Single-stage treatment of pyogenic spinal infection with titanium mesh cages

Study Design: Single institution retrospective review Objectives: To report a series of pyogenic spinal infections treated with single-stage debridement and reconstruction with titanium mesh cages. Summary of Background Data: Various studies have reported surgical results of pyogenic spinal osteomyelitis with anterior debridement, strut grafting and fusion, including delayed posterior spinal instrumentation. Additionally, various authors have recommended against the use of instrumentation because of the concern about glycocalyx formation on the metal and chronic infection. At our institution, we routinely treat chronic vertebral osteomyelitis with single-stage debridement, reconstruction with a titanium mesh cage filled with allograft chips and demineralized bone matrix, and posterior pedicle screw instrumentation. To our knowledge, this is the largest single series reporting single-stage debridement and instrumentation of pyogenic spinal infection with titanium mesh cages and posterior instrumentation. Materials and Methods: We retrospectively reviewed the patient records and radiographs of 21 consecutive patients (average age 49.3 years, range 23 to 80 years) with pyogenic vertebral osteomyelitis, all treated with titanium mesh cages. Average follow-up was 44 months (range, 25 to 70 months). Spinal levels included 6 thoracic, 4 thoracolumbar, 9 lumbar, and 2 lumbosacral (L5-S1) lesions. All patients had preoperative serum evaluation, which usually included blood cultures, complete blood count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP), in addition to plain radiographs and magnetic resonance imaging. A positive needle biopsy was available in only 2/7 patients (29%), and overall, preoperative pathogen identification was available in only 7/21 patients (33%). All patients were treated postoperatively with a minimum of 6 weeks of intravenous antibiotics, with a specific antibiotic regimen directed toward the postoperative pathogen when identified (17/21 cases). Extensive radiographic evaluation was also performed. Results: ESR and CRP were routinely elevated (18/20 and 11/17 cases respectively), whereas the white blood count was elevated in only 8 out of 21 cases (38%). The average duration of symptoms to diagnosis was approximately 13.6 weeks (range 3 weeks to 10 months). The indications for surgery included neurologic compromise, significant vertebral body destruction with loss of sagittal alignment, failure of medical treatment, and/ or epidural abscess. All patients had resolution of infection, as noted by normalization of the ESR and CRP. Further, 16 out of 21 patients also had a significant reduction of pain. There were no deaths or new postoperative neurologic compromise. The most common pathogen was Staphylococcus aureus. Two patients required a second surgery (posterior irrigation and debridement) during the same admission for persistent wound drainage. Radiographically, the average segmental kyphosis (or loss of lordosis) was 11.5 degrees (range, 0 to 24 degrees) preoperatively, and + 0.8 degrees (range, -3 to + 5 degrees) at latest postoperative follow-up. There was an average of 2.2 mm cage settling (range, 0 to 5 mm) on latest follow-up. There were no instrumentation failures, signs of chronic infection, or rejection. Conclusions: Titanium mesh cages present a viable option for single-stage anterior surgical debridement and reconstruction of vertebral osteomyelitis, without evidence of chronic infection or rejection. When used in conjunction with pedicle screw instrumentation, there is minimal cage settling without loss of sagittal alignment.