Arch Orthop Trauma Surg (2011) 131:173–178
DOI 10.1007/s00402-010-1115-2
ORTHOPAEDIC SURGERY
Percutaneous discectomy and drainage for postoperative
intervertebral discitis
Jian Li • Denglu Yan • Lijun Duan •
Zhi Zhang • Haodong Zhu • Zaihen Zhang
Received: 28 January 2010 / Published online: 20 May 2010
Ó Springer-Verlag 2010
Abstract
Background Postoperative intervertebral discitis occurs
following spinal surgery. This study was done to evaluate
the effect of percutaneous discectomy and drainage (PDD)
for postoperative intervertebral discitis.
Methods A retrospective study of postoperative inter-
vertebral discitis treated by PDD procedures was conducted
from January 1997 to June 2006. There were 34 patients
(24 males, 10 females); 10 cases of after lumbar discec-
tomy (L3–4 in 3 patients, L4–5 in 7 patients), 21 cases of
after percutaneous lumbar discectomy (L3–4 in 7 patients,
L4–5 in 14 patient), 2 cases of after percutaneous cervical
discectomy (C5–6 in 1 patient, C6–7 in 1 patient), and 1
case of C5–6 after percutaneous cervical nucleoplasty.
Results All patients tolerated the procedure well and
there were 31 cases had followed up. VAS scores dem-
onstrated statistically significant improvement after PDD
when compared with preoperational values (P \ 0.01).
Elevated CRP and ESR values returned to normal range
within 3–8 weeks. CRP and ESR values demonstrated
statistically significant improvement after PDD when
compared with preoperative values (P \ 0.01). Biopsies of
the disc were performed in all patients and pus was seen in
17 patients at the pathology levels. Inflammatory cells were
observed nine cases (4 cases showed infiltration of lym-
phocytes and plasmacytes, 5 cases showed infiltrate of
polymorphonuclear leucocytes). Cultures of disc and bone
J. Li
D. Yan (&)
Z. Zhang
H. Zhu
Z. Zhang
Orthopedic Department, Third Hospital of Guangzhou Medical
College, Guangzhou, People’s Republic of China
e-mail: spineyan@hotmail.com
L. Duan
West China Second University Hospital, Sichuan University,
Chengdu, People’s Republic of China
tissue showed 17 cases of sterile and 14 had positive cul-
ture. Spine X-rays films showed narrowed disc space in 29
cases, and bridging osteophytes were noted in 19 patients.
Destructive and sclerotic changes of vertebral bodies with
narrowing of disc spaces were observed in 14 patients.
Conclusions The results show that PDD is a minimally
invasive procedure for obtaining sufficient biopsy material
for histological analysis and culture in cases of discitis, and
has a good clinical outcome recommended for patients with
early stage postoperative intervertebral discitis without
neurologic deficit.
Keywords Intervertebral
Diskitis
Treatment

Percutaneous
Discectomy
Introduction
Intervertebral discitis most frequently occurs following
spinal surgery, and its incidence after conventional or
minimally invasive surgery varies between 0.1 and 4.0%
[3, 6, 9, 15, 19, 24, 28]. The histological findings of discitis
included disc vascularisation, the formation of mature
granulation tissue in both discs and vertebral bodies, and
the occasional presence of acute inflammatory cells in
addition to chronic inflammation. Positive cultures may be
obtained only in 42 and 73% of patients [19, 22]. Periop-
erative bacterial contamination is considered a more likely
cause of postoperative septic discitis than blood borne
bacterial infection. When blood cultures are non-confir-
matory, biopsies by open or minimally invasive surgery are
alternative methods for bacteriologic verification [11].
Early diagnosis is crucial in the management of discitis
because delayed treatment can lead to increased morbidity
and mortality [16, 26]. Disc biopsy is critical for diagnosis
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and to administration of the correct antibiotics for treat-
ment from identifying the offending pathogen. Enoch et al.
[6] had a retrospective of 98 computer tomography (CT)-
guided biopsies in 103 patients. Malignancy was diagnosed
in 49 episodes. Discitis and paravertebral abscess accoun-
ted for 27 cases. Culture was positive in 9 of 25 (36%)
samples received by the microbiology laboratory. The
traditional approach to the management of vertebral
infection is to obtain the material by needle biopsy fol-
lowing the technique described by Valls et al. [25]. Per-
cutaneous discectomy, which has the advantage of biopsy,
decompress and solution irrigation the disc space, when
combined with antibiotic therapy, may serve as an alter-
native to open surgery [8, 9, 19].
Percutaneous discectomy and drainage (PDD) is a
minimally invasive procedure for conservative treatment of
discitis [9, 19]. With improved instruments, the pathogens
and infected tissue can continue to be sucked out by this
minimally invasive procedure, which not only relief in-
tradisc pressure and irrigation of inflammatory factors, but
also preserving the adequate stability contributing to
immediate back pain relief. A series of 34 postoperative
intervertebral discitis patients been treated by PDD in our
clinical, and 31 cases had followed up from 2 to 10 years.
Patients and methods
A retrospective study of postoperative intervertebral dis-
citis treated by PDD procedures was conducted from Jan-
uary 1996 to June 2006. The inclusion criteria were early
stage postoperative intervertebral discitis without neuro-
logic deficit. Exclusion criteria included spontaneous
infectious intervertebral discitis, intervertebral discitis with
neurologic deficit, and infection associated with epidural
abscess. Four spontaneous infectious intervertebral discitis
cases been excluded. The patients’ all medical records
were reviewed, which include the visual analogue pain
(VAS) scale for cervical and back pain.
All patients were treated for the disc herniation com-
plaints of radicular pain, and the local pain of neck or back
were from 1.2 to 4.3 on VAS (average 2.69 ± 1.78) before
first surgery. There were no patients with postoperative
pneumonia or urogenital infections. However, intractable
neck or back pain was presented and narcotic pain control
and bed rest was required. Intervertebral discitis was
diagnosed on the basis of clinical examination, includ-
ing elevated erythrocyte sedimentation rate (ESR) and
C-reactive protein (CRP; normal range 0–5 mg/L) values,
and roentgenographic and magnetic resonance imaging
(MRI) findings. Then, there were 34 patients (24 males, 10
females); 10 cases of after lumbar discectomy (L3–4 in 3
patients, L4–5 in 7 patients), 21 cases (L3–4 in 7 patients,
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Arch Orthop Trauma Surg (2011) 131:173–178
L4–5 in 14 patients) of after percutaneous lumbar discec-
tomy (PLD), 2 cases (C5–6 in 1 patient, C6–7 in 1 patient)
of after percutaneous cervical discectomy (PCD), and 1
case of C5–6 after percutaneous cervical nucleoplasty
(PCN).
The patient presented symptoms of local intractable pain
from 1 to 21 days after spine surgery (average 14 days).
On examination, all patients show no warmth in the region.
The spine movements were terminally restricted, but there
was no motor weakness. Babinski’s sign was negative and
there were no objective sensory deficits. Haematological
investigations revealed a raised CRP (9.6–36 mg/L, aver-
age 24.1 ± 2.2 mg/L) or ESR (range 32–95 mm/h, average
61.8 ± 8.3 mm/h). The leucocyte count was raised in 15
patients, and the neutrophilic granulocyte was raised in 19
patients. The blood culture and tuberculin skin tests were
negative.
Surgical procedures
All procedures were under local anaesthesia. For the cer-
vical spine procedures, the patient was placed in a supine
position with the neck extended by placing a rolled towel
under the shoulders. A soft strap was placed over the
forehead for stabilization. The shoulders were gently dis-
tracted downward with tape. C-arm fluoroscopy was used
in anteroposterior and lateral planes to localise the level of
discitis and directed the placement of a spinal needle onto
the disc surface. Initially, at the point of entry adjacent to
the medial border of the right sternocleidomastoid muscle,
firm pressure was applied digitally in the space between the
muscle and the trachea and pointed towards the vertebral
surface. The larynx and trachea were displaced medially
and the carotid artery laterally. The anterior cervical spine
was palpated with the fingertips, and a spinal needle was
used to puncture the right side of the neck and passed into
the disc space. Lumbar patient was positioned prone, and
the procedures as previously reported [9, 19].
C-arm fluoroscopy was used in anteroposterior and lat-
eral planes to localise the level of discitis and directed the
placement of a spinal needle onto the disc surface. After
guiding pin punctures and passed into the disc space, a
small stab incision was made and a dilator cannula was
inserted over the guiding pin until it reached the annulus.
Then, biopsy instrument was used to get the tissue as
sample, and additional tissue from the disc was obtained by
means of discectomy forceps. Following biopsy and
debridement procedures, normal saline solution was used
for irrigation. After completion of the discectomy, a guide
wire was introduced into the disc space, and a silica gel
drainage tube was inserted into the debrided disc space
over the guide wire and connected to a negative-pressure
Arch Orthop Trauma Surg (2011) 131:173–178
vacuum draining bag, and then the drainage tube was
removed the next day after PDD.
These tissue samples of all patients were sent for Gram
stain and aerobic, anaerobic, fungal, and tuberculosis cul-
tures. Histopathological examination of the samples was
also performed. Prophylactic intravenous antibiotics
(cefazolin, the choice of antibiotic should be taken in to
account for the drug’s ability to penetrate bone and inter-
vertebral disc) were administered from been diagnosed
before surgery and continued till the culture specimen
sensitive out. Intravenous antibiotics were used until after
3 weeks of the symptoms disappeared and ESR return
normal, and then the patient was discharged on oral anti-
biotics for another 3 weeks. The cervical patients had
immobilization in a cervical cast at least for 2 weeks, and
the lumbar patients were told to be in bed rest at least for
4 weeks.
Statistical analyses
Statistical analyses were performed independently by a
non-clinical research assistant and an outside party to
ensure objectivity using SPSS Version 16.0 software. The
treatment effect was evaluated by the Macnab standard
[17] and using VAS for cervical and back pain. The Stu-
dent’s t test with a two-tailed paired comparison was used
to compare the means between visits and to compare suc-
cess based on demographic variables. The results were
considered statistically significant if the P value was equal
to or less than 0.05 for continuous variables.
Results
All patients tolerated the procedure well and there were 31
cases had followed up (3 cases lost) from 2 to 10 years
(average 6.4 years). Macnab standard results were excel-
lent in 17 cases, good in 9 cases and fair in 5 cases (5
lumbar patients had back pain). The rate of excellent and
good was 83.9%.
Twenty-five patients (89.3%) reported immediate relief
of back pain following PDD. All cervical patients had pain
improvement within 24 h and condition improved within
the first week after the procedures. None had recurrence of
neck pain at the last follow-up. At 1-week follow-up, 23
lumbar patients did not have back pain, and 5 lumbar
patients had back pain. The pain index was 9.67 ± 0.44
preoperatively, 3.51 ± 0.74 1 week postoperatively,
2.23 ± 0.52 4 weeks postoperatively, and 2.44 ± 0.61 on
8 weeks follow-up. VAS scores demonstrated statistically
significant improvement after PDD when compared with
preoperational values (P \ 0.01).
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Elevated CRP (mg/L) and ESR (mm/h) values returned
to normal range within 3–8 weeks. The average CRP and
ESR were 24.1 ± 2.2 and 61.8 ± 8.3 preoperatively,
13.3 ± 2.8 and 32.4 ± 9.6 1 week postoperatively,
3.1 ± 1.6 and 18.4 ± 3.5 4 weeks postoperatively, and
0.91 ± 0.32 and 8.5 ± 2.6 on 8 weeks follow-up. CRP
and ESR values demonstrated statistically significant
improvement in PDD when compared with preoperational
values (P \ 0.01).
Biopsies of the disc were performed in all patients and
pus was seen in 17 patients at the pathology levels.
Inflammatory cells were observed in nine cases (4 cases
showed infiltration of lymphocytes and plasmacytes, 5
cases showed infiltrate of polymorphonuclear leucocytes).
Cultures of disc and bone tissue showed 17 cases of sterile
and 14 had positive culture [9 cases of Gram-positive
bacteria (7 patients had Staphylococcus aureus, 2 patients
had Staphylococcus epidermides), 2 cases of Escherichia
coli, 2 cases of Klebsiella, and 1 cases of Pseudomonas
cepacia]. Systemic antibiotics were administered according
to the sensitivity studies for identified pathogens.
Spine X-rays films showed narrowed disc space in 29
cases, and bridging osteophytes were noted in 19 patients.
Destructive and sclerotic changes in vertebral bodies with
narrowing of disc spaces were observed in 14 patients. The
cervical discitis cases showed narrowed disc space and
erosive and sclerotic remodel in the vertebral endplate 1
and 3 years later, and one case had spontaneous fusion at
the C4–5 level.
Discussion
Patients with infectious discitis who have had surgery of
the spine can be considered to have postoperative discitis
[1, 4, 6, 11, 27]. There is a considerable variation in the
time of manifestation of the symptoms of postoperative
septic discitis. Iversen et al. [12] reported a large series of
patients with postoperative septic discitis, the average time
ranged from 2 to 5 weeks after surgery. In the current
series of patients, the patient presented symptoms of local
intractable pain from 1 to 21 days after spine surgery, and
the symptoms developed 3 weeks postoperatively in only
one patient. Cervical discitis is a known complication of
cervical discography [3, 28]. Heyde et al. [11] reported 20
consecutive patients, and thought spondylodiscitis in cer-
vical spine should be treated early and aggressive to avoid
local and systemic complications. There were three cervi-
cal postoperatively intervertebral discitis in this study, one
case of C5–6 and one case of C4–5 after PCD (Fig. 3), and
1 case of C5–6 after PCN.
Surgical intervention is indicated for patients with sig-
nificant neurological deficit, large epidural abscesses,
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extensive vertebral body destruction, severe kyphotic
deformity or spinal instability, or failed antibiotic therapy
[5, 14, 20, 21]. Percutaneous discectomy was employed for
infectious spondylitis in selected cases, which can obtain a
sufficient amount of material for microbiological exami-
nation directly from the infected region [8, 9]. In addition,
eradication and irrigation of infected and necrotic tissue
from a disc and even an epidural space facilitate a fenes-
tration similar to open debridement [1, 10]. Iversen et al
[12] reported postoperative septic discitis had a signifi-
cantly higher incidence of chronic low back pain. In this
study, Macnab standard results were excellent in 17 cases,
good in 9 cases and fair in 5 cases (5 lumbar patients had
back pain). The rate of excellent and good was 83.9%.
Twenty-five patients (89.3%) reported immediate relief of
back pain following PDD. VAS scores demonstrated sta-
tistically significant improvement in PDD when compared
with preoperational values (P \ 0.01). Elevated CRP and
ESR values returned to normal range within 3–8 weeks,
which demonstrated statistically significant improvement in
PDD when compared with preoperative values (P \ 0.01).
The results of percutaneous biopsy may be negative for
various reasons, including inadequate amount of specimen,
sampling error, or previous antibiotic therapy. Fouquet
et al. [7] obtained bacteriological diagnosis in 9 (36%) of
25 patients biopsied, using a Mazabraud trocar. Staatz et al.
[23] reported 16 (76%) positive cultures for 21 patients,
using CT-guided, percutaneous, and catheter drainage.
Rankine et al. [21] isolated an organism in 6 of 12 patients
not taking antibiotics and only 2 of 8 patients taking anti-
biotics. Haaker et al. [9] identified the specific infection in
45% of 16 lumbar disc infection patients. Bavinzski et al.
[1] succeeded in making a bacteriologic diagnosis in 88%
in 17 cases with postoperative septic discitis using a closed
suction irrigation system. Culture was positive in 9 of 25
(36%) samples received by the microbiology laboratory
[6]. Staphylococcus aureus and Mycobacterium tubercu-
losis (3 cases) were the most frequent organisms isolated,
followed by group G streptococci and coagulase-negative
staphylococci [26].
In this study of 31 discitis cases, the blood culture and
tuberculin skin tests were negative. All patients had got the
tissue samples (Fig. 1) and sent for Gram stain and aerobic,
anaerobic, fungal, tuberculous cultures, and histopatholo-
gical examination. The inflammatory cells were observed
in nine cases (4 cases showed infiltration of lymphocytes
and plasmacytes, 5 cases showed infiltrate composed of
lymphocytes and polymorphonuclear leucocytes, Fig. 2).

Fig. 1 a Resect the infected tissues and gets the disc tissue as histopathology sample at L4–5 discitis case, b an enlargement in the picture
showed it, c pressurised irrigation with more than 2 L of saline or antibiotics solution irrigation the disc space, d disc tissue from PDD

Fig. 2 a Histopathology sample at L4–5 discitis case, b histopathology shows the sample was disc tissue, c an enlargement in the picture showed
nucleus pulpous, d an enlargement in the picture showed the acute inflammatory reaction of neutrophile granulocyte infiltration

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Fig. 3 a Lateral plain radiograph of cervical spine shows loss of disc
height at C4–5. b Lateral fluoroscopic images during PDD of infected
disc. c Lateral plain radiograph of 6 months after PDD shows the disc
Fig. 4 a Lateral plain radiograph of cervical spine shows loss of disc
height at L3–4 (arrows). MRI demonstrates decreased signal intensity
on T1-weighted sequence (b) in L5 and L6 vertebral bodies, and
increased T2 signal (c) intensity within the disc space as well as
altered signal within the adjacent vertebral bodies. d Lateral
False-positive and false-negative cultures were seen in the
17 patients, and bacteria were isolated in 14 were positive
(11 cases of E. coli, 2 cases of Klebsiella, and 1 case of
P. cepacia). The biopsy of microbiological yield in this
study was 45.2% (14/31), and the no-infection discitis was
54.8% (17/31) which may be caused by a chemical or
aseptic process, or the pre-biopsy administration of anti-
biotics may yield negative cultures [7].
The radiological findings of discitis are a narrowed
disc space, erosions, and sclerotic changes on the
opposite region of the vertebral bodies [2, 13, 18].
Nielsen et al. [18] reported a series of 53 patients with
postoperative discitis, intercorporeal fusion had occurred
in 17%, whilst Wirtz et al. [27] reported osseous fusion
had occurred in 65.5% in 59 patients. PDD, a minimally
177
space narrowed. d Lateral plain radiograph of 10 years after PDD
shows spontaneous fusion at the C4–5 level
fluoroscopic images during PDD of infected disc and vertebral
bodies. Lateral plain radiograph of 3 months (e) and 6 months (f)
showed narrowed disc space and erosive in the vertebral endplate and
aggravation narrowed disc space
invasive technique, remove some of the infected material
may shorten the time of healing with spontaneous
interbody fusion. In our case, spine films showed nar-
rowed disc space in 24 cases, and bridging osteophytes
were noted in 15 patients. Destructive and sclerotic
changes in vertebral bodies with narrowing of disc
spaces were observed in four patients. The C4–5 discitis
cases plain films showed narrowed disc space, and
10 years after PDD shows spontaneous fusion at the C4–
5 level (Fig. 3). The L4–5 discitis cases, MRI demon-
strates decreased signal intensity on T1-weighted
sequence in the L–4 and L–5 vertebral bodies; 2 months
after operation shows almost signal intensity on T1-
weighted sequence in vertebral bodies, and the narrowed
disc space (Fig. 4).
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Conclusion
Percutaneous discectomy and drainage is a minimally
invasive procedure for obtaining sufficient biopsy material
for histological analysis and culture in cases of discitis, and
has good clinical outcome recommended for patients with
early stage postoperative intervertebral discitis without
neurological deficit.
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