Orthopedics

Feature Article 

Comparison of Instrumented and Noninstrumented Surgical Treatment of Severe Vertebral Osteomyelitis

Sina Pourtaheri, MD; Kimona Issa, MD; Tyler Stewart, MD; Eiman Shafa, MD; Remi Ajiboye, MD; Rafael A. Buerba, MD; Elizabeth Lord, MD; Ki Hwang, MD; Daniel Mangels, MD; Arash Emami, MD

Abstract

The purpose of this study was to compare the outcomes of instrumented versus noninstrumented (decompression) surgical treatment of vertebral osteomyelitis. The study population included 104 patients with spinal osteomyelitis who were treated at the authors' institution between 2004 and 2012. This included 62 men and 42 women who underwent either instrumented (n=57) or noninstrumented (n=47) surgery. Mean patient age was 59 years, and mean follow-up was 38 months (range, 12–78 months). Specifically, the following criteria were assessed: mortality rates, infection clearance rates, clinical outcomes measured by Oswestry Disability Index (ODI), mean length of stay, and baseline differences between the 2 cohorts. Although patients in the instrumented cohort had more instability, more neurologic symptoms, and larger volume infection, they had similar clearance of infection (54% vs 42.5%; odds ratio [OR], 1.55; 95% confidence interval [CI], 0.61–3.9; P=.35), mortality rate (9% vs 17%; OR, 0.47; 95% CI, 0.14–1.54; P=.21), and ODI scores (40 vs 45 points; P=.32) compared with patients in the noninstrumented group. However, mean length of stay (19 vs 13 days; P=.02) was significantly higher for patients in the instrumented group. Even in more severe cases of vertebral osteomyelitis, instrumentation resulted in comparable outcomes to decompression. [Orthopedics. 2016; 39(3):e504–e508.]

Abstract

The purpose of this study was to compare the outcomes of instrumented versus noninstrumented (decompression) surgical treatment of vertebral osteomyelitis. The study population included 104 patients with spinal osteomyelitis who were treated at the authors' institution between 2004 and 2012. This included 62 men and 42 women who underwent either instrumented (n=57) or noninstrumented (n=47) surgery. Mean patient age was 59 years, and mean follow-up was 38 months (range, 12–78 months). Specifically, the following criteria were assessed: mortality rates, infection clearance rates, clinical outcomes measured by Oswestry Disability Index (ODI), mean length of stay, and baseline differences between the 2 cohorts. Although patients in the instrumented cohort had more instability, more neurologic symptoms, and larger volume infection, they had similar clearance of infection (54% vs 42.5%; odds ratio [OR], 1.55; 95% confidence interval [CI], 0.61–3.9; P=.35), mortality rate (9% vs 17%; OR, 0.47; 95% CI, 0.14–1.54; P=.21), and ODI scores (40 vs 45 points; P=.32) compared with patients in the noninstrumented group. However, mean length of stay (19 vs 13 days; P=.02) was significantly higher for patients in the instrumented group. Even in more severe cases of vertebral osteomyelitis, instrumentation resulted in comparable outcomes to decompression. [Orthopedics. 2016; 39(3):e504–e508.]

Vertebral osteomyelitis represents approximately 2% to 7% of all reported cases of osteomyelitis. This disease involves the vertebrae and the associated disk spaces and is caused by many types of microorganisms, with Staphylococcus aureus being responsible for the majority of vertebral osteomyelitis.1–3 Although vertebral osteomyelitis remains uncommon, the incidence of this disease is rising due to an increasing number of patients with predisposing factors such as advanced age, diabetes mellitus, chronic renal or liver disease, intravenous drug use, human immunodeficiency virus (HIV) infection, chronic corticosteroid use, chemotherapy, and severe trauma.4,5

The treatment of vertebral osteomyelitis can be challenging for spine surgeons. Most cases of vertebral osteomyelitis are managed initially by needle aspiration biopsy from the intervertebral disk space or vertebral bone, which has a sensitivity ranging from a low of 30% to 50% to a high of 70% to 90% when used to identify the pathogen.6 In cases without neurologic deficits and no marked kyphotic deformity or instability, spinal infections can be managed without surgical intervention.1 Even if the majority of patients with vertebral osteomyelitis respond to medical treatment, up to 40% of patients suffering from this disease eventually will require surgical intervention.1,7–10 Surgery is indicated in cases with failure of prolonged medical management, delayed treatment or complications of sepsis, neurologic impairment, residual vertebral destruction leading to early or late spinal instability, or segmental kyphosis with intractable pain.1,6,7,9–15

The purpose of this study was to evaluate the clinical outcomes of patients treated for vertebral osteomyelitis using instrumented versus noninstrumented (decompression) surgical procedures. Specifically, the following criteria were compared: (1) mortality rates, (2) infection clearance rates, (3) clinical outcomes measured by Oswestry Disability Index (ODI), (4) mean length of stay (LOS), and (5) baseline differences between the 2 cohorts.

Materials and Methods

The study population included all patients who had a discharge diagnosis of spinal osteomyelitis and were treated at the authors' institution between January 2004 and March 2012. Patients were identified using International Classification of Diseases, 9th Revision (ICD-9) codes that included osteomyelitis (730.28, 730.08, 730.2, and 730.00), diskitis (722.90, 722.91, 722.92, and 722.93), and epidural abscess (324.1 and 234.9) of the spine. Inclusion criteria involved appropriate initial imaging, laboratory results, evaluation by the orthopedic department, and no treatment from an outside institution prior to admission. Patients who were treated nonoperatively were excluded.

A total of 104 patients (62 men and 42 women) met these criteria and were included in the study. Mean patient age was 59 years (range, 20–93 years). Indications for laminectomy were epidural abscesses requiring drainage and decompression. All patients underwent follow-up for a mean of 43 months (range, 24–72 months). Patient demographics are summarized in Table 1. Inpatient hospital charts and medical records were reviewed. Clinical information and patient demographics including age, gender, use of instrumentation during surgery, and clearance of infection, as well as mortality directly related to the osteomyelitis, were recorded. Appropriate review board approval for this study was obtained.


Patient Demographics

Table 1:

Patient Demographics

Patients were stratified by the type of surgical treatment received to either the noninstrumented (decompression) group or the instrumented group. Noninstrumented surgeries included laminectomy and debridement; instrumented surgeries included anterior spine instrumentation, posterior spine instrumentation, or combined anterior and posterior spine instrumentations. Noninstrumented surgeries were all decompressions and did not include noninstrumented fusions. Titanium cages were used for all corpectomies. Allografts included crushed cancellous bone and demineralized bone matrix. Location and surgical approach are summarized in Table 2.


Location of Osteomyelitis and Surgical Approach

Table 2:

Location of Osteomyelitis and Surgical Approach

The decision to perform the type of treatment option was according to the on-call spine surgeon's evaluation of the patient's radiographs, neurologic presentation, and medical comorbidities. Decompression cases did not require instrumentation based on the radiographic and clinical evaluations. Patients who had spinal instability were treated with instrumented surgery if possible. Overall, 57 patients received surgical instrumentation and 47 received noninstrumented surgery.

The size of infection was defined as the total volume of infected bone and soft tissues measured on coronal, sagittal, and axial magnetic resonance images (MRI). The MRIs were used to calculate the volume of infection by multiplying the length, width, and height of the total area of infection on sagittal and coronal planes and dividing it by 2. A volume of 8 cm3 was used as the cutoff for a large infection.

Mortality was defined as mortality directly related to the osteomyelitis itself within 1 year of presentation. Two experienced fellowship-trained spine surgeons and 1 musculoskeletal fellowship-trained radiologist reviewed all of the clinical and radiographic data. In all cases, consensus was reached if the patient cleared the infection.

All data were recorded using Excel (Microsoft Corporation, Redmond, Washington). Statistical analysis was performed using t test, Fisher exact test, and odds ratio (OR) to compare infection clearance rate, mortality rate, and clinical outcomes for patients who had received instrumented and noninstrumented surgery. A P value of less than .05 was used as the threshold for significance.

Results

Kaplan-Meier survival analysis demonstrated no significant difference in the 1- and 5-year mortality rates due to vertebral osteomyelitis between the instrumented and noninstrumented cohorts (89% vs 86%; P=.17) (Figure). The 1-year and overall mortality rate due to vertebral osteomyelitis in the instrumented cohort was 9% (n=5 of 57), which was lower but not significantly different from the 17% rate (n=8 of 47) in the noninstrumented group (P=.21). When evaluating the overall mortality due to any reason other than osteomyelitis, there also was no significant difference in the 5-year mortality rates between the instrumented and noninstrumented cohorts (18% vs 13%; OR, 1.3; 95% confidence interval [CI], 0.45–3.9; P=.58). For the Charleston comorbidity index, greater than 6 points was associated with a higher mortality OR due to vertebral osteomyelitis (OR, 4.12; 95% CI, 0.49–34.5; P=.19).


Kaplan-Meier survival analysis of mortality due to vertebral osteomyelitis (VO) in instrumented and noninstrumented patients.

Figure:

Kaplan-Meier survival analysis of mortality due to vertebral osteomyelitis (VO) in instrumented and noninstrumented patients.

There were no significant differences in the clearance of infection between patients who were treated with surgical instrumentation and those who were treated without instrumentation (OR, 1.55; 95% CI, 0.61–3.9; P=.35). The clearance of infection in the cohort of patients who underwent surgical instrumentation was 54% (n=31 of 57); this rate was higher than in patients who underwent decompression alone but not significantly different from the clearance rate of 42.5% (n=20 of 47) in the noninstrumented group (P=.35) (Table 3).


Clinical Outcomes

Table 3:

Clinical Outcomes

There were no significance differences in mean ODI score between the instrumented and noninstrumented groups (P=.32). In the instrumented group, mean ODI score improved from 62 points (range, 12–94 points) preoperatively to 40 points (range, 0–80 points) postoperatively. In the noninstrumented group, mean ODI score improved from 75 points (range, 50–100 points) preoperatively to 45 points (range, 12–94 points) postoperatively.

Mean LOS was significantly higher in the instrumented group (P=.02). Mean LOS in the instrumented cohort was 19 days (range, 3–75 days). This was significantly longer than the mean LOS of 13 days (range, 2–63 days) in the noninstrumented group (P=.02) (Table 3).

Overall, patients in the instrumented surgery group had more severe cases of vertebral osteomyelitis as they had a higher OR of neurologic deficiency (OR, 4.6; 95% CI, 2.3–9.3; P<.01) and instability (OR, 2.8; 95% CI, 1.1–6.9; P=.03) compared with patients in the noninstrumented group. Patients in the noninstrumented group had significantly smaller infections (29%, n=11) than patients in the instrumented group (51%, n=19) (OR, 0.39; 95% CI, 0.5–1.0; P=.047]. Overall, the instrumentation averaged 3.7 levels of surgery, with 61% undergoing a corpectomy. The mean number of corpectomies in the decompression cohort was 1.84 levels. The thoracolumbar instrumented cases averaged 2.7 levels, with 45% having corpectomies averaging 2.2 levels.

Discussion

The choice of surgical techniques, instrumentation, and the decision to stage the instrumentation portion of the surgery when treating vertebral osteomyelitis are matters of controversy.1 Options include anterior or posterior approaches, to instrument or not to instrument, and single-stage or 2-stage surgery. The decision regarding the surgical approach and technique should always be guided by the neurologic status and mechanical spinal instability.1,16 In addition, whether instrumentation affects the infection recurrence rate is another consideration. The reported infection recurrence rates after nonsurgical treatment have ranged from 0% to 25%, whereas recurrence rates ranging from 2% to 18% have been reported after the surgical treatment of vertebral osteomyelitis.7,8,10,16,17 However, there is a paucity of published studies that have compared clinical outcomes of surgical noninstrumented cases to instrumented cases. The purpose of this study was to evaluate the efficacy of different surgical treatment modalities for vertebral osteomyelitis including clearance of infection rate, clinical outcomes, and mortality rate.

There were several limitations of this study. A prospective study could have reduced potential selection and information biases. Broader quality of life measures such as patient activity or satisfaction were not evaluated. Clearance of infection was determined as resolution on imaging and serologic tests, which may not be the most accurate method for assessing clearance of infection. Neurologic outcomes in patients with preoperative neurologic deficit were not reported. Immune status, HIV status, smoking history, and the types of organisms for the patients in this study were not evaluated. However, the authors believe the outcomes are valuable because this was a large series of surgical cases with a study design superior to other studies since it compared instrumented to noninstrumented surgical cases, as opposed to comparing surgical cases to nonoperative cases.

No significant differences were noted in the mortality rate between the instrumented and noninstrumented cohorts. It would appear with the more aggressive osteomyelitis cases occurring in the instrumented cohort, a greater insult to the patient occurs with the metabolic demand and sepsis from the osteomyelitis. Many of the patients in the instrumented cohort had radical debridement, corpectomy, or both radical debridement and corpectomy. Therefore, it is possible that eradicating a large portion of the infected bone and soft tissues in the instrumented cases resulted in the patients having good outcomes. Thus, it is encouraging that even in appropriately addressed cases of severe osteomyelitis with surgery and instrumentation, clinical outcomes are comparable to less severe cases treated without instrumentation.

These findings are comparable to the report by Rayes et al,18 in which 47 patients (32 men and 15 women) with vertebral osteomyelitis underwent instrumentation procedures. In their study, mean LOS was 25 days (range, 9–78 days), and the mortality rate was 17% at a mean follow-up of 22 months (range, 1–80 months); however, there was no comparison cohort. Although the 1-year mortality of 9% in the cohort in the current study may be interpreted as high, many of the patients were noncompliant and elderly with multiple comorbidities. In addition, the mean LOS in the current study was high as these patients often had multiple medical comorbidities, and their hospital stay was prolonged due to medical management of their comorbidities.

In the current study, instrumented surgery for vertebral osteomyelitis resulted in similar clearance rates to noninstrumented cases. These outcomes are comparable to previously reported studies.7,8,10,16,17 In their case series of instrumented vertebral osteomyelitis, Rayes et al18 reported 2 recurrent infections (4.3%). The current study attempted to validate the safety of instrumentation in regard to recurrence of vertebral osteomyelitis, and it is believed that the radical surgical debridement in the instrumented cohort led to low infection recurrence rates. Therefore, instrumentation helped stabilize the spine with acceptable recurrence rates of the infection.

A higher number of patients who had mechanical instability or neurologic deficits underwent surgical instrumentation in the current study. One of the primary reasons for instrumentation in vertebral osteomyelitis is to stabilize an unstable spine due to the pervasive nature of the osteomyelitis. Another reason is iatrogenic instability as a result of the radical surgical debridement and corpectomy. The prevalence of preoperative neurologic deficits in the instrumented cohort is multifactorial. With severe collapse and spinal instability, as well as sagittal (coronal) misalignment, the involved vertebral levels have greater impingement of the theca sac and consequent neurologic deficits.

Conclusion

Surgical instrumentation to stabilize the spine, even in more severe cases of vertebral osteomyelitis, appeared to result in comparable clinical outcomes to decompression alone. Although patients who underwent instrumentation had more medical comorbidities and a higher rate of preoperative neurologic deficits and spinal instability, it is encouraging that they achieved similar clinical outcomes and mortality rates as the noninstrumented patients with less severe disease. In appropriately selected cases, adding spinal instrumentation to the surgical treatment of vertebral osteomyelitis does not appear to compromise patient outcome.

References

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Patient Demographics

DemographicInstrumented GroupNoninstrumented GroupP
Total patients, No.6242-
Age, mean (range), y57.5 (29.7–85.0)59 (21.0–82.5).59
Men to women, ratio, No.1:61:2.54
Comorbidity index, mean (range)3.7 (0–10)3.1 (0–8).34
Preoperative neurologic deficiency63%27%.01
Preoperative instability42%20%.03

Location of Osteomyelitis and Surgical Approach

Location and Surgical ApproachInstrumented GroupNoninstrumented Group
Cervical54%7%
Thoracic25%33%
Lumbar19%60%
Anterior spine instrumentation58%-
Posterior spine instrumentation13%-
Anterior and posterior spine instrumentationa29%-

Clinical Outcomes

OutcomeInstrumented GroupNoninstrumented GroupP
Osteomyelitis-related mortality9%17%.21
Nonosteomyelitis-related 5-year mortality18%13%.58
Clearance of infection54%42.5%.35
Preoperative ODI score, mean (range), points62 (12–94)75 (50–100).0175
Postoperative ODI score, mean (range), points40 (0–80)45 (20–76).32
Length of stay, mean (range), d19 (3–75)13 (2–63).02
Authors

The authors are from the Department of Orthopaedic Surgery (SP, RA, RAB, EL), David Geffen School of Medicine at UCLA, Los Angeles, California; and the Department of Orthopaedic Surgery (KI, TS, ES, KH, DM, AE), Seton Hall University School of Medicine, St Joseph's Regional Medical Center, Paterson, New Jersey.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Sina Pourtaheri, MD, Department of Orthopaedic Surgery, UCLA/Orthopaedic Institute for Children, 1250 16th St, Ste 3145B, Santa Monica, CA 90404 (spourtah@gmail.com).

Received: August 24, 2014
Accepted: November 11, 2015

Posted Online: May 02, 2016

10.3928/01477447-20160427-07

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