| Background:Lumbar spondylodiscitis,which refers to a group of serious and complicated spinal infectious diseases,is caused by pathogenic microorganisms in lumbar intervertebral disc,adjacent vertebral body and paravertebral soft tissue.It is characterized by low incidence,difficulty in early diagnosis,long treatment cycle and severe clinical symptoms.Among the spine infection,lumbar is the most common site,accounting for about 50%of all cases.With the prevalence of minimal invasive examinations and treatments for lumbar spine disorders,as well as the increasing predisposing factors such as advanced age,underlying diseases and immune dysfunction,the incidence of the disease has risen in recent years.Hematogenous pathway is the primary way of lumbar spondylodiscitis,while a small number of cases suffer from secondary infections.Patients with lumbar spondylodiscitis are usually in compromised immune status(e.g.,advanced age,underlying diseases,immunosuppression),and with poor surgical tolerance.In clinical practice,the majority of patients can be cured by conservative treatment,for those who fail conservative therapy such as progressive aggravation of symptoms,occurrence of lumbar instability or spinal deformity,formation of neural canal abscess and neurological compression,surgical intervention is needed as early as possible.The aim of the surgery is to eradicate the focus of infection,restore spinal stability and functionality.Although various surgical procedures have been used to treat lumbar spondylodiscitis,spinal fusion still remains the standard method.Eradicate lesions and obtain intervertebral bony fusion in traditional open surgery is the main way to treat lumbar infection,and good clinical effect has achieved,but there are still notable disadvantages(e.g.,large incision,long operation time,increased blood loss,more complications,delayed postoperative recovery).For patients who need surgical intervention but barely tolerate conventional open surgery,a minimally invasive surgical approach is urgently needed.Minimally invasive surgery is the trend of surgery,with the increasing development of minimally invasive technology in spine surgery,it is possible to handle spondylodiscitis with the minimally invasive procedure.It has reported that the lesion of infection is debrided and a catheter drainage is placed with the CT or endoscopic guided minimally invasive technology,but lesions cannot be eradicated thoroughly,patients with delayed healing will eventually need revised operation,and the cure rate is low.What's more,it also largely increases the risks such as infection spreading,spinal instability or deformity,bringing great suffering and burden to patients.Whether open or minimally invasive surgery is employed,complete eradication of infectious lesions and firm spinal fusion are still the consensuses for the treatment of lumbar spondylodiscitis.Therefore,it is of great practical significance to explore how to achieve the above goals by minimally invasive procedures.Purpose:The clinical effect(including functional and radiological evaluation)of extreme lateral lumbar interbody fusion(XLIF)for the treatment of lumbar spondylodiscitis were summarized,which laid the theoretical foundation and provided practical reference for clinical application of XLIF for the disease.Methods:Retrospective study was performed on the treatment of pyogenic lumbar spondylodiscitis via XLIF combined with posterior percutaneous pedicle screw fixation in our institution from 2012 to 2018.Clinical data such as operation time,blood loss,postoperative bed time,pathogen culture,antibiotic management and complications were recorded.Functional clinical effect was assessed by visual analogue scores(VAS),oswestry disability index(ODI),American spinal injury association(ASIA)classification,modified Macnab effect evaluation and inflammatory parameters changes.The radiological characteristics including bone fusion rate,sagittal balance correction and indirect decompression outcomes were evaluated by X-ray and computed tomography(CT)preoperatively and postoperatively.Results:Thirty cases were included,18 males and 12 females,with mean age of 52.8 years old(18-68 years old),and 27.6 months(18-56 months)follow-up.A total of 33 levels undergone XLIF surgery,including 27 single levels,3 double levels.And 29Polyetheretherketone(peek)cages and 4 autogenous bone grafts were implanted.The intraoperative time per segment was 273.8±54.1 min,estimate blood loss was 250.0±58.6ml,the postoperative length of stay was 4.3±2.4 days,the positive culture rate was 36.7%(11/30),and the duration of antibiotic therapy was 21 weeks(19-24 weeks).At the final follow-up,back pain VAS and ODI score were significantly reduced(6.8±1.0 vs 0.6±0.5and 78.6±8.9%vs 10.7±3.0%respectively)compared to the preoperative values(P<0.01).Total lumbar lordosis and segmental lordosis increased by 15.2%(6.4°)and 64.1%(4.1°),respectively(P<0.01),which demonstrated sagittal balance and local kyphotic deformity had corrected effectively.Moreover,at the final visit,indirect decompression parameters were significantly increased compared with that of preoperative(P<0.01),among which the disc height of anterior and posterior increased by 101.4%(7.2 mm)and 68.6%(3.5 mm)respectively,the foraminal height of left and right increased by 3.6mm(28.6%)and 3.3mm(26.0%)respectively,the foraminal area of left and right increased by 12.3mm~2(18.1%)and15.1mm~2(22.7%)respectively,the spinal canal cross sectional area increased by 24.8%(24.3mm~2),and the central sagittal diameter increased by 25.2%(3.0mm).Consequently,the grade of ASIA nerve injury was all restored to grade E,indicating good indirect decompression effect.At 3 months follow-up,inflammatory parameters including white blood cell count(WBC),erythrocyte sedimentation rate(ESR)and C-reactive protein(CRP)were normalized.The overall incidence of complications was 23.3%(7/30):abdominal distension in 3 cases(including 1 case with left ureter contusion)and anterior thigh pain or numbness in 2 cases,which were cured by conservative treatment,and cage subsidence in 2 cases with no clinical symptoms which needed no treatment.In addition,severe complications such as viscera perforation,major vascular injury and nerve denervation were not found intraoperatively,and no cage shift,screw/rod loose and fracture during follow-up.Bone fusions were verified radiographically in all cases at the final follow-up.Based on the modified Macnab,the excellent and good surgical rate was 100%,with excellent and good in 15 cases.There were no cases of infection recurrence.Conclusion:For selected patients,combined with posterior percutaneous pedicle screw fixation for the treatment of lumbar spondylodiscitis,XLIF combined with posterior percutaneous pedicle screw fixation is a perfect choice.Radical debridement under direct visualization and immediate stability of the spine can be achieved in this procedure with rapid,lasting postoperative clinical symptom relief and lumbar sagittal balance and indirect decompression significantly improved.Combined with reasonable antibiotic management,no serious complications and recurrence of infection are observed,and bony fusion is verified.Our study has shown that XLIF,compared with traditional open surgery,is a minimally invasive,safe and effective surgical procedure for treating chosen lumbar spondylodiscitis. |
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