Combined Surgical and Radiosurgical Treatment of Symptomatic Aggressive Vertebral Osteomyelitis

Abstract

Introduction: The surgical treatment of vertebral osteomyelitis can be complicated by severe additional diseases or the need for extensive debridement with concomitant risks. We report a case of combined surgical and radiosurgical treatment of idiopathic vertebral osteomyelitis of L4.

Case Report: The patient presented with progressive enlargement of the right side of the vertebral body L4 due to chronic fibrous osteomyelitis without evidence of infection, leading to compression of nerve roots L4, L5 and the dural sac with resulting radicular paresis. During decompression of the nerve roots via a dorsal approach, massive bleeding from the inflammatory vertebral body occurred, making abortion of surgery necessary. Remnant inflammatory masses of vertebral body L4 were treated by spinal robotic radiosurgery with a high tumoricidal dose of 20 Gy without clinical and radiological signs of relapse of disease in the following three years.

Conclusion: We describe a case of the combined surgical and radiosurgical treatment of lumbar osteomyelitis with symptomatic nerve root compression. Dorsal decompression followed by spinal radiosurgery for the anterior vertebral parts with avoidance of potentially dangerous anterior spondylectomy led to a rapid improvement of paresis and pain with persistent control of vertebral inflammation and enlargement. The described case of close cooperation of surgeons and radiosurgeons offered an effective and functionality preserving treatment in this challenging case.

Key words

spondylodiscitis - vertebral osteomyelitis - spinal radiosurgery - combination treatment

References

• 1 Carragee EJ. Pyogenic vertebral osteomyelitis.  J Bone Joint Surg [Am]. 1997;  79 874-880
• 2 Mylona E, Samarkos M, Kakalou E. et al . Pyogenic vertebral osteomyelitis: a systematic review of clinical characteristics.  Semin Arthritis Rheum. 2008;  10-17
• 3 Shih TT, Huang KM, Hou SM. Early diagnosis of single segment vertebral osteomyelitis − MR pattern and its characteristics.  Clin Imaging. 1999;  23 159-167
• 4 Wowra B, Zausinger S, Drexler C. et al . CyberKnife radiosurgery for malignant spinal tumors: characterization of well-suited patients.  Spine. 2008;  33 2929-2934
• 5 Ho AK, Fu D, Cotrutz C. et al . A study of the accuracy of cyberknife spinal radiosurgery using skeletal structure tracking.  Neurosurgery. 2007;  60 ONS147-ONS156
• 6 Muacevic A, Staehler M, Drexler C. et al . Technical description, phantom accuracy, and clinical feasibility for fiducial-free frameless real-time image-guided spinal radiosurgery.  J Neurosurg Spine. 2006;  5 303-312
• 7 Gerszten PC, Burton SA, Ozhasoglu C. et al . Radiosurgery for spinal metastases: clinical experience in 500 cases from a single institution.  Spine. 2007;  32 193-199
• 8 Gibbs IC, Patil C, Gerszten PC. et al . Delayed radiation-induced myelopathy after spinal radiosurgery.  Neurosurgery. 2009;  64 A67-A72

Correspondence