Full-endoscopic-assisted retroperitoneal approach for the devastating spondylodiscitis with psoas abscess

Abstract

Introduction: Spondylodiscitis with psoas abscess is a serious spinal infection often requiring prolonged antibiotics and surgery in some instances. Conventional surgical approaches can be highly invasive, posing significant risks to frail patients with multiple comorbidities. An endoscopic-assisted retroperitoneal approach offers a potential minimally invasive alternative to reduce surgical trauma.

Research question: Can an endoscopic-assisted retroperitoneal approach effectively and safely treat spondylodiscitis with psoas abscess, particularly in high-risk patients?

Materials and methods: This retrospective case series included patients treated for psoas abscess via an endoscopic-assisted retroperitoneal approach between 2013 and 2023. The collected data included demographic details, comorbidities, operative time, blood loss, postoperative pain scores, spinal injury scale outcomes, time to normalization of laboratory markers, and 6-month satisfaction scores.

Results: Of 81 patients with spinal infections who underwent surgery, nine met the inclusion criteria (mean age 65.67 ± 10.6 years). Spinal stabilization was performed in seven cases. Mean operative time was 149.44 ± 63.05 min, and mean blood loss was 88.89 ± 117.59 mL. Significant pain reduction was observed postoperatively, and 88.89 % of patients maintained or improved spinal injury scores at 1-year follow-up. Laboratory markers normalized within 1 week to 1 month in most cases. At 6 months, 77.78 % reported good to excellent satisfaction.

Discussion and conclusion: The endoscopic-assisted retroperitoneal approach is a feasible and promising option for managing spondylodiscitis with psoas abscess, offering reduced tissue damage, favorable recovery times, and encouraging clinical outcomes. It may be particularly advantageous for frail patients with multiple comorbidities.

Keywords: Case series; Endoscopic spine surgery; Lumbar spine; Psoas abscess; Retroperitoneal approach; Spondylodiscitis.

Fig. 1

A 79-year-old male with a history of Escherichia coli bacteremia presented with back and leg pain. A. The T2-weighted MRI revealed the initial stage of spondylodiscitis involving the L3-4 intervertebral disc space. B. Despite two weeks of intravenous antibiotics, his symptoms of back and leg pain worsened. The follow-up CT scan revealed the continuing enlarged psoas abscess and the ongoing destruction of the lower endplate of L3 and the upper endplate of L4 vertebrae, with soft tissue extension causing severe spinal canal stenosis. C. Postoperative plain radiograph after anterior debridement via the endoscopic-assisted retroperitoneal approach and percutaneous instrumentation. D. The follow-up CT scan one year after the operation revealed that the L3-L4 intervertebral disc space was spontaneously fused.

Fig. 2

A 69-year-old male presented with severe pain in his lower back and both thighs, with mild weakness of the hip flexion and knee extension motor power on both sides. A. and B. Plain radiograph and the CT scan of his lumbar spine revealed an osteolytic lesion of both the L3 and L4 vertebral body with the destruction of the adjacent endplate of the L3-4 intervertebral disc and the nearby psoas abscess. C. The T1-weighted MRI study with contrast confirmed the L3-4 level spondylodiscitis accompanied by epidural abscess situated posterior to the L3 vertebral body, causing severe spinal canal stenosis. D. Postoperative plain radiograph after anterior debridement via the endoscopic-assisted retroperitoneal approach and percutaneous instrumentation.

Fig. 3

Demonstration when approaching from the left side of the patient. A and B. Intraoperative fluoroscopic images show the initial docking site of the working sleeve. C. Positioning of the working sleeve on the patient's side.

Fig. 4

Examples of intraoperative visualization and its corresponding fluoroscopic images of the possible reached area by the endoscope during the anterior retroperitoneal approach. A. Ipsilateral side of the vertebral body and the adjacent intervertebral disc space. B. Posterior annulus and the epidural space (note that the intraoperative snapshot was obtained while the endoscope was turned in an anticlockwise fashion). C. Contralateral side psoas muscle through the disc space. D. An illustration to summarize the overall flexibility of this approach.