T10, T11 Osteomyelitis
75-year-old female presents with significant medical history and prior spine surgery
The patient is a 75-year-old female with a 6 month history of progressive mid back pain.
Her extensive medical history, and prior spine surgery includes:
- End stage renal disease; she is on hemodialysis
- Coronary artery disease (myocardial infarction twice)
- Chronic heart failure with ejection fraction of 20%
- Spondylolisthesis; L5-S1 with instrumented fusion 15-years ago
- Allergy to IVP dye
The patient underwent MR imaging without gadolinium.
Suspected T10-T11 discitis and osteomyelitis
Phase 1: The patient underwent needle biopsy with isolation of staphylococcus aureus. It was not certain if this was the contaminant or the pathogen. She was braced and started on minocylcine by mouth and vancomycin at dialysis.
Phase 2: During phase 1, the patient's disabling pain required heavy medications. She gradually stopped ambulating requiring a wheelchair. One month into treatment she reported a minor slip resulting in new onset of leg weakness; she was unable to get out of the wheelchair.
Phase 3: Repeat MRI was obtained (without gadolinium).
The patient was admitted to the hospital and underwent CT scan evaluation. (Figs. 5 and 6)
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The patient underwent a staged anterior/posterior procedure 2 days apart.
- Stage 1: The first procedure consisted of a minimally invasive transthoracic corpectomy with decompression, expandable cage, and T9-T11 anterior plating. During the 4 hour procedure, blood loss was 400 cc. (Figs. 7-10)
The patient was allowed to recover for 1 day and undergo hemodialysis.
- Stage 2: The second procedure consisted of percutaneous T9-T11 pedicle screw stabilization. During this 60 minute blood loss was 50 cc.
The patient's recovery was uneventful, although her estimated risk for complication was above average. She was discharged after the second procedure on postoperative day 4.
During her postop visit at 6 weeks, she was ambulating independently, off pain medications, and without wound or instrumentation issues.
At 3 months postop the patient continues to do well.
This is, unfortunately, found to be more common in the clinical setting as our patients age—particularly in the setting of an immunocompromised state. This 75-year-old female did not respond to antibiotic therapy, which covered Gram-positive organisms. These are the most common organisms in dialysis patients due to their numerous percutaneous insertions. In this population another very common scenario is renal ostrodystrophy. This is not an infection, but acts like a Charcot spine due to insensate vertebrae. Most commonly, this occurs at areas where segments have autofused above and below the destructive process. These patients, when biopsied, do not have positive cultures, since this is not an infection. Unfortunately, they often require surgical stabilization due to instability and neurologic deterioration.
In the case provided by Dr. Joseph Aferzon, he treated the patient through an anterior and posterior approach. I also commonly utilize anterior debridement followed by posterior instrumentation. I typically use a longer posterior construct, which I find helpful in patients with poor bone stock. I also like to avoid anterior instrumentation, since a portion of patients will further settle and the anterior instrumentation can migrate.
Dr. Joseph Aferzon is accomplished in minimally invasive surgery, and his treatment was well-performed and the patient had an excellent outcome. In Dr. Aferzon's case, he explains the added cost of implants is outweighed by lessening the overall patient cost. These cost issues need further exploration and, through cost analysis research and prospective registries, we should be able to refine care such that it is the most cost effective.
Author's Response to Case Discussion
In this clinical case, minimally invasive transthoracic approach with percutaneous posterior stabilization optimally met the following three criteria:
- Excellent decompression/debridement
- Optimal anterior column support
- Shortest possible fusion; across 2 motion segments
Open thoracotomy with posterior instrumentation would have met a similar clinical objective but at the cost of higher morbidity.
I believe a posterior approach would offer less optimal debridement and anterior column support, and would result in a longer posterior construct involving additional vertebral motion segments with longer fusion.
CT reconstructions show significant erosion of the superior T11 vertebra, particularly on the right side. Although a longer posterior construct would provide a greater safety margin. By staggering bicortical lateral screws and posterior pedicle screws, I successfully achieved a sufficient fixation and support across T11 vertebrae.
The reason for a staged approach is the patient’s significant cardiac disease and dialysis. I decided that the patient will have fewer complications with 2 short procedures rather than one long procedure. The patient underwent the anterior procedure on Monday, was dialyzed on Tuesday, underwent the posterior procedure on Wednesday, and was discharged to rehab on Sunday (total of 6 days).
I believe this MIS approach resulted in a shorter hospitalization and reduced perioperative morbidity, thereby offsetting the additional cost of the hardware. Precise methodologies comparing savings offered by new technologies through clinical improvement vs direct costs of new devices remain to be defined.