Posterior-Only Circumferential Decompression and Reconstruction in the Surgical Management of Lumbar Vertebral Osteomyelitis

Abstract

Study Design Case report. Objective The purpose of this report is to discuss the surgical management of lumbar vertebral osteomyelitis with a spinal epidural abscess (SEA) and present a single-stage, posterior-only circumferential decompression and reconstruction with instrumentation using an expandable titanium cage and without segmental nerve root sacrifice as an option in the treatment of this disease process. Methods We report a 42-year-old man who presented with 3 days of low back pain and chills who rapidly decompensated with severe sepsis following admission. Magnetic resonance imaging of his lumbosacral spine revealed intramuscular abscesses of the left paraspinal musculature and iliopsoas with SEA and L4 vertebral body involvement. The patient failed maximal medical treatment, which necessitated surgical treatment as a last resort for infectious source control. He underwent a previously undescribed procedure in the setting of SEA: a single-stage, posterior-only approach for circumferential decompression and reconstruction of the L4 vertebral body with posterior segmental instrumented fixation. Results After the surgery, the patient's condition gradually improved; however, he suffered a wound dehiscence necessitating a surgical exploration and deep wound debridement. Six months after the surgery, the patient underwent a revision surgery for adjacent-level pseudarthrosis. At 1-year follow-up, the patient was pain-free and off narcotic pain medication and had returned to full activity. Conclusion This patient is the first reported case of lumbar osteomyelitis with SEA treated surgically with a single-stage, posterior-only circumferential decompression and reconstruction with posterior instrumentation. Although this approach is more technically challenging, it presents another viable option for the treatment of lumbar vertebral osteomyelitis that may reduce the morbidity associated with an anterior approach.

Keywords: circumferential decompression and reconstruction; lumbar vertebral osteomyelitis; posterior-only approach; spinal epidural abscess.

Fig. 1

Preoperative T2-weighted noncontrast magnetic resonance imaging. (A) Midsagittal cut demonstrating T2 hyperintensity with limited diffusion of L4 vertebral body and epidural space. (B, C) Axial cuts demonstrating marked inflammatory changes around the left iliopsoas, quadratus lumborum, and left paracentral musculature with multiple ill-defined fluid collections.

Fig. 2

Postoperative sagittal (A) and anteroposterior (B) X-ray films, and sagittal noncontrast computed tomography (C) images demonstrating L4 vertebral body resection with expandable cage reconstruction and pedicle instrumentation from L2 to S1 with cross-link placement at L2–3 and L5–S1. (D) Sagittal T2-weighted noncontrast magnetic resonance image demonstrating resection of the L4 vertebral body with decompressive laminectomy and evacuation of epidural abscess.

Fig. 3

Noncontrast computed tomography scan axial cut image demonstrating lucency around the sacral pedicle screws.

Fig. 4

Anteroposterior (A) and lateral (B) X-rays following reoperation for pseudarthrosis demonstrating additional interbody cage placement at L2–L3 and L5–S1 with anterior plate and screw fixation at L5–S1.