Abstract BACKGROUND Lumbar osteomyelitis frequently affects patients with medical comorbidities and poor preoperative health. Surgery is indicated when medical management fails or patients present with spinal instability or neural compromise. Successful arthrodesis can be difficult and sometimes requires alternative surgical techniques. OBJECTIVE To report 3 novel methods, each illustrated by a case, for achieving arthrodesis for lumbar osteomyelitis. METHODS A retrospective review was performed of 3 cases of surgical treatment of lumbar osteomyelitis. Novel aspects of the surgical techniques are reported, as are perioperative clinical details and imaging results. RESULTS In the first patient, a vascularized iliac crest graft on a quadratus lumborum pedicle was rotated into the posterolateral fusion bed of the affected level. In the second, an anterior approach with debridement of affected lumbar levels was followed by rotation of a vascularized iliac crest graft on an iliacus muscle pedicle into the anterior lumbar defect. In the third, a structural, nonvascularized iliac crest graft was harvested via a lateral approach to provide better surgical access, and an autologous tricortical bone graft was obtained for placement in the debridement defect. Follow-up imaging suggested successful early incorporation of all the grafts in the fusion beds. CONCLUSION Patients with multiple risk factors for pseudarthrosis and recurrent infection often require alternative surgical strategies to augment fusion. These 3 novel methods for lumbar debridement, fixation, and fusion using vascularized or nonvascularized autograft accommodate posterior, anterior, and lateral surgical approaches. Further experience with these techniques is required to compare outcomes with those of traditional techniques. Augmented fusion strategies, Lumbar osteomyelitis, Vascularized autograft ABBREVIATIONS ABBREVIATIONS CT computed tomography MRI magnetic resonance imaging Vertebral osteomyelitis is a relatively common disorder with a growing incidence in the adult population.1-6 Surgical treatment is indicated for patients who fail medical therapy or who present with neurological compromise, spinal instability, or significant deformity. The surgical management of these patients is difficult, as the majority of patients present with numerous medical comorbidities and risk factors for perioperative morbidity.6 Successful arthrodesis is critical for achieving good postoperative outcomes, but pseudarthrosis rates in patients with vertebral osteomyelitis are high due to their comorbidities and active infection in the fusion site. Several studies have reported using allograft bone products in the treatment of osteomyelitis with acceptable rates of postoperative infection and pseudarthrosis.1,7-10 However, for patients with osteomyelitis and numerous other risk factors for pseudarthrosis, alternative surgical strategies utilizing autograft bone are likely to be required to achieve successful arthrodesis.5 Autograft bone is generally considered superior to allograft bone products because of the increased osteogenicity, osteoinductivity, and reduced inflammatory response of autograft at the fusion site. Several studies have shown superior results for autograft used in the setting of infection.2,11,12 Autograft can be vascularized or nonvascularized for treatment of lumbar osteomyelitis. Vascularized grafts are generally considered superior given their higher osseous union rates, greater biomechanical strength, reduced risk of infection, and quicker incorporation into the host tissue bed.13-16 However, nonvascularized grafts are associated with less perioperative morbidity and may afford an adequate fusion substrate for successful arthrodesis. The iliac crest is well described in both the spine and plastic surgery literature for use as nonvascularized autograft or free-transfer vascularized autograft.17-20 The lumbar segmental vessels (which provide a posteromedial-to-lateral vascular supply) and the deep circumflex iliac arteries (which provide an anterolateral-to-medial vascular supply) provide robust vascular pedicles to the iliac wings. The iliac wings are further fed by a rich network of periosteal feeding vessels that receive their blood supply primarily through the vessels feeding the quadratus lumborum muscles posterolaterally and the paraspinal muscles posteromedially.21 By harvesting iliac crest in a manner that preserves the periosteum and muscle attachments to the graft, one can maintain the blood supply to the graft while freeing it for medial rotation into the posterolateral spinal column. The purpose of this study was to describe 3 alternative surgical strategies for augmenting fusion rates in patients with lumbar osteodiscitis that capitalize on the advantageous anatomy of the iliac crest. METHODS In this report, we describe 3 novel techniques for the treatment of lumbar osteomyelitis that afford the benefits of autograft without the additional morbidity associated with distant graft donor sites and microvascular anastomoses. These techniques were developed by the authors using cadaveric models and were implemented in patients treated by the authors at their home institution. All 3 patients provided informed consent for their treatment. Due to the retrospective and anonymous nature of this case series, Institutional Review Board approval was not required. RESULTS Case 1: Vascularized Iliac Crest Graft from a Posterior Approach A 45-yr-old man with a remote history of an American Spinal Injury Association grade A spinal cord injury at T12 presented for a second opinion regarding a 3-mo history of low back pain and constipation. Initial work-up of his symptoms revealed osteodiscitis at L3-L4, prompting medical treatment with intravenous vancomycin. Multiple courses of treatment were required, which eventually resulted in permanent partial deafness secondary to vancomycin toxicity. The patient's pain had progressed to the point that he was unable to tolerate sitting up for any period of time. Imaging revealed a previous T11-L3 posterior segmental fixation and posterolateral fusion, as well as an L3-L4 Charcot joint (Figure 1). The patient had been told by previous surgical consultants that his instability was untreatable because of a high risk of pseudarthrosis. FIGURE 1. View largeDownload slide A, Anteroposterior plain film radiographs demonstrating a previous T11-L3 fusion and an L3-L4 Charcot joint with a large pannus. B, Sagittal computed tomography (CT) image demonstrating an L3-L4 Charcot joint. Used with permission from Barrow Neurological Institute. FIGURE 1. View largeDownload slide A, Anteroposterior plain film radiographs demonstrating a previous T11-L3 fusion and an L3-L4 Charcot joint with a large pannus. B, Sagittal computed tomography (CT) image demonstrating an L3-L4 Charcot joint. Used with permission from Barrow Neurological Institute. This patient's debilitating spinal deformity, instability, and history of failed medical management indicated surgical treatment. Given his elevated risk of pseudarthrosis, we recommended vascularized autografting at the highest risk level for pseudarthrosis (L3-L4). The patient was taken to the operating room for a revision of his posterior segmental fixation from T10-S1, with L3-L5 transforaminal lumbar interbody fusions and placement of a vascularized iliac crest graft rotated into the posterolateral fusion bed of L3-L4 on a vascular pedicle of quadratus lumborum muscle. After the revision, the posterior segmental fixation, and the transforaminal lumbar interbody fusions were performed in the usual fashion, a second incision was made horizontally over the patient's left posterior iliac crest. A segment of iliac crest measured to fit in the ipsilateral L3-L4 posterolateral fusion bed was harvested using a sagittal saw, taking care to leave intact the quadratus lumborum muscle attachments and periosteum. After the gluteus and iliacus muscles had been freed from the graft, the graft was mobilized superiorly to approximately the T12 level, taking care to leave a layer of ventral fascia to prevent lumbar hernia. The osteomuscular flap was then tunneled medially beneath the paraspinal muscles and into the L3-L4 posterolateral fusion bed (Figure 2), where it was secured to the segmental fixation hardware. Securing the graft in this fashion generated a loading pressure between the graft and the decorticated surface of the transverse processes, thereby promoting graft incorporation and remodeling. The total operative time was 8 h, and the estimated blood loss was 1200 mL. The patient was discharged home on postoperative day 4 with good pain control while sitting upright. FIGURE 2. View largeDownload slide Intraoperative imaging from the patient described in case 1 demonstrating placement of iliac crest vascularized bone graft (IC-VBG) into the posterior fixation construct. Used with permission from Barrow Neurological Institute. FIGURE 2. View largeDownload slide Intraoperative imaging from the patient described in case 1 demonstrating placement of iliac crest vascularized bone graft (IC-VBG) into the posterior fixation construct. Used with permission from Barrow Neurological Institute. Follow-up imaging at 3 mo revealed good incorporation of the graft into the host tissue bed, good graft hyperdensity indicating continued viability of the bone, and continued stability at the L3-L4 level. Unfortunately, the patient had also developed pseudarthrosis at L5-S1, as evidenced by significant bone demineralization around the bilateral S1 screws (Figure 3). The patient initially tolerated the pseudarthrosis, but at 6-mo follow-up, he was complaining of recurrent low back pain. He was taken back to the operating room for an L5-S1 anterior lumbar interbody fusion, followed by revision posterolateral fusion and extension of fixation to the ilium. Intraoperatively, we noted that the vascularized iliac crest graft retained its viability and had incorporated well into the Charcot joint level. FIGURE 3. View largeDownload slide CT image 3 mo after surgery showing A, persistent graft hyperdensity and early incorporation into the fusion site (arrow indicates bone graft) and B, bilateral S1 screw lucency, providing indirect evidence of L5-S1 pseudarthrosis. Used with permission from Barrow Neurological Institute. FIGURE 3. View largeDownload slide CT image 3 mo after surgery showing A, persistent graft hyperdensity and early incorporation into the fusion site (arrow indicates bone graft) and B, bilateral S1 screw lucency, providing indirect evidence of L5-S1 pseudarthrosis. Used with permission from Barrow Neurological Institute. Case 2: Vascularized Iliac Crest Graft From an Anterior Approach A 61-yr-old man with a history of chronic lymphocytic leukemia, intravenous drug abuse, and hepatitis C virus infection presented for neurosurgical consultation regarding progressively worsening back pain, radicular leg pain, and bilateral distal leg weakness. Magnetic resonance imaging (MRI) of the lumbar spine revealed suppurative L4-L5 osteodiscitis, which had previously been treated with intravenous antibiotics and a decompressive laminectomy (Figure 4). Despite treatment, the patient's symptoms progressed to the point of debilitation. Given the patient's progressive spinal instability, neural compromise, and failed medical management, he was offered revision surgical treatment. FIGURE 4. View largeDownload slide Sagittal T1-weighted MRI with contrast showing active osteomyelitis eroding through the L4-L5 vertebral bodies and disc space. Used with permission from Barrow Neurological Institute. FIGURE 4. View largeDownload slide Sagittal T1-weighted MRI with contrast showing active osteomyelitis eroding through the L4-L5 vertebral bodies and disc space. Used with permission from Barrow Neurological Institute. A 2-stage procedure was planned: posterior segmental fixation and posterolateral fusion with revision decompressive laminectomies from L2-S1, followed by anterior lumbar debridement and placement of a vascularized iliac crest graft on a pedicle of iliacus muscle and deep posterior circumflex artery. The patient was taken to the operating room, where a traditional anterior lumbar approach was performed. The osteomyelitic bone and disc at L4-L5 were then debrided. Next, the iliac crest was identified laterally, along with the deep posterior circumflex vessels. Care was taken to keep the iliacus muscle attachments and periosteum intact, and a sagittal saw and osteotome were used to harvest a segment of iliac crest the approximate size of the anterior lumbar defect. Once harvested, the graft was mobilized on a vascular pedicle of deep posterior circumflex artery and iliacus muscle. The osteomuscular flap was tunneled beneath the psoas muscle and into the ventral lumbar defect, where it was secured in place using a combination of trauma fragment screws and plates (Figure 5). FIGURE 5. View largeDownload slide Immediate postoperative sagittal CT image demonstrating placement of the vascularized iliac crest and anterior fixation hardware (arrow indicates bone graft). Used with permission from Barrow Neurological Institute. FIGURE 5. View largeDownload slide Immediate postoperative sagittal CT image demonstrating placement of the vascularized iliac crest and anterior fixation hardware (arrow indicates bone graft). Used with permission from Barrow Neurological Institute. The patient tolerated the procedure well. Several weeks afterward, the patient developed abdominal pain. Imaging was concerning for a retroperitoneal collection of fluid that appeared to involve the graft harvest site (Figure 6A). Surgical drainage revealed a hematoma, and cultures of the hematoma were positive for coagulase-negative Staphylococcus. Because the autograft was vascularized, we were able to treat the potentially infected graft in situ with intravenous antibiotics. Four weeks after this washout procedure and 8 wk after the index procedure, spinal imaging revealed a viable autograft with early evidence of incorporation into the host tissue bed (Figure 6B). FIGURE 6. View largeDownload slide A, Axial view of CT image of the abdomen and pelvis taken 3 wk after the index procedure demonstrating a large abdominal fluid collection that appears to involve the graft donor site (left iliac crest). B, CT imaging 8 wk after surgery showing continued graft viability and early incorporation into the fusion bed despite surgical site infection. Used with permission from Barrow Neurological Institute. FIGURE 6. View largeDownload slide A, Axial view of CT image of the abdomen and pelvis taken 3 wk after the index procedure demonstrating a large abdominal fluid collection that appears to involve the graft donor site (left iliac crest). B, CT imaging 8 wk after surgery showing continued graft viability and early incorporation into the fusion bed despite surgical site infection. Used with permission from Barrow Neurological Institute. Case 3: Nonvascularized Iliac Crest Autograft to Facilitated Exposure and Arthrodesis in a Lateral Trans-psoas Approach A 66-yr-old man presented with a 15-yr history of low back pain that had significantly progressed in severity over the course of 6 wk. The patient also noted intermittent pain radiating down his left leg into the dorsal aspect of his foot. Pain-limited weakness was present in the left hip flexors and knee extensors, but all other muscle groups were otherwise full strength. MRI revealed osteomyelitis and discitis involving the L4-L5 level (Figure 7). An infectious diseases workup was performed, but no organism or source of infection was identified. FIGURE 7. View largeDownload slide A, Sagittal and B, axial T2-weighted MRI demonstrating L4-5 osteodiscitis. C, Sagittal T1-weighted and D, T1-weighted MRI with contrast demonstrating vivid enhancement at the infected level. Used with permission from Barrow Neurological Institute. FIGURE 7. View largeDownload slide A, Sagittal and B, axial T2-weighted MRI demonstrating L4-5 osteodiscitis. C, Sagittal T1-weighted and D, T1-weighted MRI with contrast demonstrating vivid enhancement at the infected level. Used with permission from Barrow Neurological Institute. Given the osteolysis of the L4 and L5 vertebral bodies and endplates, we decided to debride the infection from a lateral retroperitoneal approach and to use a nonvascularized iliac crest autograft to promote fusion across the large disc space (Figure 8). A 2-stage surgery was planned. In the first stage, the patient was positioned in the lateral position with the right side down, and true anteroposterior and lateral radiographs were obtained at the operative level. A horizontal incision was centered over the L4-L5 disc space, and dissection was carried down to the superior iliac crest. A reciprocating saw was used to harvest a 3.5 × 1-cm segment of the superior iliac crest. Doing so served the dual purpose of providing unhindered access to the L4-L5 disc space, which the crest partially obstructed, and providing autograft for fusion across the L4-L5 level. Next, under electromyographic monitoring, sequential dilators were placed through the psoas muscle centered over the disc space. The expandable self-retaining retractor was then secured, and the operative field was interrogated with direct electromyographic stimulation to ensure that the lumbar plexus would not be injured. Specimens for cultures were taken from the purulent disc space, and the osteomyelitic segment was debrided. The iliac crest graft was then placed into the defect at L4-L5. FIGURE 8. View largeDownload slide A, Intraoperative lateral fluoroscopic imaging demonstrating placement of the nonvascularized iliac crest autograft and harvest site that permitted easier access to the lateral L4-L5 disc space. B, Immediate postoperative sagittal CT imaging showing placement of the nonvascularized iliac autograft (arrow). Used with permission from Barrow Neurological Institute. FIGURE 8. View largeDownload slide A, Intraoperative lateral fluoroscopic imaging demonstrating placement of the nonvascularized iliac crest autograft and harvest site that permitted easier access to the lateral L4-L5 disc space. B, Immediate postoperative sagittal CT imaging showing placement of the nonvascularized iliac autograft (arrow). Used with permission from Barrow Neurological Institute. The patient tolerated the procedure well, and cultures identified the organism as Peptostreptococcus species. The second stage of the operation was performed in a delayed fashion after 2 wk of treatment with intravenous antibiotics, and included an L4-L5 laminectomy and pedicle screw fixation to stabilize the affected level and decompress the neural elements. Compression across the L4-L5 level was performed during final tightening of the pedicle screw fixation to pressure load the iliac crest graft with the L4 and L5 vertebral bodies to promote fusion. At the 6-mo follow-up, the patient's radicular leg pain had completely resolved, and his lumbar back pain had improved substantially. At the planned 1-yr-follow-up, computed tomograms of the lumbar spine will be obtained to evaluate fusion. DISCUSSION Vertebral osteomyelitis of the lumbar spine is an increasingly common and difficult disease to treat. Traditional methods of surgical debridement and allograft fusion are unlikely to be sufficient for high-risk patients. This report provides 3 alternative methods of treatment that utilize vascularized and nonvascularized autograft from posterior, anterior, or lateral approaches to the lumbar spine. In 1975, Taylor et al22 described the free fibula transfer for vascularized bone grafting in spinal reconstructive surgery. Since that time, the free fibular transfer has been the primary surgical technique for vascularized bone grafting in the spine. Although free fibular grafts have been successful, a number of challenges have precluded their wider use in the treatment of lumbar osteomyelitis. These challenges include increased donor site morbidity, increased operative time, and increased blood loss, as well as the fact that they require an anterior or combined anterior–posterior approach to allow identification of adequate recipient vessels for the required microvascular anastomoses.6 Several studies have documented that these challenges result in a significant rate of procedure abortion or anastomosis failure and that they significantly contribute to the technical demand and length of a procedure.5,23-26 An alternative to free-transfer bone grafting in the lumbar spine is pedicled bone grafting. Harvesting a piece of bone near the lumbar spine and rotating it as an osteomuscular flap on a preexisting vascular pedicle retains all the benefits of a vascularized bone graft without the added difficulty and associated morbidity of a free tissue transfer. We have recently evaluated different methods for rotating pedicled bone grafts into the spine using cadaveric models, and are preparing these studies for publication. As evident from the 3 illustrative cases presented here, these highly comorbid patients are prone to perioperative morbidity. Pursuing larger index operations in these patients increases their risk for developing perioperative complications. However, we hypothesize that these larger index procedures will afford better overall outcomes if they circumvent the need for larger revision procedures secondary to failed arthrodesis. For example, in the first case, a revision procedure was required secondary to pseudarthrosis at the L5-S1 level. In this case, the spine level that received the vascularized autograft (the highest risk level for pseudarthrosis) demonstrated excellent incorporation into the fusion bed on both postoperative imaging and intraoperative exploration. It was therefore unnecessary to perform a surgical revision of this level when treating the distal segment pseudarthrosis. In the second case, the patient developed a postoperative hematoma and surgical site infection. The use of vascularized autograft allowed the active infection to be treated in situ, rather than requiring a large revision procedure to replace the bone graft to prevent it from becoming sequestrum. Given the inherent donor site and index site morbidity added by these complex procedures, we nevertheless would only advocate for their use when traditional surgical techniques fail, or when the severity of illness warrants alternative techniques to augment fusion and reduce the risk of graft infection and subsequent failure. CONCLUSION Lumbar vertebral osteomyelitis is increasingly prevalent and difficult to treat in the adult population. Traditional treatment methods include fixation of the spine and arthrodesis using allograft or cancellous autograft bone products. Certain patients with multiple risk factors for pseudarthrosis and recurrent infection who are likely to fail traditional techniques may benefit from vascularized or nonvascularized autograft fusion. This study describes 3 novel methods for performing lumbar debridement, fixation, and fusion using vascularized or nonvascularized autograft. Additionally, these methods can accommodate posterior, anterior, and lateral surgical approaches. A larger, prospectively collected case series is needed before further conclusions can be drawn regarding the arthrodesis and complication rates associated with these techniques. Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. REFERENCES 1. Acosta FL Jr , Chin CT , Quinones-Hinojosa A , Ames CP , Weinstein PR , Chou D . Diagnosis and management of adult pyogenic osteomyelitis of the cervical spine . Neurosurg Focus . 2004 ; 17 ( 6 ): E2 . Google Scholar CrossRef Search ADS PubMed 2. Chelsom J , Solberg CO . Vertebral osteomyelitis at a Norwegian university hospital 1987-97: clinical features, laboratory findings and outcome . Scand J Infect Dis . 1998 ; 30 ( 2 ): 147 - 151 . Google Scholar CrossRef Search ADS PubMed 3. Jensen AG , Espersen F , Skinhoj P , Rosdahl VT , Frimodt-Moller N . Increasing frequency of vertebral osteomyelitis following Staphylococcus aureus bacteraemia in Denmark 1980-1990 . J Infect . 1997 ; 34 ( 2 ): 113 - 118 . Google Scholar CrossRef Search ADS PubMed 4. Schimmer RC , Jeanneret C , Nunley PD , Jeanneret B . 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Sasso RC , LeHuec JC , Shaffrey C , Spine Interbody Research G . Iliac crest bone graft donor site pain after anterior lumbar interbody fusion: a prospective patient satisfaction outcome assessment . J Spinal Disord Tech . 2005 ; 18 ( Suppl ): S77 - S81 . Google Scholar CrossRef Search ADS PubMed 21. Ghassemi A , Furkert R , Prescher A et al. Variants of the supplying vessels of the vascularized iliac bone graft and their relationship to important surgical landmarks . Clin Anat . 2013 ; 26 ( 4 ): 509 - 521 . Google Scholar CrossRef Search ADS PubMed 22. Taylor GI , Miller GD , Ham FJ . The free vascularized bone graft. A clinical extension of microvascular techniques . Plast Reconstr Surg . 1975 ; 55 ( 5 ): 533 - 544 . Google Scholar CrossRef Search ADS PubMed 23. Ackerman DB , Rose PS , Moran SL , Dekutoski MB , Bishop AT , Shin AY . The results of vascularized-free fibular grafts in complex spinal reconstruction . J Spinal Disord Tech . 2011 ; 24 ( 3 ): 170 - 176 . Google Scholar CrossRef Search ADS PubMed 24. Lee MJ , Ondra SL , Mindea SA , Fine NA , Dumanian GA . Indications and rationale for use of vascularized fibula bone flaps in cervical spine arthrodeses . Plast Reconstr Surg . 2005 ; 116 ( 1 ): 1 - 7 . Google Scholar CrossRef Search ADS PubMed 25. Winters HA , van Engeland AE , Jiya TU , van Royen BJ . The use of free vascularised bone grafts in spinal reconstruction . J Plast Reconstr Aesthet Surg . 2010 ; 63 ( 3 ): 516 - 523 . Google Scholar CrossRef Search ADS PubMed 26. Yelizarov VG , Minachenko VK , Gerasimov OR , Pshenisnov KP . Vascularized bone flaps for thoracolumbar spinal fusion . Ann Plast Surg . 1993 ; 31 ( 6 ): 532 - 538 . Google Scholar CrossRef Search ADS PubMed Acknowledgment The authors would like to acknowledge the Barrow Neuroscience Publications staff for assistance with manuscript preparation. COMMENT The authors present a well-written description of alternative techniques for lumbar arthrodesis in the setting of vertebral osteomyelitis. As referenced in the study, the higher fusion rates of autograft over allograft, and with vascularized over non-vascularized bone grafts has been well established. They report 3 cases of surgical treatment of lumbar osteomyelitis with the use of vascularized and non-vascularized iliac crest for the treatment of spinal instability that are at high risk for pseudoarthrosis, in hopes of achieving a more rapid and stronger fusion. Techniques such as osteomuscular, pedicled iliac crest graft can be rotated and placed into the fusion bed via either traditional anterior or posterior approaches. This rotational grafting strategy is also an alternative to free-transfer bone grafting techniques, which are associated with significant morbidity and technical difficulty. The 3 illustrative cases provide an informative overview of the relevant anatomical considerations as well as a general framework to better understand the appropriate use of the techniques. The primary indication would be complex infections, which are unlikely to achieve fusion with standard arthrodesis techniques, although the strategy could easily be extrapolated to other cases of degenerative spine disease with osteoporosis or failed lumbar fusions. As spine surgeons expand the applications of osteomuscular bone grafting, we should expect larger clinical series to support its use, especially in complex and difficult to treat patients. By linking the specialties of spine surgery and reconstructive plastic surgery to advance this type of technique, the authors have made a valuable addition to the surgeon's armamentarium. Alexander E. Ropper Houston, Texas Copyright © 2017 by the Congress of Neurological Surgeons This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
Operative Neurosurgery – Oxford University Press
Published: Aug 9, 2017
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