Romanian Neurosurgery (Dec 2021)
Postoperative lumbar spondylodiscitis
Abstract
Background. Several causes that can trigger POD can be incriminated: the patient's immune status, surgical technical errors, intra-operative contamination, foreign materials microfilm. Extensive analysis is required to eradicate the limited or diffuse infection and manage the optimal therapeutic attitude conservative or by surgery to get: faster recovery time, to improve symptoms, to allow mobilization, to offer a good quality of life and to reduce the average length of hospital stay. Objectives. To perform a systematic review of POD outcomes via retrospective analysis of current studies based on the mechanism, the pathogenesis, the management of patient's immunological status, aetiology (microorganism involved, foreign material applied for hemostasis, application of spinal instrumentation, cement, screws, spinal devices), laboratory (TLC, ESR, CRP), MRI/CT-scan, antibiotherapy guidelines and the type of surgery performed: classical or minim-invasive, length of procedure, intraoperative accidents, the experience of the neurosurgeon, post-operative stay in ICU, etc. Methods. Several data were taken into account regarding lumbar infections using a comprehensive review of the literature published studies from 1998 to 2021. Demographic data, clinical variables, length of hospital stay, duration of antibiotic treatment, and post-treatment complications were assessed. Results. We performed a systematic review concerning 31 studies regarding clinical status, diagnosis and treatment. Conclusions. Based on our systematic analysis, training and continuous education in spine surgery are necessary to prevent POD. The diagnosis of lumbar POD is based on history and physical examination, biochemical markers, neuroradiologic studies, using appropriate MRI imaging. Most cases of lumbar POD can be managed by conservative treatment with antibiotics after causative germ isolation and antibiogram. Surgery is performed on patients with conservative treatment failure - resistant to antibiotic therapy, as those with neurological complications: acute paraplegia, pain resistance to analgetics, acute sepsis, abscesses, spinal instability, severe kyphosis. Early surgery with wound irrigation/debridement is more readily able to disrupt biofilm formation and facilitate penetration of systemic antimicrobials to allow for resolution of the infection, vacuum-assisted closure facilitates wound healing and eradicates spinal infections, decrease the rate of complications, permit rapid pain relief while preserving the instrumentation/stability, better clinical outcomes, infection control before extensive destruction of the vertebrae, spinal instability and kyphotic deformity appear. Instrumentation can usually be preserved in patients with early infections (e.g., 6 weeks to even years) PSII. Patients should be adequately followed for one postoperative year, to ensure that the infection has been fully eradicated. Implant sonication provides cultures for direct identification of active and/or persistent biofilm, while the introduction of enzymes that dissolve the biofilm matrix (e.g., DNase and alginate lyase) and quorum-sensing inhibitors that increase biofilm susceptibility to antibiotics may further help manage postoperative infection (2)(27-31).
