Elsevier

The Spine Journal

Volume 4, Issue 4, July–August 2004, Pages 388-395
The Spine Journal

Clinical Studies
Preliminary results of staged anterior debridement and reconstruction using titanium mesh cages in the treatment of thoracolumbar vertebral osteomyelitis

https://doi.org/10.1016/j.spinee.2004.01.004Get rights and content

Abstract

Background context

Vertebral osteomyelitis can be successfully treated with spinal immobilization and parenteral antibiotics. Failure of medical therapy may necessitate surgical treatment consisting of anterior debridement and structural anterior column reconstruction. Autologous structural bone graft has traditionally been the gold standard in anterior column reconstruction. Because of the morbidity related to graft harvest, vertebral body replacement cages have emerged as a viable option for reconstructing a deficient anterior column.

Purpose

To evaluate the efficacy of titanium mesh cages in the reconstruction of anterior column defects in the presence of active pyogenic infection.

Study design

Prospective case series.

Methods

Eleven patients underwent operative treatment for osteomyelitis of the thoracolumbar spine using staged anterior debridement and reconstruction with cylindrical titanium mesh cages followed by delayed posterior spinal fusion with pedicle screw instrumentation during a 2-year period. Patients were postoperatively evaluated clinically and radiographically.

Results

Follow-up averaged 17±9 months. Average increase in kyphosis of 10±6 degrees corresponding to 4±4 mm loss in the height (subsidence) of the anterior construct. One patient died during revision surgery for hardware failure. Seven of the remaining 10 patients have not required antibiotics after the initial postoperative course of treatment. Three patients are maintained on chronic suppressive therapy as a precaution. There has been no evidence of recurrence or residual infection in any patient. Seven of the 10 patients were pain free at latest follow-up. There has been one case of pseudarthrosis.

Conclusion

Cylindrical titanium mesh can be used with consistently good results for large anterior column defect reconstructions even in the face of active pyogenic infection. In our cohort of patients with pyogenic vertebral osteomyelitis, the use of titanium mesh cages has not been associated with early recurrence of infection.

Introduction

The majority of patients with pyogenic vertebral osteomyelitis can be treated nonsurgically with antibiotics and immobilization. This type of treatment has been shown to be effective in 60% to 95% of cases [1], [2], [3], [4]. However, in patients with significant bone destruction, progressive deformity, neurological impairment, antibiotic-resistant sepsis or recurrence of infection, operative treatment consisting of anterior debridement and strut grafting with or without posterior stabilization can be used to successfully control disease. Hodgson and Stock [5] first described surgical debridement of vertebral osteomyelitis in the setting of spinal tuberculosis. This procedure was later shown to be effective in the treatment of pyogenic vertebral osteomyelitis [1], [6], [7].

Surgical debridement of the compromised anterior column that has lost its structural integrity requires reconstruction. Structural autograft continues to be the gold standard in anterior reconstruction. Unfortunately, there may be substantial morbidity involved in the harvest of a large structural autograft [8]. Other available options include structural allograft, or prosthetic implants, such as titanium mesh cages. Implantation of metallic instrumentation into an infected field has been considered problematic because foreign material may interfere with successful eradication of infection. However, reconstruction of unstable skeletal segments seems to facilitate control of infection and promotes healing. Titanium cages offer immediate vertical stability, limit donor site morbidity and bypass the difficulties involved in obtaining large structural autograft. Titanium has also been shown to be more resistant to adherence by bacteria than other metals [9], [10]. The purpose of this study was to investigate the use of titanium cylindrical mesh cages to reconstruct anterior column defects in the treatment of pyogenic vertebral osteomyelitis.

Section snippets

Materials and methods

All patients with vertebral osteomyelitis requiring surgical treatment who presented to our institution between July 1998 and June 2000 were followed prospectively. Eleven patients (nine male and two female) with thoracolumbar osteomyelitis were surgically treated at our institution during this 2-year period. All patients underwent anterior column reconstruction using cylindrical titanium mesh. Surgical indications included symptomatic instability, progressive deformity, inability to eradicate

Results

Ten of 11 patients were followed an average of 17±9 months. One patient died in the immediate perioperative period (see below). All 10 patients were free of any sign of recurrent or residual infection at latest follow-up. Seven of the patients have been able to completely discontinue antibiotics without recurrence of infection. The three remaining patients have remained on chronic suppressive oral antibiotic therapy despite normalized ESR because of high risk of recurrence. Seven of 10 patients

Discussion

Most patients with pyogenic vertebral osteomyelitis can be treated conservatively with parenteral antibiotics and immobilization [12], [13]. In a small subset of patients surgery becomes necessary (Fig. 2). Pathologic fracture of the vertebral body, intractable pain, failure of nonsurgical treatment, abscess formation, neurological deterioration and progressive deformity are all indications for surgical intervention. The surgical treatment of vertebral osteomyelitis should follow the principles

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FDA device/drug status: approved for this indication (titanium mesh cages for anterior reconstruction).

Nothing of value received from a commercial entity related to this research.

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