At 6 weeks post-onset, X-rays revealed vertebral body changes. Enhanced imaging showed endplate erosion with a rough TFC (total disc replacement) and high signal intensity around it.
3. Discussion
3.1 The primary features of spinal infection include spastic low back pain, fever, elevated erythrocyte sedimentation rate (ESR), and increased C-reactive protein (CRP). Infections typically occur through bacterial contamination of surgical incisions, hematogenous spread, or direct inoculation into the intervertebral space, leading to disc degeneration and necrosis, followed by subchondral bone destruction. This process results in the accumulation of inflammatory substances. When bacteria and these substances enter the spinal canal, they can form an epidural abscess, and if they spread to adjacent vertebral bodies, it leads to purulent spondylitis. Spinal infections following TFC implantation are rare. In this case series, there were two acute and three subacute cases. The clinical presentation was severe, persistent low back pain, often accompanied by fever and elevated ESR. Pain worsened with movement and could radiate to the perineum and lower limbs. MRI findings showed that three patients had suppurative spondylitis, while two had intervertebral disc space infections.
3.2 Surgical Strategies
Postoperative spinal infections often cause significant pain and limited mobility, which greatly impact patients' physical and mental well-being. Therefore, the primary treatment goal is to relieve low back pain and restore lumbar function as soon as possible. Historically, non-surgical management was the preferred approach for postoperative infections, with surgery considered only when conservative treatment failed or when complications such as spinal abscesses developed. Non-surgical treatment essentially relies on the natural fusion of the affected intervertebral space, a process that usually takes 3 to 6 months. During this time, patients endure prolonged discomfort. However, after TFC implantation, spinal infections become more complex due to the lack of blood supply to the adult intervertebral disc, making it difficult for antibiotics to reach the site. Additionally, the presence of metallic implants provides a favorable environment for bacterial growth. Inflammatory materials surrounding the TFC are not easily absorbed, so non-surgical treatment often fails to control the infection effectively. In this group of five patients, four to six weeks of bed rest and high-dose broad-spectrum antibiotics were administered before TFC removal, but symptoms remained largely unchanged. As a result, the TFC was removed promptly, and the infected tissue was cleared 4 to 6 weeks after the onset. This led to rapid relief of low back pain. The natural progression of spinal infection following TFC implantation resembles acute osteomyelitis, with early stages characterized by degenerative necrosis and later stages involving repair and reconstruction. Early removal of the TFC and debridement of the infected area can help transition the lesion into the repair phase sooner, significantly reducing patient discomfort and improving outcomes.
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