Multilevel Corpectomy for Subaxial Cervical Spondylodiscitis: Literature Review and Role of Navigation, Intraoperative Imaging and Augmented Reality.

BACKGROUND:Subaxial cervical spine spondylodiscitis represents a real challenge in spine surgery. In later stages multiple spinal metamers can the interested by the pathological infection and the alteration of the spinal stability leading to spinal deformity. There is scant literature on subaxial cervical spondylodiscitis management and especially on ≥three-level cervical corpectomies. The authors conducted a literature search on this specific topic and presented an emblematic case of a patient treated with circumferential cervical fixation and four-level cervicothoracic corpectomy. MATERIALS AND METHODS:A comprehensive literature review was performed using the combined Medical Subject Headings (MeSH) terms (multilevel) AND (sub axial spine OR cervical spine) AND (spine osteomyelitis OR spinal osteomyelitis), to search in the PubMed and Scopus databases. Our case was also included in this literature review. From our literature search the authors selected 13 papers, eight were excluded because they did not match our inclusion criteria (the involvement of only one or two levels, or did not perform corpectomy, discectomy, or cervical spine localization). The authors also presented a 71-year-old patient, in poor general clinical status who underwent several cage repositioning, with a final four-level corpectomy (C5, C6, C7, and T1), expandable C5-T1 cage positioning and C4-T2 anterior plating performed merging augmented reality, neuronavigation and intraoperative imaging. RESULTS:This systematic review included 28 patients treated with ≥ three-level corpectomy (11 patients with three-level corpectomy, 15 patients with four-level corpectomy, and 2 patients with six-level corpectomy), 6 women, 5 men, and 17 not reported specifically, with a mean age of 55.9 years (range: 44-72 years). The combined anterior and posterior approach was taken in all but one case, which was treated with the anterior approach only. In one case of six-level cervicothoracic corpectomy, sternotomy was necessary. All reported patients recovered after surgery, except one who died after nosocomial pneumonia. No major intraoperative complications were reported. Usual postoperative complications include wound hematoma, pneumonia, subsidence, epidural hematoma, dural leakage, dysphagia, soft tissue swelling. The mean follow-up time was 31.9 months (range: 8-110 months). CONCLUSION:According to the literature search performed by the authors, multilevel corpectomies for cervical spinal osteomyelitis is a safe and effective complex surgical procedure, even in extended procedures involving up to six levels or those at the cervicothoracic junction. The use multimodal navigation merging intraoperative imaging acquisition, navigation, and augmented reality may provide useful information during implant positioning in complex and altered anatomy and for assessing the best final result.