Seven cases of a previously undescribed lesion of the lumbar spine consisting of a burst fracture of the vertebral body associated with a posterior subluxation of the adjacent lower level facet joints are described. The lesion is due to a flexion-distraction mechanism. All seven cases reported involve a burst fracture (four upper burst, one burst-split, and two complete burst fractures). The dislocation line goes through the upper end-plate, through the posterior wall of the fractured vertebra, through the spinal canal, and through the caudal facet joints. The caudal disk is not destroyed primarily, but is involved in cases of burst-split or complete burst fractures. The treatment is surgical: reduction of the posterior subluxation, reduction of the burst fracture with anterior distraction (e.g., AO internal fixator or any other pedicle system allowing anterior distraction and reduction of the burst fracture), transpedicular bone grafting of the burst fracture if necessary, and fusion of the destroyed motion segment(s).
Summary: External skeletal fixation is a well-known tool in the management of infection of long bones. However, the application of external skeletal fixation in the treatment of spinal infection has not been previously reported. We have used percutaneous external spinal fixation (PESF) for the treatment of osteomyelitis of the spine in 23 patients since 1981. The treatment consists of percutaneous vertebral biopsy for bacteriologic diagnosis, installation of a suction/irrigation system into the intervertebral disk space, and posterior stabilization (and reduction if indicated) with an external fixator placed percutaneously. This treatment was conceived in 15 patients as definitive treatment. One patient died due to pulmonary embolism. In 12 patients, the infection healed without further operative treatment. Preoperative kyphosis averaged 15° (range 0-30°). At follow-up, kyphotic deformity also averaged 15° (range 0-30°). Two patients required anterior debridement and bone grafting because of progression of bony destruction. In eight patients, PESF was performed emergently, followed by planned anterior debridement and interbody grafting. The treatment was successful in all patients. All fusions healed. Preoperative kyphosis averaged 18° (range 0-40°). At follow-up, kyphotic deformity averaged 10° (range 0-22°). Our present indications are listed below and comprise pyogenic and tuberculous osteomyelitis of the spine localized between T3 and S1. The procedure is an alternative to conservative or more invasive operative treatment modalities in the following conditions: (a) painful lesions of the spine with minimal bone loss, not amenable to efficient orthotic stabilization (thoracic spine from T3 to T9, lumbosacral junction, elderly patients, or presence of deleterious general conditions); (b) osteomyelitis of the spine from T3 to S1, when emergency decompression of the spine is mandatory because of neurologic deterioration due to the kyphotic deformity or to a noncapsulated epidural abscess and anterior decompression is not possible emergently; (c) pyogenic osteomyelitis of the spine at L5/S1, when operative treatment is indicated. In addition, percutaneous insertion of external skeletal fixation is indicated in the presence of infected wounds, making internal posterior stabilization unsuitable (e.g., after open decompression of epidural abscess, postoperative infections).
