title: Corpectomy followed by the placement of instrumentation with titanium cages and recombinant human bone morphogenetic protein-2 for vertebral osteomyelitis.
abstract: OBJECTIVE
  The treatment of vertebral osteomyelitis includes antibiotics with or without surgical intervention. The decision to place instrumentation into an infected spinal column remains controversial. The use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in patients with osteomyelitis is also extremely controversial. The authors review their experience in performing corpectomy and fusion with titanium cages and rhBMP-2 in patients with vertebral instability and/or neurological compromise due to vertebral osteomyelitis.
  
  
  METHODS
  Data obtained in 15 patients treated between 2001 and 2005 were included in this analysis. Nine patients presented primarily with axial pain and six with radiculopathy or myelopathy. Seven patients had an associated epidural abscess. The cervical spine was affected in six patients, the thoracic spine in five, and the lumbar spine in four. All patients underwent corpectomy of the involved vertebral bodies; the authors then performed spinal reconstruction, placing a titanium cage-plate system with morcellized allograft/autograft and rhBMP-2. In 10 patients, supplemental posterolateral screw-rod fixation was conducted. A one-level corpectomy was performed in one patient, a two-level corpectomy in 13, and a six-level corpectomy in one. A morcellized allograft and rhBMP-2-filled titanium cage was used in 10 patients, and an autograft and rhBMP-2-filled cage in five patients. The most common pathogen was Staphylococcus aureus. All patients received intravenous antibiotics for at least 6 weeks postoperatively, and life-long antibiotic therapy was required in three patients with coccidiomycoses, candida, and tuberculosis osteomyelitis, respectively. There were no recurrent infections. Radiography demonstrated evidence of fusion in all patients at the last follow-up examination. The mean follow-up period was 20 months.
  
  
  CONCLUSIONS
  Corpectomy followed by titanium cage-plate reconstruction and the placement of rhBMP-2 may be a safe and effective treatment for selected patients with vertebral osteomyelitis. This surgical therapy does not appear, at least based on preliminary results, to lead to recurrent hardware infections. Based on the results obtained in this limited series, the authors found that rhBMP-2 can be used in the setting of active infection with excellent fusion rates and without complication. The morbidity associated with the autograft donor site is avoided when using cages. Antibiotic therapy tailored to the specific organism should be continued for at least 6 weeks after surgery, and life-long therapy is required in cases of fungal or tuberculosis infections.
authors.affiliation: Department of Neurosurgery and UCSF Spine Center, University of California, San Francisco, California. 94143-0350, USA. draryan@draryan.com
authors.forename: Henry E
authors.initials: HE
authors.lastname: Aryan
authors.forename: Daniel C
authors.initials: DC
authors.lastname: Lu
authors.forename: Frank L
authors.initials: FL
authors.lastname: Acosta
authors.forename: Christopher P
authors.initials: CP
authors.lastname: Ames
mesh_terms: D000328:Adult; D001672:Biocompatible Materials / Q000627:therapeutic use; D055396:Bone Morphogenetic Protein 2; D019485:Bone Morphogenetic Proteins / Q000627:therapeutic use*; D001863:Bone Screws; D003131:Combined Modality Therapy; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D019637:Orthopedic Procedures / Q000295:instrumentation*; D010019:Osteomyelitis / Q000382:microbiology / Q000473:pathology / Q000628:therapy*; D011182:Postoperative Care; D012189:Retrospective Studies; D013123:Spinal Fusion / Q000295:instrumentation*; D013131:Spine / Q000473:pathology / Q000601:surgery*; D013203:Staphylococcal Infections / Q000382:microbiology; D053831:Surgical Fixation Devices; D014025:Titanium / Q000627:therapeutic use*; D016212:Transforming Growth Factor beta / Q000627:therapeutic use*
chemical_list: C525718:BMP2 protein, human; D001672:Biocompatible Materials; D055396:Bone Morphogenetic Protein 2; D019485:Bone Morphogenetic Proteins; D016212:Transforming Growth Factor beta; D014025:Titanium