L5 vertebral osteomyelitis treated with L5 corpectomy and anterior instrumentation: case report

ABSTRACT

Study design: A case report.

Objective: Pyogenic osteomyelitis is the most common form of vertebral infection and typically resolves following conservative treatment with antibiotics administered long term and immobilization. In cases of spinal instability, severe neurological deficit or disease refractory to medical management, neurosurgical intervention is warranted. Historically, these patients have undergone radical vertebral debridement and grafting with or without posterior instrumentation. We report the case of a 46-year-old female intravenous drug user presenting with L5 pyogenic osteomyelitis with L5 vertebral compression and cortex retropulsion following L2 – L4 laminectomy for epidural abscess 8 weeks prior.

Methods: The patient underwent an anterior approach single-stage L5 corpectomy, L4/5 and L5/S1 discectomies, expandable titanium-cage insertion and anterior plating from L4 to the sacrum.

Results: The patient recovered without any complications. The infection was successfully eradicated and her fusion remains solid 18 months postoperatively.

Conclusions: To our knowledge, this is the first case of L5 vertebral osteomyelitis treated with a single-stage corpectomy and anterior instrumentation.

REFERENCES

• 1 Kulkowski J. Pyogenic osteomyelitis of the spine: an analysis and discussion of 102 cases.  J Bone Joint Surg Am. 1936;  18 343-364
• 2 Hadjipavlou A G, Mader J T, Necessary J T. et al . Hematogenous pyogenic spinal infections and their surgical management.  Spine. 2000;  25 1668-1679
• 3 McHenry M C, Easley K A, Locker G A. Vertebral osteomyelitis: long-term outcome for 253 patients from seven Cleveland-area hospitals.  Clin Infect Dis. 2002;  34 1342-1350
• 4 Dia L-Y, Chen W-H, Jiang L-S. Anterior instrumentation for the treatment of pyogenic vertebral osteomyelitis of thoracic and lumbar spine.  Eur Spine J. 2008;  17 1027-1034
• 5 Korovessis P, Repantis T, Iliopoulos P. et al . Beneficial influence of titanium mesh cage on infection healing and spinal reconstruction in hematogenous septic spondylitis: a retrospective analysis of surgical outcome of twenty-five consecutive cases and review of literature.  Spine. 2008;  33 E759-E767
• 6 Kuklo T R, Potter B K, Bell R S. et al . Single-stage treatment of pyogenic spinal infection with titanium mesh cages.  J Spinal Disord Tech. 2006;  19 376-382
• 7 Lu D C, Wang V, Chou D. The use of allograft or autograft and expandable titanium cages for the treatment of vertebral osteomyelitis.  Neurosurgery. 2009;  64 122-130
• 8 Ruf M, Stoitze D, Merk H R. et al . Treatment of vertebral osteomyelitis by radical debridement stabilization using titanium mesh cages.  Spine. 2007;  32 E275-E280
• 9 Canale S T, Beaty J H. Campbell's Operative Orthopaedics. 11th ed. Vol 2 Philadelphia: Mosby-Elsevier 2008: 2295
• 10 Liljenzvist U, Lerner T, Bullman V. et al . Titanium cages in the surgical treatment of severe vertebral osteomyelitis.  Eur Spine J. 2003;  12 606-612
• 11 Ozuna R M, Delamarter R B. Pyogenic vertebral osteomyelitis and postsurgical disc space infection.  Orthop Clin North Am. 1996;  27 87-94
• 12 Rezai A R, Woo H H, Errico T J. et al . Contemporary management of spinal osteomyelitis.  Neurosurgery. 1999;  44 1018-1026
• 13 Faraj A A, Webb J K. Spinal instrumentation for primary pyogenic infection: report of thirty-one patients.  Acta Orthop Belg. 2000;  66 242-247
• 14 Kostuik J P. Anterior spinal cord decompression for lesions of the thoracic and lumbar spine, techniques, new methods of internal fixation results.  Spine. 1983;  8 512-531
• 15 Nather A, David V, Hee H T. et al . Pyogenic vertebral osteomyelitis: a review of fourteen cases.  J Orthop Surg. 2005;  13 240-244
• 16 Woertgen C, Rothoerl R D, Englert C. et al . Pyogenic spinal infections and outcome according to the 36-item short form health survey.  J Neurosurg Spine. 2006;  4 441-446
• 17 Hee H, Majd M, Holt R. et al . Better treatment of vertebral osteomyelitis using posterior stabilization and titanium mesh cages.  J Spinal Disord. 2002;  15 149-156
• 18 Lee M C, Wang M Y, Fessler R G. et al . Instrumentation in patients with spinal infection.  Neurosurg Focus. 2004;  17 E7
• 19 Safran O, Rand N, Kaplan L. et al . Sequential or simultaneous, same-day anterior decompression and posterior stabilization in the management of vertebral osteomyelitis of the lumbar spine.  Spine. 1998;  23 (17) 1885-1890

COMMENTARY

Author James M Schuster

Institution Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA

The author describes surgical treatment of L5 osteomyelitis after failure of laminectomy and antibiotic therapy. Because of the amount of vertebral body destruction, surgery would have to reconstruct the incompetent anterior column with stabilization. Generally an anterior approach for further decompression and reconstruction with either allograft, expandable, or fixed length cage would be used. It is sometimes difficult to seat a graft or cage between L4 and S1 because of the obliquity of the sacrum even with cages with variable angle end plates. Stabilization options include a simultaneous anterior stabilization as described by the authors versus a subsequent posterior stabilization. Anterior stabilization, while allowing a one-stage procedure, may require mobilization of the iliac vessels, which can be difficult in an infected surgical bed. However, in this case the previous posterior approach would also make posterior stabilization more difficult. One other option would be a one-stage posterior corpectomy, expandable cage reconstruction, and pedicle screw stabilization [1]. However, because of infection and a previous posterior approach, this would be least advisable.

I would have performed a similar anterior approach with an expandable cage and allograft [2], but because of difficulty mobilizing the iliac vessels, I would have performed a subsequent posterior/pedicle screw stabilization.

• Initial therapy for osteomyelitis is bacterial-specific antibiotic therapy unless there is neurological compromise, progressive deformity, or failure of medical management.

• Surgical treatment must decompress neural elements, debride infected and devitalized tissues, reconstruct structural defects, and stabilize unstable segments.

• The surgical approach must consider the levels of involvement and the surgeons experience and familiarity with the various surgical options, and possible access to an experienced surgeon.

1. Hunt T, Shen FH, Arlet V (2006) Expandable cage placement via a posterolateral approach in lumbar spine reconstructions: technical note. J Neurosurg Spine; 5 (3): 271 – 274.

2. Schuster JM, Avellino A, Mann F, et al (2000) The use of structural allografts in spinal osteomyelitis: a review of 47 cases. J Neurosurg Spine; 93 (1): 8 – 14.

EDITORIAL PERSPECTIVE

The case presented by Crabtree and colleagues and the commentary by Schuster perfectly epitomize a quandary of modern spine surgery. Tried and true surgical therapies—as commented by Schuster—in form of an anterior corpectomy of the collapsed and infected L5 vertebral body followed by anterior column reconstruction with a structural graft (eg, an allograft, an autogenous tricortical graft, or some form of structural material cage with bone-graft filling) and followed by a posterior decompression and stable segmental fixation is outflanked by a more aggressive but elegant single-stage anterior decompression, reconstruction, and stabilization with a new device designed for a different indication (in this case designed for the treatment of degenerative lumbosacral disc disease).

Clearly the latter technique is appealing by virtue of obviating the need for a supplemental posterior procedure. However, this perceived advantage comes at the price of unknown and likely less favorable biomechanical stability at the notoriously complex lumbosacral junction. The fixation device used, an appropriately named „Anterior Tension Band Plate,” was designed for less destabilizing one- or two-level anterior discectomies and fusion in presence of degenerative diseases at the lumbosacral junction and was not really tested for corpectomy situations, such as performed here.

Of course, the surgery described in this case report was performed flawlessly by highly experienced surgeons who apparently proceeded with attention to detail and presumably encountered adequate bone stock in their patient. Case reports like these may, however, invite undue imitation and lead to unfavorable outcomes in the hands of less experienced and detail-oriented surgeons.

The EBSJ editorial team congratulates Crabtree and colleagues for their fine work and excellent result. However, based on current literature we side with Schuster in recommending the more predictable anterior debridement and posterior reconstruction approach for this challenging issue.