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.
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.
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.
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.
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:
DimarJRCarreonLYGlassmanSDCampbellMJHartmanMJJohnsonJR: Treatment of pyogenic vertebral osteomyelitis with anterior debridement and fusion followed by delayed posterior spinal fusion. Spine29:326–3322004
FayaziAHLudwigSCDabbahMBryan ButlerRGelbDE: Preliminary results of staged anterior debridement and reconstruction using titanium mesh cages in the treatment of thoracolumbar vertebral osteomyelitis. Spine J4:388–3952004
FukutaSMiyamotoKMasudaTHosoeHKodamaHNishimotoH: Two-stage (posterior and anterior) surgical treatment using posterior spinal instrumentation for pyogenic and tuberculotic spondylitis. Spine28:E302–E3082003
KlöcknerCValenciaR: Sagittal alignment after anterior debridement and fusion with or without additional posterior instrumentation in the treatment of pyogenic and tuberculous spondylodiscitis. Spine28:1036–10422003
KorovessisPPetsinisGKoureasGIliopoulosPZacharatosS: 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?. Spine31:1014–10192006
MasudaTMiyamotoKHosoeHSakaedaHTanakaMShimizuK: Surgical treatment with spinal instrumentation for pyogenic spondylodiscitis due to methicillin-resistant Staphylococcus aureus (MRSA): a report of five cases. Arch Orthop Trauma Surg126:339–3452006
RathSANeffUSchneiderORichterHP: Neurosurgical management of thoracic and lumbar vertebral osteomyelitis and discitis in adults: a review of 43 consecutive surgically treated patients. Neurosurgery38:926–9331996
SafranORandNKaplanLSagivSFlomanY: Sequential or simultaneous, same-day anterior decompression and posterior stabilization in the management of vertebral osteomyelitis of the lumbar spine. Spine23:1885–18901998