrumentation, only seven patients (21%) required implant removal or replacement. Conclusions: Non-fused PPS–rod placements into infection-free vertebrae alone or in combination with posterior debridement through a small incision worked effectively in providing local stabilization without contamination of the metal implant from the infected tissue. MIS LLIF allowed for direct access to the infected focus for bone grafting in cases of extensive vertebral body destruction.

Single-Stage Debridement and Reconstruction with Trabecular Metal Cage for Active Infectious Spondylodiscitis: A Retrospective Cohort Study

“…It's noteworthly that over 90% of the patients yielded positive culture results. The positive rate of bacterial culture in previous studies was approximately 65%-76% [25].…”

A triple minimally invasive surgery combination for subacute osteoporotic lower lumbar vertebral collapse with neurological compromise: a potential alternative to the vertebral corpectomy/expandable cage strategy

“…Although the number of patients was small, this method consistently improved radicular pain and neurological deficits in all 5 patients, showing postoperative improvements in the ODI scores from 76 to 30 and in the JOA scores from 9.6 to 23.2 on average, with a mean follow-up of 34.8 (range 27-48) months. This triple MIS combination provided stable anterior column restoration segmentally as well as adequate neural decompression indirectly, 20,27,28,[42][43][44][45][46] with a small amount of EBL (range 20-72 mL), which resulted from minimizing soft-tissue dissection and avoiding easily bleeding direct spinal canal decompression.…”

“…Such a whole-segment spine lengthening at the LLIF level 20,27,43 as shown by CT must have stretched the posterior longitudinal ligament anteriorly to push back both the retropulsed fragments and the disc bulge, unbuckled the ligamentum flavum posteriorly to diminish its volume, and eventually enlarged the dural sac as shown by MRI. 27 Interestingly, all these beneficial MRI changes, which reflect the indirect neural decompression through ligamentotaxis, 44 further improved rather than diminished at longer postoperative time points.…”

“…The newly developed Less Imaging Cannulated Awl and Probe (LICAP) system (Tanaka Corp.), coupled with nerve root monitoring with PPS stimulation, facilitated safe screw placement without the use of fluoroscopy or computer-aided navigation systems. 27,30,42,43 After inserting the extender to load the L4 pedicle screws, which had already been inserted in step 1, we passed the subfascial rods through all the extenders bilaterally, and locked them in place with the setscrews.…”

Paradoxical Response after MISt for Spinal Tuberculosis Worsened Neurologic Symptoms: A Case Report

“…Minimally invasive spine stabilization (MISt) using percutaneous pedicle screws (PPS) is becoming increasingly useful in the treatment of spondylodiscitis and spinal tuberculosis (TB) 1) . Although anterior curettage and bone grafting are basic surgical procedures in such interventions, a recent report has described infection resolution with posterior instrumentation alone 2) .…”