ه الرحمن ه الرحمن بسم الّل بسم الّلالرحیمالرحیم

INFECTIOUSINFECTIOUSSPONDILODISCISPONDILODISCI

TISTIS

DefinitionDefinition

Infection of Infection of intervertebral intervertebral discdisc

and adjacent and adjacent vertebraevertebrae

Microbial AgentsMicrobial Agents

Pyogens (Pyogens (Staph -E coli) Staph -E coli) AcuteAcute

Brucella- Salmonella Brucella- Salmonella SubacuteSubacute

Tuberculosis Tuberculosis ChronicChronic

PATHOGENESISPATHOGENESIS

Hematogenous

Direct inoculation

Adjacent tissue

ANT POST

Spinal arterySpinal artery

ANT POST

INITIATION

ANT POST

INITIATION DESTRUCTION

Anterior

TUBERCULOSIS

DESTRUCTION

BRUCELOSIS

Anterior

REPAIR

ANT

INITIATION REPAIR

COURSE

DESTRUCTION

SPONDYLODISCITIS SPONDYLODISCITIS OF OF

TUBERCULOSISTUBERCULOSIS

(POTT(POTT’’S disease)S disease)

EpidemiologyEpidemiology

2 % musculoskeletal2 % musculoskeletal 1% spine1% spine

Site:Site: Upper thoracic: ChildrenUpper thoracic: Children Lower thoracic: AdultLower thoracic: Adult

Lung involvement: 20-30%Lung involvement: 20-30%

Clinical Manifestation

STAGE 1(INITIATION)

STAGE 2(DESTRUCTION) STAGE 3

(REPAIR)

Clinical Manifestation

1-2 yearsmonths

STAGE 1(INITIATION)

Mechanical painMild tenderness

Clinical Manifestation

STAGE 1(INITIATION)

STAGE 2(DESTRUCTION)

months

ConstitutionalSevere Back pain

Clinical Manifestation

Ph/Ex:Severe TendernessBlockage (erect posture)Gibbous deformityCold abscessNeurological (paraplegia)

STAGE 1(INITIATION)

STAGE 2(DESTRUCTION) STAGE 3

(REPAIR)

Mechanical painReduce symptomReduce spasm

1-2 years

Clinical Manifestation

DIAGNOSISDIAGNOSIS

IMAGINGIMAGING

RADIOGRAPHYRADIOGRAPHY

LAB TESTSLAB TESTS

LAB TESTSLAB TESTS ESRESR PPD (+)PPD (+) Sputum smear & cultureSputum smear & culture Abscess or bone biopsy: Culture / Abscess or bone biopsy: Culture /

PathologyPathology

TREATMENTTREATMENT

TREATMENTTREATMENT Medical:Medical:

Mainstay of treatment Mainstay of treatment Alone is successful in Alone is successful in 70%70% DurationDuration: 18 m (9-12 m ?): 18 m (9-12 m ?)

TREATMENTTREATMENT Surgical:Surgical:

Advanced neurological deficitAdvanced neurological deficit Progressive Neurological deficits Progressive Neurological deficits Kyphosis > 40 degreesKyphosis > 40 degrees

MonitoringMonitoring ClinicalClinical

painpain constitutionalconstitutional mobilitymobility neurological signsneurological signs

ESR, CRPESR, CRP

RadiologyRadiology may be progress during first 6 month may be progress during first 6 month

of treatmentof treatment

BRUCELLOSISBRUCELLOSISSPONDYLODISCITISSPONDYLODISCITIS

EPIDEMIOLOGYEPIDEMIOLOGY

Spine: Spine: 7-8% of skeletal7-8% of skeletal

Site: Site: Lumbosacral (Anterior)Lumbosacral (Anterior)

BRUCELOSIS

CLINICAL CLINICAL MANIFESTATIONMANIFESTATION

CLINICAL CLINICAL MANIFESTATIONMANIFESTATION

Constitutional:Constitutional: FeverFever Night SweatNight Sweat MalaiseMalaise ArthralgiaArthralgia ApatheticApathetic

Then: Severe low back pain Then: Severe low back pain

CLINICAL CLINICAL MANIFESTATIONMANIFESTATION

CLINICAL CLINICAL MANIFESTATIONMANIFESTATION

Physical examination:Physical examination:BlockageBlockage

Severe tendernessSevere tenderness

Fever Fever

SplenomegalySplenomegaly

LymphadenopathyLymphadenopathy

DIAGNOSISDIAGNOSIS

DIAGNOSISDIAGNOSIS Clinical presentationClinical presentation RadiographyRadiography Supporting laboratory finding Supporting laboratory finding History of potential exposure:History of potential exposure:

Endemic areaEndemic area Microbiology laboratoryMicrobiology laboratory Unpasteurized milk productsUnpasteurized milk products Contact with animalsContact with animals History of similar illness in the family History of similar illness in the family

(documented in almost 50% of cases).(documented in almost 50% of cases).

LaboratoryLaboratoryWBC: NL or lowWBC: NL or low

ESR, CRP: NLESR, CRP: NL

Wright; Cooms WrightWright; Cooms Wright

B/C or Bone marrow culture (7-35 B/C or Bone marrow culture (7-35 d)d)

ELISAELISA

TreatmentTreatment

2 Drug:2 Drug: Rifampin 600-900 mg/dRifampin 600-900 mg/d Doxycycline 100 mg twice dailyDoxycycline 100 mg twice daily

3 months3 months

SALMONELLA SALMONELLA SPONDYLODISCITISSPONDYLODISCITIS

SALMONELLA SALMONELLA SPONDYLODISCITISSPONDYLODISCITIS

Clinical sign & radiologic future is Clinical sign & radiologic future is similar to Brucellosis.similar to Brucellosis.

Diarrhea: 60%Diarrhea: 60%

Positive S/C (most commonly)Positive S/C (most commonly)

SALMONELLA SPONDYLODISCITISSALMONELLA SPONDYLODISCITIS

Treatment:Treatment:QuinolonesQuinolones

CeftriaxoneCeftriaxone

For 4 wFor 4 w

PYOGENIC PYOGENIC SPONDYLODISCITISPONDYLODISCITI

SS

PYOGENIC SPONDYLODISCITISPYOGENIC SPONDYLODISCITIS

staphylococcus aureusstaphylococcus aureus (50 (50 –– 70%) 70%)

History of recent infection (UTI; History of recent infection (UTI;

septicemia)septicemia)

Acute severe back pain; High fever; Acute severe back pain; High fever;

ChillsChills

Patient is ill. Patient is ill.

Blockage; Severe tendernessBlockage; Severe tenderness

Lumbar spine (45%) Thoracic (35%) Lumbar spine (45%) Thoracic (35%)

PYOGENIC SPONDYLODISCITISPYOGENIC SPONDYLODISCITIS

Radiography:Radiography: severe destructivesevere destructive rapidly progressive lesionrapidly progressive lesion Large bone bridgeLarge bone bridge

PYOGENIC SPONDYLODISCITISPYOGENIC SPONDYLODISCITIS

MRI: MRI:

PYOGENIC SPONDYLODISCITISPYOGENIC SPONDYLODISCITIS

Laboratory:Laboratory:LeucocytosisLeucocytosis

ESR (useful in fallow up)ESR (useful in fallow up)

CultureCultureB/C: 50% - B/C: 50% -

70%70%

Biopsy: 70% - Biopsy: 70% - 90%90% UTD UTD

19.319.3

PYOGENIC SPONDYLODISCITISPYOGENIC SPONDYLODISCITIS

Diagnosis:Diagnosis:Clinical presentationClinical presentation

RadiologyRadiology

laboratorylaboratory

PYOGENIC SPONDYLODISCITISPYOGENIC SPONDYLODISCITIS

Treatment: Treatment: Two drugs (Staph & gram negative Two drugs (Staph & gram negative organisms)organisms)

Six weeksSix weeks

Surgery:Surgery:

-- progressive progressive

-- cord compression cord compression

BrucellosisBrucellosis TuberculosisTuberculosis

SiteSite Lumbar and othersLumbar and others DorsolumbarDorsolumbar

VertebraeVertebrae Multiple or Multiple or contiguouscontiguous

ContiguousContiguous

DiskitisDiskitis LateLate EarlyEarly

BodyBody Intact until lateIntact until late Morphology lost earlyMorphology lost early

Canal Canal compressioncompression

RareRare CommonCommon

EpiphysitisEpiphysitis Anterosuperior Anterosuperior (Pom's sign)(Pom's sign)

General: upper and lower General: upper and lower disk regions, central, disk regions, central, subperiostealsubperiosteal

OsteophyteOsteophyte Anterolateral Anterolateral (parrot beak)(parrot beak)

UnusualUnusual

DeformityDeformity Wedging Wedging uncommonuncommon

Anterior wedge, gibbusAnterior wedge, gibbus

RecoveryRecovery Sclerosis, whole Sclerosis, whole bodybody

VariableVariable

Paravertebral Paravertebral abscessabscess

Small, well-Small, well-localizedlocalized

Common and discrete loss, Common and discrete loss, transverse processtransverse process

Psoas Psoas abscessabscess

RareRare More likelyMore likely