[Multistep surgery for spondylosyndesis. Treatment concept of destructive spondylodiscitis in patients with reduced general condition].
OBJECTIVE
Retrospective assessment of multistage surgery in the treatment of progressive spondylodiscitis in patients with critical physical status.


METHODS
A total of 34 patients (mean age 58.6 years) with 37 progressive spondylodiscitis foci and destruction of one to three vertebral segments (1.9 mean) were recorded within an 8-year period. Time between first complaints and operative treatment was 3 months (mean). Preoperative health status was critically reduced in 11 patients (ASA IV) and poor general condition (ASA III) was seen in 23 patients when vital indication was seen preoperatively. Considerable systemic disease (n=31), further infection focus (n=18), and nosocomial trauma (n=5) were causally related. Spondylodiscitis was seen more frequently in the lumbar (n=20) and thoracolumbar than in the thoracic (n=10) and cervical spine (n=1). Staphylococcus aureus was detectable from operative specimens and hemoculture in 15 cases, MRSA in 6 of these.


METHODS
In cases of monosegmentary involvement (n=7) ventral debridement, biopsy, and application of antibiotic chains were followed by autologous interbody bone grafting in a second stage operation. In 29 cases with destruction of two (n=27) and three (n=3) segments, posterior instrumentation including laminectomy in 4 patients was completed by anterior debridement and application of antibiotic chains during a first surgical intervention. After stabilization of physical condition and having reached a macroscopically indisputable implant bed, the ventral fusion with autologous interbody bone grafting or cage in combination with a plate or internal fixation system was performed as the last of several surgical steps.


RESULTS
No case of perioperative mortality was observed. Intensive care continued 9.1 days and hospitalization 49.5 days (mean). During a 37.6-month follow-up two late recurrences were observed.


CONCLUSIONS
A multistep surgical procedure under protection of dorsal instrumentation can limit perioperative mortality in patients in critical general condition by avoiding an extended one stage dorsoventral spondylodesis. After eradication of further infection foci and stabilization of physical condition, ventral instrumentation is completed under elective conditions.
Klinik und Poliklinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universität zu Köln. isenbergajem@aol.com
J
J
Isenberg
A
A
Jubel
U
U
Hahn
H
H
Seifert
A
A
Prokop
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003646:Debridement / Q000379:methods*; D015299:Discitis / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D018450:Disease Progression; D005260:Female; D006801:Humans; D007405:Intervertebral Disc Displacement / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D007796:Laminectomy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011859:Radiography; D012189:Retrospective Studies; D013123:Spinal Fusion / Q000379:methods*; D016896:Treatment Outcome