Comparative Study Between Bony

Fusion Either Central Or Lateral Only

And In Association With
Transpedicular Screw Fixation In
Management Of Lumbar
Spondylodiscitis

Thesis
Submitted for partial fulfillment of M.D. in
neurosurgery
 Presented by
Abdel Azim Labib El hoseny
General surgery master degree
Under supervision of
Dr. Shehaib Mohammed Alkhadrawy
Professor of neurosurgery
Faculty of medicine – Alazhar university

Dr. Hamdey Mohammed Behairy

Assist. Prof. of neurosurgery
Faculty of Medicine – Alazhar University
• Aim of the work:-

1. Definition of spondylodiscitis.
2. Clinical aspects of spondylodiscitis.
3. Diagnosis of spondylodiscitis.
4. Different modalities of management of
spondylodiscitis.
5. To compare between bony fusion either central or
lateral only and in association with transpedicular
screw fixation in management of spondylodiscitis.
PATIENTS AND METHODS

• This is a prospective non controlled non randomized

study which included 40 patients with lumbar or
lumbosacral spondylodiscitis who were treated
between August 2015 and February 2017 and were
followed up until July 2017.

• The study was conducted in neurosurgery

department of Alazhar university hospital and
Shebein-Elkom neurosurgery hospital.
• Inclusion criteria:

• patients who had been diagnosed as lumbar or

lumbosacral spondylodiscitis and have one or more of the
following pathological changes:

• Refractoriness to medical management after at least 2-3

weeks ( persistent elevation ESR & CRP ), significant
neurological deficit, the presence of epidural abscess,
spinal deformity, or instability, Severe destruction of
endplates, Septic pseudarthrosis, Severe Persistent pain,
septicemia despite antibiotic treatment, systemic effects
of chronic infection such as malnutrition and cachexia and
unsure diagnosis.
• Exclusion criteria:

• Patients showed improvement on medical treatment

(clinically and laboratory), multiple distant level
involvement evidenced by MRI, or patients unfit for
surgery.
• All patients were subjected to the following:
• Complete History talking:

• Personal (age, sex, occupation, residence, marital status

and habits).
• Complaint (the patient’s own words).
• Present history (Onset, course and duration of the
complaints are assessed (parasthesia, weakness,
wasting, sphincter disturbance, sexual disorders), then
any relieving or exaggerating factors, response to any
previous lines of treatment.
• Past history & family history (The patient is asked for any
past history of diseases, drug, operation, or any invasive
procedure such as lumbar puncture.
• The 10 subtest items include
(1) feeding
(2) moving from wheelchair to bed and return
(3) personal grooming
(4) getting on/off the toilet
(5) bathing
(6) walking or propelling a wheelchair.
(7) stair climbing.
(8) dressing and undressing
(9) bowel
(10) bladder continence.
- Each subtest item on the original Barthel Index is
rated 0, 5 or 10 (or 15 for two of the test items).
Maximum total score is 100.

- A total score of 100 represents the highest level of

independence although a perfect score does not
necessarily mean that a person is able to perform
instrumental activities of daily living.

-The central or lateral bony fusion status and sagittal

alignment of the infected segments were assessed
using radiographic studies.
• In all patients Visual pain analogue scale (VAS) was
used to assess the severity of pain. If a zero means
"no pain" and a ten (10) means pain as bad as it
could be, on this scale of 0 to 10 the patient was
asked to put x through the number corresponding to
severity to his pain (Wewers and Lowe., 1990).

• The activity of daily living was assessed by barthel

index. The original Barthel Index was developed in
the USA by Florence Mahoney and Dorothea Barthel
(1965) (Laake et al., 1995).
- Barthel Index was developed to measure activities of
daily living.
• Complete examination:
• General (weight, height, vital signs, head, chest, heart
abdomen, pelvis) searching for primary infection or
systemic disease that may affect the surgery.
• examination of the back
• Inspection of the back for deformity
• Palpation of the spine for local tenderness
• Evaluation of range of movement and muscle spasm
• Neurological evaluation:
• a- Sensory examination:
• - Superficial sensation including: Pain, Touch,
Temperature, Perianal sensation.
• - Deep sensation: Joint sensation, Sense of joint motion,
sense of position and deep pressure sense.
• b- Motor examination for Muscle state, tone, power
and deep tendon reflexes. Motor power will be
assessed according to United Kingdom medical
research council (MRC, 1976) grading system for
muscle strength;
• Grade 0: No voluntary muscle contraction.
• Grade 1: Flicker or trace of muscle contractions, no
joint movement.
• Grade 2: Active movement but only with gravity
eliminated.
• Grade 3: Active movement against gravity but not
against resistance.
• Grade 4: Active movement against resistance.
• Grade 5: Normal strength.
• c- Frankel scale was used to categorize the neuro-
logical deficit preoperative as follows;
• Frankel-A: patient has no motor or sensory function
below the spinal cord injury level (complete)
• Frankel-B: patient has no motor function below the
injury level (incomplete)
• Frankel-C: patient has motor and sensory function
below the level of injury but the motor function was
useless.
• Frankel-D: patient has motor useful, but not normal
function below the level of spinal cord injury
• Frankel -E: patient has no motor, sensory or sphincter
disturbance. (Frankel et al., 1969)
• Frankel scale was used to categorize the neuro-logical
deficit preoperative as follows;

• Frankel-A: patient has no motor or sensory function

below the spinal cord injury level (complete)
• Frankel-B: patient has no motor function below the
injury level (incomplete)
• Frankel-C: patient has motor and sensory function
below the level of injury but the motor function was
useless.
• Frankel-D: patient has motor useful, but not normal
function below the level of spinal cord injury
• Frankel -E: patient has no motor, sensory or sphincter
disturbance. (Frankel et al., 1969)
• Investigations (pretreatment):
• Routine laboratory investigations; (CBC, liver function
tests, kidney function tests, coagulation profile,
random blood glucose level, chest x- ray and ECG).
Special interest should be given to analysis of the
laboratory values of CRP, ESR and WBC count. An
elevated value of ESR and CRP were considered to be
common laboratory abnormality.

• Of these, CRP level was a more valuable serum

marker during follow-up study because of its temporal
pattern in the blood stream and comparatively quicker
normalization with effective treatment.
• Postoperative spondylodiscitis was suspected
when the mean CRP level had not returned to a
value below 50% of the peak value on the second
Postoperative day, or when these markers fail to
show a decline from preoperative values with
aggravated clinical symptoms and signs such as
fever, intractable pain, or neurological deficit.

• Neuroimaging studies (plain X-ray- CT-MRI); MRI

(with contrast) was the gold standard in the
diagnosis and help to suspect the causative
organism and to identify the complication as
epidural abscess.
• Surgical treatment with spinal instrumentation:
• Surgical debridement, complete removal of the infected,
necrotic tissue was attempted with extensive irrigation
with antibiotic solution; decompression only, and
decompression associated with instrumentation were
done to all patients according to the pathology and
availability of certain implants.
• Different approaches and different instrumentation was
used including:
– Posterior decompression and central or lateral bony
fusion only. Transpedicular screws fixation.
– Combined Posterior decompression with posterior
Transpedicular screws fixation.
– Transforaminal Lumbar Interbody Fusion (TLIF) and
Posterior Instrumentation
• In order to gain more accurate results, Biopsy material has
undergone aerobic, anaerobic, fungal, mycobacterial cultures
and stained with gram stain, Ziehl-Neelsen and special stain for
fungi.
• During each procedure the following points had been reported:
• Operative duration
• Operative complication
• Blood loss: by calculating the blood in the container of suction
in every case.
• Postoperative complication
• Postoperative ambulation period
• Postoperative hospital stay
• Difficulties encountered
• Postoperative antibiotic was given according to cultures results
and the duration was monitored by laboratory markers.
• Postoperative follow up:

• All patients were followed up monthly for the first

3months post-operative then every two months until
the end of this study through:

• Clinical follow up: the clinical outcome was assessed

according to Barthel Index which has been used since
1960s because of its high reliability and validity, as
regarding activity of daily living (ADL).

• Visual pain analogue scale (VAS) was used to assess

the severity of pain. The postoperative results were
compared with the preoperative to identify the clinical
outcome.
• Laboratory markers (WBC count, CRP and ESR)

• Radiological follow up:

• In all patients, X-rays of the affected spine A-P and
lateral views was done within 3 days post-operatively,
and then with each follow up for assessment of
subsidence of infection, implants related
complications, changes in the sagittal alignment and
bony fusion. CT was done in cases that needed more
evaluation.
• The (t) test is used to asses the statistical
significance of difference between two means. By
knowing the (t) test and the degree of freedom, the
(P) value is calculated from special tables, and so,
the significance of the results was determined from
the “t” distribution tables.

• P <0.05 = insignificant difference, P >0.05 =

significant difference.
• P > 0.01 = highly significant difference , P > 0.001 =
very highly significant difference.
 RESULTS
• Descriptive demographic data of studied
patients:

• The study included 31 male (77.5%) and 9 female

(22.5%), male: female ratio 3.4:1 and the mean age
was 50 ± 4 years, ranging from 22 to 62 years (Figure
49).
• Descriptive clinical data of studied patients:
• Predisposing factors for spondylodiscitis:
• In the studied series, risk factors were identified in 36
patients (90%). Many patients with spondylodiscitis had
previous spinal procedures (20 cases) including lumbar
spine surgery (19 cases) and lumbar puncture in one
case of suspected meningitis, diabetes mellitus (6
cases), chronic liver disease (3 cases), and chronic renal
disease (1 case) was diagnosed
• preoperatively, systemic infections (3 cases) such as
pneumonia (1 case), meningitis (1 case), acute pyelo-
nephritis (1 cases), other predisposing factors, such as
smoking (1 case), intravenous drug abuse (1 case) and
one female on chronic steroid for systemic lupus
erythromatosis.
• Clinical picture preoperatively:

• The duration of symptoms before diagnosis ranged

from 2 to 24 weeks with the mean duration 11.60 ±
6.64 weeks.

• The clinical presentations varied between the

studied patients; the classical presentation of
spondylodiscitis (persistent back pain, local
tenderness, limited movement, paravertebral muscle
spasm) was present in most cases (36 cases) fever
was present in 11 cases, radiculopathy in 20 cases,
neurological deficit in 6 cases, Constitutional
symptoms in 5 cases and chills/rigors in 4 cases
• Distribution and number of spinal infections:
• The lumbar spine was the most common site of
spondylodiscitis (32 cases), followed by the
lumbosacral spines spine (8 cases).
• The number of infected vertebral bodies varied from
one to three; one infection sites in four patients, two
levels of vertebral body infection were identified in
thirty-three patients, fol­lowed by three infection sites
in three patients.
Bacteriology & Source of infection:
• Approaches:

• Among the 40 surgically-treated patients, 20 patients

were managed by posterior surgical approach for
bony fusion either central (14) or lateral (6) only and
20 patients were managed by posterior surgical
approach for bony fusion in association with
transpedicular screw-rod fixation. (Fig.53).
• We used transpedicular screws in 20 patients,
transpedicular screws + lumbar cage in 12
patients, transpedicular screws + bone graft in
the another patients (Fig.54).
• Laboratory outcome:

• Figure (56): the mean values

of laboratory markers
preoperative and
at the end of follow up.

Figure (57): the mean values

of WBCS count preoperative
and at the end of follow up.
• Clinical outcomes:

• Figure (58): comparison between grades of Frankel

scale preoperative and at the end of follow up.
• Figure (59): comparison between the mean value of
VAS scores preoperative and at the end of follow up.
• Figure (60): comparison between the mean value of
Barthel index preoperative and at the end of follow
up.
• Results of comparisons between clinical data
of the studied series:
• Figure (61): comparison between the
instrumentation and non instrumentation group in
the mean values of CRP in the end of follow up
period.
• Figure (62): comparison between the instrumentation and
non instrumentation group as regard complications.

• In comparing the two microbiological groups regarding

safety and effectiveness parameters; there was significant
difference (p- value <0.05) between Granulomatous and
Pyogenic group in the mean values of VAS in the end of
follow up period with 2.4 ± 1 for Granulomatous and 1.6 ±
1for Pyogenic group
• Figure (63): comparison between the Granulomatous
and Pyogenic group in the mean values of VAS in the
end of follow up period.
• Figure (64): comparison between the
instrumentation and non instrumentation
group in the mean values hospital stay & CRP
in the end of follow up period
• Figure (65): comparison between instrumentation
and non instrumentation group regarding
Refractoriness to medication/severe pain as an
indication for surgery in the mean days of hospital
stay.
hospital stay (days)

16
14
12
10
Instrumentation group 8
Non instrumentaion group 6
4
2
0
Non instrumentaion Instrumentation
group group
• Figure (66): comparison between the central or
lateral bony fusion only group and the central or
lateral bony fusion in association with transpedicular
screws group in the means of blood loss and
operative time.
ILLUSTRATIVE CASES
• Case N. 1
• 51 yr old male patient, Diabetic, L4-5 post-operative
spondylodiscitis, treated with pedicular screws
fixation and lateral bone graft, culture showed strept.
• Preoperative radiograph
of the lumbar spine anterior
and lateral: narrowing of the
intervertebral space L4 and L5
with osseous destruction of
base plate L4 and upper plate L5
• Preoperative MRI of the lumbar spine T1- (right) and
T2- (left) weighted sequences: note the enhanced
signal of the intervertebral disk L4/L5 and the
epidural abscess at the posterior wall of L4
• Follow-up X rayof the lumbar spine
anteriorposterior
• and lateral showing position of the posterior
instrumentation. Bony fusion of L4 and L5
• Case N. 2
• A 55 year old male patient presenting with immobilizing
low back pain fever and an elevated CRP serum level

• MR images demonstrating the bony endplate lesions at

the L4/5 level
• abscess in the right psoas muscle at the L4/5
level (white arrow)
• Post-operative a.p. and lateral conventional X-rays in
an upright standing position at 3 months (a) and 1
year (b) postoperative follow-up showed good
central bony fusion in association with pedicular
screws fixation.
• DISCUSSION
• In the pre-1990 period, implants were seldom used in
the management of pyogenic spinal infections.
• A number of reports had implicated that radical
debridement and autogenous strut-graft fusion
combined with antibiotics coverage without
instrumentation was the most commonly adopted
therapy.
• Even the importance of immobilization for the
suppression of infection have been emphasized by
several researchers, but it was not until the 1990s of
the last century, internal fixation started gaining some
acceptance in reconstructive surgery performed in
the setting of active infection (Fukuta et al.,2003).
• Several authors have suggested bed rest and
prolonged external bracing rather than placing
spinal instrumentation (Asamoto et al., 2005).
Others have advocated a staged instrumented
operation with a period of antibiotics therapy after
debridement only surgery (Ozalay et al., 2010).
• The complications after surgical treatment without
instrumen­tation are loss of correction, listhesis,
pseudarthrosis, and spinal stenosis, Although the
use of both allograft and autografts has been
accepted as safe, demonstrations of the effec­
tiveness of instrumentation have been speculative,
based on several retrospective reviews (Heo et al.,
2011).
• Some authors see that autolo­gous bone grafts have
limitations in cases with extensive bone loss and may
result in donor site morbidity.
• In addition, autolo­gous bone grafts are of
insufficient length when we perform multilevel
corpectomy.
• Allofibular bone grafts have insufficient contact
surface between the vertebral bodies and graft (Heo
et al., 2011).
• The use of instrumentation has many
advantages as it provides alterability of length,
sufficient contact sur­face, confers better
sagittal balance, provides little loss of
correction, lack of donor site morbidity and
allows high fusion rates compared with non-
instrumented cases.
• Instrumentation may also decrease the need
for prolonged external immobilization (Lim et
al., 2008).
• Some authors see that Recurrence of infection in the
presence of instrumentation is similar to that in its
absence, indicating that infection may not be a
contraindication for its use (Lim et al., 2008).

• We think the culprit for the recurrence of infection is not

the implants itself, but is the compromised general
health condition of the patients.

• In vertebral osteomyelitis predominantly involves the

vascular vertebral body, with involvement of the
posterior elements in only 5% of the cases. This explains
why anterior debridement has become the gold standard
for a better infection control (Ozalay et al., 2010).
 SUMMARY
• The study included 31 male (77.5%) and 9 female (22.5%), male: female ratio 3.4:1 and the mean age was 50 ± 4
years, ranging from 22 to 62 years. The most common predisposing factor for spondylodiscitis was previous spinal
procedures, including lumbar spine surgery and lumbar puncture in one case of suspected meningitis, followed by
diabetes mellitus.
• The duration of symptoms before diagnosis ranged from 2 to 24 weeks with the mean duration 11.60 ± 6.64
weeks. The clinical presentations varied between the studied patients; the classical presentation of
spondylodiscitis (persistent back pain, local tenderness, limited movement, paravertebral muscle spasm) was
present in most cases.
• The lumbar spine was the most common site of spondylodiscitis, followed lumbosacral spines. Among the 35
patients with culture data, Staphylococcus aureus was the most common strain in studied series, followed by
mycobacterium tuberculosis.
• Indications for surgery in our patients varied according to the present pathology, the clinical picture and response
to previous medication. In most cases more than one indication was present. The main indication was
Refractoriness to medical management.
• In our study, Among the 40 surgically-treated patients, 20 patients were managed by posterior surgical approach
for bony fusion either central(14) or lateral only(6) and 20 patients were managed by posterior surgical approach
for bony fusion in association with transpedicular screw-rod fixation.
• The incidence of Complications in our series was 20% (6 cases); all was managed without any residual effects.
There was a single mortality from a cause not related to surgery. All patients were followed up for at least 6
months.
• All laboratory markers, clinical outcome and radiological findings showed a highly significant improvement at end
of follow up period.
•
•
•
•
 CONCLUSIONS
• The majority of early stage spondylodiscitis responds well to
conservative treatment. Surgical intervention Success was
obtained in both groups especially The excellent results were with
instrumentation group.
• instrumentation can relieve pain, improve sagittal balance and
neurologic function, and finally result in early ambulation, so we
concluded that posterior instrumentation methods after aggressive
debridement is a highly effective and safe method in the treatment
of spondylodiscitis in selected patients. If the debridement of
infected tissue is complete, instrumentation shows neither
persistence nor recurrence of secondary infection and does not
prolong the usage of antibiotics and hospitalization.
• So Further double-blinded and randomly controlled prospective
study and multicenter cooperation would be necessary to draw a
more definite conclusion.