The use of titanium mesh cages in the reconstruction of anterior column defects in active spinal infections: can we rest the crest?

Abstract

Study design: Retrospective clinical series.

Purpose: To assess whether titanium cages are an effective alternative to tricortical iliac crest bone graft for anterior column reconstruction in patients with active pyogenic and tuberculous spondylodiscitis.

Overview of literature: The use of metal cages for anterior column reconstruction in patients with active spinal infections, though described, is not without controversy.

Methods: Seventy patients with either tuberculous or pyogenic vertebral osteomyelitis underwent a single staged anterior debridement, reconstruction of the anterior column with titanium mesh cage and adjuvant posterior instrumentation. The lumbar spine was the predominant level of involvement. Medical co-morbidities were seen in 18 (25.7%) patients. A significant neurological deficit was seen in 32 (45.7%) patients. At follow up patients were assessed for healing of disease, bony fuson, and clinical outcome was assessed using Macnab's criteria.

Results: Final follow up was done on 64 (91.4%) patients at a mean average of 25 months (range, 12 to 110 months). Pathologic organisms could be identified in 42 (60%) patients. Forty two (60%) patients had histopathological findings consistent with tuberculosis. Thirty of 32 (93.7%) patients showed neurological recovery. The surgical wound healed uneventfully in 67 (95.7%) patients. Bony fusion was seen in 60 (93.7%) patients. At final follow up healing of infection was seen in all patients. As per Macnab's criteria 61 (95.3%) patients reported a good to excellent outcome.

Conclusions: Inspite of the theoretical risks, titanium cages are a suitable alternative to autologous tricortical iliac crest bone graft in patients with active spinal infections.

Keywords: Anterior column reconstruction; Discitis; Thoracolumbar spine; Titanium cage.

Fig. 1

A 26-year-old female with tuberculous spondylodiscitis at T5-6 with muti-drug resistant Mycobacterium tuberculosis. (A) Preoperative plain radiograph (lateral view) demonstrating the kyphotic deformity (34°) and partial destruction of T6. (B) Preoperative T2 weighted magnetic resonance imaging (MRI), sagittal section demonstrating the epidural and anterior vertebral abscess. (C) Preoperative T2 weighted MRI, axial section showing the large anterior abscess. (D) Follow up plain radiograph (lateral view) at 21 months showing fusion and the intact implants. (E) Computed tomogram (sagittal section) facilitating the demonstration of interbody fusion at T5-6.