Infection After Vertebroplasty or Kyphoplasty: A Series of 9 Cases

H. Abdelrahman, et al.

Department of Spinal Surgery,

Zentralklinik Bad Berka, Germany;

Department of Orthopedics & Traumatology

Assiut University, Assiut, Egypt;

Spine Unit, LEL Hadare University Hospital,

Alexandria University, Egypt

The Spine Journal 13 (2013) 1809-1817

The authors presented a case series with long-term follow-up of spinal infection after vertebroplasty/kyphoplasty, specifically presenting 9 cases, re a study of 1,307 patients, 6 of whom had postoperative infections and 3 additional patients were referred from other institutions. 

The average age of these patients was 73.8 years.  Three cases with early infection presented within 1 month.  The average time from augmentation and revision surgery was from 10 to 395 days.  All patients were treated surgically except for one, who died before the planned revision surgery. The surgery performed for all cases included debridement and corpectomy through anterior approaches, with posterior instrumentation, and the most common causative organism was staph aureus in 3 cases.  They noted that 3 of the patients became paraparetic, 2 having improved functionally and could walk unassisted, and 1 improved, but still used a wheelchair. 

The authors note that although these procedures are minimally invasive interventions, postoperative infections can develop into life threatening complications and these factors should be accounted for in decision-making in the elderly age group, most commonly affected by osteoporotic fractures and especially in suspicious and high risk immune compromised patients. 

They note that the risk of infection after cement augmentation by vertebroplasty is extremely low.  They found that the infection rate was approximately 1 in 200. 

They noted that there were comorbidities and risk factors in all of these patients who developed infection, including urinary tract infections, hypertension, cardiac disease, obesity, and diabetes mellitus.  They noted that among this group of patients who developed infections, there were patients with preoperative elevation of infection parameters, suggesting hidden infections in 2. 

They noted the types of preoperative risk factors for patients undergoing vertebroplasty/kyphoplasty included urinary tract infections, diabetes, cholecystitis, meningitis, rheumatoid arthritis, discitis, cirrhosis, alcoholism, smoking, and also utilization of post-transplant immunosuppressant agents, obesity, decubitus ulcer, post-laminectomy wound infection, infected total hip replacement, viral infection, lymphangitis, COPD, and Parkinson’s disease.  They noted that causative organisms noted in theirs and other series included staph aureus, mycobacterium TB, serratia marcescens, enterobacter, MR coagula-negative, staph, enterococcus, and strep T. haemolyticus. 

They noted that infection parameters were high in all of their series cases, including the mean CRP of 164.83, sed rate of 69.22, WBC of 11,478, and fever present in 5 of 9 patients.  The authors recommend that in order to minimize the incidence of post-vertebroplasty/kyphoplasty infection, there be an avoidance of cement augmentation techniques in patients with elevated inflammatory parameters, including mild increase in nonspecific inflammatory parameters (CRP, ESR, and WBC), which may occur because of coincident trauma, in addition to patients with preoperative infectious focus.  They state such patients should not undergo surgery until successful treatment of the infection and in the severely immune compromised patient or suspicious cases of infection the use of perioperative prophylactic antibiotics and/or Tobramycin-loaded cement seems justified, in addition to intraoperative biopsy for histopathology and culture and sensitivity should be routinely taken in cases with suspicious non-osteoporotic fractures. 

Editorial Commentary:  Vertebroplasty/kyphoplasty are often very helpful in patients with severe pain not controlled by medication and in which the patient is significantly restricted from activities of daily living.  Infections can occur with any procedure, and the surgeon must exercise the same precautions for this procedure as any other procedure with respect to reducing the risk for infection. 

A very important point is that the patient should be screened very carefully prior to the surgery with respect to other potential causes of back pain or radicular pain that would require other types of treatment or interventions.  Diagnostic studies, including x-rays, bone scans, and CT, in addition to MRI would all be considered appropriate to rule out other causes of back pain, in addition to assessing for the vertebral fracture or for other vertebral fractures that may be present as well. 

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