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  • ISSN: 2373-9819
    JSM Clin Case Rep 2(4): 1045.
    Submitted: 05 February 2014; Accepted: 03 March 2014; Published: 14 March 2014
    Case Report
    Anterior and Navigated Posterior Fusion in Cervical Spondylodiscitis. A Case Report and Review of the Literature
    Timo Stübig*, Sebastian Decker, Stephan Brand, Martin Panzica, Christian Krettek and Christian W Müller
    Department of Trauma, Hannover Medical School, Germany
    *Corresponding author: Timo Stübig, Department of Trauma, Medical School Hannover, Carl- Neuberg-Str. 130625 Hannover, Germany, Tel: 495115322026; Fax: 495115325788; Email: stuebig.timo@mh-hannover.de
    Object: We describe the surgical treatment of a 44 year old woman presenting with spondylodiscitis from C4 to C6 and incomplete tetraparesis. She was transferred to our hospital after incomplete cervical decompression from C3-6 in a county hospital. Our therapy regimen was performed in 3 stages: First wie performed an implant removal and external fixation using a halofixateur with microbial eradication followed by anterior fusion and finally navigated posterior stabilization and fusion from C3 to C7. This is the first documented case of computer navigated posterior CT-based fusion in multilevel cervical spondylodiscitis. The postoperative CT showed a correct implant positioning, the initial neurological symptoms decreased during the admission in our hospital and thereafter.
    Spondylodiscitis represents an important clinical problem that often requires aggressive medical therapy often followed by surgical debridement and stabilization [1]. There are three main contamination routes: hematogenous spread, external inoculation or involvement from adjacent tissue [1, 2].
    Known risk factors for spondylodiscitis include diabetes mellitus, rheumatoid arthritis, immunosuppression, alcoholism, long-term steroid use, concomitant infections, severe trauma, tumor and previous surgery [1, 3, 4].
    Cervical spondylodiscitis is a rare disease, that is linked, in comparison with other spinal locations, with significantly more neurological involvement, it also requires more often surgical treatment and represents an increased mortality [5].
    Microbiological findings
    Identifying the causative agent is crucial for successful conservative treatment; however the agent is found in 49% of cases only [6, 7].
    In pyogenic spondylodiscitis, Staphylococcus aureus is the most frequent isolated agent, being found in more than 50% of the pyogenic spondylodiscitis while Gram-negative species as Escherichia coli are found in immunocompromised patients, the agents found in intravenous drug abusers consist of Staphylococcus aureus, Pseudomonas aeruginosa and S. epidermidis [8]. In patients with infective endocarditis, Streptococcus viridans should also be suspected. Coagulasenegative staphylococci and Propionibacterium are the microorganisms that are found in osteomyelitis after spinal surgery, particularly if instrumentation is used [1,9,10].
    Diagnostic imaging
    The first step in diagnostic imaging are plain photographs, which should be followed by magnet resonance imaging, as these imaging modalities can reach an accuracy of 90% in the diagnosis of spondylodiscitis [1,11]. Furthermore, specific aspects like epidural abscesses, the simultaneous presence of soft tissue swelling, obliteration of fat planes around the vertebral bodies, and fragmentation or erosive changes in the vertebral end plates can be evaluated [1, 11] . Magnet Resonance Imaging (MRI) is reported to be more sensitive than Computertomography (CT) especially in the early detection of osteomyelitis. However there may be several indications for the use of CT, e.g. when contradictions to MRI are present, if a fracture occured or if a CTguided biopsy or drain is planned [12,13].
    While conservative treatment is the gold standard to handle spondylodiscitis, surgical treatment is necessary in some conditions, that include pathologic fractures, neurologic deficits, epidural abscess formations, persistent sepsis despite antibiotic treatment, inacceptable pain and distinctive deformities of the spinal column [1,2,14]. While cervical spondylodiscitis is generally treated using an anterior approach and anterior debridement followed by fusion, thoracic and lumbar spine patients are reported to benefit more from a posterior approach, posterior laminectomy, debridement and stabilization [1,15]. Segmental defects can be restored, depending on their size with either tricortical bone grafts, or titanium cages [16].
    Case Report
    We report a 44 year old woman with a medical history of ongoing intravenous heroin abuse and Hepatitis B and C. She was first admitted to a county hospital in august 2013 with cervicobrachialgia in her right arm. After outpatient treatment, she visited the same hospital four weeks later with pareses of both arms and the inability to walk. She also reported progressive weakness and decreased sensation in her extremities. On the same day, she received a MRI of the spine and anterior cervical body fusion with a corporectomy of C4 and 5 (See Figure 1). The microbiological diagnostics showed an infection with staphylococcus aureus. Due to a persistent infection and remaining neurological symptoms the patient was transferred to the Trauma department of Hannover Medical School.
    On admission, she presented with a temperature of 39.2 °C. Chest X-ray findings showed bipulmonal pleural effusions. Plain x-rays of the cervical spine revealed signs of cervical spondylodiscitis with partial corporectomy of the cervial body four and five with implant material in situ. Additionally, the CT scan revealed an anterior spinal haematoma that compressed the spinal cord, with destruction of the C3–C4 vertebrae.
    Laboratory investigations yielded a normal level of leucocytes, a raised C-reactive proteine with 48 mg/l, IL-6 of 54 ng/l, and Procalcitonin of 0,1 mg/l. Serum transaminases and renal function were all within normal limits. Urine analysis was normal and HIV testing negative. The microbiological investigation of apparent pleura effusions showed no microorganisms, the microbiological analysis performed by the previous hospital revealed a Staphylococcus aureus, the Antibiotic susceptibility showed multisensivity, all tested antibiotcs were sensitive. An antibiotic therapy was started with Clindamycine and Ceftriaxone.
    A MRI after admission to our clinic revealed a persistent epidural abscess from C2 to C7; a surgical procedure was planned in several stages.
    First, 3 days after admission to our hospital, we performed an anterior implant removal, debridement of the spinal canal and completion of the resection of the vertebral bodies C4 to C6. Moreover we implanted a cement spacer soaked with gentamycine. For stability purposes, a halo fixateur was applied afterwards (see Figure 1). As to an intraoperative complication, the right arteria vertebralis needed to be clipped.
    The first neurological examination could be performed postoperatively only, due to external ventilation during the first 3 days. It revealed a cervical accentuated tetraparesis with sensory impairment from C4 and 5 and motoric impairment on both arms as well as a moderate paraparesis of the lower extremities with grades of muscular strength (British Medical Research Council’s (BMRC) system from 1978) from M1 to M3.
    Second, we did implant a distractible titanium cage (ADD, Ulrich Medical, Ulm, Germany), a locked anterior plate (CSLP, Synthes, Umkirch, Germany) and again refixed the halo fixateur 2 weeks after admission to our hospital.
    Third, 4 weeks after initial admission to our clinic, a navigated CT-based three-dimensional (Brainlab, Feldkirchen, Germany) dorsal instrumentation (Mountaineer, DePuy Orthopädie GmbH, Germany) from the third to the seventh cervical body was perfomed, afterwards the halo fixateur was removed (see Figure 2). For the navigated procedure, the reference clamp was positioned on the third spinal process. The preoperative images were transferred to the navigation workstation and a manual point matching procedure was performed. Afterwards, the surgeon was able to navigate through the complete 3D CT dataset. The position of the screws was specified using a navigated drill guide. Postoperative x-rays and CT scans of the cervical spine showed a complete decompression of the cord as well as fusion from C2 to C7, the sagittal alignement was reconstructed.
    Fever disappeared by the 5th day of antibiotic treatment and neurological signs regressed progressively under prolonged physical therapy. The last documented neurological status six weeks after surgery showed intact sensory of both lower extremities and of the right arm and shoulder. On the left side, disaesthesia was found in fingers 1 to 3. The motor activity was still reduced, with increased activity in both arms from M2-5 and M5 in both lower extremities. Six weeks after admission, the patient was transferred to a rehabilitation clinic. No clinical signs of a persistent infection could be found; microbiological examination of the second and third surgery procedure could show no proof of ongoing infection.
    Figure 1 Sagittal reformations of the cervical spine. a preoperative MRI showing cervical body height reduction in cervical bodies C4,5 and 6 and signal alteration. b postoperative CT after initial surgery in another hospital with epidural abscess and loosening of the implants. c postop CT after implant removal and implantation of a pallacos spacer d postoperative CT after anterior fusion e postoperativ CT after CT based navigated posterior fusion.

    Figure 1 Sagittal reformations of the cervical spine. a preoperative MRI showing cervical body height reduction in cervical bodies C4,5 and 6 and signal alteration. b postoperative CT after initial surgery in another hospital with epidural abscess and loosening of the implants. c postop CT after implant removal and implantation of a pallacos spacer d postoperative CT after anterior fusion e postoperativ CT after CT based navigated posterior fusion.

    Figure 2 Intraoperative Setup and Screenshot of the workstation of the navigated procedure of posterior cervical fusion from C3 to C7.

    Figure 2 Intraoperative Setup and Screenshot of the workstation of the navigated procedure of posterior cervical fusion from C3 to C7.

    Spondylodiscitis in the cervical spine is less frequent than in the thoracic or lumbal localization and is linked with more neurological involvement and epidural abscesses. Furthermore cervical spondylodiscitis has to be operated on more after and mortality rates are increased compared to other locations [5,17].
    The main therapy for spondylodiscitis remains conservative treatment, especially if the microbe can be identified and no neurologic symptoms are present [1,17,18].
    In our case, the infectious agent was known: Staphylococcus aureus, that is present in over 50% of the spondylodiscitis infections [1,19].
    Furthermore, the described case showed signs of instability with loosened implant material and a vertebral height reduction and spinal angulation. The preoperative MRI showed an epidural abscess with contact of the abscess to the anterior implants. As some authors describe, that the presence of infectious material is a contradiction for bone transplants and instrumentation [18,20].
    We performed an implant removal and implantation of a pallacos spacer with antibiotics accompanied by an external fixation using a halo fixateur. As an injury of a vertebral artery occurred intraoperatively, the third stage of the surgery was performed with the aid of computer navigation. In the literature no case of 3D CT-based navigation was described for the treatment of cervical spondylodiscitis so far. Nevertheless, higher accuracy with the use of computer navigation has already been described with rates of malpositioning of 4% navigated vs 17% with fluoroscopic guidance [21]. In our case, after anteroposterior multi-level fusion of the spine, all implant material showed a correct position and stability. We could reduce radiation exposure as it was limited to only intraoperative twodimensional fluoroscopic images, which might even be lowered because of the navigation in the 3D CT dataset. With the aid of CT based navigation, the whole cervical spine could be accessed with one CT scan only, while 3D c-arm navigation can only provide a dataset with length of about 12x12 cm, which may represent about 2 to 3 cervical segments [22].
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    2. Guerado E, Cerván AM. Surgical treatment of spondylodiscitis. An update. Int Orthop. 2012; 36: 413-420.
    3. Reihsaus E, Waldbaur H, Seeling W. Spinal epidural abscess: a metaanalysis of 915 patients. Neurosurg Rev. 2000; 23: 175-204.
    4. Soehle M, Wallenfang T. Spinal epidural abscesses: clinical manifestations, prognostic factors, and outcomes. Neurosurgery. 2002; 51: 79-85.
    5. Urrutia J, Zamora T, Campos M. Cervical pyogenic spinal infections: are they more severe diseases than infections in other vertebral locations? Eur Spine J. 2013; 22: 2815-2820.
    6. Renker EK, Möhring K, Abel R, Carstens C, Wiedenhöfer B, Lehner B, et al. [Urogenic spondylodiscitis]. Orthopade. 2009; 38: 355-356, 358- 60, 362-4.
    7. 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.
    8. Zarghooni K, Röllinghoff M, Siewe J, Fätkenheuer G, Seifert H, Eysel P, et al. [Spondylodiscitis - an interdisciplinary challenge]. Dtsch Med Wochenschr. 2010; 135: 1182-1185.
    9. Kowalski TJ, Berbari EF, Huddleston PM, Steckelberg JM, Mandrekar JN, Osmon DR. The management and outcome of spinal implant infections: contemporary retrospective cohort study. Clin Infect Dis. 2007; 44: 913-920.
    10. Mylona E, Samarkos M, Kakalou E, Fanourgiakis P, Skoutelis A. Pyogenic vertebral osteomyelitis: a systematic review of clinical characteristics. Semin Arthritis Rheum. 2009; 39: 10-17.
    11. Palestro CJ, Love C, Miller TT. Infection and musculoskeletal conditions: Imaging of musculoskeletal infections. Best Pract Res Clin Rheumatol. 2006; 20: 1197-1218.
    12. Mückley T, Schütz T, Hierholzer C, Potulski M, Beisse R, Bühren V. [Psoas abscess after anterior spinal fusion]. Unfallchirurg. 2003; 106: 252-258.
    13. Mückley T, Schütz T, Kirschner M, Potulski M, Hofmann G, Bühren V. Psoas abscess: the spine as a primary source of infection. Spine (Phila Pa 1976). 2003; 28: E106-113.
    14. Jeanneret B, Magerl F. Treatment of osteomyelitis of the spine using percutaneous suction/irrigation and percutaneous external spinal fixation. J Spinal Disord. 1994; 7: 185-205.
    15. Zarghooni K, Röllinghoff M, Sobottke R, Eysel P. Treatment of spondylodiscitis. Int Orthop. 2012; 36: 405-411.
    16. Kuklo TR, Potter BK, Bell RS, Moquin RR, Rosner MK. Single-stage treatment of pyogenic spinal infection with titanium mesh cages. J Spinal Disord Tech. 2006; 19: 376-382.
    17. Hadjipavlou AG, Mader JT, Necessary JT, Muffoletto AJ. Hematogenous pyogenic spinal infections and their surgical management. Spine (Phila Pa 1976). 2000; 25: 1668-1679.
    18. Muzii VF, Mariottini A, Zalaffi A, Carangelo BR, Palma L. Cervical spine epidural abscess: experience with microsurgical treatment in eight cases. J Neurosurg Spine. 2006; 5: 392-397.
    19. Pitzen T, Meinig H, Drumm J. [Challenges and characteristics of spondylodiscitis of the cervical spine]. Orthopade. 2012; 41: 759-763.
    20. Shad A, Shariff S, Fairbank J, Byren I, Teddy PJ, Cadoux-Hudson TA. Internal fixation for osteomyelitis of cervical spine: the issue of persistence of culture positive infection around the implants. Acta Neurochir (Wien). 2003; 145: 957-960.
    21. Zhang HL, Zhou DS, Jiang ZS. Analysis of accuracy of computer-assisted navigation in cervical pedicle screw installation. Orthop Surg. 2011; 3: 52-56.
    22. Stübig T, Kendoff D, Citak M, Geerling J, Khalafi A, Krettek C, et al. Comparative study of different intraoperative 3-D image intensifiers in orthopedic trauma care. J Trauma. 2009; 66: 821-830.
    Cite this article: Stübig T, Decker S, Brand S, Panzica M, Krettek C, et al. (2014) Anterior and Navigated Posterior Fusion in Cervical Spondylodiscitis. A Case Report and Review of the Literature. JSM Clin Case Rep 2(4): 1045.
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