SPINE INFECTION

NOOR HAFIZAH BINTI HASSAN2007287236

CONTENTS:

1) PYOGENIC SPINE INFECTION:- OSTEOMYELITIS OF THE SPINE- DISCITIS

2) NON PYOGENIC (GRANULOMATOUS) SPINE INFECTION:- TUBERCULOUS SPINE INFECTION

PYOGENIC SPINE INFECTION

EPIDEMIOLOGY

AETIOLOGY

• Bacterial : Staph aureus (70 %) : Streptococcus sp. : E.coli : Pseudomonas IVDU

• Location: Lumbar spine : Thoracic spine : Cervical spine

↑ vascularity

PATHOPHYSIOLOGYROUTES OF INFECTION SPREAD:

HEMATOGENOUS SPREAD

1) Differences in blood supply in children and adult:

2) Blood supply of the vertebrae:

Batson’s plexus

CLINICAL PRESENTATION

• Back / neck pain

• Constitutional symptoms

– Fever / malaise / anorexia

• Neurological deficit:

– according to the level of vertebra

• Non specific in children

• o/e: tenderness, limited ROM

RED FLAG OF BACK PAIN:

• AGE <15 OR >55• THORACIC BACK PAIN• NIGHT PAIN•CONSTANT & PROGRESSIVE S/SX•FOCAL NEUROLOGICAL DEFICIT•HX OF MALIGNANCY• IVDU• IMMUNOCOMPROMISED

INVESTIGATION• Aim of investigation • Laboratory investigation:– FBC: ↑ WCC

: anemia of chronic disease– BLOOD C&S– ESR: > 50 mm/hr– CRP– LIVER FUNCTION TEST– RENAL PROFILE

• Radiological investigation:a) Plain x-ray:

Narrowing of Narrowing of intervertebral spaceintervertebral space

Destruction of Destruction of vertebral bodyvertebral body

b) CT scan:

Axial view of cervical vertebra:Axial view of cervical vertebra:Destruction of vertebral bodyDestruction of vertebral body

c) MRI with contrast enhancement:

Collapse of vertebral bodyCollapse of vertebral bodyRetropulsed bony fragment Retropulsed bony fragment compressing the spinal cordcompressing the spinal cord

TREATMENT

MEDICAL:• CRIB• Analgesia• Intravenous abx 4-6/52

↓ improvement

• Oral abx 6-8/52• Spinal brace

SURGICAL:• Indications:

• Failed medical treatment• Presence/development of

neurological signs • Drainage of soft tissue

abscess• Methods:

• Decompression • Stabilization

DISCITIS• Routes of infection spread:

– Iatrogenic: following procedure eg discectomy adult– Non iatrogenic: blood-borne children

• Clinical presentation:– Acute back pain / muscle spasm / systemic features

• Destruction of vertebral end plate spread to v/body• Raised ESR• Management:

– Iatrogenic: prevention!! : broad spectrum abx

– Non iatrogenic: usually self limiting

NON PYOGENIC SPINE INFECTION:

(TUBERCULOUS SPONDYLITIS)

EPIDEMIOLOGY• Extrapulmonary Tb: 20-25 % of reported case

• Skeletal Tb: 1-3 %, with spine preference

• M. Dharmalingam. Tuberculosis of the spine—the Sabah

experience. Epidemiology, treatment and results.

Tuberculosis (Edinb). 2004;84(1-2):24-8.– 33 patient (24 Males, 9 Females)– Peak incidence: 20s– Prior hx of pulmonary Tb: 66.6 %– Vertebral involvement: thoracic ( 30.3 %) > lumbar (27.2 %)

PATHOPHYSIOLOGY

Abscess

Preservation of Preservation of intervertebral discintervertebral disc

Collapse of Collapse of vertebral bodyvertebral body

Rarefaction the Rarefaction the anterior aspect of anterior aspect of

vertebral bodyvertebral body

CLINICAL PRESENTATION

• Long h/o backache

• Prior h/o pulmonary Tb or

exposure to Tb patient

• Deformity

• Cold abscess

• Paresthesia / weakness

• On examination:

- Pulmonary signs

-Angular thoracic

kyphos

- Local tenderness

- Gibbus

- Limited ROM

- Neurological exam

POTT’S PARAPLEGIA

• The most feared complication

• Early onset paresis:– Weakness of LL, UMN features, sensory dysf(x)– d/t pressure by the abscess/caseous material/

bony fragment

• Late onset: – d/t deformity/reactivation of the disease/cord

ischemia

INVESTIGATION

a) Laboratory investigation:– FBC– BLOOD C&S– ESR & CRP– LFT– RP– Mantoux test

b) Radiological investigation:– Plain x-ray:• Narrowing of i/vertebral

space• Fuzziness of end plates• Collapse of adjacent

vertebral body• Paraspinal soft tissue

shadow

– CT scan & MRI• Cord compression

T9Narrowing of Narrowing of intervertebral discintervertebral disc

Soft tissueSoft tissueshadowshadow

Soft tissueSoft tissuemassmass

Destruction of Destruction of vertebral bodyvertebral body

TREATMENT• Aim of treatment:

– To eradicate or at least arrest the disease– To prevent or correct deformity– To prevent or treat complication – paraplegia

• Medical treatment:– Anti-Tb chemotherapy 9/12– Continuous bed rest

• Surgical treatment:– To drain abscess– To correct deformity

FIRST LINE TB DRUGS

THANK YOUTHANK YOUREFERENCES:REFERENCES:

1. 1. Spinal infections. Jonathan A Clamp and Michael P Grevitt. Elsevier Ltd.

2. 2. Theodore Gouliouris, Sani H. Aliyu, and Nicholas M. Brown. Spondylodiscitis: update on diagnosis and management. J. Antimicrob. Chemother. (2010) 65 (suppl 3): iii11-iii24.

3. Peter Martin.Pyogenic osteomyelitis of the spine. British 3. Peter Martin.Pyogenic osteomyelitis of the spine. British Medical Journal, Nov 9 1946.Medical Journal, Nov 9 1946.

Extra notes: red flag of back pain

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