Instrumentation in patients with spinal infection
The recent resurgence of spinal infections, which is attributed to an increase in immunocompromised patients and antibiotic-resistant strains of bacteria, has become a significant problem for most spine surgeons. Indications for surgical intervention are not always clear. In addition, questions frequently arise about the timing of surgery and which procedure to use. The use of spinal instrumentation in the setting of infection has also been controversial. To advance discussion of these issues,
... n of these issues, we describe our experience with instrumentation in patients with spinal infection and review the current literature. CLINICAL MATERIAL AND METHODS We conducted a nonrandomized retrospective review of spinal infections treated with instrumentation between Chicago. Of 105 patients who were admitted to the neurosurgical services with spinal infections, the number of infections managed with spinal instrumentation was 31 in 30 patients. Iatrogenically acquired infections were excluded. Indications for spinal instrumentation included mechanical instability which was determined based on the results of preoperative imaging and examination. In addition, iatrogenic disruption through surgical decompression was taken into consideration. Dynamic x-ray films were not obtained in all patients. This patient population presented with disease at all levels of the spinal axis. Hence, the spectrum of surgical procedures was diverse; both anterior and posterior procedures were performed (Fig. 1) . Object. Placement of instrumentation in the setting of a spinal infection has always been controversial. Although the use of allograft and autograft bone has been accepted as safe, demonstrations of the effectiveness of titanium have been speculative, based on several retrospective reviews. The authors' goal in this study was to demonstrate the effectiveness of instrumentation in the setting of a spinal infection by retrospectively reviewing their cases over the last 4 years and searching the literature regarding instrumentation in patients with pyogenic spinal infections. Methods. The authors conducted a retrospective review of their cumulative data on spinal infections. Diagnosis was based on subjective and objective clinical findings, along with radiographic and laboratory evaluation of infection and mechanical stability. Patients with medically managed disease and those who did not receive instrumentation were eliminated from this review. Of 105 patients with spinal infections who were admitted to the neurosurgical service between January 2000 and June 2004, 30 underwent surgical debridement necessitating spinal instrumentation. There were 17 women and 13 men in this group ranging from 28 to 86 years of age. Follow-up duration ranged from 3 to 54 months. There was one death, which occurred 3 months postsurgery. In three patients a deep wound infection developed, necessitating intervention, and two patients experienced a graft expulsion. Twenty-nine patients went on to demonstrate adequate fusion based on follow-up neuroimaging studies. Conclusions. The goal of neurosurgical intervention in the setting of spinal infection is to obtain an organism culture and the debridement of infection while maintaining neurological and mechanical stability. The authors demonstrate the effectiveness of radical debridement of infected bone and placement of instrumentation in patients with spinal infections. KEY WORDS • osteomyelitis • infection • spine • instrumentation Neurosurg. Focus / Volume 17 / December, 2004 1 Abbreviation used in this paper: MR = magnetic resonance.