Antibiotic-impregnated polymethylmethacrylate strut graft as a treatment of spinal osteomyelitis: case series and description of novel technique
Wyatt L. Ramey, Alexander von Glinski, Andrew Jack, Ronen Blecher, Rod J. Oskouian, Jens R. Chapman
OBJECTIVE The surgical treatment of osteomyelitis and discitis of the spine often represents a challenging clinical entity for a multitude of reasons, including progression of infection despite debridement, development of spinal deformity and instability, bony destruction, and seeding of hardware. Despite advancement in spinal hardware and implantation techniques, these aforementioned challenges not uncommonly result in treatment failure, especially in instances of heavy disease burden with enough bony endplate destruction as to not allow support of a modern titanium cage implant. While antibiotic-infused polymethylmethacrylate (aPMMA) has been used in orthopedic surgery in joints of the extremities, its use has not been extensively described in the spine literature. Herein, the authors describe for the first time a series of patients treated with a novel surgical technique for the treatment of spinal osteomyelitis and discitis using aPMMA strut grafts with posterior segmental fusion. METHODS Over the course of 3 years, all patients with spinal osteomyelitis and discitis at a single institution were identified and included in the retrospective cohort if they were surgically treated with spinal fusion and implantation of an aPMMA strut graft at the nidus of infection. Basic demographics, surgical techniques, levels treated, complications, and return to the operating room for removal of the aPMMA strut graft and placement of a traditional cage were examined. The surgical technique consisted of performing a discectomy and/or corpectomy at the level of osteomyelitis and discitis followed by placement of aPMMA impregnated with vancomycin and/or tobramycin into the cavity. Depending on the patient's condition during follow-up and other deciding clinical and radiographic factors, the patient may return to the operating room nonurgently for removal of the PMMA spacer and implantation of a permanent cage with allograft to ultimately promote fusion. RESULTS Fifteen patients were identified who were treated with an aPMMA strut graft for spinal osteomyelitis and discitis. Of these, 9 patients returned to the operating room for aPMMA strut graft removal and insertion of a cage with allograft at an average of 19 weeks following the index procedure. The most common infections were methicillin-sensitive Staphylococcus aureus (n = 6) and methicillin-resistant S. aureus (n = 5). There were 13 lumbosacral infections and 1 each of cervical and thoracic infection. Eleven patients were cured of their infection, while 2 had recurrence of their infection; 2 patients were lost to follow-up. Three patients required unplanned return trips to the operating room, two of which were for wound complications, with the third being for recurrent infection. CONCLUSIONS In cases of severe infection with considerable bony destruction, insertion of an aPMMA strut graft is a novel technique that should be considered in order to provide strong anterior-column support while directly delivering antibiotics to the infection bed. While the active infection is being treated medically, this structural aPMMA support bridges the time it takes for the patient to be converted from a catabolic to an anabolic state, when it is ultimately safe to perform a definitive, curative fusion surgery.
https://doi.org/10.3171/2020.3.SPINE191313
Discitis
Polymethylmethacrylate
Spinal infection
Spondylodiscitis
10.3171/2020.3.SPINE191313
Dive into the research topics of 'Antibiotic-impregnated polymethylmethacrylate strut graft as a treatment of spinal osteomyelitis: case series and description of novel technique'. Together they form a unique fingerprint.
Polymethyl Methacrylate Medicine & Life Sciences 100%
Osteomyelitis Medicine & Life Sciences 96%
Anti-Bacterial Agents Medicine & Life Sciences 58%
Discitis Medicine & Life Sciences 55%
Transplants Medicine & Life Sciences 55%
Operating Rooms Medicine & Life Sciences 33%
Ramey, W. L., von Glinski, A., Jack, A., Blecher, R., Oskouian, R. J., & Chapman, J. R. (2020). Antibiotic-impregnated polymethylmethacrylate strut graft as a treatment of spinal osteomyelitis: case series and description of novel technique. Journal of Neurosurgery: Spine, 33(3), 415-420. https://doi.org/10.3171/2020.3.SPINE191313
Antibiotic-impregnated polymethylmethacrylate strut graft as a treatment of spinal osteomyelitis : case series and description of novel technique. / Ramey, Wyatt L.; von Glinski, Alexander; Jack, Andrew et al.
In: Journal of Neurosurgery: Spine, Vol. 33, No. 3, 09.2020, p. 415-420.
Ramey, WL, von Glinski, A, Jack, A, Blecher, R, Oskouian, RJ & Chapman, JR 2020, 'Antibiotic-impregnated polymethylmethacrylate strut graft as a treatment of spinal osteomyelitis: case series and description of novel technique', Journal of Neurosurgery: Spine, vol. 33, no. 3, pp. 415-420. https://doi.org/10.3171/2020.3.SPINE191313
Ramey WL, von Glinski A, Jack A, Blecher R, Oskouian RJ, Chapman JR. Antibiotic-impregnated polymethylmethacrylate strut graft as a treatment of spinal osteomyelitis: case series and description of novel technique. Journal of Neurosurgery: Spine. 2020 Sep;33(3):415-420. https://doi.org/10.3171/2020.3.SPINE191313
Ramey, Wyatt L. ; von Glinski, Alexander ; Jack, Andrew et al. / Antibiotic-impregnated polymethylmethacrylate strut graft as a treatment of spinal osteomyelitis : case series and description of novel technique. In: Journal of Neurosurgery: Spine. 2020 ; Vol. 33, No. 3. pp. 415-420.
@article{14f20281d0694f85b2d87f5d4b8d7dc8,
title = "Antibiotic-impregnated polymethylmethacrylate strut graft as a treatment of spinal osteomyelitis: case series and description of novel technique",
abstract = "OBJECTIVE The surgical treatment of osteomyelitis and discitis of the spine often represents a challenging clinical entity for a multitude of reasons, including progression of infection despite debridement, development of spinal deformity and instability, bony destruction, and seeding of hardware. Despite advancement in spinal hardware and implantation techniques, these aforementioned challenges not uncommonly result in treatment failure, especially in instances of heavy disease burden with enough bony endplate destruction as to not allow support of a modern titanium cage implant. While antibiotic-infused polymethylmethacrylate (aPMMA) has been used in orthopedic surgery in joints of the extremities, its use has not been extensively described in the spine literature. Herein, the authors describe for the first time a series of patients treated with a novel surgical technique for the treatment of spinal osteomyelitis and discitis using aPMMA strut grafts with posterior segmental fusion. METHODS Over the course of 3 years, all patients with spinal osteomyelitis and discitis at a single institution were identified and included in the retrospective cohort if they were surgically treated with spinal fusion and implantation of an aPMMA strut graft at the nidus of infection. Basic demographics, surgical techniques, levels treated, complications, and return to the operating room for removal of the aPMMA strut graft and placement of a traditional cage were examined. The surgical technique consisted of performing a discectomy and/or corpectomy at the level of osteomyelitis and discitis followed by placement of aPMMA impregnated with vancomycin and/or tobramycin into the cavity. Depending on the patient{\textquoteright}s condition during follow-up and other deciding clinical and radiographic factors, the patient may return to the operating room nonurgently for removal of the PMMA spacer and implantation of a permanent cage with allograft to ultimately promote fusion. RESULTS Fifteen patients were identified who were treated with an aPMMA strut graft for spinal osteomyelitis and discitis. Of these, 9 patients returned to the operating room for aPMMA strut graft removal and insertion of a cage with allograft at an average of 19 weeks following the index procedure. The most common infections were methicillin-sensitive Staphylococcus aureus (n = 6) and methicillin-resistant S. aureus (n = 5). There were 13 lumbosacral infections and 1 each of cervical and thoracic infection. Eleven patients were cured of their infection, while 2 had recurrence of their infection; 2 patients were lost to follow-up. Three patients required unplanned return trips to the operating room, two of which were for wound complications, with the third being for recurrent infection. CONCLUSIONS In cases of severe infection with considerable bony destruction, insertion of an aPMMA strut graft is a novel technique that should be considered in order to provide strong anterior-column support while directly delivering antibiotics to the infection bed. While the active infection is being treated medically, this structural aPMMA support bridges the time it takes for the patient to be converted from a catabolic to an anabolic state, when it is ultimately safe to perform a definitive, curative fusion surgery.",
keywords = "Discitis, Management, PMMA, Polymethylmethacrylate, Spinal infection, Spondylodiscitis",
author = "Ramey, {Wyatt L.} and {von Glinski}, Alexander and Andrew Jack and Ronen Blecher and Oskouian, {Rod J.} and Chapman, {Jens R.}",
note = "Publisher Copyright: {\textcopyright}AANS 2020, except where prohibited by US copyright law",
doi = "10.3171/2020.3.SPINE191313",
journal = "Journal of neurosurgery. Spine",
publisher = "American Association of Neurological Surgeons",
T1 - Antibiotic-impregnated polymethylmethacrylate strut graft as a treatment of spinal osteomyelitis
T2 - case series and description of novel technique
AU - Ramey, Wyatt L.
AU - von Glinski, Alexander
AU - Jack, Andrew
AU - Blecher, Ronen
AU - Oskouian, Rod J.
AU - Chapman, Jens R.
N1 - Publisher Copyright: ©AANS 2020, except where prohibited by US copyright law
N2 - OBJECTIVE The surgical treatment of osteomyelitis and discitis of the spine often represents a challenging clinical entity for a multitude of reasons, including progression of infection despite debridement, development of spinal deformity and instability, bony destruction, and seeding of hardware. Despite advancement in spinal hardware and implantation techniques, these aforementioned challenges not uncommonly result in treatment failure, especially in instances of heavy disease burden with enough bony endplate destruction as to not allow support of a modern titanium cage implant. While antibiotic-infused polymethylmethacrylate (aPMMA) has been used in orthopedic surgery in joints of the extremities, its use has not been extensively described in the spine literature. Herein, the authors describe for the first time a series of patients treated with a novel surgical technique for the treatment of spinal osteomyelitis and discitis using aPMMA strut grafts with posterior segmental fusion. METHODS Over the course of 3 years, all patients with spinal osteomyelitis and discitis at a single institution were identified and included in the retrospective cohort if they were surgically treated with spinal fusion and implantation of an aPMMA strut graft at the nidus of infection. Basic demographics, surgical techniques, levels treated, complications, and return to the operating room for removal of the aPMMA strut graft and placement of a traditional cage were examined. The surgical technique consisted of performing a discectomy and/or corpectomy at the level of osteomyelitis and discitis followed by placement of aPMMA impregnated with vancomycin and/or tobramycin into the cavity. Depending on the patient's condition during follow-up and other deciding clinical and radiographic factors, the patient may return to the operating room nonurgently for removal of the PMMA spacer and implantation of a permanent cage with allograft to ultimately promote fusion. RESULTS Fifteen patients were identified who were treated with an aPMMA strut graft for spinal osteomyelitis and discitis. Of these, 9 patients returned to the operating room for aPMMA strut graft removal and insertion of a cage with allograft at an average of 19 weeks following the index procedure. The most common infections were methicillin-sensitive Staphylococcus aureus (n = 6) and methicillin-resistant S. aureus (n = 5). There were 13 lumbosacral infections and 1 each of cervical and thoracic infection. Eleven patients were cured of their infection, while 2 had recurrence of their infection; 2 patients were lost to follow-up. Three patients required unplanned return trips to the operating room, two of which were for wound complications, with the third being for recurrent infection. CONCLUSIONS In cases of severe infection with considerable bony destruction, insertion of an aPMMA strut graft is a novel technique that should be considered in order to provide strong anterior-column support while directly delivering antibiotics to the infection bed. While the active infection is being treated medically, this structural aPMMA support bridges the time it takes for the patient to be converted from a catabolic to an anabolic state, when it is ultimately safe to perform a definitive, curative fusion surgery.
AB - OBJECTIVE The surgical treatment of osteomyelitis and discitis of the spine often represents a challenging clinical entity for a multitude of reasons, including progression of infection despite debridement, development of spinal deformity and instability, bony destruction, and seeding of hardware. Despite advancement in spinal hardware and implantation techniques, these aforementioned challenges not uncommonly result in treatment failure, especially in instances of heavy disease burden with enough bony endplate destruction as to not allow support of a modern titanium cage implant. While antibiotic-infused polymethylmethacrylate (aPMMA) has been used in orthopedic surgery in joints of the extremities, its use has not been extensively described in the spine literature. Herein, the authors describe for the first time a series of patients treated with a novel surgical technique for the treatment of spinal osteomyelitis and discitis using aPMMA strut grafts with posterior segmental fusion. METHODS Over the course of 3 years, all patients with spinal osteomyelitis and discitis at a single institution were identified and included in the retrospective cohort if they were surgically treated with spinal fusion and implantation of an aPMMA strut graft at the nidus of infection. Basic demographics, surgical techniques, levels treated, complications, and return to the operating room for removal of the aPMMA strut graft and placement of a traditional cage were examined. The surgical technique consisted of performing a discectomy and/or corpectomy at the level of osteomyelitis and discitis followed by placement of aPMMA impregnated with vancomycin and/or tobramycin into the cavity. Depending on the patient's condition during follow-up and other deciding clinical and radiographic factors, the patient may return to the operating room nonurgently for removal of the PMMA spacer and implantation of a permanent cage with allograft to ultimately promote fusion. RESULTS Fifteen patients were identified who were treated with an aPMMA strut graft for spinal osteomyelitis and discitis. Of these, 9 patients returned to the operating room for aPMMA strut graft removal and insertion of a cage with allograft at an average of 19 weeks following the index procedure. The most common infections were methicillin-sensitive Staphylococcus aureus (n = 6) and methicillin-resistant S. aureus (n = 5). There were 13 lumbosacral infections and 1 each of cervical and thoracic infection. Eleven patients were cured of their infection, while 2 had recurrence of their infection; 2 patients were lost to follow-up. Three patients required unplanned return trips to the operating room, two of which were for wound complications, with the third being for recurrent infection. CONCLUSIONS In cases of severe infection with considerable bony destruction, insertion of an aPMMA strut graft is a novel technique that should be considered in order to provide strong anterior-column support while directly delivering antibiotics to the infection bed. While the active infection is being treated medically, this structural aPMMA support bridges the time it takes for the patient to be converted from a catabolic to an anabolic state, when it is ultimately safe to perform a definitive, curative fusion surgery.
KW - Discitis
KW - PMMA
KW - Polymethylmethacrylate
KW - Spinal infection
KW - Spondylodiscitis
U2 - 10.3171/2020.3.SPINE191313
DO - 10.3171/2020.3.SPINE191313
JO - Journal of neurosurgery. Spine
JF - Journal of neurosurgery. Spine