Titanium cages in the surgical treatment of severe vertebral osteomyelitis

Abstract

The role of spinal implants in the presence of infection is critically discussed. In this study 20 patients with destructive vertebral osteomyelitis were surgically treated with one-stage posterior instrumentation and fusion and anterior debridement, decompression and anterior column reconstruction using an expandable titanium cage filled with morsellised autologous bone graft. The patients' records and radiographs were retrospectively analysed and follow-up clinical and radiographic data obtained. At a mean follow-up of 23 months (range 12-56 months) all cages were radiographically fused and all infections eradicated. There were no cases of cage dislocation, migration or subsidence. Local kyphosis was corrected from 9.2 degrees (range -20 degrees to 64 degrees ) by 9.4 degrees to -0.2 degrees (range -32 degrees to 40 degrees ) postoperatively and lost 0.9 degrees during follow-up. All five patients with preoperative neurological deficits improved to Frankel score D or E. Patient-perceived disability caused by back pain averaged 7.9 (range 0-22) in the Roland-Morris score at follow-up. In cases of vertebral osteomyelitis with severe anterior column destruction the use of titanium cages in combination with posterior instrumentation is effective and safe and offers a good alternative to structural bone grafts. Further follow-up is necessary to confirm these early results.

Fig. 1a–e.

An 80-year-old male (patient number 9) with vertebral osteomyelitis and destruction of L3 and marked frontal and sagittal plane deformity (a, b), treated with one-stage posterior transpedicular stabilisation of T12–L5, anterior subtotal corpectomy of L3 and reconstruction with an expandable titanium cage was performed. Postoperative X-rays (c, d) demonstrate good frontal and sagittal plane correction, but a lucent line at the distal cage—bone interface. At 22 months follow-up (e) the lucent line has disappeared, with radiographically fused interfaces and initial bony incorporation of the cage

Fig. 2a, b.

A 71-year-old male (patient number 5) with destructive vertebral osteomyelitis of L1, treated with one-stage posterior transpedicular stabilisation and anterior corpectomy L1 and reconstruction with expandable titanium cage (a). b Fifty-six months postoperatively there is complete bony incorporation of the cage with complete anterior bony bridging

Fig. 3a–d.

A 63-year-old female (patient number 11) with vertebral osteomyelitis and destruction of L3. a, b Considerable spinal canal encroachment by infectious debris can be seen. The patient underwent one-stage posterior stabilisation of L1–L5 and anterior corpectomy, spinal canal decompression and reconstruction with expandable titanium cage. c, d Follow-up X-rays after 26 months. Slight lucencies are visible around the pedicle screws in L5 (c)

Fig. 4a–d.

A 55-year-old female (patient number 6) with diabetes mellitus and severe vertebral osteomyelitis with complete destruction of L3 and an extensive epidural abscess from T11 down to S1 (*, a, b) and bilateral psoas abscesses (*, c). Treatment by one-stage posterior transpedicular stabilisation T12–L5 and posterior drainage of the epidural abscess via multilevel flavotomies, L3 anterior corpectomy with drainage of the psoas abscesses, and anterior column reconstruction with an expandable titanium cage. Lateral X-ray at 26 months' follow-up visit (d) demonstrates solid interbody fusion and anterior bony coverage of the cage. The infection was eradicated without further revisions