Endoscopic Treatment for Lumbar Infectious Spondylitis
Endoscopic Treatment for Lumbar Infectious Spondylitis
This study was approved by the Institutional Review Board of E-DA Hospital, a 1200-bed tertiary referral center (IRB number: EMPR-101-027). Thirty-two patients with infectious spondylitis underwent PEDI procedures between January 2005 and July 2010 at our institute. There were 9 women and 23 men with an average age of 57.4 years (range, 38–88 years). The patients' medical records, including outpatient and emergency room notes, admission notes, inpatient progress and nursing notes, discharge summaries, procedure notes, surgical reports, radiology reports, pathology reports, and microbiology laboratory results were reviewed. The microbiology reports comprised microscopy and culture findings and any specific pathogens identified by either method. All of the patients presented with intractable back pain requiring narcotic pain control and bed rest. Infectious spondylitis was diagnosed on the basis of clinical examinations, including elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) values, and radiographic and magnetic resonance imaging (MRI) findings.
The surgical indications of the 32 patients undergoing PEDI included single-level infectious spondylodiscitis, postoperative infectious spondylodiscitis, advanced infection with epidural abscess, psoas muscle abscess, pre-vertebral or para-vertebral abscess, multilevel infectious spondylitis, and recurrent infection after anterior debridement and fusion. The infectious spondylitis of all patients who underwent PEDI in this study did not respond to conservative administration of empirical antibiotics and was not so severe to absolutely need aggressive surgical debridement. Patients who sustained severe infection resulting in severe structural deformity or significant neurological deficit were excluded in this study and they were advised to receive open surgery for their severe infectious spondylitis.
The patient was placed prone on a radiolucent frame suitable for fluoroscopy. All procedures were performed under local anesthesia with conscious sedation similar to that used for standard lumbar discography. Under fluoroscopic guidance, the target site was located and the entry site was marked on the skin at a point 8–12 cm from the midline. After sterile preparation, draping, and local anesthesia, a spinal needle was inserted directly into the center of the target disc. Conscious sedation was performed through administering IV bolus dose of fentanyl 50 mcg and propofol 0.5 mg · kg. A guide wire was introduced through the spinal needle into the central disc space, and the spinal needle was then withdrawn. After creating a small stab-wound incision (about 1 cm), a dilator and a cannulated sleeve were guided over the wire and progressed sequentially into the disc center. Additional IV bolus dose of propofol 0.5 mg · kg were administered if the patients complained pain during the procedures. Fluoroscopy was repeated in 2 orthogonal planes to verify the correct position of the endoscope tip. The tissue dilator was then removed, and the cutting tool was inserted. The cutting tool, a cylindrical sleeve with a serrated edge at its distal end, was used to harvest a core of the biopsy specimen. Discectomy forceps were then inserted through the cannulated sleeve to extract additional tissue from the infected disc. Percutaneous debridement was conducted piecemeal by manipulating the biopsy forceps, flexible rongeurs, and shaver into different positions to withdraw as much tissue as possible under fluoroscopic monitoring and endoscopic view (Figure 1). The same procedures were repeated on the other side. These 2 working sheaths were left on both sides for sufficient extirpation and extensive debridement of the infected intervertebral disc and even some endplate from different endoscopic direction.
(Enlarge Image)
Figure 1.
Intraoperative endoscopic views from the inside of L5-S1 infectious spondylitis. At the beginning of the PEDI procedure, the endoscopic view was not clear due to pus accumulation and granulation tissue at the infected disc level (A). Discectomy forcep, flexible rongeur, and shaver were then inserted through the cannulated sleeve to withdraw as much infected tissue as possible (B). By aggressive percutaneous debridement, the endoscopic view became much clear and the vertebral endplate above the infected disc level could be identified (C).
After the biopsy and debridement procedures, at least 10,000 mL of dilute betadine solution was used for irrigation. Approximately 35 mL of povidone-iodine was diluted with 1,000 mL normal saline to achieve a 0.35% betadine solution for use during the operation. One portal was connected to a lavage fluid pump for the inflow and the other portal was connected to a suction bottle for the outflow, with continuous infusion (Figure 2). The suction function is usually kept open from the beginning to the end of the procedure for further drainage of the lavage fluid and abscess. Finally, 2 drainage tubes were inserted into the debrided disc space and connected to a negative-pressure Hemovac. The biopsy specimen contained disc material and parts of vertebral endplates of adjacent vertebrae. Each biopsy specimen was examined for microorganisms and evaluated histopathologically.
(Enlarge Image)
Figure 2.
PEDI procedure. Two portal working sheaths were used for percutaneous endoscopic debridement followed by dilute betadine solution irrigation (PEDI) for treating patients with lumbar infectious spondylitis (A). A negative-pressure Hemovac with 2 drainage tubes was inserted through the sheaths for further continuous drainage of the offending pathogens (B). Informed consent was obtained from the patient for his image to be published in this study.
Clinical outcomes were assessed by careful physical examination, Macnab criteria, regular serological tests, and imaging studies during admission, at 1 month after discharge and every 3 months to determine whether continued conservative treatment was sufficient or open surgical intervention was required. All patients were followed up for at least 24 months after undergoing PEDI treatment.
Methods
Patients
This study was approved by the Institutional Review Board of E-DA Hospital, a 1200-bed tertiary referral center (IRB number: EMPR-101-027). Thirty-two patients with infectious spondylitis underwent PEDI procedures between January 2005 and July 2010 at our institute. There were 9 women and 23 men with an average age of 57.4 years (range, 38–88 years). The patients' medical records, including outpatient and emergency room notes, admission notes, inpatient progress and nursing notes, discharge summaries, procedure notes, surgical reports, radiology reports, pathology reports, and microbiology laboratory results were reviewed. The microbiology reports comprised microscopy and culture findings and any specific pathogens identified by either method. All of the patients presented with intractable back pain requiring narcotic pain control and bed rest. Infectious spondylitis was diagnosed on the basis of clinical examinations, including elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) values, and radiographic and magnetic resonance imaging (MRI) findings.
The surgical indications of the 32 patients undergoing PEDI included single-level infectious spondylodiscitis, postoperative infectious spondylodiscitis, advanced infection with epidural abscess, psoas muscle abscess, pre-vertebral or para-vertebral abscess, multilevel infectious spondylitis, and recurrent infection after anterior debridement and fusion. The infectious spondylitis of all patients who underwent PEDI in this study did not respond to conservative administration of empirical antibiotics and was not so severe to absolutely need aggressive surgical debridement. Patients who sustained severe infection resulting in severe structural deformity or significant neurological deficit were excluded in this study and they were advised to receive open surgery for their severe infectious spondylitis.
Intervention
The patient was placed prone on a radiolucent frame suitable for fluoroscopy. All procedures were performed under local anesthesia with conscious sedation similar to that used for standard lumbar discography. Under fluoroscopic guidance, the target site was located and the entry site was marked on the skin at a point 8–12 cm from the midline. After sterile preparation, draping, and local anesthesia, a spinal needle was inserted directly into the center of the target disc. Conscious sedation was performed through administering IV bolus dose of fentanyl 50 mcg and propofol 0.5 mg · kg. A guide wire was introduced through the spinal needle into the central disc space, and the spinal needle was then withdrawn. After creating a small stab-wound incision (about 1 cm), a dilator and a cannulated sleeve were guided over the wire and progressed sequentially into the disc center. Additional IV bolus dose of propofol 0.5 mg · kg were administered if the patients complained pain during the procedures. Fluoroscopy was repeated in 2 orthogonal planes to verify the correct position of the endoscope tip. The tissue dilator was then removed, and the cutting tool was inserted. The cutting tool, a cylindrical sleeve with a serrated edge at its distal end, was used to harvest a core of the biopsy specimen. Discectomy forceps were then inserted through the cannulated sleeve to extract additional tissue from the infected disc. Percutaneous debridement was conducted piecemeal by manipulating the biopsy forceps, flexible rongeurs, and shaver into different positions to withdraw as much tissue as possible under fluoroscopic monitoring and endoscopic view (Figure 1). The same procedures were repeated on the other side. These 2 working sheaths were left on both sides for sufficient extirpation and extensive debridement of the infected intervertebral disc and even some endplate from different endoscopic direction.
(Enlarge Image)
Figure 1.
Intraoperative endoscopic views from the inside of L5-S1 infectious spondylitis. At the beginning of the PEDI procedure, the endoscopic view was not clear due to pus accumulation and granulation tissue at the infected disc level (A). Discectomy forcep, flexible rongeur, and shaver were then inserted through the cannulated sleeve to withdraw as much infected tissue as possible (B). By aggressive percutaneous debridement, the endoscopic view became much clear and the vertebral endplate above the infected disc level could be identified (C).
After the biopsy and debridement procedures, at least 10,000 mL of dilute betadine solution was used for irrigation. Approximately 35 mL of povidone-iodine was diluted with 1,000 mL normal saline to achieve a 0.35% betadine solution for use during the operation. One portal was connected to a lavage fluid pump for the inflow and the other portal was connected to a suction bottle for the outflow, with continuous infusion (Figure 2). The suction function is usually kept open from the beginning to the end of the procedure for further drainage of the lavage fluid and abscess. Finally, 2 drainage tubes were inserted into the debrided disc space and connected to a negative-pressure Hemovac. The biopsy specimen contained disc material and parts of vertebral endplates of adjacent vertebrae. Each biopsy specimen was examined for microorganisms and evaluated histopathologically.
(Enlarge Image)
Figure 2.
PEDI procedure. Two portal working sheaths were used for percutaneous endoscopic debridement followed by dilute betadine solution irrigation (PEDI) for treating patients with lumbar infectious spondylitis (A). A negative-pressure Hemovac with 2 drainage tubes was inserted through the sheaths for further continuous drainage of the offending pathogens (B). Informed consent was obtained from the patient for his image to be published in this study.
Outcome Measures
Clinical outcomes were assessed by careful physical examination, Macnab criteria, regular serological tests, and imaging studies during admission, at 1 month after discharge and every 3 months to determine whether continued conservative treatment was sufficient or open surgical intervention was required. All patients were followed up for at least 24 months after undergoing PEDI treatment.