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INTRODUCTION
Post operative spondylo-discitis is a rare
but unavoidable complication of lumbar disc surgery. The
typical clinical symptoms and diagnostic procedures of this
particular complication are varied. Clinical findings are the
mainstay in diagnosing this condition. Meaningful results can
be obtained by MRI. The sequelae of spondylodiscitis is so
severe that, the patient may not be able to take up the original
occupation, and so at any cost, this complication should be
avoided if possible and once it sets in, it should be diagnosed
and treated early.
J.Orthopaedics 2004;1(3)e1
REVIEW OF
LITERATURE
Bircher MD et al(1) in their study
concluded that although well described in orthopaedic literature
and some orthopaedic textbooks postoperative discitis is
regularly missed or diagnosed late. If the ESR is routinely
measured preoperatively and at 2 weeks postoperatively this
condition should not be missed.
Fouquet B et al(2) concluded that two
major types of potsop discitis have been previously described:
septic discitis and avascular or chemical discitis. Percutaneous
discal biopsy is an important way of distinguishing these two
entities. This study further confirmed that there are two major
features of discitis that can be recognized by histological and
biological tests allowing for different tests
Frank AM (3) et al made the final
conclusion in their study that spondylodiscits is a well known
as well as unavoidable complication of lumbar disc surgery. MRI
is proved to be the most sensitive and reliable investigation.
Therapy of spondylodiscits using light corset described along
with antibiotics gave good results.
Frank AM et al (4), in their study found
the main symptom is increasing low back pain, with difficulty in
forward flexion of the body, with a raised ESR. And they
observed good long term results in all patients with light
corset and long antibiotic therapy.
Friedman JA (5) et al concluded spontaneous
discitis has predominantly has been described in children and
needed a broader spectrum of antibiotic coverage. Outcomes
were similar between the groups.
Hadjipavlou Ag et (6)all concluded that
Serretia spondylodiscits can cause severe spinal infections
after elective spinal surgery. And that one should maintain
high index of suspicion in diagnosing and treating the infection
caused by this potential pathogen. They also pointed out that
one should not procrastinate in initiating treatment.
Imae S et al(7) in their study concluded
that post operative spondylodiscits is a rare but severe
complication of disc surgery. They were of the view that low
back pain gradually receded along with ESR and C reactive
protein, with long term antibiotics. About 40 days later these
patients were almost free of back pain.
Jimenez Mejias ME,(8) studied 31 cases of
postoperative pyogenic spondylodiscits comparing them with 72
cases of non postoperative pyogenic spondylodiscits.
Predisposing factors were less frequent in post operative
pyogenic spondylodiscits than Non post operative spondylodiscits
cases.
Kylanpaa-Back ML (9) observed that MRI has
proven to be the most effective method for demonstrating
postoperative discitis. They also concluded that patients with
post operative spondylodiscits are rarely capable to return to a
physically strenuous work. Every effort, including antibiotic
prophylaxis, should be undertaken to reduce the risk of this
serious complication.
Ledermann HP et al(10) reached the final
conclusion that most MR imaging criteria commonly used to
diagnose disc infection offer good sensitivity. In typical
manifestations of proven spinal infections some of the described
imaging criteria may not be observed.
Lunge PC(11) concluded in his study that
in microdiscectomy prophylactic antibiotic should be given and a
complete removal of the ligamentum flavum on the side of surgery
should be ensured to avoid infection and recurrent root
impingement.
Lindholm TS et al(12) were of the view that
the incidence of discitis is 75%. About 50% of patients in their
study had retired from regular work. They concluded that early
diagnosis and appropriate management of the disease is
especially urgent to overcome and inhibit the consequences of
post op discitis.
Maiuri F et al(13) opined that early
diagnosis of spondylodiscits is often difficult because of long
latent period. Radiographs of the spine, CT Scan and bone scan
provided insufficient data. MRI is the investigation of choice
in diagnosing spondylodiscits.
Natale M et al(14) in their experience
reported 19 cases of spondylodiscits developed after operations
for herniated lumbar disc.
Nielsen VA, et al(15) observed that the
earliest lesion was blurring of the end plate or minor
destructions, leading to cavitations of the vertebral body.
Mean time from operation to the first clinical symptoms was 3
weeks. Mean time from operation to first radio logic lesion was
2 months, from operation to maximal lesion 4 months, and to the
first radiologic sign of healing 5.5 months. A follow up study
was carried out and the radiologic findings were compared to
those of a matched control group. A significantly higher
incidence of decrease in disc height, intercorporal fusion and
major osteophytes was found in the discitis group..
Parry MF et al(16) were of the view that
postop wound infection after laminectomy was uncommon. They
observed 3 patients with discitis due to candida aqlbicans.
Peruzzi P et al(17) were of the view that ,
discitis is a rare complication of disc operation, with an
incidence of 0.2 to 0.8 %. Discitis may be suspected within 2
weeks with a clinical feature of back pain and spasm.
Postacchini F, et al(!8) I their study
noted twelve cases of intervertebral discitis following lumbar
discetomy in 70 patients without evidence of postoperative
fiction. They advised close post operative observation
permitted early detection of intervertebral discitis. Early
and high dose antibiotic treatment, even if unspecific, can
resolve this infection in a few weeks.
Rohde V et al(19) concluded that
spondylodiscits is rare complication. Theoretically it can be
prevented by treating these patients with prophylactic
antibiotics. In their study 3.7% of incidence of postoperative
spondylodiscits was found in absence of prophylactic
antibiotics. Gentamicins containing caliginous sponges placed
in the cleared disc spaces were effective in preventing post
operative spondylodiscits.
Schinkel C et al(20) were of the view that,
spondylodiscits is a rare bacterial infection of the vertebra
and intervertebral disc and an inflammatory destructive
course. They were of the view that spondylodiscits requires
immediate debridement of the focus, when conservative management
fails.
Schulitz K.P et al(21) were of the view
that infection of the retro or intradiscal space is probable
when the temperature rises above 37 degrees and CRP exceeds 2
microgram/ml 5 days postop. Infection can be cured by treatment
with antibiotics bed rest and plaster cast.
Schulitz KP et al(22) in another study
concluded that after discectomies CRP ESR and temperature should
be measured from the 3rd day on. Pathologic values should
initiate MRI examination. In cases of retrodiscal infection or
discitis conservative treatment with antibiotics is sufficient.
In cases of retrodiscal abscess operative intervention should be
considered.
Siddiqui AR et al(23) concluded that
endemic conditions require that laminectomy at a hospital be
limited to those situations where the benefits of surgery exceed
the considerable risk of potsop discitis.
Silber JS et al (24) concluded that
fortunately the incidence of potsop discitis is low around .2%.
The commonest etiologic agent is staph. aureus and the most
sensitive test for diagnosis as well as assessment of treatment
is CRP. MRI is the most diagnostic tool. They stressed that the
treating surgeon should maintain a index of suspicion for early
diagnosis. They observed good long term outcome with antibiotic
treatment and spinal immobilization. Operative intervention is
rarely necessary in patients in patients who do not respond to
conservative treatment.
Trappe AE, et al(25) observed that
postoperative lumbar spondylodiscits can cause a failed back
syndrome. With 0.1 to 3 % according to the literature it
belongs to rarer complication following lumbar disc surgery.
Principles of therapy consist of lumbar immobilization with a
light cast orthosis for an average of 12 weeks and additional
antibiotic therapy up to two weeks beyond normalization of ESR.
Finally results of therapy are presented wth a satisfying
outcome in 84.2% of cases.
Tronnier V(26) in their study reported
that 17% of patients had positive bacteriological culture in
their intervertebral disc space. They noted possible
involvement of other predisposing factors like pre or
perioperative infections or immunocompromise. They also noted
that routine application of antibiotics or antiseptic solution
to the disc space at the end of the operation could
decontaminate the operative site and prevent clinical infection
despite positive culture findings.
Van Goethen JW et al(27) inferred that
spondylodiscits is a serious complication of surgery the
diagnosis depending on the correlation of clinical .laboratory
and imaging findings. They also concluded that MRI appears to be
more useful for exclusion rather than conclusion of potsop
discitis.
Weber M et al(28) inferred that when
pyogenic osteomyelitis may no longer be overlooked b after
discectomy due to its progression it is misinterpreted as as
discitis following removal of intervertebral disc.in their study
9 patients with vertebral oseomyelitis suffered from potsop
discitis. They also concluded that osteomyelitis may mimic
degenerative changes preoperatively.
Wirtz DC et al(29) were of the view that at
the time of diagnosis signs of florid inflammation were seen in
60% x rays ,93% CT and all MRIs. Therapeutically speaking
conservative minimally invasive and other operative procedures
are not rival but rather complimentary.
Zink PM, et al (30) in their study observed
that spondylodiscits is a well know complication of frequency
0.1 to 3%. According to the authors, the etiological factors
are combination of the operated segment instability, damage to
the upper and lower end plates due to disc space curettage and
transmission of germs. Their basic treatment consisted of 3 X
80 mg of perioperative doses of Gentamicin I/M. They
recommended the following for the prevention of post operative
spondylodiscits. A careful operating technique, perioperative
antibiotic, and insertion of Sulmycin Implants in the disc
spaces.
The final conclusion is that post operative
spondylodiscits is an unavoidable complication of spine surgery.
Considering the septic and aseptic forms of discitis every
precaution should be taken to prevent the septic form. Discitis
should be suspected in any patient with exaggerated symptoms
after surgery and should be properly investigated to confirm the
diagnosis. Once the diagnosis is confirmed early parenteral
antibiotics should be administered. Many authors claim that all
these patients will become asymptomatic over time and the long
term results are good.
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