Blecher R, et al. Asian Spine J. 2014 Oct;8(5):639-645. http://dx.doi.org/10.4184/asj.2014.8.5.639

Retrospective case series analysis. To identify relevant clinical and radiographic markers for patients presenting with infectious spondylo-discitis associated with spinal instability directly related to the infectious process. We evaluated patients presenting with de-novo intervertebral discitis or vertebral osteomyelitis /discitis (VOD) who initiated non-surgical treatment. Patients who failed conservative treatment and required stabilization surgery within 90 days were defined as “failed treatment group” (FTG). Patients who experienced an uneventful course served as controls and were labeled as “nonsurgical group” (NSG). A wide array of baseline clinical and radiographic parameters was retrieved and compared between 2 groups. Overall 35 patients had initiated non-surgical treatment for VOD. 25 patients had an uneventful course (NSG), while 10 patients failed conservative treatment (“FTG”) within 90 days. Factors found to be associated with poorer outcome were intra-venous drug abuse (IVDA) as well as the presence of fever upon initial presentation. Radiographically, involvement of the same-level facets and the extent of caudal and rostral VB involvement in both MRI and CT were found to be significantly associated with poorer clinical and radiographic outcome. We show that clinical factors such as IVDA status and fever as well as the extent of osseous and posterior element involvement may prove to be helpful in favoring surgical treatment early on in the management of spinal infections.

The extreme lateral interbody fusion technique (XLIF) is a modification of the retroperitoneal approach to the lumbar spine. This is a minimally invasive technique allowing direct access to the disc space without peritoneal or posterior paraspinal musculature damage. Nevertheless, the retroperitoneal part of the colon can be injured in this operative technique. To our knowledge, a study analyzing the anatomical considerations of the extreme lateral interbody fusion technique with regards to potential colon injuries has not been previously performed. Therefore, the aim of this study was to evaluate the potential risk of colon injuries during the extreme lateral approach to the lumbar spine. The extreme lateral approach to the lumbar spine was performed on four fresh-frozen cadaveric sides. K-wires were placed into the intervertebral discs and positioned at L1/L2, L2/L3, L3/L4, and L4/L5 levels. Next, the distances from the wires to the most posterior aspect of the adjacent ascending or descending colon were measured. The mean distance from the intervertebral disc space to the ascending or descending colon was 23.2 mm at the L2/L3 level, 29.5 mm at the L3/L4 level, and 40.3 mm at the L4/L5 level. The L1/L2 level was above the colon on both sides. Our study quantified the relationship of the retroperitoneal colon during an extreme lateral interbody fusion approach. Our results, as well as previously described cases of bowel perforations, suggest a greater risk for colon injuries at the L2/3 and L3/4 levels.​​​​​​​

The authors describe a 67-year-old man with a prior history of alcohol abuse who presented with a complaint of worsening low back pain. Four months prior to his presentation, the patient had undergone extreme lateral interbody fusion (XLIF) of his lumbar 3-4 segment for the treatment of his chronic low back and legs pain. Imaging revealed a loosening of his interbody fusion implant on top of his prior lumbar spine instrumentation. In surgery, the removal of his loose implant was followed by decompression, the stabilization of the collapsed segment, and the implant of antibiotic-impregnated polymethyl-methacrylate (PMMA) spacer and beads. At a later stage, the patient underwent an interbody fusion of the affected segment as well as a segmental fusion from T10 to his pelvis. Whereas all aerobes and anaerobes stains were negative for organisms, multiple fungal smears from the failed segment were positive for yeast, and the patient was placed on oral fluconazole. Infections complicating the surgical site of interbody fusions performed by minimally invasive techniques are rare. To the best of our knowledge and after reviewing the literature, this is the first report of an extreme lateral interbody fusion implant complicated by fungal osteomyelitis.