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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

Korovessis, Panagiotis, MD, PhD; Repantis, Thomas, MD; Iliopoulos, Panagiotis, MD; Hadjipavlou, Alexander, Prof*

doi: 10.1097/BRS.0b013e318187875e
Clinical Case Series
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Study Design. Single institution, single surgeon retrospective review.

Objective. To investigate if the use of titanium mesh cage on the site of infection could be beneficial for successful outcome of the operative treatment for pyogenic spondylitis.

Summary of Background Data. There is a controversy concerning the optimal treatment for pyogenic spondylitis regarding approach, instrumentation and staging. This large series reports on single-stage instrumented open and minimally invasive surgery for septic spondylitis.

Methods. Twenty-four patients aged 57 ± 16 years suffering from persistent or complicated septic spondylitis were treated by a total of 25 single stage combined surgeries (first: anterior debridement/partial vertebrectomy plus mesh cage filled with autologous bone graft; second: pedicle screw fixation with open and minimal invasive techniques). The indications for surgery included neurologic compromise, significant vertebral body destruction with kyphosis associated with segmental instability, failure of medical treatment, and/or epidural/ paravertebral abscess formation. Needle biopsy was performed in all patients before surgery. Patients were evaluated before and after surgery in terms of pain and neurologic level, sagittal segmental spinal balance, radiologic fusion and recovery.

Results. All but 1 tetraplegic patient with simultaneous cervical and lumbar spondylitis, who died because of massive clot lung embolism 2 months after surgery, were followed for 56 months (range, 31–116 months) The visual analogue scale score improved from 6.5 before surgery to 1.8 after surgery. The segmental kyphotic deformity was corrected at an average of 6°, without cage settling. An insignificant loss of kyphosis correction of an average 0.6° was measured in the thoracolumbar junctiononly. Blood loss, surgical time, and surgical complicationswere significant less in the patients who operated with minimal invasive technique. Patients with incomplete neurologic impairment improved after surgery. Physical function (SF-36) averaged 72 1 year after surgery. All operated patients had resolution of infection. There was neither migration of mesh cage nor posterior instrumentation failure at the last follow-up observation.

Conclusion. The present study showed that radical debridement of spinal infection and anterior insertion of titanium cage, filled with autogenous bone graft, secured with pedicle screw instrumentation should have had a beneficial influence on the eradication of infection, segmental and global spinal reconstruction and fusion. Supplementary posterior minimal invasive pedicle screw fixation eliminates posterior soft tissue injury and preserves blood supply, and reduces surgical time, blood loss, and surgical complications.

Sick patients with persistent septic spondylitis can successfully undergo instrumented combined, 1-stage, same-day surgery. The presence of the titanium mesh cage, filled with autogenous bone graft, at the site of infection combined with local debridement and supplementary minimal invasive posterior fixation in the lumbosacral spine seem to have a beneficial influence on the eradication of infection, spinal reconstruction and fusion, and reduction of pain.

From the Department of Orthopaedic, General Hospital “Agios Andreas,” Patras, Greece; and *Department of Orthopedics, University of Crete, Greece.

Acknowledgment date: August 22, 2007. First revision date: December 15, 2007. Second revision date: March 13, 2008. Third revision date: May 9, 2008. Acceptance date: May 9, 2008.

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

The authors of this study have received the permission to use their own data from previous publications in the Spine (Ref. No. 13) and Clin Orthop Related Research (Ref. No. 14) from Lippincott and Springer companies respectively.

Address correspondence and reprint requests to Panagiotis G. Korovessis, MD, PhD, Department of Orthopaedic, General Hospital “Agios Andreas,” Patras, Greece; E-mail: korovess@otenet.gr

© 2008 Lippincott Williams & Wilkins, Inc.