Elsevier

World Neurosurgery

Volume 116, August 2018, Pages e48-e56
World Neurosurgery

Original Article
Clinical and Radiographic Results of a Minimally Invasive Lateral Transpsoas Approach for Treatment of Septic Spondylodiscitis of the Thoracolumbar and Lumbar Spine

https://doi.org/10.1016/j.wneu.2018.03.193Get rights and content

Highlights

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    A less-invasive treatment for septic spondylodiscitis of thoracolumbar and lumbar spine.

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    Indications: Spondylodiscitis without severe kyphosis and neurologic impairment.

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    Postoperative graft subsidence results in a loss of restored disc height and lordosis.

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    Postoperative graft subsidence did not influence clinical outcomes significantly.

Background

The minimally invasive lateral transpsoas approach allows retroperitoneal access for discectomy and graft placement. However, the procedure has rarely been used for the treatment of septic spondylodiscitis. The purposes of this study were to evaluate the clinical and radiographic outcomes from this minimally invasive procedure for septic spondylodiscitis.

Methods

Thirty-one consecutive patients (17 males and 14 females) were included in this study from July 2013 to January 2016. Clinical outcomes were assessed by Oswestry Disability Index, visual analog scale, modified Macnab criteria, and inflammatory parameters. Radiographic results were analyzed by studying the changes in diseased disc height, lordosis, and fusion status.

Results

The Oswestry Disability Index and visual analog scale score improved by 58% and 69% at the last follow-up. The modified Macnab criteria were found to be excellent in 21 patients (68%) and good in 10 (32%). Inflammatory parameters normalized over the average 24 months follow-up. There were no major complications that might have influenced the outcomes in this cohort. A complete fusion after 12 months was achieved in 87% of patients. A mean 7.5 mm restoration in disc height and 6.4° restoration in lumbar lordosis were observed in all patients, whereas an average 4.5 mm loss in restored height resulting from graft subsidence was observed in 24 patients during the follow-up. However, graft subsidence did not influence clinical outcomes significantly.

Conclusions

A minimally invasive lateral transpsoas approach in combination with instrumentation provides a novel treatment for patients with septic spondylodiscitis without severe kyphosis and neurologic impairment.

Introduction

Septic spondylodiscitis has affected an increasing number of people as a result of an increase in the populations of elderly people, diabetics, immunocompromised people, intravenous drug users, patients requiring hemodialysis, and frequent use of invasive spine procedures. It commonly occurs in patients with primary active infections elsewhere in the body such as bacteremia or urinary or respiratory tract infections.1, 2 According to the practical guidelines proposed by the Infectious Diseases Society of America in 2015, although a combination of intravenous antibiotics followed by oral antibiotics is the standard conservative treatment, surgical intervention is indispensable for some situations.3

The indications for surgical intervention in septic spondylodiscitis of the thoracolumbar/lumbar spine include failure of adequate antibiotic treatment, progressive neurologic deficits, progressive spinal deformity, and instability.3, 4 The basic principle of surgical treatment is debridement of infected tissue, restoration of spinal alignment, and stabilization with instrumentation.5, 6 An increasing number of reports have suggested that radical debridement and bone grafting are superior to nonoperative treatment.5, 6, 7, 8 Because disc space and adjacent vertebral bodies are most commonly involved in patients with septic spondylodiscitis, a combined approach consisting of radical anterior debridement and bone grafting, followed by posterior pedicle screw fixation, is the most widely used.9, 10 However, when an anterior procedure is performed, blood vessels can be injured easily as a result of the scarring and adhesion with distorted local anatomy.11 Also, a poor general medical condition and chronic comorbidities in affected patients call for a less-invasive technique.12

Lateral lumbar interbody fusion (LLIF), as a minimally invasive lateral transpsoas approach, allows retroperitoneal access for discectomy and graft placement, with a lower complication rate.13 It was first performed in the treatment of degenerative disc disease with favorable clinical outcomes, and as far as we know, this procedure has rarely been used for the treatment of thoracolumbar/lumbar spondylodiscitis.14 Hence, reports of clinical applications in patients with spondylodiscitis are limited.

From this point of view, we present the lateral transpsoas approach, as a novel less-invasive application, to treat septic spondylodiscitis of thoracolumbar and lumbar spine. Clinical and radiographic results along with perioperative complications are evaluated retrospectively.

Section snippets

Inclusion and Exclusion Criteria

Informed consent was obtained from patients with septic spondylodiscitis of the thoracolumbar and lumbar spine whose main disease involved only 1 level. All patients met the strict operative criteria including vertebral destruction with/without instability, or failure of medical treatment. Unchanged clinical status (persistent or progressive pain and systemic symptoms of infection), persistent increase of systemic inflammatory markers, and radiographic evidence of progressive epidural and/or

Demographic Data

Patient demographics are summarized in Table 1. The mean age of the 31 male patients was 59.2 ± 13.1 years (range, 25–79 years), and the mean body mass index was 25.3 ± 4.1 kg/m2 (range, 18.1–32.0 kg/m2). The infected segments involved T11-12 in 2 patients, T12-L1 in 4 patients, L1-2 in 5 patients, L2-3 in 7 patients, L3-4 in 7 patients, and L4-5 in 6 patients. Among the 31 patients, most (27 patients, 87%) accepted structured allograft bones for interbody fusion, whereas the remaining 4

Discussion

In septic spondylodiscitis, the intervertebral disc and the adjacent vertebral bodies are the primary sites for pathologic lesions. Thus, surgical debridement is possibly required to eradicate the infection, to secure an adequate blood supply for tissue healing, and to maintain spinal stability.20 In the present study, a lateral lumbar retroperitoneal transpsoas approach is adopted as an anterior approach to assess the anterior pathologic portion. It provides a direct access to the vertebral

Conclusions

The minimally invasive lateral transpsoas approach in combination with instrumentation leads to successful radical debridement and spinal reconstruction with satisfactory clinical outcomes. This novel minimally invasive application is likely to be beneficial for patients with septic spondylodiscitis of the thoracolumbar and lumbar spine without severe kyphosis and neurologic impairment.

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    • Cited by (6)

    Conflict of interest statement: This work was supported by the Sun Yat-sen University Clinical Research 5010 Program (grant number 2013006).

    Lei He and Peigen Xie contributed equally to this work.

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