Surgical treatment of infectious spondylitis in patients undergoing hemodialysis therapy

Abstract

Treatment of infectious spondylitis in hemodialysis patients remains a challenge because of comorbidities. This study aimed to evaluate the impact of end-stage renal disease (ESRD) on the clinical manifestations and surgical outcomes of patients with spinal infection. Sixteen patients who underwent surgical intervention were included. There were 3 thoracic and 13 lumbar lesions. All patients presented with intractable back pain at the start of treatment. Six patients had a fever, nine had inflammation at the hemodialysis access site, and six of them had concomitant bacteremia. Ten patients had an elevated leukocyte count. Serological tests indicated an elevation of the C-reactive protein and erythrocyte sedimentation rate level in all patients. Five patients had a neurological compromise. Postoperative complications included two mortalities, two iliac bone graft and implant dislodgement, and one retroperitoneal wound dehiscence. The preoperative mean visual analog scale score was 7.7 (range, 6-9), which improved to 3.4 (range, 2-5) at the final follow-up for 14 surviving patients. Neurological improvement was obtained by at least one grade in four Frankel C category patients. The radiographs revealed a good bony fusion in 12 cases although with a variable bone graft subsidence. In conclusion, early diagnosis of infectious spondylitis is difficult due to latent symptoms. A spine infection should be suspected in hemodialysis patients with severe back pain, even when they are afebrile. Surgical intervention for infectious spondylitis in ESRD patients undergoing hemodialysis can be performed with acceptable outcomes; however, the complication and mortality rates are relative high.

Fig. 1

A case of L4–5 infection. a, b Preoperative magnetic resonance imaging (MRI) and lateral plain radiograph. c Immediate plain radiograph after autogenous tricortical iliac bone graft for spinal reconstruction. d A two-stage operation with posterior instrumentation and fusion was performed to maintain the correction of kyphosis and to stabilize the unstable segment. e Removal of the loosening pedicle screws 6 months after initial surgery was performed. At the final follow-up, the interbody fusion was good

Fig. 2

A case of L4–5 infection, with an anterior interbody fusion with tricortical iliac strut bone graft. a, b Preoperative magnetic resonance imaging (MRI) and lateral plain radiograph. c Immediate plain radiograph after autogenous tricortical iliac bone graft for spinal reconstruction. d At the final follow-up, the interbody fusion was good, although there were bone graft subsidence and a decrease in lordotic angle. However, this did not cause clinical symptoms