Adjacent segment infection after surgical treatment of spondylodiscitis

Abstract

Background: This is the first case series to describe adjacent segment infection (ASI) after surgical treatment of spondylodiscitis (SD).

Materials and methods: Patients with SD, spondylitis who were surgically treated between 1994 and 2012 were included. Out of 1187 cases, 23 (1.94 %) returned to our institution (Zentralklinik Bad Berka) with ASI: 10 males, 13 females, with a mean age of 65.1 years and a mean follow-up of 69 months.

Results: ASI most commonly involved L3-4 (seven patients), T12-L1 (five) and L2-3 (four). The mean interval between operations of primary infection and ASI was 36.9 months. All cases needed surgical intervention, debridement, reconstruction and fusion with longer instrumentation, with culture and sensitivity-based postoperative antimicrobial therapy. At last follow-up, six patients (26.1 %) were mobilized in a wheelchair with a varying degree of paraplegia (three had pre-existing paralysis). Three patients died within 2 months after the ASI operation (13 %). Excellent outcomes were achieved in five patients, and good in eight.

Conclusions: Adjacent segment infection after surgical treatment of spondylodiscitis is a rare complication (1.94 %). It is associated with multimorbidity and shows a high mortality rate and a high neurological affection rate. Possible explanations are: haematomas of repeated micro-fractures around screw loosening, haematogenous spread, direct inoculation or a combination of these factors. ASI may also lead to proximal junctional kyphosis, as found in this series. We suggest early surgical intervention with anterior debridement, reconstruction and fusion with posterior instrumentation, followed by antimicrobial therapy for 12 weeks.

Level of evidence: Level IV retrospective uncontrolled case series.

Keywords: Adjacent segment disease; Adjacent segment infection; Spinal infection; Spondylitis; Spondylodiscitis.

Fig. 1

Patient 4: sagittal MRI cuts T2- and T1-weighted, and lateral radiographs; a preoperatively, b after primary operation, c adjacent segment infection, screw loosening and marked adjacent segment kyphosis and d last FU after 5.5 years

Fig. 2

Patient 18: a preoperative MRI and radiographs, b postoperative, c ASI in MRI and radiographs and d after reoperation

Fig. 3

Patient 8: sagittal MRI cuts T2- and T1-weighted, and lateral radiographs; a preoperatively, b after primary operation, c adjacent segment infection, no screw loosening or marked adjacent segment kyphosis, and d last FU after 2.5 years

Fig. 4

Patient 12: sagittal MRI cuts T2- and T1-weighted, and lateral radiographs; a preoperatively, b after primary operation, c adjacent segment infection, and d after ASI surgery