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| REFLECTION |
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| Year : 2022 | Volume
: 9
| Issue : 2 | Page : 73-74 |
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Minimally invasive spinal surgery and disc space infection
PS Ramani
Lilavati Hospital and Research Center, Mumbai, Maharashtra, India
| Date of Submission | 11-Oct-2021 |
| Date of Acceptance | 12-Oct-2021 |
| Date of Web Publication | 31-May-2022 |
Correspondence Address:
P S Ramani
Lilavati Hospital and Research Center, Mumbai, Maharashtra
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/joss.joss_12_21
How to cite this article:
Ramani P S. Minimally invasive spinal surgery and disc space infection. J Spinal Surg 2022;9:73-4 |
The present era is rightly called minimally invasive spinal surgery (MISS) era. It is indeed a good development as surgically it is minimally morbid to the patient. Infection in the spine following surgery is not uncommon. However, it has been observed that in the last few years, the rate of pyogenic disc space infection has increased.[1],[2]
Although the gold standard is conservative treatment with antibiotics, rest and frame type of Belt, in a few patients, the surgical intervention is needed to relieve pain, eradicate infection, prevent neurological deficit, and watch for the development of instability when vertebra gets destroyed necessitating stabilization.[3]
The diagnosis is difficult due to ongoing pain which is exaggerated and patient visiting doctor without appointment.[3] The pointer of suspicion of infection lies in the following factors, namely continuous and severe pain, sleepless nights, and patient not willing to resume activities. Of course, erythrocyte sedimentation rate and C-reactive protein are the hallmarks of diagnosis and sometimes raised white blood cell polymorph count. However, blood tests are not always reliable and one has to depend on clinical observation.
There is no doubt that endoscopic surgical percutaneous approach, whichever route it may be, along with percutaneous instrumentation is an excellent modern approach for the early stage of the disease. It is also useful in patients with comorbidities or elderly. Unfortunately, most elderly patients coming to doctor for seeking relief from pain have advanced disease and then endoscopic approach is not suitable.
Today, the era of using specific antibiotics following culture and antibiotic sensitivity of pus is common. It results in computed tomography (CT)-guided biopsy of infective focus being mandatory.
The main question remains to be answered is why there is increase in the incidence of disc space infection following endoscopic MISS surgery with or without implants. Although there is no definite answer forthcoming, I am convinced that there was compromise in sterility. I am obliged to come to this conclusion by the following fact. I have personally examined and treated three patients in the last 2 years where CT-guided biopsy was done in an imaging center rather than in the hospital. Obviously, in such places, there is compromise in sterility procedure.
In major hospitals where there is no compromise on sterility, one does not see rise in infection.
Each young spinal surgeon today has his own set of endoscope. It is portable and he feels convinced that he can do the surgery in smaller nursing homes. Such practice perhaps creates increase in infection following endoscopic surgery. It is not related to the type of endoscope used.
| The Infection | |  |
Infection following surgical procedure on spine is commonly termed as spondylodiscitis where infection usually occurs in the disc space with surgical intervention. It then quickly affects the adjacent vertebral end plates giving rise to severe back pain. The infection then can spread to spinal canal, paravertebral tissues, and posterior components of the vertebral bodies. The incidence in Europe today is from 0.4% to 2.8% or roughly 1000 new cases every year.[3],[4],[5]
Another factor is increase in life expectancy with more immune compromised patients. The fact that there is significant increase in spinal surgical procedures also by the logic of numbers adds to increase in the incidence of infection.
In modern medicine today which is advanced fortunately, the diagnosis is made early and quickly which in turn has helped to decrease the morbidity and mortality. Immunocompromisation[3],[4],[6] arises from infection such as human immunodeficiency virus, intravenous drug abuse, organ transplant immunosuppression, alcoholic liver cirrhosis, and of course comorbidities such as diabetes, hypertension, renal compromise, rheumatism, and low socioeconomic status. In view of such factors, the mortality today still remains between 2% and 20%.[4],[6]
Staphylococcus is the most common organism causing disc space infection, especially in developed countries (20%–84%).[3],[6],[7]
| Prognosis | | |
When treatment is initiated promptly, the prognosis is good. The delay in the diagnosis explains why the mortality remains high at 2%–20%.[6]
The use of implants help to give stability, corrects deformity, and achieves good bony fusion.[7]
| Final words | | |
Conservative treatment with antibiotics, analgesics, rest, and frame type belt is the hall mark of treatment of disc space infection.
In few cases, endoscopic surgery with percutaneous spinal stabilizing instruments helps to achieve stability, realignment, and fusion.
| References | | |
| 1. | Lener S, Hartmann S, Barbagallo GM, Certo F, Thomé C, Tschugg A. Management of spinal infection: A review of the literature. Acta Neurochir (Wien) 2018;160:487-96.  |
| 2. | Mavrogenis AF, Megaloikonomos PD, Igoumenou VG, Panagopoulos GN, Giannitsioti E, Papadopoulos A, et al. Spondylodiscitis revisited. EFORT Open Rev 2017;2:447-61. |
| 3. | Soares do Brito J, Tirado A, Fernandes P. Surgical treated spondylodiscitis epidemiological study. Acta Med Port 2016;29:319-25. |
| 4. | Tsai TT, Yang SC, Niu CC, Lai PL, Lee MH, Chen LH, et al. Early surgery with antibiotics treatment had better clinical outcomes than antibiotics treatment alone in patients with pyogenic spondylodiscitis: A retrospective cohort study. BMC Musculoskelet Disord 2017;18:175. |
| 5. | Graells XS, Kulcheski AL, Bondan ET. Thoraco lumbar spondylodiscitis and the surgical approach. A retrospective analysis. Coluna Columna 2019;18:154-7. |
| 6. | Herren C, Jung N, Pishnamaz M, Breuninger M, Siewe J, Sobottke R. Spondylodiscitis: Diagnosis and treatment options. Dtsch Arztebl Int 2017;114:875-82. |
| 7. | Gregori F, Grasso G, Iaiani G, Marotta N, Torregrossa F, Landi A. Treatment algorithm for spontaneous spinal infections: A review of the literature. J Craniovertebr Junction Spine 2019;10:3-9. |
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