8/9/2019 Spinal Infection Ok
1/55
SPINAL INFECTION
8/9/2019 Spinal Infection Ok
2/55
PYOGENICVERTEBRAL OSTEOMYELITIS
30-70%
8/9/2019 Spinal Infection Ok
3/55
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
8/9/2019 Spinal Infection Ok
4/55
PYOGENIC VERTEBRAL
OSTEOMYELITIS
Level ofVertebralInfectiony lumbar spine (45% )
y
thoracic spine (35%)
y cervical spine (20%)
8/9/2019 Spinal Infection Ok
5/55
INFECTING ORGANISM
Staph.aureus -- M/C organism
Gram-neg.
:
E.coli,P.aeruginosa,Klebsiella
Anaerobic:rare
monomicrobial disease15% IVDU = polymicrobial
infection
8/9/2019 Spinal Infection Ok
6/55
CLINICAL MANIFESTATION (Radicular pain)
50%
(Paraplegia,Quadriplegia),
Discitis
8/9/2019 Spinal Infection Ok
7/55
LABORATORY FINDINGS
leuko
cyto
sis:
acute>
chro
nicelevatedESR
H/Cpositive24-100%
8/9/2019 Spinal Infection Ok
8/55
IMAGING-PLAIN FILMS
loss ofbonytrabeculationcloseto
thecartilaginousplate
irregularnarrowing ofthe
vertebraldiscspacebetween
involvedadjacentvertebra
vertebralbodycollapse
8/9/2019 Spinal Infection Ok
9/55
IMAGING-PLAIN FILMS
evident ofrapidboneregeneration:bonespurs,
densenew bone
8/9/2019 Spinal Infection Ok
10/55
4GRADE
Grade1 discspace
narrowing
Grade 2 bony
destructio
nendplate
Grade 3 less 50% body
destruction
Grade4 more 50%
bodydestruction
8/9/2019 Spinal Infection Ok
11/55
RADIONUCLIDE SCANS
verysensitiveandearly
non-specific
Tc-99mcombined withGallium
8/9/2019 Spinal Infection Ok
12/55
CTDetact beforesuchchangesare
apparent onplain films
useful fory detectingthepresence ofbonysequestra orinvolucra,
y adjacentsofttissueabscesses
y findingandlocalizingthe optimalapproach forabiopsy
Howevery earlydestructivechangesmaybemissed
y hasahigh falsenegativerate forepiduralabscess
8/9/2019 Spinal Infection Ok
13/55
MRIthemostsensitiveradiologic
techniqueto detectvertebral
detection ofepiduralabscesses
butcannotbeusedinpatientswithcertainmetalimplants
8/9/2019 Spinal Infection Ok
14/55
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
8/9/2019 Spinal Infection Ok
15/55
PYOGENIC VERTEBRAL
OSTEOMYELITIS
Treatment
ATB4-8wkparenteral
continue oralATBimmobilized,externalbracingduring
ambulation
goal=preserve ormaintainneuralfunctionspontaneousvertebralbodyfusioninastable anatomicalposition
8/9/2019 Spinal Infection Ok
16/55
INDICATION FOR SURGERY
Spinalinstability
Spinal fusiondecompression
8/9/2019 Spinal Infection Ok
17/55
( EPIDURAL ABSCESS, SUBDURAL ABSCESS)
Epidermiology
0.2-1.2/10000 57
Epiduralabscess
y (50%)(35%)(15%)(82%)(18%)
Subduralabscess
y ,
8/9/2019 Spinal Infection Ok
18/55
Abscess compressing the
spinal cord and vasculature.
8/9/2019 Spinal Infection Ok
19/55
LocationLocationandand
frequencyfrequency
of theof the
abscess inabscess in
relationrelationto theto thespine.spine.
8/9/2019 Spinal Infection Ok
20/55
PREDISPOSING FACTOR
DM
chronic renal disease
immunocompromise alcoholism
malignancy
IVDU
recent spinal surgery
spinal trauma
8/9/2019 Spinal Infection Ok
21/55
MICROBIOLOGY
Staph.aureus
Aerobicanaerobicstreptococcus
Multiple organism(10%)E.coli,Pseudomonas
aeruginosa,Diplococcus pneumoniae,Serratiamarcescens Enterobacter,
TB
8/9/2019 Spinal Infection Ok
22/55
SPINALABSCESS
Hematogenous spread :skin, soft tissue,
respiratory tract, oralcavity, infectedintravenous injection sites
direct extension ofvertebral osteomyelitis
50% no prior source of
infection identified
8/9/2019 Spinal Infection Ok
23/55
CLINICAL MANIFESTATION
2y Acute 16y Chronic 16
y Fever Malaise
y Back pain
y Radiculopathy/paresis Bladder/bowel
dysfunction Plegiay Sepsis/mental status change
8/9/2019 Spinal Infection Ok
24/55
INVESTIGATION
CBC
y Leukocytosis WBC12000-17000 percu.mm.
ESR BloodcultureSepsis
8/9/2019 Spinal Infection Ok
25/55
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
8/9/2019 Spinal Infection Ok
26/55
TREATMENT
1.) 3-4 Osteomyelitis 6-8
2.)
8/9/2019 Spinal Infection Ok
27/55
Gadolinium-enhanced MRI ofthe spine showing varyingdegrees of peripheral
enhancement (arrow)
8/9/2019 Spinal Infection Ok
28/55
PROGNOSIS
18-23%
y
y
8/9/2019 Spinal Infection Ok
29/55
SPINAL
TUBERCULOSIS
8/9/2019 Spinal Infection Ok
30/55
SPINAL TUBERCULOSISUsuallyinvolvedthevertebralbody
10% involvedneuralarch,transverseprocess,spinousprocess
infectionmayspreaddorsallyto thespinalcanal
impairedneural function,collapsedvertebra
compressthespinalcord orcordaequina
8/9/2019 Spinal Infection Ok
31/55
SPINAL TUBERCULOSIS
Tuberculousepiduralabscess orgranulomamayalso cause
neurologicaldysfunction withoutanyevidence ofbonyinvolvement
Treatment:healthe
disease,prevent orimproveneurologicaldysfunction,preventany furthergibbusdeformity
8/9/2019 Spinal Infection Ok
32/55
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)
8/9/2019 Spinal Infection Ok
33/55
Tuberculous spondylitis
Thoracolumbarspine -T9 -T10 T9-10disc - Bilateralparaspinal soft
tissue (arrows).
8/9/2019 Spinal Infection Ok
34/55
SPINAL TUBERCULOSIS
Recommendtreatment
surgery forparaplegiashouldbe
reserved forthoseshow noimprovement onprolonged
chemotherapy withseveral
regimens
8/9/2019 Spinal Infection Ok
35/55
DISCITIS
Childhood discitis
Postoperative discitis
8/9/2019 Spinal Infection Ok
36/55
CHILDHOOD DISCITIS
Younger children > olderchildren
Its cause is unclear :infective or chemicalprocess
L-levelHematogenous spread :S.aureus (C/S +ve 50%)
8/9/2019 Spinal Infection Ok
37/55
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
8/9/2019 Spinal Infection Ok
38/55
CHILDHOOD DISCITIS
Laboratory findings
normal leukocyte count
and differentiateelevated ESR
8/9/2019 Spinal Infection Ok
39/55
CHILDHOOD DISCITIS
Imagingirregular narrowing on
both sides of the involveddisc
symmetrical vertebralbody enlargement
narrow disc space , thevertebra abutting theinvolved disc may
spontaneous fuse
8/9/2019 Spinal Infection Ok
40/55
INTERVERTEBRAL DISC SPACE INFECTION
8/9/2019 Spinal Infection Ok
41/55
Discitisseen onMRI
8/9/2019 Spinal Infection Ok
42/55
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
8/9/2019 Spinal Infection Ok
43/55
POSTOPERTIVE DISCITIS
0.1-4% of lumbar discoperations
L4- L5 interspacedirect disc injuries asepticnecrosis
bacteria ; iatrogenicintroduce orhematogenous spread
C-reactive protein ;
8/9/2019 Spinal Infection Ok
44/55
POSTOPERTIVE DISCITIS
Signs & symptoms Local backache,paravertebral muscle
spasm, tenderness , fever
Movement usually increase the pain
Laboratory findings Leukocytosis
Elevated ESR prolong > 2 weeks afteroperation
8/9/2019 Spinal Infection Ok
45/55
POSTOPERTIVE DISCITIS
Imaging narrowing of disc space with vertebral
body end plate absorption
the disc appear hypodense
with healing ; fusion or bridging of theaffected disc space
8/9/2019 Spinal Infection Ok
46/55
POSTOPERTIVE DISCITIS
Imaging-MRI
the most sensitive
diagnostic methodT1w : sharp decrease inthe bony signal
T2w : show a more intensesignal
8/9/2019 Spinal Infection Ok
47/55
POSTOPERTIVE DISCITIS
Prevention
Cessation of disc space
curettage
Treatment
Bed rest until movementwithout aggravating thepain
Broad spectrum ATB
8/9/2019 Spinal Infection Ok
48/55
MYELITIS
8/9/2019 Spinal Infection Ok
49/55
MYELITIS
(myelitis) graymatter
poliomyelitis
whitematterleukomyelitis
transversemyelitis ascendingmyelitis
8/9/2019 Spinal Infection Ok
50/55
CAUSES
occurinisolation orinthesetting ofanother
illness.
Whenit occurs withoutapparentunderlyingcause,itisreferredto asidiopathic.
Idiopathictransversemyelitis isassumedto bea
result ofabnormalactivation oftheimmune
systemagainstthespinalcord.
8/9/2019 Spinal Infection Ok
51/55
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
8/9/2019 Spinal Infection Ok
52/55
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
8/9/2019 Spinal Infection Ok
53/55
SYMPTOMS AND SIGNS
Painintheneck,back, orheadmay occur
weakness
tingling
numbness ofthe feetandlegs difficultyvoidingdevelop overhoursto a few
days
paraplegia
loss ofsensationbelow thelesion urinaryretention
fecalincontinence
8/9/2019 Spinal Infection Ok
54/55
DIAGNOSIS
DiagnosisrequiresMRIandCSFanalysis
MRItypicallyshowscordswellingandhelpsexclude othertreatablecauses ofspinalcorddysfunction(eg,spinalcordcompression)
Tests fortreatablecausesshouldinclude
chestx-ray
serologictests formycoplasma,Lymedisease,andHIV
vitaminB12
folate levels
ESR antinuclearantibodiesand
CSF
bloodVenerealDiseaseResearchLaboratory(VDRL)tests
8/9/2019 Spinal Infection Ok
55/55
TREATMENT
directedatthecause orassociateddisorder
Inidiopathiccases,high-dosecorticosteroidsare
often
given
and
so
metimesfo
llow
edbyplasma
exchangebecausethecausemaybeautoimmune