Introduction
Materials and methods
Study design
Patients
Patient | Age (years)/sex | Risk factors, previous operations, co-morbidities and co-infections | ASA score | Main presentation | Duration of symptoms (months) | WBC (/mm3) | ESR (mm/h) | CRP (mg/dL) | Frankel grade (primary) | Frankel grade (ASI) | FU Frankel grade | FU after primary operation (months) | Final outcome (Odom’s criteria) |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
1 | 69.4/M | MO, DM, BPH, HT, AA, renal stones, hypothyroidism. ASI: fever, UTI, sepsis | 4 | Fever | 1.5 | 18.4 | 94 | 226.7 | E | E | E | 59.4 | Good |
2 | 68.8/F | DM, HT, PNP, heel ulcers, UTI, TKR | 3 | Weakness | 2 weeks | 8.5 | 65 | 42.2 | C | C | C | 45.7 | Good |
3 | 40.8/F | MO | 1 | BP | 1 | 9.8 | 90 | 94.8 | E | E | E | 182 | Excellent |
4 | 55.1/M | Alcoholism, paraplegia sub-L2 | 2 | Weakness | 5 | 12.3 | 68 | 139.1 | C | C | C | 67.3 | Fair |
5 | 50.6/M | DM, HT | 3 | Paraplegia | 1.5 | 7.8 | 93 | 103.1 | B | B | B | 13.1 | Died MOF, septic shock (40 days) |
6 | 70.8/F | HT, breast cancer, OP, IHD | 4 | BP | 5 | 9.7 | 84 | 229.7 | E | C | B | 16.5 | Died MOF, pneumonia, septicemia (16 days) |
7 | 75.6/F | Poliomyelitis, Parkinsonism, MO, HT, DM, IHD, hypothyroidism | 4 | BP | 5 | 9.1 | 17 | 5 | C | C | C | 32.7 | Good |
8 | 77.8/F | Sigmoid colon cancer, depression, hypothyroidism, MO, OP, HT, UTI | 4 | BP | 1.5 | 4.8 | 48 | 45.9 | E | E | E | 30.3 | Died GIT bleeding |
9 | 81.1/M | PLS, re-infection | 1 | BP | 1 | 10.8 | 100 | 172 | E | E | E | 93.8 | Excellent |
10 | 56/F | Alcoholism, alcoholic liver cirrhosis, chronic anaemia | 3 | BP | 1 week | 10.3 | 48 | 67.4 | E | E | E | 4.8 | Good |
11 | 47.6/M | HT | 2 | Weakness | 1 day | 2.6 | 91 | 45.9 | D | C | C | 73.2 | Died MOF, sepsis MRSA (29 days) |
12 | 75.9/F | DM, IHD, OP | 3 | BP | 3 weeks | 10 | 110 | 267 | E | E | E | 95.8 | Excellent |
13 | 69.8/F | Septicaemia, shoulder infection, fever | 4 | BP | 2.5 | 20.9 | 135 | 155.8 | E | E | E | 38 | Excellent |
14 | 57.7/F | Hypothyroidism, hip abscess | 2 | Paraparesis | 2 weeks | 10.5 | 66 | 7.9 | C | E | E | 130.5 | Excellent |
15 | 73/M | HT | 2 | BP | 3.5 | 7.2 | 70 | 72.2 | E | D | C | 30 | Fair |
16 | 65.7/M | Parkinsonism, UTI | 2 | BP | 1 | 7 | 4 | 5 | E | E | C | 70.3 | Fair |
17 | 73.1/M | Chronic respiratory insufficiency, HT, paraplegia, OP, IHD, hemiparesis, vertebral fracture | 4 | BP | 1 | 5.8 | 140 | 121.8 | C | C | B | 10.2 | Poor |
18 | 55.7/F | Bronchial asthma, re-infection | 2 | BP | 4 | 8.1 | 31 | 11.2 | E | E | E | 87.5 | Good |
19 | 69.9/M | DM, HT, cortison, RI, HI. ASI: septicaemia, fever, toe infection | 4 | Weakness | 6 days | 6.5 | 69 | 74.8 | C | C | D | 46.4 | Good |
20 | 80.2/F | OP, HT, MVR, UTI, HBV, cholecystectomy | 3 | BP | 1 | 7.1 | 104 | 113 | E | D | D | 36.2 | Good |
21 | 57.7/M | IHD, MO, HT, RI. ASI: septicaemia | 3 | BP | 4 | 10.9 | 140 | 31 | E | E | E | 58 | Good |
22 | 65.1/F | RA, foot infection, cholecystectomy, cortisone. ASI: septicaemia, UTI | 3 | BP | 6 | 21.7 | 88 | 138 | E | D | D | 210.3 | Died MOF (after long intensive care and multiple wound infetions) |
23 | 59.6/F | DM, RI, HT, bilateral TKR, ovarian cancer operation, chemotherapy | 3 | BP | 1 week | 6.3 | 35 | 10.1 | E | E | E | 156 | Fair |
Patient | Interval before ASI surgery (months) | ASI level(s) | Presentation (ASI) | WBC (/mm3) | ESR (mm/h) | CRP (mg/dL) | Septicaemia | Screw loosening | Change in ASK |
---|---|---|---|---|---|---|---|---|---|
1 | 5.3 | L3–4 | Fever | 12.7 | 54 | 86.2 | Yes (Escherichia coli) | No | – |
2 | 19.6 | L3–4, L5–S1 | BP | 11.7 | 132 | 93.7 | No | Yes (+cage) | 15° |
3 | 11.9 | L3–4 | BP | 10 | 83 | 99 | No | No | – |
4 | 14.4 | L2–3 | Decubitus ulcer | 7.5 | 57 | 38.2 | No | Yes | 28° |
5 | 6 | T11–12 | BP | 10.2 | 73 | 240.7 | Yes (MRSA) | Yes | 26° |
6 | 8.6 | T12–L1 | BP | 7.1 | 94 | 71.4 | Yes (Pseudomonas aeruginosa MDR) | Yes | 17° |
7 | 16.8 | L3–4 | BP | 5.1 | 17 | 3 | No | No | – |
8 | 12.3 | L2–3 | BP | 9.5 | 61 | 55.4 | No | No | – |
9 | 61.1 | T12–L1 | BP | 10.3 | 84 | 203 | No | Yes | – |
10 | 14 days | L3–4 | BP | 14.3 | 85 | 84.4 | No | No | – |
11 | 72.3 | L1–L2 | Weakness | 2.4 | 81 | 62.7 | Yes (Staphylococcus aureus) | Yes | – |
12 | 86.2 | L4–5 | BP | 5.7 | 97 | 38.9 | No | No | – |
13 | 27.4 | T12–L1 | BP | 7 | 84 | 45.5 | Yes (Staphylococcus aureus) | No | – |
14 | 6 | L1–2 | BP | 14.3 | 140 | 180 | No | Yes | – |
15 | 17.4 | L1–2 | Cauda equina syndrome | 8.9 | 90 | 44.8 | No | Yes | – |
16 | 39 | T11–L1 | BP | 6 | 5 | 1.9 | No | No | – |
17 | 4.5 | L3–4 | Wound infection | 10.2 | 140 | 274.4 | No | Yes | 10° |
18 | 46 | L2–3 | BP | 5.2 | 37 | 7.7 | No | No | – |
19 | 25.9 | T1–2 | Fever | 23.4 | 105 | 270.2 | Yes (Staphylococcus aureus) | No | – |
20 | 9.9 | L2–3 | BP | 34 | 47 | 63.5 | No | Yes | – |
21 | 4.4 | T2–3 | Fever | 5.1 | 140 | 102.3 | Yes (Pseudomonas aeruginosa MDR) | Yes | – |
22 | 205.6 | L3–4 | GIT infection | 11 | 84 | 89 | Yes (Escherichia coli) | Yes | 15° |
23 | 147.3 | L5–S1 | BP | 9.8 | 45 | 6.4 | No | Yes | – |
Treatment
Follow-up
-
Excellent: all preoperative symptoms relieved, abnormal findings unchanged or improved.
-
Good: minimum residual of preoperative symptoms not requiring medication or limiting activity, and abnormal findings unchanged or improved.
-
Fair: definite relief of some preoperative symptoms with others remaining unchanged or only slightly improved.
-
Poor: symptoms and signs unchanged from preoperative status or worse.
Statistical analysis
Results
Demography
Clinical presentation
Laboratory findings
Diagnostic imaging
Primary surgery
Primary surgery | Surgery for ASI | |
---|---|---|
Operative time (min) | 217 ± 69.5 | 215 ± 106.8 |
Blood loss (ml) | 1223 ± 710 | 1241 ± 587.1 |
Mono-segmental operation | 7 (30.4 %) | 0 |
Bi-segmental | 8 (34.8 %) | 6 (26.1 %) |
Three segments | 5 (21.7 %) | 4 (17.4 %) |
Four segments | 2 (8.7 %) | 3 (13 %) |
Five segments | 1 (4.3 %) | 5 (21.7 %) |
>Five segments | 0 | 5 (21.7 %) |
One setting operation | 22 (95.7 %) | 20 (87 %) |
Two settings | 1 (4.3 %) | 3 (13 %) |
Posterior approach only | 1 (4.3 %) | 5 (21.7 %) |
Anterior approach only | 1 (cervical) (4.3 %) | 0 |
Anterior and posterior approaches | 21 (91.3 %) | 18 (78.3 %) |
Bone graft only | 8 (34.8 %) | 13 (56.5 %) |
Bone graft and cage | 15 (65.2 %) | 10 (43.5 %) |
Interbody fusion | 16 (69.6 %) | 21 (91.3 %) |
Corpectomy and fusion | 7 (30.4 %) | 2 (8.7 %) |
Open technique | 17 (73.9 %) | 15 (65.2 %) |
Minimally invasive technique | 6 (26.1 %) | 8 (34.8 %) |
Microorganism | ||
Staphylococcus aureus
| 5 (21.7 %) | 4 (17.4 %) |
Staphylococcus epidermidis
| 3 (13 %) | 3 (13 %) |
Pseudomonas aeruginosa
| 4 (17.4 %) | 3 (13 %) |
Enterococcus faecalis
| 2 (8.7 %) | 0 |
Escherechia coli
| 1 (4.3 %) | 1 (4.3 %) |
No organism | 8 (34.8 %) | 12 (52.2 %) |
Postoperative treatment
Surgery for adjacent segment infection
Radiological results
Functional outcome
Outcome (Odom’s criteria) | Excellent | Good | Fair | Poor | Died | Total |
p value |
---|---|---|---|---|---|---|---|
Sex | |||||||
Male | 1 | 3 | 3 | 1 | 2 | 10 (43 %) | 0.406 |
Female | 4 | 5 | 1 | 0 | 3 | 13 (57 %) | |
Involvement of segments | |||||||
Monosegmental | 5 | 5 | 4 | 1 | 2 | 17 (74 %) | 0.171 |
Bisegmental | 0 | 2 | 0 | 0 | 3 | 5 (22 %) | |
Multisegmental | 0 | 1 | 0 | 0 | 0 | 1 (4 %) | |
General condition (ASA score) | |||||||
ASA 1 (best) | 2 | 0 | 0 | 0 | 0 | 2 (9 %) | 0.133 |
ASA 2 | 1 | 1 | 3 | 0 | 1 | 6 (26 %) | |
ASA 3 | 1 | 4 | 1 | 0 | 2 | 8 (35 %) | |
ASA 4 (worst) | 1 | 3 | 0 | 1 | 2 | 7 (30 %) | |
Preoperative neurology (Frankel grade) | |||||||
B (paralysis) | 0 | 0 | 0 | 0 | 1 | 1 (4 %) | 0.66 |
C | 1 | 3 | 1 | 1 | 0 | 6 (26 %) | |
D | 0 | 0 | 0 | 0 | 1 | 1 (4 %) | |
E (normal) | 4 | 5 | 3 | 0 | 3 | 15 (65 %) | |
Region of primary infection | |||||||
Cervical | 0 | 1 | 0 | 0 | 0 | 1 (4 %) | 0.793 |
Thoracic | 1 | 1 | 0 | 0 | 1 | 3 (13 %) | |
Thoracolumbar | 1 | 1 | 1 | 1 | 0 | 4 (17 %) | |
Lumbar | 3 | 5 | 3 | 0 | 4 | 15 (65 %) | |
Other factors | |||||||
Septicemia | 1 | 3 | 0 | 0 | 4 | 8 (35 %) | 0.119 |
Screw loosening | 2 | 3 | 3 | 1 | 4 | 13 (57 %) | 0.406 |
ASK (>10°) | 0 | 1 | 1 | 1 | 3 | 6 (26 %) | 0.092 |