Treatment guidelines incorporating minimally invasive surgery for pyogenic spondylitis

Abstract

Introduction: In Japan, the incidence of pyogenic spondylitis is increasing due to unprecedented population aging and the number of immunocompromised hosts with various complications. We report the effectiveness of minimally invasive surgery using a percutaneous pedicle screw (PPS) and fully endoscopic spine surgery (FESS) for treating spondylitis refractory to conservative treatment at our hospital.

Methods: Of 34 patients treated between April 2017 and March 2021, we retrospectively reviewed 15 consecutive patients who underwent surgical treatment and were followed up for >1 year. The underlying disease, the affected site, the bacteria responsible for the infection, the surgical method, the number of days to surgery, the time to CRP negativity (postoperative), and the length of hospital stay were evaluated. A spinal surgeon completed the radiographic assessments independently.

Results: All 15 patients, 12 men and three women (mean age, 69 years; 36-87 years), underwent minimally invasive spinal surgery. All the patients had underlying diseases, mostly diabetes and cancer. Most affected sites were the L4/5 levels. The bacteria responsible for the infection were identified in 13 (87%) patients. Most bacteria were detected in the blood and only six were detected locally. PPS was performed in nine cases, FESS in two cases, and a combination of PPS and FESS in four cases as the surgical method. The mean duration of days before was 39 days. The average time to CRP negative was 30 days, postoperatively. The average length of the hospital stay was 74 days. In all 15 cases, the infection subsided, and finally, 10 of the 15 cases showed bone fusion at the affected site.

Conclusion: Conservative treatment is the basic treatment for pyogenic spondylitis. However, surgical treatment may be necessary in some cases, if little improvement is observed.

In principle, the surgical treatment at our hospital stabilises the vertebral body affected by PPS. However, FESS is a useful tool that can identify the causative organism necessary for diagnosis and treatment, irrigate with copious amounts of saline, scratch lesions under direct vision, and drain. Good results were obtained by combining these two methods, depending on the case.