Postoperative infections in interbody fusion for degenerative spinal disease
ABSTRACT Scant literature exists on the treatment of infection after interbody fusion. Some authors advocate removal of the interbody grafts. Salvage of the grafts was possible in 92.3% (12 of 13) of the infections in a series of 326 consecutive patients with degenerative spinal diseases treated by three surgeons. Posterior interbody fusion and posterolateral instrumented fusion was performed in 267 patients and anterior interbody fusion was done in 59 patients. Eight infections in the first group (3%) and six in the second group (10.1%) were identified. Mean followup was 18 months (range, 12-38 months). All infections were early, presenting at a mean of 18 days (range, 11-28 months). All but one infection were in the posterior wound and deep. A high number of risk factors were present in these patients. Initial treatment included wound debridement and broad spectrum antibiotics, until culture results indicated the final antibiotic regimen. Infection recurred as osteomyelitis in one patient with multiple previous surgeries and anterior/posterior fusion. This was treated with removal of the posterior instrumentation and the interbody graft and extensive anterior/posterior reconstruction. Clinical outcomes were good in 10 patients, fair in two and poor in one using the Stauffer-Coventry scale. One pseudarthrosis was identified in a patient with anterior interbody fusion at final followup. Salvage of the interbody graft and retaining the instrumentation was safe in most cases in the presented series and did not adversely affect outcome. Level of Evidence: Therapeutic study, level IV (case series). Please see the Guidelines for Authors for a complete description of levels of evidence.
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ABSTRACT: Purpose Beside mechanical complications, the majority of adverse events after total disc arthroplasty (TDA) are related to the surgical approach. Septic complications are very uncommon and only one previous case has been published. The objective of this article is to describe the clinical circumstances, treatment, and outcomes of septic complication after TDA at L4–L5, involving an uncommon pathogen (Mycoplasma hominis). Methods A 38-year-old woman underwent a MobiDisc® TDA at L4–L5 level for discogenic pain. One month postoperatively, she complained of acute low back and abdominal pain associated with fever (39 °C). C-reactive protein level was elevated (197 mg/L; normal <5 mg/L) and the white blood cell count was normal (7 × 109/L; normal 4–10 × 109/L). A computerized tomography (CT) showed a left psoas-based retroperitoneal abscess. Treatment consisted of open debridement, drainage and empirical antibiotic therapy. Intraoperative cultures yielded M. hominis after 7 days incubation. Antibiotic therapy was adapted and discontinued after 2 months. The patient had failed to mention earlier that she had been suffering from abnormal vaginal discharge for some time and was using an intrauterine contraceptive device. Results At 1.5-year follow-up, review confirmed healing of the infection with biological normalization without residual collection, radiolucent lines or osteolysis around the prosthesis at radiographs, CT and MRI. Conclusions Mycoplasma hominis can be involved as an extragenital pathogen in musculoskeletal infections. Because its culture and identification are difficult, special media and real-time PCR are required in case of postoperative deep wound infection after anterior lumbar spine surgery, especially in the case of previous genitourinary infections, to decrease the delay in diagnosis and treatment.European Spine Journal 09/2012; 22(3). DOI:10.1007/s00586-012-2511-9 · 2.47 Impact Factor
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ABSTRACT: Retrospective case series. To present results of recombinant human bone morphogenetic protein-2 (rhBMP-2) use in medically nonresponsive pyogenic vertebral osteomyelitis (PVO), treated by anterior/posterior debridement and instrumented fusion in the cervical, thoracic, and lumbosacral spine. Surgical options for PVO vary, as do their outcomes, and can be complicated by recurrence, pseudarthrosis, and death. Although rhBMP-2 use in spinal fusion is increasing, its utility in PVO is unknown. Additionally, use in areas of infection is listed as a contraindication, although this is not supported by laboratory (animal) studies or clinical studies in long bones. Between 2003 and 2005, 14 patients who underwent circumferential fusion for PVO were included in this study. Average patient age was 54 years (range, 27-77 years). Eight (57%) patients had 3 or more vertebral bodies involved. Diagnostic studies included radiographs, CT, MRI, and markers of infection [(C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood count (WBC)]. All patients underwent anterior fusion with rhBMP-2 inserted in structural allograft (11 patients) or titanium cylindrical cages (3 patients), followed by posterior instrumented fusion with autogenous iliac crest graft (8 occurring on the same day). Follow-up averaged 22 months (range, 11-30 months). All were studied with plain radiographs, including flexion-extension lateral films and fine cut CT scans with reconstruction. Pain ratings were recorded by visual analog scores (VAS). Clinical resolution of infections, normalization of lab values, and bony fusion, based on dynamic radiographs and CT scans, were seen in all patients at latest follow-up. Staphylococcus aureus was the most frequently identified organism (8 patients). Four (29%) patients had positive blood cultures (all MRSA). Predisposing comorbidities were present in 12 patients. Six patients had epidural abscesses. Eight (57%) patients presented with neurologic deficits, ranging from paraparesis to quadriplegia. Complete recovery was seen in 7 (quadriplegia unchanged). At 1 year, mean VAS pain scores improved significantly (P < 0.05) from 7.9 (range, 3-10) to 2.8 (range, 0-6). Perioperative complications (non-BMP related) occurred in 2 patients. There were no surgically-related deaths. rhBMP-2 use, in combination with antibiotics and circumferential instrumented fusion, provides a safe and successful surgical treatment of medically nonresponsive PVO, with solid fusions obtained, good clinical results, and no adverse side effects from the BMP.Spine 12/2007; 32(26):2996-3006. DOI:10.1097/BRS.0b013e31815cde3e · 2.45 Impact Factor
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ABSTRACT: Inflammatory markers such as the C-reactive protein (CRP), white blood cell count and body temperature are easy to measure and are used as indicators of infection. The way in which they change in the early post-operative period after instrumented spinal surgery has not been reported in any depth. We measured these markers pre-operatively and at one, four, seven and 14 days postoperatively in 143 patients who had undergone an instrumented posterior lumbar interbody fusion. The CRP proved to be the only sensitive marker and had returned to its normal level in 48% of patients after 14 days. The CRP on day 7 was never higher than that on day 4. Age, gender, body temperature, operating time and blood loss were not related to the CRP level. A high CRP does not in itself suggest infection, but any increase after four days may presage infection.The Bone & Joint Journal 12/2007; 89(11):1478-81. DOI:10.1302/0301-620X.89B11.19478 · 2.80 Impact Factor