PURPOSE: This study evaluates two basic hypotheses: (1) the risk of an isolated dorsal approach to ventral lumbar spondylodiscitis based on clinical and radiographic results and (2) the risk of anterior radical debridement due to using a titanium implant in the site of bone infection. METHODS: Group A consisting of 23 patients was treated only by a dorsal transmuscular approach and group B consisting of eight patients was treated by two-stage posteroanterior surgery. Both evaluated groups were assessed before surgery, six weeks and one year after surgery with the Japanese Orthopaedic Association (JOA) score, visual analogue scale (VAS) and Kirkaldy-Willis functional criteria. To evaluate the sagittal balance restoration, measurement by the Cobb modified angle of the affected segment was performed. RESULTS: Differences (p < 0.001) in group A were found between JOA values before surgery (average 9.30) and at six weeks after surgery (average 11.82) and 12 months after surgery (13.27) and VAS differences before surgery (average 7.39), six weeks after surgery (average 3.82) and 12 months after surgery (average 2.36) in group A. According to the Kirkaldy-Willis functional criteria, 11 patients were evaluated as excellent, nine patients as good and two patients as poor. The values of the JOA score in group B showed an improvement compared with the JOA values before surgery (average 9.38) at six weeks after surgery (average 11.75) and 12 months after surgery (average 13.63), and the VAS score before surgery (average 7.38) was found to have improved six weeks after surgery (average 4.63) and 12 months after surgery (average 2.25). The functional evaluation according to the Kirkaldy-Willis functional criteria assessed three patients as excellent, four patients as good and one patient as fair. Radiographic examinations of group A revealed the following findings before surgery (average 1.75), six months after surgery (average -3.73) and 12 months after surgery (average -0.79) and in group B before surgery (average 3.71), six weeks after surgery (average -8.21) and 12 months after surgery (average -6.45). CONCLUSIONS: The results demonstrate the minimum serious surgical complications and greater loss of sagittal balance without clinical correlation in group A. We did not find any relapse or persistence of the infection in the post-operative period in group B.

Department of Orthopedics 1st Medical Faculty of Charles University and Hospital Na Bulovce Prague Czech Republic

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Akbar M, Lehner B, Doustdar S, Fürstenberg CH, Hemmer S, Bruckner T, et al. Pyogenic spondylodiscitis of the thoracic and lumbar spine: a new classification and guide for surgical decision-making. Orthopade. 2011;40:614–623. doi: 10.1007/s00132-011-1742-5. PubMed DOI

Lange T, Schulte TL, Ullmann V. Two recurrences of adjacent spondylodiscitis after initial surgical intervention with posterior stabilization, debridement, and reconstruction of the anterior column in a patient with spondylodiscitis: a case report. Spine. 2010;35:E804–E810. doi: 10.1097/BRS.0b013e3181d56955. PubMed DOI

Asamoto A, Doi H, Kobayashi N, Endoh T, Sakagawa H, et al. Spondylodiscitis: diagnosis and treatment. Surg Neurol. 2005;64:103–108. doi: 10.1016/j.surneu.2004.11.034. PubMed DOI

Cervan A, Colmenero Jde D, Del Arco A, Villanueva F, Guerado E. Spondylodiscitis in patients under haemodialysis. Int Orthop. 2012;36(2):421–426. doi: 10.1007/s00264-011-1433-1. PubMed DOI PMC

Osenbach RK, Hitchon PW, Menezes AH. Diagnosis and management of pyogenic vertebral osteomyelitis in adults. Surg Neurol. 1990;33:266–275. doi: 10.1016/0090-3019(90)90047-S. PubMed DOI

Carrega G, Arena S, Bartolacci V, Gavino D, Mecca D, Sandrone C, Santoriello L, Tabasso G, Riccio G. Non-tubercular vertebral osteomyelitis: diagnosis and therapy of 45 patients from a single Italian centre. Infez Med. 2003;11:183–188. PubMed

Quiñones-Hinojosa A, Jun P, Jacobs R, Rosenberg WS, Weinstein PR. General principles in the medical and surgical management of spinal infections: a multidisciplinary approach. Neurosurg Focus. 2004;17:E1–E15. PubMed

Rath SA, Neff U, Schneider O, Richter HP. Neurosurgical management of thoracic and lumbar vertebral osteomyelitis and discitis in adults: a review in 43 consecutive surgically treated patients. Neurosurgery. 1996;38:926–933. doi: 10.1097/00006123-199605000-00013. PubMed DOI

Lee JS, Moon KP, Kim SJ, et al. Posterior lumbar interbody vision and posterior instrumentation in the surgical management of lumbar tuberculous spondylitis. J Bone Joint Surg Br. 2007;89:210–214. doi: 10.1302/0301-620X.89B2.17849. PubMed DOI

Zarghooni K, Röllinghoff M, Sobottke R, Eysel P. Treatment of spondylodiscitis. Int Orthop. 2012;36(2):405–411. doi: 10.1007/s00264-011-1425-1. PubMed DOI PMC

Di Martino A, Papapietro N, Lanotte A, Russo F, Vadalà G, Denaro V. Spondylodiscitis: standards of current treatment. Curr Med Res Opin. 2012;28:689–699. doi: 10.1185/03007995.2012.678939. PubMed DOI

Karadimas EJ, Bunger C, Lindblad BE, Hansen ES, Høy K, Helmig P, Kannerup AS, Niedermann B. Spondylodiscitis. A retrospective study of 163 patients. Acta Orthop. 2008;79:650–659. doi: 10.1080/17453670810016678. PubMed DOI

Hempelmann RG, Mater E, Schön R. Septic hematogenous lumbar spondylodiscitis in elderly patients with multiple risk factors: efficacy of posterior stabilization and interbody vision with iliac crest bone graft. Eur Spine J. 2010;19:1720–1727. doi: 10.1007/s00586-010-1448-0. PubMed DOI PMC

Zaveri GR, Mehta SS. Surgical treatment of lumbar tuberculous spondylodiscitis by transforaminal lumbar interbody vision (TLIF) and posterior instrumentation. J Spinal Disord Tech. 2009;22:257–262. doi: 10.1097/BSD.0b013e31818859d0. PubMed DOI

Madert J, Liem M, Frosch KH, Niemeyer T. Dorsolateral access and interbody spinal vision in spondylodiscitis of the thoracolumbar spine (TLIF technique) Oper Orthop Traumatol. 2013;25:262–272. doi: 10.1007/s00064-012-0214-3. PubMed DOI

Guaredo E, Cerván A. Surgical treatment of spondylodiscitis. An update. Int Orthop. 2012;36(2):413–420. doi: 10.1007/s00264-011-1441-1. PubMed DOI PMC

Oxland TR, Grant JP, Dvorak MF, et al. Effects of endplate removal on the structural properties of the lower lumbar vertebral bodies. Spine. 2003;28:771–777. PubMed

Pee YH, Park JD, Choi Y, Lee S. Anterior debridement and fusion followed by posterior pedicle screw fixation in pyogenic spondylodiscitis: autologous iliac bone strut versus cage. J Neurosurg Spine. 2008;8:405–412. doi: 10.3171/SPI/2008/8/5/405. PubMed DOI

Korovessis P, Petsinis G, Koureas G, Iliopoulos P, Zacharatos S. Anterior surgery with insertion of titanium mesh cage and posterior instrumented fusion performed sequentially on the same day under one anesthesia for septic spondylitis of thoracolumbar spine: is the use of titanium mesh cages safe? Spine (Phila Pa 1976) 2006;31:1014–1019. doi: 10.1097/01.brs.0000215049.08622.9d. PubMed DOI

Lim JK, Kim SM, Jo DJ, Lee TO. Anterior interbody grafting and instrumentation for advanced spondylodiscitis. J Korean Neurosurg Soc. 2008;43:5–10. doi: 10.3340/jkns.2008.43.1.5. PubMed DOI PMC

Klöckner C, Valencia R. Sagittal alignment after anterior debridement and fusion with or without additional posterior instrumentation in the treatment of pyogenic and tuberculous spondylodiscitis. Spine. 2003;28:1036–1042. PubMed

Rajasekaran S, Soundarapandian S. Progression of kyphosis in tuberculosis of the spine treated by anterior arthrodesis. J Bone Joint Surg Am. 1989;71:1314–1323. PubMed

Stulik J, Vyskocil T, Bodlák P, et al. Injury to major blood vessels in anterior thoracic and lumbar spinal surgery. Acta Chir Orthop Traumatol Cech. 2006;73:92–98. PubMed