Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5205_Библиотеки_им_академика_М_И_Перельмана.pdf
170
L. P. Martins
36. WHO 2024: https://www.who.int/news-room/
fact-sheets/detail/hiv-aids.
37. Higuera-Rueda C, Emara AK, Nieves-Malloure Y,
et al. The Effectiveness of closed incision negative
pressure therapy versus silver-impregnated dressings in mitigating surgical site complications in
high-risk patients after revision knee arthroplasty:
The PROMISES randomized controlled trial. J
Arthroplast. 2021;36(7S):S295–S302.e14.
38. Newman JM, Siqueira MBP, Klika AK, et al.
Use of closed incisional negative pressure wound
therapy after revision total hip and knee arthroplasty in patients at high risk for infection: a prospective, randomized clinical trial. J Arthroplasty.
2019;34(3):554–9.
39. Manoharan V, Grant A, Harris A, et al. Closed
incision negative pressure wound therapy vs conventional dry dressings after primary knee arthroplasty: a randomized controlled study. J Arthroplast.
2016;31(11):2487–94.
40. Pachowsky M, Gusinde J, Klein A, et al. Negative
pressure wound therapy to prevent seromas and treat
surgical incisions after total hip arthroplasty. Int
Orthop. 2012;36(4):719–22.
41. Frisbie JJ, Bordoli SJ, Simmons JM, Zuiderveen
SK.Utilizing closed incisional negative pressure therapy reduces peripheral bypass infection rates without
increasing costs. Cureus. 2020;12(7):e9217. https://
doi.org/10.7759/cureus.9217. PMID: 32821568;
PMCID: PMC7430538
Vertebral Osteomyelitis
andTuberculosis
LuisaPaganiniMartin, AndreaAngelini,
andPietroRuggieri
13
13.1 Vertebral Osteomyelitis
13.1.1 History
Osteomyelitis, mainly after a fracture, is a disease that has been described since Hippocrates
(460–370BC). Acute hematogenous osteomyelitis, in its term, was only much later described in
1773, by Bromeld, as bone that “may become
carious, rst in its internal parts and that from
external injury, as well as from a vitiated state of
the animal uids.” He called this an abscessus in
medulla, and advised to drain the infected bone
as soon as possible [1].
The rst published paper on the theme dates
back to 1948, already showing a massive difference in prognosis after the advent of penicillin,
with deadly incidence reducing from 33% to
10% after 1940, although the treatment—both
surgical and clinical—was still very erratic at the
time [2]. Over 2000 years have passed since
Hippocrates, some 250 since Bromeld and
another 80 since penicillin started being used.
The treatment basis for this disease remains
L. P. Martin
Orthopedics and Rheumatology, Hospital Israelita
Albert Einstein, Sao Paulo, Brazil
A. Angelini · P. Ruggieri (*)
Department of Orthopedics and Orthopedic
Oncology, University of Padova, Padova, Italy
e-mail: andrea.angelini@unipd.it; pietro.ruggieri@
unipd.it
mainly unaffected, with proper antibiotic therapy
and mechanical debridement being the most
important parts of it, to this day.
Vertebral osteomyelitis, in its turn, is rarer
than its long bone counterpart, accounting for 1%
of skeletal infections, a number which seems to
be growing as IV drug users and age expectancy
numbers rise [3]. It has been progressively better
studied as both radiological and laboratory tests
have gotten better, making it easier to diagnose
and treat this condition.
13.1.2 Epidemiology
Most common studies show that vertebral osteomyelitis affects approximately 0,059/100.000
people, with 60% of those being male, with a
mean age of 66years [4]. Although it tends to
present in older patients, there is a trend toward
younger patients, which corresponds to IV drug
users, with a mean age of 35years [3]. In general,
patients presenting with vertebral osteomyelitis
have underlying diseases, reportedly more than
one per patient. These were mainly diabetes mellitus (24%), intravenous drug abuse (11%),
immunosuppression (7%), malignancy (6%),
alcoholism (5%), and rheumatic disease (5%),
with lower percentages in patients with liver cirrhosis, renal failure, and previous decit of the
vertebrae, such as radiation or osteopenic fracture. Other underlying medical illnesses, such as
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
P. Ruggieri et al. (eds.), Bone and Joint Infections, https://doi.org/10.1007/978-3-031-96383-4_13
171
172
L. P. Martin et al.
pulmonary brosis, heart conditions, malnutrition, myelodysplasia, sarcoidosis, septic phlebitis, or partial gastrectomy, occurred in 10% of the
patients [3].
13.1.3 Pathophysiology
Vertebral osteomyelitis occurs mainly due to two
mechanisms: direct inoculation or hematogenous
seeding [5]. In half of the cases, arterial or venous
conduits at the intervertebral disks or endplates
allow bacteria to access the vertebral column.
These areas have slower blood ow, which allows
the bacteria to extend from the disk to the adjacent endplate, and vice versa.
Direct inoculation is another common method
of bacterial colonization, and can occur after routine procedures such as lumbar puncture, discography, laminectomy, discectomy, or any other
spinal intervention. Less commonly, bacterial
inoculation occurs through local extension from
adjacent areas of infection (3% of cases), including retropharyngeal abscesses or infected aortic
grafts [6].
Staphylococcal infections (S. aureus and S.
epidermidis) are the most common organisms
found, with an incidence of 32–67%. Loibl etal.
[7] noted worse outcomes in patients who had to
be admitted to the ICU (58% vs. 34.7%). As for
Gram-negative infections, Graham et al. [8]
noted a 12.7% incidence of Escherichia coli,
Pseudomonas aeruginosa, Haemophilus inuenzae, and Klebsiella pneumoniae.
Approximately 9% of cases will display a polymicrobial etiology [3]. Although positive cultures are helpful for targeted antibiotic therapy,
Yoon and colleagues [9] noted similar outcomes,
duration of treatment, and normalization of labs
between culture- positive and culture-negative
patients, as well as Lora-Tamayo etal. [10]. The
latter noted a higher rate of sepsis, fevers, and
elevated labs on culture- positive patients, indicating that positivity (as well as clinical symptoms) seems to be linked to a higher number of
circulating bacteria.
13.1.4 Most Common Manifestations
Most patients present with back pain (85%), which
can be acute (approximately 10days) or chronic
(up to 2months), as well as fever in 60% of cases.
In a large systematic review, with over a 1000
patients, 34% also had neurological symptoms,
ranging from radiculopathy to urine retention, and
even paralysis [3]. Neurological compromise
tends to increase when diagnosis is delayed [10].
Concomitant infections (urinary tract infection,
abscesses, skin infections, pneumonia, etc.) are
relatively common, and are found in 47% of culture-positive and 4% of culture- negative Pyogenic
Vertebral Osteomyelitis (PVO) [4]. That being
said, it presents as back pain in older patients, predominantly male, with underlying diseases.
Younger patients are most commonly IV drug
users (Fig.13.1). Diagnosis seems to be made earlier on patients presenting with either fever or neurological symptoms, as back pain alone can have a
myriad of other diagnostic possibilities.
13.1.5 Diagnosis
Lumbar vertebrae seem to be more commonly
involved (58%), followed by thoracic and cervical areas (30% and 11%, respectively). Three to
fteen percent of patients present with multiple
level involvement [3]. In a study with IV drug
users, those numbers change dramatically, with
up to 68% of patients presenting with multiple
levels of infection [11]. Routine laboratory analysis of complete blood count, erythrocyte sedimentation rate (ESR), and CRP is helpful in the
infectious workup. Blood cultures can reveal the
microbiological etiology in 58% of patients and
should be obtained during febrile episodes if possible [3].
Bone biopsies, both CT-guided and open,
result in a positive diagnosis in a mean of 77%
(47–100%) of cases, while blood cultures yield
a positive result in 58% of cases on average
(ranging from 30% to 78%). We would recommend doing both, whenever possible. S. aureus
ab
13 Vertebral Osteomyelitis andTuberculosis
Fig. 13.1 L2–L3
Spondylodiscitis in a
young 46-year-old drug
user. (a) MRI and (b)
CT scan show extensive
destructione of the disk
and adjacent vertebral
bodies
173
remains the most common organism, as with
other forms of osteomyelitis, with an incidence
of 32–67% in a major literature review.
Streptococcus shows in second place in most
studies, with an incidence of up to 23% [3].
Some studies seem to show a trend toward infection by Pseudomonas aeruginosa in IV drug
users, accounting for up to 38% of cases in this
particular population [11]. In 85% of the cases,
a single organism was identied, with multiple
organisms appearing in 9% [3].
more than a third of the bone structure has been
destroyed. Late vertebral osteomyelitis can demonstrate signs of bone formation including sclerosis, osteophytosis, and osteolytic lesions [12].
The high incidence of altered x-rays can be
explained due to the fact that most diagnostics
seem to be on a later stage, given that it usually
presents only with back pain in older males with
more than one comorbidity—a common symptom for this population. Bone scanning was performed in over half of the cases (58%), with a
94% positivity. CT scans and MRIs were not
always performed (ranging from 0% to 100% in
13.1.6 Imaging Studies
different studies), but showed positive ndings in
94% of the cases [3], including specicities as to
Usually, the rst exam to be performed are traditional x-rays (up to 95% of cases), and, although
they take longer to show abnormalities, there
were alterations on 89% of them [3]. Early ndings (2–3 weeks) are commonly unremarkable
and may only reveal endplate blurring, erosion of
the endplate corners, disk height loss, and paraspinal soft-tissue swelling. Vertebral body
destructive changes on x-ray are only seen after
levels involved, epidural or vertebral abscesses,
vertebral and disc destruction (Fig. 13.2).
CT-guided biopsy can be a useful adjunct in the
diagnosis. Recent studies demonstrate a
CT-guided biopsy-positive culture rate of
19–60% in patients with suspected osteomyelitis
[13–15]. Antibiotics before CT biopsy can signicantly affect culture yields. De Lucas etal.
[15] identied a causative organism in 60% of
174
ab
cd
L. P. Martin et al.
Fig. 13.2 L4–L5 Spondylodiscitis in a 82-year-old male
caused by S. aureus (white arrow) (a) MRI changes display low T1 signal intensity in affected disk and (b) high
patients not previously treated with antibiotics,
compared with 23% of patients who had received
antibiotics. Early MRI changes display high T2
T2in disk and adjacent vertebrae. (c) Axial CT shows disk
degeneration; (d) Sagittal CT scan show lytic and sclerotic changes of the adiacent vertebral bodies
ndings of high T2 disk signal with disk height
loss and contrast uptake within the disk are highly
sensitive (70–100%) for diagnosis [3].
and low T1 signal intensity in affected disks and
adjacent vertebrae. High T2 signal in the paraspinal soft tissues, with inammation and edema
13.1.7 Treatment
visualized more clearly with fat saturation or
short tau inversion recovery sequences, is also
associated with early MRI changes. Contrast is
often used to display the diffuse enhancement of
the subchondral bone and disk. The early MRI
Consultation with infectious disease specialists
is useful for recommendations on duration of
treatment, dosing, route, and antibiotic selection.
Duration of treatment is controversial and ulti-
13 Vertebral Osteomyelitis andTuberculosis
175
mately is guided by individual clinical evaluation. Antibiotic therapy is done in all cases,
worldwide, ever since the advent of penicillin.
Today, as opposed to the 1950s, the drugs used
are, when possible, guided by the positivity of
organisms found and their respective antibiograms, with dose and drug delivery means being
adjusted according to clinical response. Risk
factors for failure of treatment were
ESR>55mm/h and CRP>2.75 after 4weeks of
antibiotic treatment [9]. There seem to be no signicant changes in prognosis between 6 and
12weeks of treatment, nor between less than or
greater than 7days of IV treatment [12]. Surgical
treatment, on the other hand, has evolved a lot
during the last years, mainly with minimally
invasive approaches, better xation methods,
surgical planning and guided procedures, as well
as substances for on- site use that can be bacteriostatic and/or have local antibiotic, enhancing
direct drug delivery.
In patients treated nonoperatively, bracing for
comfort and prevention of deformity is a reasonable treatment option, although there is no clinical evidence to support whether or not bracing
affects outcome. Surgical management should be
considered in patients who are refractory to antibiotic treatment or display neurological decits,
spinal instability, or progressive deformity with
vertebral body destruction [16].
Approximately half of patients on a large
systematic review [3] were subjected to surgical
treatment (48%) as initial treatments for biopsies and cultures as well as for spinal stabilization and abscess drainage (23% and 21%),
compression relief (13%), debridement, excision of sinuses, removal of infected hardware,
resection of infected aneurysms, or grafts (2%).
Correction of postinfection deformity is less
common (2%), but is also cited [3]. In a study
with over 800 cases, previous vertebral osteomyelitis resulted in hospital stays, blood loss,
and fusion levels higher, but did not seem to
affect any other aspect after 1year post operation [17]. Although no denitive threshold for
surgical management of PVO based on spinal
instability or kyphotic deformity exists, Dietze
etal. recommend using the following parame-
ters to suggest spinal instability: vertebral body
collapse >50%, >20 degrees of angulation, and
>5 degrees of vertebral translation [6].
As to different approaches to the spine, an
anterior approach affords a more complete
debridement, but posterior approaches tend to
be less morbid. Apart from debridement itself,
which is consensus in the literature, much controversy exists as to the use of instrumentation,
one vs two-step procedures, and allograft vs
autograft use. Despite controversy, many studies suggest it is safe to use instrumentation in
the surgical treatment of vertebral osteomyelitis. Bydon etal. [18] reported on 118 patients,
noting similar rates of recurrent infection (8.3%
for debridement and 9.8% for debridement with
instrumentation) and reoperation (19.4% for
debridement and 17.1% for debridement with
instrumentation). The use of cages with bone
graft placed into vertebral defects after debridement is a helpful adjunct in reconstruction.
Robinson etal., Kuklo etal., and Sundara etal.
[19–21] reported successful outcomes in small
series of patients submitted to cage placement,
with good outcomes after 36–44months of follow-up. Bone grafting is commonly used in
these cases to increase the rate and probability
of fusion. Common autograft sources are tricortical iliac crest, rib, and bular strut, as well as
humeral and femoral struts after extensive
debridement and/or corpectomy. Although
allograft avoids the morbidity of donor site harvesting, autograft is theorized to have superior
rates of incorporation. However, there is concern about introducing an allograft into the
infected surgical eld. Some small case series
suggest a similar recurrence rate of infection
and clinical outcomes when compared to autograft [12].
The mortality rate is low (6%), and most occur
due to S. aureus septicemia, but the relapse percentage is about 32% [3]. Twenty-seven percent
had life-quality affecting complications, in the
same meta-analysis. Factors associated with an
increased mortality include elevated C-reactive
protein (CRP) at admission, advanced age, and a
Charlson Comorbidity index of >2 [7]. The most
common complications were persistent pain
176
L. P. Martin et al.
(28%), motor weakness or paresis (16%), and
bowel or bladder dysfunction (7%). Of 128
patients (from two different studies), the majority
(80%) had a favorable outcome, while 20% had
unaltered or deteriorated functional status [22,
23]. We have found only one study comparing
functional outcome between nonsurgically and
surgically treated patients, reporting that nonsurgical patients had a 64% chance of disabling pain
or relapse, versus 26% of surgically treated
patients [24].
13.2 Vertebral Tuberculosis
13.2.1 History
Tuberculous bacilli have lived among mankind
for—arguably—as long as human beings have
walked the earth. Proof of this is that there is
Paleopathological evidence of tuberculosis of
bones, joints, and spine in prehistoric humans
[25]. The ancient texts of Rig Veda and the
Atharva Veda (3500–1800BC), in India, mention it by the name of “Yakshama” [26]. Spinal
tuberculosis was rst scientically described in
the Western world by Percivall Pott, in 1799, as
“That kind of palsy of lower limbs which is frequently found to accompany a curvature of the
spine” [27–29]. From then on, the actual bacilli
were identied in 1870, and the use of the
Bacilli Calmette Guerin (BCG) vaccine was
introduced in 1945. The rst antitubercular
drugs appeared in 1948. In most developing
countries, intradermal BCG vaccination is used
for all newborns, and the protection afforded by
it is about 80%. For healthcare students (such as
myself a long time ago), immunity is checked,
and we re- vaccinate the nonimmune in the rst
year of studies. The World Health Organization
(WHO) has stated, in the 1990s, that tuberculosis should remain present in human populations
as long as there are conditions that reduce innate
immunology and cell-mediated immunity, such
as malnutrition, poor sanitation, crowded living
conditions, exanthematous fevers, repeated
pregnancies, alcohol and substance abuse, diabetes, and advanced age [29–31].
13.2.2 Epidemiology
We have seen a recent increase in cases, particularly among the immunosuppressed population,
secondary to a global migration phenomenon.
WHO has reported a global increase in international migrants from 173 to 244 million between
2000 and 2015. There has also been an increased
occurrence of multidrug-resistant bacterial
strains of tuberculosis in developing countries
[32]. The latest WHO report on tuberculosis
(WHO, November 2023) estimates 40 million
people treated for TB between 2018 and 2022,
being the second cause of death from infectious
disease in 2022 (behind COVID); 7.5 million
were diagnosed in 2022 alone.
Spinal tuberculosis constitutes 50% of skeletal tubercular infections, and the incidence of
extrapulmonary TB is about 3% [33]. That would
amount to approximately 112,500 new cases of
spinal TB diagnosed in 2022, worldwide.
13.2.3 Pathophysiology
Spinal TB is usually secondary to hematogenous
spread from a primary site of infection, usually
the lungs. The most common site is paradiscal,
because the paradiscal vessels tend to supply the
subchondral bone, on either side of the disc
space. That also amounts to a common clinical
characteristic, which is the tubercular infection
“skipping” the discs and involving the vertebrae.
As for the specic regions of the bone, it tends to
include the vertebral body, the posterior structures, and form paravertebral abscesses. The progressive destruction of the bony structure leads to
instability and deformity, most commonly in
kyphosis [33].
13.2.4 Most Common Manifestations
As in pyogenic vertebral osteomyelitis, the
patients typically present with back pain. The
latter presentation involves deformity, instability, and neural decit. The back pain is directly
correlated to the disease’s activity, its bone
13 Vertebral Osteomyelitis andTuberculosis
177
destruction, and consequent instability. The
pain is present even while the patient is resting.
Constitutional symptoms, including weight or
appetite loss, fever, and fatigue, are less commonly present than in patients with pulmonary
disease [34, 35]. The abscesses formed in the
disease are called “cold,” because they typically
lack all the inammatory signs that are more
obvious in abscesses. They can present in the
retropharyngeal space, anterior or posterior triangles of the neck or axilla when affecting the
cervical spine (Fig.13.3), as pre- or paravertebral abscesses in the thoracic spine, and may
track down along the psoas muscle, Petit’s triangle, Scarpa’s triangle, or the gluteal region in
lumbar cases [36].
As the greater part of cases involve the anterior portion of the spine, the most common deformity found is kyphosis, especially in the thoracic
and thoracolumbar spine. Jain etal. observed that
kyphotic deformity greater than 60 degrees leads
to signicant disability and can potentially inict
neurological décits [37]. The neurological decits can occur at the active stage of the disease,
from direct compression from abscesses, instability, or sequestrum, or afterwards, secondary to
mechanical traction or later [38].
The initial compression in tuberculosis
involvement tends to be secondary to anterior
vertebral body collapse [39], leading to anterior spinal tract involvement, which involves
hyperreexia of deep tendons, positive
Babinski sign, (exaggerated deep tendon
reexes and Babinski sign), and progression to
upper motor neuron syndrome. As the disease
progresses, the lateral spinal tracts are progressively involved, with loss of crude touch, pain,
and temperature, followed by posterior column
decit, with sphincter disturbances and complete sensory loss.
There are ve classical stages of Pott paraplegia, as dened by the modied Tuli classication,
as follows [40, 41]:
• Stage 1: Decit only appears upon clinical
examination: ankle clonus, exaggerated deep
tendon reexes, and Babinski or plantar
extensor
• Stage 2: Patient has upper motor neuron-type
of motor decit, with spasticity; however, he/
she remains ambulatory. The anticipated
motor score in tetraparesis is 60–100, and in
paraparesis the score is between 80 and 100;
sensory decit involves the lateral column
ab
Fig. 13.3 Tubercular spondylodiscitis in a 32-year-old male affecting the cervical spine. (a, b) extensive destruction of
the anterior vertebral body with spinal cord compression
178
L. P. Martin et al.
• Stage 3: Bedridden and spastic patient.
Anticipated motor score in tetraparesis is
0–30, and in paraparesis is between 50 and 80;
sensory decit involves the lateral column
• Stage 4: Bedridden, severe sensory loss/pressure scores. Anticipated motor score in tetraplegia is 0 and in paraplegia is between 0 and
50; sensory decit involves posterior and lateral columns
• Stage 5: Similar to stage 4 +/− bladder/bowel
involvement +/− exor spasms/accid tetraplegia/paraplegia
Most of the neural decits should t into this
classication, but neural decits in intraspinal granulomas, cauda equina, or other atypical manifestations may not correctly correspond to these stages.
13.2.5 Pediatric Spinal Tuberculosis
It is useful to note that, due to the immaturity and
increased exibility of the spine in children, they
are more prone to developing a severe progression of the deformity. This worsening can also
occur after the disease has healed, so these
patients should be followed until they reach skeletal maturity. Rajasekaran etal. described four
signs of “spine at risk” in children, which include
retropulsion of the posterior aspect of the
involved vertebra, facet subluxation, lateral translation of vertebrae, and the toppling of one vertebra over the other. He proposed that children with
two or more of these signs had posterior facet
disruption and required surgical intervention.
He also proposed a classication system for
the progression of the deformity in children:
• Type 1: curvature increases until skeletal matu-
rity, and surgical intervention was required
• Type 2: deformity decreased with growth
progression
• Type 3: minimal change in the deformity
either during active or healed phases of the
disease [42, 43]
13.2.6 Diagnosis
The gold standard in the diagnosis is having a
positive culture for Mycobacterium. However,
the mycobacteria are fastidious, and the cultures typically show poor sensitivity. Other
standards for diagnosis are caseating granulomas found on histopathological analysis, serological inammatory markers, molecular
diagnosis, and smear staining for acid-fast
bacilli.
Imaging Modalities As in pyogenic osteomyelitis, plain radiographs tend to show signs of
vertebral involvement in later stages, and computer tomography and magnetic resonance have
been progressively more helpful over the Years
(Fig.13.4). Particularly in TB involvement, it is
important to inspect the chest cavity, either by
plain X-rays or CT scans, as up to a third of these
patients will also present with pulmonary disease [44].
Laboratory Tests Although there are more
common (and nonspecic) serum tests, such as
erythrocyte sedimentation rate (ESR) and
hemo sedimentation velocity (HSV), it is
important to note that there are specic tests
for latent tuberculosis, such as the Mantoux
test, the Interferon- gamma release assay, and
ELISA.
The Mantoux test has 40–55% sensitivity and
75% specicity, and it has a low cost. However, it
is not accurate in endemic countries or immunodecient patients.
The Interferon-gamma release assay has
50–65% sensitivity and 85% specicity, and it
measures the interferons produced in response to
the tubercular antigens. For this reason, it is also
not very useful in endemic regions.
Interferon-gamma release assay (50–65% sensitivity and 85% specicity): Measuring interferons produced in response to tubercular antigens;
not useful in endemic regions [45, 46].
bc
13 Vertebral Osteomyelitis andTuberculosis
a
dfg
179
e
Fig. 13.4 L3-L4 Spondylodiscitis in a 41-year-old male
caused by Mycobacterium tubercolosis. (a, b) radiograph
in AP and lateral view; (c) sagittal MRI conrm that the
infection is limited to the vertebral bodies without involve-
13.2.7 Treatment
The basis of tuberculosis treatment is always chemotherapy, with multidrug treatment. WHO’s
most recent guidelines [47] recommend a six to
nine-month treatment with four drugs,
9–12 months on regimens that do not include
rifampin and/or for patients with extensive or
advanced disease, particularly if it is difcult to
assess the response to therapy (Fig. 13.5) [48].
ment of the spinal canal; (d, e) Axial and sagittal CT scan
show lytic erosion in L3 and L4 vertebra… (f, g) that
improved after 1month of follow-up
Local guidelines should be followed, especially in
regions with a high incidence of the disease, especially because of local drug-resistant strains. More
importantly for orthopedic surgeons, spinal tuberculosis—as their pyogenic counterpart—should
be classied as to spinal stability and the need for
surgical intervention. About surgery, the traditional approach to treatment, described since the
1950s, was to perform radical debridement
through an anterior approach [49]. However, with