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First report on treating spontaneous infectious spondylodiscitis of lumbar spine with posterior debridement, posterior instrumentation and an injectable calcium sulfate/hydroxyapatite composite eluting gentamicin: a case report
© The Author(s). 2016
Received: 14 March 2016
Accepted: 27 October 2016
Published: 12 December 2016
Spontaneous infectious spondylodiscitis is a rare, but serious disease with the risk of progressive neurological impairment. The surgical approach to spontaneous infectious spondylodiscitis is in most cases an anterior debridement and fusion, often in staged surgeries. Here we report a case of single-stage posterior debridement and posterior instrumented fusion in combination with an injectable calcium sulfate/hydroxyapatite composite eluting gentamicin.
A 59-year-old Caucasian man presented with a 6-week history of lumbar pain without sensory or motor disorders of his lower extremities. A magnetic resonance imaging scan of his lumbar spine in T2-weighted sequences showed a high signal of the intervertebral disc L4/L5 and in T1-weighted sequences an epidural abscess at the posterior wall of L4. Additional computed tomography imaging revealed osteolytic destruction of the base plate of L4 and the upper plate of L5. Antibiotic therapy was started with intravenous ciprofloxacin and clindamycin. We performed a posterior debridement via a minimally invasive approach, a posterior percutaneous stabilization using transpedicular screw-rod instrumentation and filled the intervertebral space with an injectable calcium sulfate/hydroxyapatite composite which elutes a high concentration of gentamicin. The patient’s lower back pain improved quickly after surgery and no recurrence of infection has been noticed during the 1-year follow-up. Computed tomography at 11 months shows complete bony fusion of L4 and L5.
An injectable calcium sulfate/hydroxyapatite composite releasing a high level of gentamicin can support the surgical treatment of spondylodiscitis in combination with posterior debridement and transpedicular screw-rod instrumentation.
KeywordsSpondylodiscitis Surgical treatment Posterior instrumentation Local antibiotic Injectable calcium sulfate/hydroxyapatite Gentamicin Vertebral osteomyelitis Case report
Infectious spondylodiscitis is usually secondary to spinal surgery. Spontaneous infectious spondylodiscitis (SIS), caused by the hematogenous spread of bacteria, is a relatively rare disease. However, a rise in the incidence of SIS has recently been noticed due to increasing life expectancy, use of endovascular devices, diabetes mellitus, and HIV [1, 2].
Conservative treatment of SIS is effective in most patients , but surgical treatment is advocated in cases of poor response to conservative treatment, progressive neurologic impairment, spinal instability, or progressive bone alteration [4–6]. Anterior debridement and fusion , mostly in a staged approach  are usually suggested. Here we report a case in which an injectable, antibiotic-eluting bone graft substitute (BGS) was used to facilitate fusion in single-stage posterior debridement and posterior instrumentation.
To the best of our knowledge, this is the first case where an injectable, gentamicin-eluting BGS was used to facilitate fusion in the treatment of SIS. The presentation of our patient was quite typical for a SIS: mean age about 50 years , back pain not responding to nonsurgical treatment , and elevation of inflammatory markers (CRP) . The preferred diagnostic tool is an MRI scan, with 76% definite and 20% possible diagnosis of SIS, if the patient presents with symptoms that have lasted longer than 2 weeks . Operative treatment of SIS is indicated in cases of poor response to conservative treatment, progressive neurologic impairment, spinal instability, or progressive bone alteration [4–6]. There is still an ongoing debate about the most suitable surgical approach. Some spine surgeons prefer an anterior approach with debridement, fusion with autograft, and anterior or posterior instrumentation [13, 14]. However, a minimally invasive posterior approach might be less exhausting for the patient. Moreover, debridement of the posterior intervertebral space and the epidural abscess might be easier via the posterior approach . Independent of the surgical approach, usually autogenous bone grafts are considered to be the “gold standard” in spine reconstruction [7, 16]. However, some well-recognized complications associated with graft harvesting from the iliac crest including pain at the donor site, nerve injury, hematoma, infection, and pelvis fracture have to be taken into account [16–19]. These risks could be avoided with the use of a synthetic BGS. Usually, the use of a synthetic BGS is not indicated in septic or post-septic sites due to the risk of a foreign body contamination as a trigger of recurring infection. Therefore, the combination of a calcium sulfate/hydroxyapatite composite with local antibiotic gentamicin (CERAMENT™ G, Bonesupport, Lund, Sweden) seemed to be a reasonable alternative. So far, the applied BGS in our case has been used in bone reconstruction after osteomyelitis , but not in spine surgery. The composite enabled us to combine posterior debridement, posterior stabilization, and filling of the intervertebral space in a one-stage procedure. Antibiotics were administered for 4 weeks intravenously, followed by a 4-week course of oral administration, as suggested by Zhang et al. .
The administration of local anti-infective substances is becoming more popular in the treatment of SIS.
Other groups have used antibiotic bone cement beads , a combination of antibiotic-impregnated BGS and autograft  or bioactive glass S53P4 . In our opinion, the advantage of the injectable calcium sulfate/hydroxyapatite composite plus gentamicin is the high local concentration of gentamicin at the desired location , the complete resorption of the BGS, and its osteoconductivity.
An injectable calcium sulfate/hydroxyapatite composite eluting a high level of gentamicin can support the surgical treatment of spondylodiscitis in combination with posterior debridement, transpedicular screw-rod instrumentation, and systemic antibiotic therapy. A CT scan confirmed complete fusion after 11 months.
The authors want to thank all residents and staff of the spinal unit at University Hospital Düsseldorf for their support and excellent patient care.
No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly to the subject of this manuscript.
Availability of data and materials
Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.
RB performed the spinal surgery. RB and AS have been following the patient and drafted the manuscript. HJS coordinated the study, participated in the design of the study, and helped to draft the manuscript. All authors participated in the writing of the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Ethics approval and consent to participate
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. An ethics committee approval for a case report is not applicable according to German legislation.
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- Kapsalaki E, Gatselis N, Stefos A, et al. Spontaneous spondylodiscitis: presentation, risk factors, diagnosis, management, and outcome. Int J Infect Dis. 2009;13:564–9.View ArticlePubMedGoogle Scholar
- Sur A, Tsang K, Brown M, Tzerakis N. Management of adult spontaneous spondylodiscitis and its rising incidence. Ann R Coll Surg Engl. 2015;97:451–5.View ArticlePubMedPubMed CentralGoogle Scholar
- Bettini N, Girardo M, Dema E, Cervellati S. Evaluation of conservative treatment of non specific spondylodiscitis. Eur Spine J. 2009;18 Suppl 1:143–50.View ArticlePubMedPubMed CentralGoogle Scholar
- Gonzalvo A, Abdulla I, Riazi A, De La Harpe D. Single level/single-stage debridement and posterior instrumented fusion in the treatment of spontaneous pyogenic osteomyelitis/discitis: long-term functional outcome and health-related quality of life. J Spinal Disord Tech. 2011;24:110–5.View ArticlePubMedGoogle Scholar
- Cornett CA, Vincent SA, Crow J, Hewlett A. Bacterial spine infections in adults: evaluation and management. J Am Acad Orthop Surg. 2016;24:11–8.View ArticlePubMedGoogle Scholar
- Berbari EF, Kanj SS, Kowalski TJ, Darouiche RO, Widmer AF, Schmitt SK, Hendershot EF, Holtom PD, Huddleston 3rd PM, Petermann GW, Osmon DR. Executive Summary: 2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the diagnosis and treatment of native vertebral osteomyelitis in adults. Clin Infect Dis. 2015;61:859–63.View ArticlePubMedGoogle Scholar
- Fang D, Cheung KM, Dos Remedios ID, Lee YK, Leong JC. Pyogenic vertebral osteomyelitis: treatment by anterior spinal debridement and fusion. J Spinal Disord. 1994;7:173–80.View ArticlePubMedGoogle Scholar
- Fayazi AH, Ludwig SC, Dabbah M, Bryan Butler R, Gelb DE. Preliminary results of staged anterior debridement and reconstruction using titanium mesh cages in the treatment of thoracolumbar vertebral osteomyelitis. Spine J. 2004;4:388–95.View ArticlePubMedGoogle Scholar
- Theodoridis T, Krämer J, Kleinert H. Conservative treatment of lumbar spinal stenosis--a review. Z Orthop Unfall. 2008;146:75–9.View ArticlePubMedGoogle Scholar
- Zhang L, Cai WH, Huang B, Chen LW, Zhang N, Ni B. Single-stage posterior debridement and single-level instrumented fusion for spontaneous infectious spondylodiscitis of the lumbar spine. Acta Orthop Belg. 2011;77:816–22.PubMedGoogle Scholar
- Friedman JA, Maher CO, Quast LM, McClelland RL, Ebersold MJ. Spontaneous disc space infections in adults. Surg Neurol. 2002;57:81–6.View ArticlePubMedGoogle Scholar
- Skaf GS, Domloj NT, Fehlings MG, et al. Pyogenic spondylodiscitis: an overview. J Infect Public Health. 2010;3:5–16.View ArticlePubMedGoogle Scholar
- Ozalay M, Sahin O, Derincek A, et al. Non-tuberculous thoracic and lumbar spondylodiscitis: single-stage anterior debridement and reconstruction, combined with posterior instrumentation and grafting. Acta Orthop Belg. 2010;76:100–6.PubMedGoogle Scholar
- Shiban E, Janssen I, da Cunha PR, Rainer J, Stoffel M, Lehmberg J, Ringel F, Meyer B. Safety and efficacy of polyetheretherketone (PEEK) cages in combination with posterior pedicel screw fixation in pyogenic spinal infection. Acta Neurochir (Wien). 2016;158:1851–7.View ArticleGoogle Scholar
- Mann S, Schütze M, Sola S, Piek J. Nonspecific pyogenic spondylodiscitis: clinical manifestations, surgical treatment, and outcome in 24 patients. Neurosurg Focus. 2004;17:E3.View ArticlePubMedGoogle Scholar
- Graziano GP, Sidhu KS. Salvage reconstruction in acute and late sequelae from pyogenic thoracolumbar infection. J Spinal Disord. 1993;6:199–207.View ArticlePubMedGoogle Scholar
- Myeroff C, Archdeacon M. Autogenous bone graft: donor sites and techniques. J Bone Joint Surg Am. 2011;93:2227–36.View ArticlePubMedGoogle Scholar
- Silber JS, Anderson DG, Daffner SD, Brislin BT, Leland JM, Hilibrand AS, Vaccaro AR, Albert TJ. Donor site morbidity after anterior iliac crest bone harvest for single-level anterior cervical discectomy and fusion. Spine (Phila Pa 1976). 2003;28:134–9.View ArticleGoogle Scholar
- Heneghan HM, McCabe JP. Use of autologous bone graft in anterior cervical decompression: morbidity & quality of life analysis. BMC Musculoskelet Disord. 2009;10:158.View ArticlePubMedPubMed CentralGoogle Scholar
- McNally MA, Ferguson JY, Lau AC, Diefenbeck M, Scarborough M, Ramsden AJ, Atkins BL. Single-stage treatment of chronic osteomyelitis with a new absorbable, gentamicin-loaded, calcium sulphate/hydroxyapatite biocomposite: a prospective series of 100 cases. Bone Joint J. 2016;98-B:1289–96.View ArticlePubMedGoogle Scholar
- Lee BJ, Lee SR, Kim ST, Kim TH, Lee SH. Spinal epidural abscess with pyogenic arthritis of facet joint treated with antibiotic-bone cement beads - a case report. Asian Spine J. 2007;1:61–4.View ArticlePubMedPubMed CentralGoogle Scholar
- von Stechow D, Rauschmann MA. Effectiveness of combination use of antibiotic-loaded PerOssal with spinal surgery in patients with spondylodiscitis. Eur Surg Res. 2009;43:298–305.View ArticleGoogle Scholar
- Kankare J, Lindfors NC. Reconstruction of vertebral bone defects using an expandable replacement device and bioactive glass S53P4 in the treatment of vertebral osteomyelitis: three patients and three pathogens. Scand J Surg. 2016. [Epub ahead of print].Google Scholar
- Stravinskas M, Horstmann P, Ferguson J, Hettwer W, Nilsson M, Tarasevicius S, Petersen MM, McNally MA, Lidgren L. Pharmacokinetics of gentamicin eluted from a regenerating bone graft substitute: in vitro and clinical release studies. Bone Joint Res. 2016;5:427–35.View ArticlePubMedPubMed CentralGoogle Scholar