1
Q
What is vertebral osteomyelitis aka?
A
- Spondylodiscitis
2
Q
Describe the epidemiology of pyogenic vertebral osteomyelitis?
A
- usually adults
- median age is 50-60 years
- location
- 50-60% lumbar spine
- 30-40% thoracic spine
- -10% cervical spine
- risk factors
- IV drug abuse
- diabetes
- recent systemic infection ( UTI/penumonia)
- obesity
- malignancy
- immunodeficiency/ immunosupressive medication
- malnutrition
- trauma
- smoking
3
Q
Describe the pathogens involved?
A
- Staph aureus- most common 50-65%
- staph epidermis
- gram negative infections- GI/Resp tract
- pseudomonas- iv drug use
- salmonella- sickle cell disease
4
Q
What is the pathology of pyogenic vertebral osteomyelitis?
A
- Haematogenous seeding
- thru arterial /venous to endplates and intervertebral discs
- Direct Inoculation
- thru trauma, open fractures, surgery
- Contiguous spread from local infection
- retropharyngeal/ retroperitoneal abscess
5
Q
What is the incidence of neurological invovlement in pyogenic vertebral osteomyelitis?
A
- neurological deficit involvement in 10-20%
- resulting from
- direct infectious involvement of neural elements
- compression due to epidural abscess
- compression from instability of the spine
6
Q
what is an epidural abscess?
A
- Collection of pus/ inflammatory granulation tissue between dura mater and surrounding adipose tissue
- usually associated with vertebral osteomyelitis
- present in 18% pts with spondylodiskitis
- 50% pt with epidural abscess will have neurological symptoms
7
Q
describe the signs & symptoms of pyogenic vertebral osteomyelitis?
A
- Hx of UTI, Pneumonia, skin infection, organ transplant
Symptoms
- Fever- only present in 1/3rd pts
- Pain
- often severe/ insidious in onset
- worse with activity & unrelenting
- awakens at night- infection/malignancy
- Neurology -10-20%
- radiculopathy
- myelopathy
8
Q
What investigations are useful in pyogenic vertebral osteomyelitis?
A
xrays
- findings often delayed by weeks
- paraspinous soft tissue swelling- loss of poas shadow
- seen first few days
- Disc space narrowing and disc destruction
- seen at 7-10 days
- disc destruction atypical of neoplasm
- Endplate erosion/ sclerosis
- 10-21 days
- local osteopenia
CT
- Useful to show bony abnormalities, abcess formation, extent of bony involvement
MRI
- With GADOLINIUM contrast
- gold standard for dx and tx
- most sensitive 96%
- most specific 93%
- most speciifc to differentiate from tumour
- findings include
- paraspinal and epidural inflammation
- disc and endplate enhancement with gadolinium
- T2 weighted hyperintensity of disk/ endplate
Bone Scan
- Technetium Tc99m Bone scans
- pt who can’t obtain MRI
- 90% sensitive but lack specificity
- combined Tc99m with gallium 67 more specific and sensitive than Tc99m alone
9
Q
what laboratory tests are useful in pyogenic vertebral osteomyelitis?
A
- WBC- only elevated in 50%
- ESR- elevated 90% cases, monitored, less reliable than crp
- CRP- elevated 90%, monitor success of tx
- Blood Cultures
- when positive 85% accurate for isolating organism
- Ct guided or open biopsy
- BC negative and no indications for immediate surgery
10
Q
What is DDX of pyogenic vertebral osteomyelitis?
A
- Spinal tumours
- MRI gadollium contrast most specific modality to differentiate tumour
- disc space involvement
- end plate erosion
- significant inflammation
11
Q
What is the tx of pyogenic vertebral osteomyelitis?
A
Non operative
- Bracing and long term antibiotics 6-12 weeks
- most cases
- bracing improves pain & prevent deformity
- if pt ill start broad spectrum antibiotics
- vancomycin ( pencillin R & gram positive)
- 3rd gen cephalosporins ( gram neg )
- change when known sensitiviites
- direct iv antib for 4-6 wks then convert PO
Operative
- Neurological decompression, surgical debridement and spinal stabilization
- Anterior debridement + strut grafting +/- posterior instrumentation- gold standard
- refractory cases
- neurological deficits
- progressive deformity & gross spinal instability
- Posterior debridement and decompression
- usually ineffective for debridment
*
- usually ineffective for debridment
12
Q
What are the goals of surgical tx of pyogenic vertebral osteomyelitis?
A
Anterior debridement, stru graft +/- poterior instrumentation
- Identify organism
- eliminate infection
- prevent or remove neurological deficits
- maintain spinal stability
strut graft
- autogenous tricortical iliac crest, rib or fibula- safe and efective in presence of acute infection
- better incorportation cf allograft
- improved deformity correction with ti mesh cages filled with autograft
Instrumentation
- contraversial in presence of acute infection
- some i& d wiht staged instrumentation
- single stage w bone graft + insrumentation
- posterior instrumentation - when severe kyphotic deformity/ multilevel
13
Q
What is a spinal epidural abscess?
A
- A collection of pus or inflammatory granulation tissue between the dura mater and surrounding adipose tissue
14
Q
what is the epidemiology of spinal abscess?
A
- Usually seen in adults >60 years of age
- locations
- usually thoracolumbar spine
- risk factors
- Iv drug abuse
- immunodeficiency
- maligancy
- immunosuppresive medication
- recent spinal procedure
15
Q
What is the pathophysiology of epidural abscess?
A
- Haematogenous spread- 50%
- spread from discitis- 33%
Pathogens
- Staph aureus- most common 50-65%
- Gram negative - E coli- 18%
- Pseudomonas common in iv drug abusers
16
Q
Do pts with epidural abscess have neurological deficits?
A
- 33% pt with epidural abscess have neurological symptoms
- 4-22% incidence of permanent paralysis
- direct compression/infract in spinal cord
17
Q
What associated conditions are with epidural abscess?
A
- Vertebral osteomyelitis and discitis
- present in 18% of pt with spondylodiscitis
- image shows extensive destruction of the lumbar spine extending over three vertebral segments with associated epidural abcess necessitating surgical decompression and fusion.
18
Q
What is the prognosis with epidural abscess?
A
- Preop degree of neurological deficit most important indicator of clinical outcome
- mortality 5%
- Early diagnosis essential
19
Q
What are the signs and symptoms of epidural abscess?
A
Symptoms
- Fever present ii 50%
- systemic illness more profound than vertebral osteomyelitis
- Pain- severe insidious in onset, occurs 87%
Signs
- Neurological deficit - 33%
- radiculopathy or myelopathy
Labs
- WCC leukocytosis 22,000 cells/mm3
- ESR elevated >90% cases
- CRP elevated in 90% cases
20
Q
What imaging is useful in dx of epidural abscess?
A
Xrays
- usually normal
CT
- poorly sensitive for epidural abscess
Ct myelogram
- 90% sensitive but invasive
MRI w gadolinlium
- investigation of choice
- show extent of abscess, presence of vertrebral osteomyelitis, allow visualisation of neurological compression
- gadolinium allows differentiation of PUS from CSF
- Ring of enhancing lesion is pathognomonic for abscess
21
Q
What is the tx of epidura abscess?
A
Non operative
- bracing and iv antibiotics
- small abscess with minima compression on neural elements
- no neurological deficits
- pt of close clinical follow up
- historically surgcial emergency
- Recent trend towards non op mx as new studies show non op tx effective in pts without neurological deficit
Surgery
- Surgical decompression +/- spinal stabilisation
- for neurological deficits
- spinal cord compression on imaging MRI >50% compression of thecal sac
- presistent infecton despite Antib for 6 weeks
- progressive deformity or instability
- post op antib for 2-4 wks if no bony involvement
- 6 weeks if bony involvement
22
Q
Describe the surgical techniques of decompression of epidural abcess?
A
- Decompressive laminectomy
- most common form of operative tx
- when abscess is posterior and there is no contiguous spondylodiscitis
- Anterior debridement and strut grafting when
- abcess is located anteriorly
- anterior vertebral body & discs involved- preence of spondylodiscitis
- see picture-shows anterior debridement, corpectomy, fibular strut grafting, and Kaneda instrumentation.
23
Q
What is the epidemiology of spinal TB ?
A
- Increasing in US to increasing immunocompromised population
- HIV positive population - cd4 counts 50-200
location
- 15% pt with TB will have extrapulmonary
- spine, esp thoracicspine most common extrapulmonary site
- 5% TB pts have spine involvement
24
Q
What is the pathoanatomy of spinal TB?
A
- Early infection
- begins in metaphyseal body
- spreads under ALL
- leads to
- contiguous multilevel involvement
- skip lesions/ non contiguous segment 15%
- paraspinal abscess 50%
- usually anterior & quite large
- usually doesn’t involve disc space- pyogenic vertebral OM does!
- Chronic infection
- severe kyphosis
- sinus formation
- Pott’s paraplegia
- spinal cord injury caused by abscess/bony sequestra or meningomyelitis
25
What are the signs and symptoms of TB spine?
Symptoms
* onset insidious than pyogenic infection
* **chronic illness**
* **malaise**
* **night sweats**
* weight loss
* back pain
* late symptom, after bony destruction
Signs
* **Kyphotic deformity**
* neurological deficits
26
What imaging is helpful in dx of TB spine?
* **CXR**
* 66% abnormal
* ordered for any pt suspected of TB
* **Spine xrays**
* early infection
* involvement of anterior vertebral body with sparing of disc space
* late infection
* disc space desctruction, lucency & compression of adj vertebral bodies
* MRI with gadolinium
* prefered for dx and tx
* Nuclear medicine studies
* Obtain with combination of technetium & gallium
* shown to have highest sensitivity for detecting infection
27
What lab studies are helpful in dx of tb spine?
* WBC normal
* ESR- usually elevated, normal in 25%
* PPD- purified derivative of tuberculin
* positive in 80%
* CT guided biopsy with culture and staining
* tested for **acid fast bacilli** on **Lowenstein- Jensen medium**
* **Ziehl neilson stain- red snappers- see pic**
* mycobacteria may take 10 wks to grow in culture
* PCR faster identification 95% sensitivity/93% accuracy
28
What are the dx of tb spine?
* Atypical bacteria
* actinomyces israeii
* nocardia asteriods
* brucella
* Fungi
* Coccidoides immitis
* Blastomyces dermatitidis
* Cryptococcus neoformans
* Aspergillosis
* Spirochetes
* Treponema pallidum
29
What is the tx of TB spine?
Non operative
* **Isoniazid, rifampicin, pyrazanamide therapy**
* meds mainstay of tx
* tx for 9-18 months
* **ethanbutol and streptomycin** added for part of tx
* **Spinal orthosis**
* for pain control & prevent deformity
Surgery
* **Anterior debridement +uninstrumentation strut grafting + posterior stabilising** indications
* **neurological deficit**
* advanced spinal instability/**progressive kyphosis**
* adv disease with caseation prevent access by antibiotics
* failure of non op tx after 3-6/12
30
What are the advantages of surgical tx?
* Less progressive kyphosis
* earlier healing
* decrease sinus formation
* pts with neurological deficits, early debridement and decompression lead to improved neurological recovery
31
What is the epidemiology of paediatric disc space infections?
* **More common than adults**
* more common in **Males**
* effects **children \<5 years**
* **Lumbar spine most common 50-60%**
32
What is the pathoanatomy of paediatric disc space infections?
* Blood vessels extend from cartilagenous end plate through nucleus propulsus in children
* _allows direct innoculation of disc_
* _infection may spread from endplate, thru disc to vertebral body_
* In adults blood supply only travels to annulus fibrosis so limiting disc space infection
33
What are the typical organisms in disc space infections in children?
* **Staph aureus**- most common 80%
* **Tuberculosis**
* **Salmonella in** sickle cell anaemia pts
34
What is the symptoms and signs of a chid with spinal disc infection?
Symptoms
* Toddler
* refusing to sit/walk/painful limp
* loss of appetite
* fever (25% will be febrile)
* abdominal pain
* older children
* point tenderness back pain
Signs
* Limited rom
* localised/tenderness of back
35
What is seen on imaging?
xrays
* radiographic findings are unreliable
* early manifestation at 1 week
* normal
* loss of lumbar lordosis- earliest sign
* disc space narrowing 10-21 days post infection
* end plate erosion 10-21 days post infection
MRI
* diagnostic test of choice
Labs
* CRP/ESR/WCC- high normal or elevated
36
What is the tx of disc space infection?
Non operative
* **Bedrest, immobilisation, antibiotics 4-6 weeks**
* with early infection, NO ABSCESS, or displacment of thecal sac
* antibiotics target staph aureus 7-10 days
* Watch serial labs for response
* CT biopsy if no improvement- rule out TB
Surgery
* **Surgical debridement and antibiotic treatment**
* for late infections
* parapsinal abscess in presence of neurological defecit
* aim to get cultures then antibiotics and brace
*
37
What are the complications of paediatric spinal disc infections?
* Long term narrowing of disc space
* Fusion between vertebra
* back pain
38
Spine FRCS
flashcards
Decks in class (20)
# Cards
-
biomechanics of the spine0
-
Lumbar disc Herniation21
-
Spinal cord injuries29
-
Spondylolysis7
-
Spondylolisthesis34
-
Thoracolumbar injuries18
-
Systemic conditions47
-
Scheuermann's kyphosis16
-
Spine Anatomy FRCS50
-
Degenerative Cervical spine40
-
Adult spinal deformity27
-
Degenerative thoracolumbar spine72
-
Infection38
-
Incomplete spinal cord injuries18
-
Syrinx, Syringomyelia and Disatematomyelia14
-
Cauda Equina syndrome11
-
Paediatric Idiopathic Scoliosis28
-
Congenital Scoliosis9
-
Paediatric Cervical spine20
-
Paedriatric14
