We describe a clinical algorithm, based on decades of front-line experience of diagnosis and surgical treatment of human Brucellar spondylodiscitis in the largest medical center of the China's Xinjiang Pastoral Area.
Diagnosis and Surgical Treatment for Human Brucellar Spondylodiscitis. Brucellar spondylodiscitis is one of the most prevalent and severe osteoarticular presentation of human Brucellosis. The clinical features of BS are non-specific, and can overlap with a wide spectrum of other infectious and non-infectious diseases.
Although some new therapeutic guidelines are recommended in literature, the optimal treatment regimen and the duration of antibiotics remain controversial. In this study, we presented a diagnostic method of BS and a single-stage surgical treatment for BS, by transforaminal decompression, debridement, interbody fusion, and internal fixation via posterior-only approach. A detailed protocol of our method is given below.
Initial diagnosis of BS is based on the clinical manifestations and the radiographic assessments. The clinical signs and the symptoms mainly including back pain, fever, malaise, sweating, weight loss, arthralgia, and myalgias. The radiographic assessments including plain radiograph, CT, and MRI.
The confirmed diagnosis is established according to the presence of all the following three criteria:a clinical picture compatible with BS, absence of any aetiology other than Brucellosis that can explain spinal involvement, standard tube agglutination test providing a titer of antibodies to Brucella of more than 1 to 160. Operative procedure for single-stage transforaminal decompression, debridement, interbody fusion, and internal fixation via a posterior-only approach. Place the patient on a four-poster frame in prone position after administration of general anesthesia with endotracheal intubation.
Disinfect the surgical area with iodine, and then cover with standard surgical towels. Make a mid-line longitudinal incision over the spinous process of the infected vertebra. Expose the posterior spinal construction, including lamina, facet joints, and transverse processes.
Place the pedicle screws into both sides of the affected vertebra with the assistance of the C-arm fluoroscopy. Note, in order to achieve adequate debridement, the pedicle screws are placed as close to the superior or inferior end-plates as possible, to keep them away from the site of infection. Screws are fixed to a temporary rod on one side, where neurologic and radiological manifestation is less severe.
Perform the facetectomy at the involved level on side where neurologic and the radiological manifestations are most severe. The granulation tissues, infected disc are debrided with curettes, and the vertebral end-plates are scraped. Protect the nerve root with a nerve retractor.
Note, removed tissues and abscess are sent for histopathology examination. If the decompression and debridement are not sufficient under a unilateral facetectomy, the same procedure should be performed on the opposite side. After required removal of the lesions and the decompression of the neural elements, a large amount of normal saline is utilized to forcefully recover rear irrigation, to clear the residual Brucellar lesion.
Absorbable gelatin sponge mixed with streptomycin is used for both hemostasis and a local antibiotic treatment in the surgical area. Implant a locally harvested autogenous bone in a defected space for interbody fusion, using bone graft funnel and the bone pusher. Pedicle screws on both sides are fixed to pre-contoured rods under slight compression.
Drainage and incision sutures are performed post-operatively. Representative Results. Our histopathological examinations revealed the necrotizing granulomatous inflammation.
The HE stain showed signs of infiltration of inflammatory cell, which bears the actual extent in the opposite samples from prevertebral tissue post-operatively. The cellular infiltration was predominated with lymphocytes and monocytes. This is a 69-year old male, present with L3-L4 Brucellar Spondylodiscitis.
The post-operative x-ray showed intervertebral bone grafting and instrumentation. Tail-mounts post-operative x-ray showed a good fixed position and interbody fusion. The accurate and timely diagnosis of Brucellar Spondylodiscitis is vital to reduce the burden caused by this severe infectious disease.
For the patients of definitive surgical indications of Brucellar Spondylodiscitis, single-stage transforaminal decompression, debridement, interbody fusion, and internal fixation via posterior-only approach, is an effective and safe surgical technique that should be considered as a choice for the treatment.
