Feature Article
Bilateral Portal Percutaneous Endoscopic Debridement and Lavage for Lumbar Pyogenic Spondylitis
Orthopedics, 2015;38(10):e856–e863
Abstract
Common management approaches for spinal infections include conservative administration of antibiotics and aggressive surgical debridement. Minimally invasive endoscopic treatment has been reported and is gaining widespread attention because of its simplicity and effectiveness. This study retrospectively evaluated the clinical outcomes of bilateral portal percutaneous endoscopic debridement and lavage with dilute povidone-iodine solution in the treatment of patients with lumbar pyogenic spondylitis. From January 2007 to December 2011, a total of 22 patients diagnosed with single-level lumbar pyogenic spondylitis underwent bilateral portal percutaneous endoscopic debridement and lavage with dilute povidone-iodine solution at the authors’ institution. Clinical outcomes were assessed by careful physical examination, visual analog scale pain score, modified MacNab criteria functional score, regular serologic testing, and imaging studies to determine whether percutaneous endoscopic debridement and lavage treatment was successful or if surgical intervention was required. Causative bacteria were identified in 19 (86.4%) of 22 biopsy specimens. Eighteen patients had satisfactory relief of back pain and uneventful recovery after this treatment. The success rate was 81.8% (18 of 22). Both visual analog scale and modified MacNab criteria scores improved significantly in successfully treated patients. No major surgical complications were noted, except for 3 patients who had residual or subsequent paresthesia in the affected lumbar segment. Percutaneous endoscopic debridement and lavage is a minimally invasive procedure that can yield a higher bacterial diagnosis, relieve back pain, and help to eradicate lumbar pyogenic spondylitis. It is an effective alternative treatment for patients with spinal infection before extensive open surgery. [Orthopedics. 2015; 38(10):e856–e863.]
- 1.Rezai AR, Woo HH, Errico TJ, Cooper PR. Contemporary management of spinal osteomyelitis. Neurosurgery. 1999; 44 (5):1018–1025.
10.1097/00006123-199905000-00047 Crossref MedlineGoogle Scholar - 2.Carragee EJ. Pyogenic vertebral osteomyelitis. J Bone Joint Surg Am. 1997; 79 (6):874–880. Crossref MedlineGoogle Scholar
- 3.Kemp HB, Jackson JW, Jeremiah JD, Hall AJ. Pyogenic infections occurring primarily in intervertebral discs. J Bone Joint Surg Br. 1973; 55 (4):698–714. Crossref MedlineGoogle Scholar
- 4.An HS, Seldomridge JA. Spinal infections: diagnostic tests and imaging studies. Clin Orthop Relat Res. 2006; 444:27–33.
10.1097/01.blo.0000203452.36522.97 Crossref MedlineGoogle Scholar - 5.Bonfiglio M, Lange TA, Kim YM. The classic: pyogenic vertebral osteomyelitis. Disk space infections: 1973. Clin Orthop Relat Res. 2006; 444:4–8.
10.1097/01.blo.0000201172.64764.bb Crossref MedlineGoogle Scholar - 6.Hadjipavlou AG, Mader JT, Necessary JT, Muffoletto AJ. Hematogenous pyogenic spinal infections and their surgical management. Spine (Phila Pa 1976). 2000; 25 (13):1668–1679.
10.1097/00007632-200007010-00010 Crossref MedlineGoogle Scholar - 7.Carragee EJ. The clinical use of magnetic resonance imaging in pyogenic vertebral osteomyelitis. Spine (Phila Pa 1976). 1997; 22 (7):780–785.
10.1097/00007632-199704010-00015 Crossref MedlineGoogle Scholar - 8.Chew FS, Kline MJ. Diagnostic yield of CT-guided percutaneous aspiration procedures in suspected spontaneous infectious diskitis. Radiology. 2001; 218 (1):211–214.
10.1148/radiology.218.1.r01ja06211 Crossref MedlineGoogle Scholar - 9.Rankine JJ, Barron DA, Robinson P, Millner PA, Dickson RA. Therapeutic impact of percutaneous spinal biopsy in spinal infection. Postgrad Med J. 2004; 80 (948):607–609.
10.1136/pgmj.2003.017863 Crossref MedlineGoogle Scholar - 10.Yang SC, Fu TS, Chen LH, Chen WJ, Tu YK. Identifying pathogens of spondy-lodiscitis: percutaneous endoscopy or CT-guided biopsy. Clin Orthop Relat Res. 2008; 466 (12):3086–3092.
10.1007/s11999-008-0441-y Crossref MedlineGoogle Scholar - 11.Fouquet B, Goupille P, Jattiot F, Discitis after lumbar disc surgery: features of “aseptic” and “septic” forms. Spine (Phila Pa 1976). 1992; 17 (3):356–358.
10.1097/00007632-199203000-00019 Crossref MedlineGoogle Scholar - 12.Staatz G, Adam GB, Keulers P, Vorwerk D, Günther RW. Spondylodiskitic abscesses: CT-guided percutaneous catheter drainage. Radiology. 1998; 208 (2):363–367.
10.1148/radiology.208.2.9680560 Crossref MedlineGoogle Scholar - 13.Lin CP, Ma HL, Wang ST, Liu CL, Yu WK, Chang MC. Surgical results of long posterior fixation with short fusion in the treatment of pyogenic spondylodiscitis of the thoracic and lumbar spine: a retrospective study. Spine (Phila Pa 1976). 2012; 37 (25):e1572–e1579.
10.1097/BRS.0b013e31827399b8 Crossref MedlineGoogle Scholar - 14.Kambin P, Schaffer JL. Percutaneous lumbar discectomy: review of 100 patients and current practice. Clin Orthop Relat Res. 1989; 238:24–34. CrossrefGoogle Scholar
- 15.Hermantin FU, Peters T, Quartararo L, Kambin P. A prospective, randomized study comparing the results of open discectomy with those of video-assisted arthroscopic microdiscectomy. J Bone Joint Surg Am. 1999; 81 (7):958–965. Crossref MedlineGoogle Scholar
- 16.Yeung AT, Tsou PM. Posterolateral endoscopic excision for lumbar disc herniation: surgical technique, outcome, and complications in 307 consecutive cases. Spine (Phila Pa 1976). 2002; 27 (7):722–731.
10.1097/00007632-200204010-00009 Crossref MedlineGoogle Scholar - 17.Emery SE, Chan DP, Woodward HR. Treatment of hematogenous pyogenic vertebral osteomyelitis with anterior debridement and primary bone grafting. Spine (Phila Pa 1976). 1989; 14 (3):284–291. MedlineGoogle Scholar
- 18.Krödel A, Stürz H, Siebert CH. Indications for and results of operative treatment of spondylitis and spondylodiscitis. Arch Orthop Trauma Surg. 1991; 110 (2):78–82.
10.1007/BF00393878 Crossref MedlineGoogle Scholar - 19.Haaker RG, Senkal M, Kielich T, Krämer J. Percutaneous lumbar discectomy in the treatment of lumbar discitis. Eur Spine J. 1997; 6 (2):98–101.
10.1007/BF01358740 Crossref MedlineGoogle Scholar - 20.Nagata K, Ohashi T, Ariyoshi M, Sonoda K, Imoto H, Inoue A. Percutaneous suction aspiration and drainage for pyogenic spondylitis. Spine (Phila Pa 1976). 1998; 23 (14):1600–1606.
10.1097/00007632-199807150-00018 Crossref MedlineGoogle Scholar - 21.Hadjipavlou AG, Katonis PK, Gaitanis IN, Muffoletto AJ, Tzermiadianos MN, Crow W. Percutaneous transpedicular discectomy and drainage in pyogenic spondylodiscitis. Eur Spine J. 2004; 13 (8):707–713.
10.1007/s00586-004-0699-z Crossref MedlineGoogle Scholar - 22.Hanaoka N, Kawasaki Y, Sakai T, Percutaneous drainage and continuous irrigation in patients with severe pyogenic spondylitis, abscess formation, and marked bone destruction. J Neurosurg Spine. 2006; 4 (5):374–379.
10.3171/spi.2006.4.5.374 Crossref MedlineGoogle Scholar - 23.Tofuku K, Koga H, Yone K, Komiya S. Continuous irrigation in pyogenic spondylitis accompanied by iliopsoas abscess. Spine (Phila Pa 1976). 2007; 32 (14):e382–e387.
10.1097/BRS.0b013e318067e35e Crossref MedlineGoogle Scholar - 24.Fu TS, Yang SC, Tsai TT, Percutaneous endoscopic debridement and drainage in immunocompromised patients with complicated infectious spondylitis. Minim Invasive Ther Allied Technol. 2010; 19 (1):42–47.
10.3109/13645700903384450 Crossref MedlineGoogle Scholar - 25.Yang SC, Chen WJ, Chen HS, Kao YH, Yu SW, Tu YK. Extended indications of percutaneous endoscopic lavage and drainage for the treatment of lumbar infectious spondylitis. Eur Spine J. 2014; 23 (4):846–853.
10.1007/s00586-013-3157-y Crossref MedlineGoogle Scholar - 26.Klöckner C, Valencia R. Sagittal alignment after anterior debridement and fusion with or without additional posterior instrumentation in the treatment of pyogenic and tuberculous spondylodiscitis. Spine (Phila Pa 1976). 2003; 28 (10):1036–1042.
10.1097/01.BRS.0000061991.11489.7F Crossref MedlineGoogle Scholar - 27.Hill RL, Casewell MW. The in-vitro activity of povidone-iodine cream against Staphylococcus aureus and its bioavailability in nasal secretions. J Hosp Infect. 2000; 45 (3):198–205.
10.1053/jhin.2000.0733 Crossref MedlineGoogle Scholar - 28.Reimer K, Wichelhaus TA, Schäfer V, Antimicrobial effectiveness of povidone-iodine and consequences for new application areas. Dermatology. 2002; 204 (suppl 1):S114–S120.
10.1159/000057738 Crossref MedlineGoogle Scholar - 29.Block C, Robenshtok E, Simhon A, Shapiro M. Evaluation of chlorhexidine and povidone iodine activity against methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus faecalis using a surface test. J Hosp Infect. 2000; 46 (2):147–152.
10.1053/jhin.2000.0805 Crossref MedlineGoogle Scholar - 30.Yasuda T, Yoshimura S, Katsuno Y, Comparison of bactericidal activities of various disinfectants against methicillin-sensitive Staphylococcus aureus and methicillin-resistant Staphylococcus aureus. Postgrad Med J. 1993; 69 (suppl 3):S66–S69. MedlineGoogle Scholar
- 31.Goldenheim PD. An appraisal of povidone-iodine and wound healing. Postgrad Med J. 1993; 69 (suppl 3):S97–S105. MedlineGoogle Scholar
- 32.Cheng MT, Chang MC, Wang ST, Yu WK, Liu CL, Chen TH. Efficacy of dilute betadine solution irrigation in the prevention of postoperative infection of spinal surgery. Spine (Phila Pa 1976). 2005; 30 (15):1689–1693.
10.1097/01.brs.0000171907.60775.85 Crossref MedlineGoogle Scholar - 33.Yang SC, Fu TS, Chen HS, Kao YH, Yu SW, Tu YK. Minimally invasive endoscopic treatment for lumbar infectious spondylitis: a retrospective study in a tertiary referral center. BMC Musculoskelet Disord. 2014; 15:105.
10.1186/1471-2474-15-105 Crossref MedlineGoogle Scholar
