Spinal Infection Ok

8/9/2019 Spinal Infection Ok

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SPINAL INFECTION


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PYOGENICVERTEBRAL OSTEOMYELITIS

30-70%


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EPIDERMIOLOGY

1:100000-250000

Risk factors

y Diabetes mellitusy Advanced age

y Intravenous drug use

y Congenital immunodepression

y Long-term systemic administration of steroidsy Organ transplantation

y Malnutrition

y Cancer


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PYOGENIC VERTEBRAL

OSTEOMYELITIS

Level ofVertebralInfectiony lumbar spine (45% )

y

thoracic spine (35%)

y cervical spine (20%)


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INFECTING ORGANISM

Staph.aureus -- M/C organism

Gram-neg.

:

E.coli,P.aeruginosa,Klebsiella

Anaerobic:rare

monomicrobial disease15% IVDU = polymicrobial

infection


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CLINICAL MANIFESTATION (Radicular pain)

50%

(Paraplegia,Quadriplegia),

Discitis


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LABORATORY FINDINGS

leuko

cyto

sis:

acute>

chro

nicelevatedESR

H/Cpositive24-100%


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IMAGING-PLAIN FILMS

loss ofbonytrabeculationcloseto

thecartilaginousplate

irregularnarrowing ofthe

vertebraldiscspacebetween

involvedadjacentvertebra

vertebralbodycollapse


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IMAGING-PLAIN FILMS

evident ofrapidboneregeneration:bonespurs,

densenew bone


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4GRADE

Grade1 discspace

narrowing

Grade 2 bony

destructio

nendplate

Grade 3 less 50% body

destruction

Grade4 more 50%

bodydestruction


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RADIONUCLIDE SCANS

verysensitiveandearly

non-specific

Tc-99mcombined withGallium


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CTDetact beforesuchchangesare

apparent onplain films

useful fory detectingthepresence ofbonysequestra orinvolucra,

y adjacentsofttissueabscesses

y findingandlocalizingthe optimalapproach forabiopsy

Howevery earlydestructivechangesmaybemissed

y hasahigh falsenegativerate forepiduralabscess


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MRIthemostsensitiveradiologic

techniqueto detectvertebral

detection ofepiduralabscesses

butcannotbeusedinpatientswithcertainmetalimplants


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PYOGENIC VERTEBRAL

OSTEOMYELITIS

Treatment

underlyinginfecti

on

H/C bone biopsy or aspiration of the disc space

for culture may provide a definitive organism

Failure to identifing the pathogen by culture--> an open bone biopsy


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PYOGENIC VERTEBRAL

OSTEOMYELITIS

Treatment

ATB4-8wkparenteral

continue oralATBimmobilized,externalbracingduring

ambulation

goal=preserve ormaintainneuralfunctionspontaneousvertebralbodyfusioninastable anatomicalposition


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INDICATION FOR SURGERY

Spinalinstability

Spinal fusiondecompression


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( EPIDURAL ABSCESS, SUBDURAL ABSCESS)

Epidermiology

0.2-1.2/10000 57

Epiduralabscess

y (50%)(35%)(15%)(82%)(18%)

Subduralabscess

y ,


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Abscess compressing the

spinal cord and vasculature.


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LocationLocationandand

frequencyfrequency

of theof the

abscess inabscess in

relationrelationto theto thespine.spine.


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PREDISPOSING FACTOR

DM

chronic renal disease

immunocompromise alcoholism

malignancy

IVDU

recent spinal surgery

spinal trauma


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MICROBIOLOGY

Staph.aureus

Aerobicanaerobicstreptococcus

Multiple organism(10%)E.coli,Pseudomonas

aeruginosa,Diplococcus pneumoniae,Serratiamarcescens Enterobacter,

TB


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SPINALABSCESS

Hematogenous spread :skin, soft tissue,

respiratory tract, oralcavity, infectedintravenous injection sites

direct extension ofvertebral osteomyelitis

50% no prior source of

infection identified


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CLINICAL MANIFESTATION

2y Acute 16y Chronic 16

y Fever Malaise

y Back pain

y Radiculopathy/paresis Bladder/bowel

dysfunction Plegiay Sepsis/mental status change


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INVESTIGATION

CBC

y Leukocytosis WBC12000-17000 percu.mm.

ESR BloodcultureSepsis


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SPINALABSCESS

ImagingStudies Immediate imaging of the spinal canal and

cord is imperative

spinal MRI is the procedure of choice

If MRI is unavailable, CT myelography or

conventional myelography can reveal an

intraspinal extramedullary massa "surgical"

lesion


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TREATMENT

1.) 3-4 Osteomyelitis 6-8

2.)


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Gadolinium-enhanced MRI ofthe spine showing varyingdegrees of peripheral

enhancement (arrow)


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PROGNOSIS

18-23%

y

y


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SPINAL

TUBERCULOSIS


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SPINAL TUBERCULOSISUsuallyinvolvedthevertebralbody

10% involvedneuralarch,transverseprocess,spinousprocess

infectionmayspreaddorsallyto thespinalcanal

impairedneural function,collapsedvertebra

compressthespinalcord orcordaequina


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SPINAL TUBERCULOSIS

Tuberculousepiduralabscess orgranulomamayalso cause

neurologicaldysfunction withoutanyevidence ofbonyinvolvement

Treatment:healthe

disease,prevent orimproveneurologicaldysfunction,preventany furthergibbusdeformity


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Mycobacterium Tuberculosis

endplate arterioles lower thoracic thoracic upperlumbar spine

Radiographic features:

osteolytic lesion anterior vertebral endplate , loss of disk height paraspinal soft tissue swelling

vertebral body collapse,gibbus deformity disk space

Intervertebral disk space vertebral endplate

infectious disease spine

Pyogenic spondylitis

u ercu ous pon y s(Potts Disease)


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Tuberculous spondylitis

Thoracolumbarspine -T9 -T10 T9-10disc - Bilateralparaspinal soft

tissue (arrows).


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SPINAL TUBERCULOSIS

Recommendtreatment

surgery forparaplegiashouldbe

reserved forthoseshow noimprovement onprolonged

chemotherapy withseveral

regimens


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DISCITIS

Childhood discitis

Postoperative discitis


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CHILDHOOD DISCITIS

Younger children > olderchildren

Its cause is unclear :infective or chemicalprocess

L-levelHematogenous spread :S.aureus (C/S +ve 50%)


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CHILDHOOD DISCITIS

Signs & symptoms

2-4 weeks of low grade

fever,irritable,later develop alimp

refuse to sit, stand, or walk

constipation and abdominaldistention

older children : lower back, hip

or thi h ain


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CHILDHOOD DISCITIS

Laboratory findings

normal leukocyte count

and differentiateelevated ESR


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CHILDHOOD DISCITIS

Imagingirregular narrowing on

both sides of the involveddisc

symmetrical vertebralbody enlargement

narrow disc space , thevertebra abutting theinvolved disc may

spontaneous fuse


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INTERVERTEBRAL DISC SPACE INFECTION


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Discitisseen onMRI


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CHILDHOOD DISCITIS

Treatment

Immobilize in a body cast

for several weeksFull ambulation usingexternal support

ATB if vertebralosteomyelitis is suspected: empirical ATB include

MRSA ,changing ATB from


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POSTOPERTIVE DISCITIS

0.1-4% of lumbar discoperations

L4- L5 interspacedirect disc injuries asepticnecrosis

bacteria ; iatrogenicintroduce orhematogenous spread

C-reactive protein ;


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Signs & symptoms Local backache,paravertebral muscle

spasm, tenderness , fever

Movement usually increase the pain

Laboratory findings Leukocytosis

Elevated ESR prolong > 2 weeks afteroperation


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Imaging narrowing of disc space with vertebral

body end plate absorption

the disc appear hypodense

with healing ; fusion or bridging of theaffected disc space


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Imaging-MRI

the most sensitive

diagnostic methodT1w : sharp decrease inthe bony signal

T2w : show a more intensesignal


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Prevention

Cessation of disc space

curettage

Treatment

Bed rest until movementwithout aggravating thepain

Broad spectrum ATB


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MYELITIS


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MYELITIS

(myelitis) graymatter

poliomyelitis

whitematterleukomyelitis

transversemyelitis ascendingmyelitis


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CAUSES

occurinisolation orinthesetting ofanother

illness.

Whenit occurs withoutapparentunderlyingcause,itisreferredto asidiopathic.

Idiopathictransversemyelitis isassumedto bea

result ofabnormalactivation oftheimmune

systemagainstthespinalcord.


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DISEASESASSOCIATED WITH

TRANSVERSE MYELITIS

Parainfectious (occurringatthetime ofandin

association withanacuteinfection oranepisode of

infection).

Viral:herpessimplex,herpeszoster,cytomegalovirus,

Epstein-Barrvirus,enteroviruses (poliomyelitis,

Coxsackievirus,echovirus),humanT-cell,leukemia

virus,humanimmunodeficiencyvirus,influenza,

rabies

Bacterial:Mycoplasma pneumoniae,Lymeborreliosis,syphilis,tuberculosis

Postvaccinal (rabies,cowpox)

Systemic autoimmune disease


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DISEASESASSOCIATED WITH

TRANSVERSE MYELITIS

Systemic lupus erythematosis

Sjogren's syndrome

Sarcoidosis

Multiple Sclerosis Paraneoplastic syndrome

Vascular

Thrombosis ofspinal arteries

Vasculitis secondary to heroin abuse

Spinal arterio-venous malformation


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SYMPTOMS AND SIGNS

Painintheneck,back, orheadmay occur

weakness

tingling

numbness ofthe feetandlegs difficultyvoidingdevelop overhoursto a few

days

paraplegia

loss ofsensationbelow thelesion urinaryretention

fecalincontinence


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DIAGNOSIS

DiagnosisrequiresMRIandCSFanalysis

MRItypicallyshowscordswellingandhelpsexclude othertreatablecauses ofspinalcorddysfunction(eg,spinalcordcompression)

Tests fortreatablecausesshouldinclude

chestx-ray

serologictests formycoplasma,Lymedisease,andHIV

vitaminB12

folate levels

ESR antinuclearantibodiesand

CSF

bloodVenerealDiseaseResearchLaboratory(VDRL)tests


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TREATMENT

directedatthecause orassociateddisorder

Inidiopathiccases,high-dosecorticosteroidsare

often

given

and

so

metimesfo

llow

edbyplasma

exchangebecausethecausemaybeautoimmune

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Spinal Infection Ok