Percutaneous suction and irrigation for the treatment of recalcitrant pyogenic spondylodiscitis

Abstract

Background: The primary management of pyogenic spondylodiscitis is conservative. Once the causative organism has been identified, by blood culture or biopsy, administration of appropriate intravenous antibiotics is started. Occasionally patients do not respond to antibiotics and surgical irrigation and debridement is needed. The treatment of these cases is challenging and controversial. Furthermore, many affected patients have significant comorbidities often precluding more extensive surgical intervention. The aim of this study is to describe early results of a novel, minimally invasive percutaneous technique for disc irrigation and debridement in pyogenic spondylodiscitis.

Materials and methods: A series of 10 consecutive patients diagnosed with pyogenic spondylodiscitis received percutaneous disc irrigation and debridement. The procedure was performed by inserting two Jamshidi needles percutaneously into the disc space. Indications for surgery were poor response to antibiotic therapy (8 patients) and the need for more extensive biopsy (2 patients). Pre- and postoperative white blood cell count (WBC), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), Oswestry disability index (ODI), and visual analogue score (VAS) for back pain were collected. Minimum follow-up was 18 months, with regular interval assessments.

Results: There were 7 males and 3 females with a mean age of 67 years. The mean WBC before surgery was 14.63 × 10⁹/L (10.9-26.4) and dropped to 7.48 × 10⁹/L (5.6-9.8) after surgery. The mean preoperative CRP was 188 mg/L (111-250) and decreased to 13.83 mg/L (5-21) after surgery. Similar improvements were seen with ESR. All patients reported significant improvements in ODI and VAS scores after surgery. The average hospital stay after surgery was 8.17 days. All patients had resolution of the infection, and there were no complications associated with the procedure.

Conclusions: Our study confirms the feasibility and safety of our percutaneous technique for irrigation and debridement of pyogenic spondylodiscitis. Percutaneous irrigation and suction offers a truly minimally invasive option for managing recalcitrant spondylodiscitis or for diagnostic purposes. The approach used is very similar to discography and can be easily adapted to different hospital settings.

Level of evidence: Level III.

Keywords: Minimally invasive technique; Pyogenic spondylodiscitis; Spinal abscess drainage; Spinal percutaneous drainage.

Fig. 1

Intraoperative positioning of the patient. The patient is positioned prone on bolsters. The surgical area is draped and a C-arm is positioned perpendicular to the patient for intraoperative monitoring of needle placement

Fig. 2

Lordosis of the C-arm is adjusted on the AP view to obtain a perfectly parallel view of the vertebral endplates of the target disc (green dotted lines). Following this, lateral tilt of the C-arm is adjusted to obtain an oblique view of the target disc making sure that the articular facet is correctly visualised in the posterior third of the disc space (red dotted lines). The entry point into the disc is marked on the schematic drawing (left panel)

Fig. 3

The needles are advanced inside the disc space. (Left panel) final position of the needles in the AP view; (middle panel) final position of the needles in the lateral view; (right panel) intraoperative position of the needles

Fig. 4

A 75-year-old patient with pyogenic spondylodiscitis at L3/L4. S. aureus had been identified by blood cultures 10 days earlier and IV antibiotic therapy was started soon afterwards. After 10 days of IV therapy, the patient was still complaining of significant pain with incomplete improvement of the inflammatory markers (CPR 135 mg/L). (Left panel) MRI sagittal view of the involved disc space; (middle panel) axial view at the level of the L3/L4 disc space and the L4 vertebral body showing a significant disc abscess and bilateral psoas abscesses. (Right panel) standing X-ray of the lumbar spine showing resolution of the infection and fusion of the involved segment 8 months after the end of treatment