Safety of instrumentation in patients with spinal infection

Clinical article

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Object

Treatment of spine infection remains a challenge for spine surgeons, with the most effective method still being a matter of debate. Most surgeons agree that in early stages of infection, antibiotic treatment should be pursued; under certain circumstances, however, surgery is recommended. The goals of surgery include radical debridement of the infective focus. In some cases, when surgery causes mechanical spinal instability, the question arises whether the risk of recurrent infection outweighs the benefits of spinal instrumentation and stabilization. The authors report their series of cases in which instrumentation was placed in actively infected sites and review the relevant literature.

Methods

The authors performed a retrospective analysis of all cases of spinal infection that were surgically treated with debridement and placement of instrumentation at their institution between 2000 and 2006. Patient presentation, risk factor, infective organism, surgical indication, level of involvement, type of procedure, and ultimate outcome were reviewed. Improved outcome was based on improvement of initial American Spinal Injury Association Impairment Score.

Results

Forty-seven patients (32 men, 15 women) were treated with instrumented surgery for spinal infection. Their average age at presentation was 54 years (range 37–78 years). Indications for placement of instrumentation included instability, pain after failure of conservative therapy, or both. Patients underwent surgery within an average of 12 days (range 1 day to 5 months) after their presentation to the authors' institution. The average length of hospital stay was 25 days (range 9–78 days). Follow-up averaged 22 months (range 1–80 months). Eight patients died; causes of death included sepsis (4 patients), cardiac arrest (2), and malignancy (2). Only 3 patients were lost to follow-up. Using American Spinal Injury Association scoring as the criterion, the patients' conditions improved in 34 cases and remained the same in 5. Complications included hematoma (2 cases), the need for hardware revision (1), and recurrent infection (2). Hardware replacement was required in 1 of the 2 patients with recurrent infection.

Conclusions

Instrumentation of the spine is safe and has an important role in stabilization of the infected spine. Despite the presence of active infection, we believe that instrumentation after radical debridement will not increase the risk of recurrent infection. In fact, greater benefit can be achieved through spinal stabilization, which can even promote accelerated healing.

Abbreviations used in this paper: ASIA = American Spinal Injury Association; CBC = complete blood count; CRP = C-reactive protein; DM = diabetes mellitus; ESR = erythrocyte sedimentation rate; IVDA = intravenous drug abuse; MRSA = methicillin-resistant Staphylococcus aureus; MSSA = methicillin-sensitive S. aureus; VB = vertebral body.

Article Information

Address correspondence to: Chaim B. Colen, M.D., Ph.D., 930 Professional Office Building, Department of Neurological Surgery, Wayne State University, 4160 John R., Detroit, Michigan 48201. email: chaim7@hotmail.com.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 10. A and B: Axial (A) and sagittal (B) Gd-enhanced T1-weighted MR images showing a homogenously enhancing epidural mass at C4–5 with disc protrusion, compressing the cord. C and D: Postoperative anteroposterior (C) and lateral (D) radiographs obtained after C4–5 anterior cervical discectomy and fusion with plate and cage placement.

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    Case 11. A and B: Axial (A) and sagittal (B) Gd-enhanced T1-weighted MR images showing an enhancing epidural mass that surrounds the cord from the level of C-2 to C-6. This mass is compressing the cord most severely at C4–5 and extends to the prevertebral space through the disc space at C4–5. C and D: Postoperative anteroposterior (C) and lateral (D) radiographs obtained after C4–5 anterior cervical discectomy and fusion with autologous bone graft. The spine is stabilized at C-4 and C-5 with bone graft and plate.

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    Case 1. A and B: Axial (A) and sagittal (B) Gd-enhanced T1-weighted MR images showing an enhancing epidural mass at the C4–7 levels with compression of the cord. This lesion also involves the C-5 and C-6 VBs, which are partially collapsed, and extends to the prevertebral space. C and D: Postoperative anteroposterior (C) and lateral (D) radiographs obtained after C5–6 corpectomy and fusion with autologous bone graft. The spine is stabilized from C-4 to T-1 with bone graft and plate.

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    Case 24. A and B: Axial (A) and sagittal (B) Gd-enhanced T1-weighted MR images showing collapsed T-7, T-8, and T-9 VBs associated with heterogeneously enhancing mass lesion. This lesion extends to the prevertebral space as well as the epidural space compressing the cord. C and D: Postoperative anteroposterior (C) and lateral (D) radiographs obtained after T7–9 corpectomy and fusion with methylmethacrylate filled into the interbody space. The spine is stabilized from T-6 to T-10 with methylmethacrylate, rods, and screws.

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    Case 34. A and B: Axial (A) and sagittal (B) T1-weighted Gd-enhanced MR images showing the heterogeneously enhanced mass lesion located at the level of the L1–2 disc space, which involves and collapses the VBs of L-1 and L-2. This mass lesion extends to the prevertebral space and to the epidural space, compressing the conus medullaris and cauda equina. C and D: Postoperative anteroposterior (C) and lateral (D) radiographs obtained after L1–2 corpectomy and fusion with cage placement. The spine is stabilized from T-12 to L-3 with cage, rods, and screws.

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