Banal vs tb infection of spine team viii

TeamVIII
ZT/AT/VC/AB/RE
MOD:QM
SUPV: dr. HenryYurianto M.phill, P.hD, Sp.OT
BAGIAN ORTOPEDI &TRAUMATOLOGI FAKULTAS KEDOKTERAN UNHAS MAKASSAR

 2% to 7% of all cases of
osteomyelitis
 predilection for the elderly
 two thirds are male
 The incidence may be higher
in younger patients who are
IV drug abusers
Pyogenic vertebral osteomyelitis tuberculous spondylitis
Rothman-simeone. The Spine, 6th ed.2011
 In developing countries, the
disease is still a significant
source of morbidity and
mortality
 the most common cause of
nontraumatic paraplegia
 HIV-positive, 24% spinal
tuberculosis

 29% genitourinary tract
 13% soft tissue infections
 11% respiratory tract
infections
 1.5% in IV drug abusers
 hematogenous spread
 The pulmonary systems
 genitourinary systems
 visceral lesions by direct
extension

 Staphylococcus aureus
 Escherichia coli
 Pseudomonas species
 Proteus species
 Pseudomonas aeruginosa
 Salmonella
 Mycobacterium tuberculosis

 Gambar di hp
 Batson’s plexus may be the
route of hematogenous
spread of infection
 microorganisms lodge in the
low-flow vascular arcades in
the metaphysis, infection
spreads
 The disc is destroyed by
bacterial enzymes
 Gambar di hp
 endplates and bone are
destroyed but the disc is
frequently better preserved
 There are three major types
of spinal involvement:
 Paradiscal
 Central
 anterior

 xx
 With paradiscal disease, the
infection begins in the
metaphyseal area and
spreads under the anterior
longitudinal ligament to
involve the adjacent bodies.
 the disc is relatively resistant
to infection and may be
preserved, even with
extensive bone loss

 xx
 In cases classified as central
involvement, the disease
begins within the middle of
the vertebral body and
remains isolated to one
vertebra.
 lead to vertebral collapse and
therefore are the most likely
type to produce significant
spinal deformity

 Determined by the virulence
of the organism and the
resistance of the host.
 acute, subacute, or chronic
 Fever 52%, pain in the back or
neck 90%
 acute infection: fever, local
spine pain, severe muscle
spasm, and limitation of
motion of the spine.
 xxx

 lumbar spine involvement; straight-
leg raise test (+), reluctance to bear
weight, and hip flexion contracture
due to psoas irritation, Hamstring
tightness and loss of lumbar
lordosis
 Subacute and chronic infections:
vague history. Pain may be the only
symptom
 15% atypical symptoms: chest pain,
abdominal pain, hip pain, radicular
symptoms, or meningeal irritation.
 xxx

 48% lumbar >> 35% thoracic
>> 6.5% cervical >> 5%
thoracolumbar and
lumbosacral.
 17% neurologic deficit
secondary to nerve root or
spinal cord involvement
 xxx

 ESR
 CRP
 blood cultures and vertebral
cultures when both were
positive. 100% correlation
 xxx

 The findings on plain
radiographs are characteristic
but do not appear for at least 2
to 4 weeks.
 narrowing of the disc space 74%
 After 3 to 6 weeks, destructive
changes in the body can be
noted, usually beginning as a
lytic area in the anterior aspect
 Reactive bone formation and
sclerosis are present in 11%
 xxx

 CT:
 may show cystic changes in the
bone, as well as soft tissue masses
 gas in the soft tissues or within the
bone and disc
 lytic destruction of the body.
 The prevertebral soft tissue
involvement completely surrounds
the spine anteriorly
 destruction of the vertebra
generally an osteolytic process
around the disc space
 A relatively unique feature of
tuberculous infection is
vertebral fragmentation and
paraspinal calcifications
 The destruction tends to
extend into the pedicle,
which is uncommon in
pyogenic infections.

 Myelography and
postmyelography CT:
 indicated in cases of neurologic
deficit and radicular pain to rule
out epidural and subdural
abscesses
 MRI:
 imaging modality of choice for the
evaluation of spine infections.
 early diagnosis of infection and
recognition of paravertebral or
intraspinal abscess
 xxx

 MRIT1-weighted sequences:
 there is a confluent decreased
signal intensity of the vertebral
bodies and adjacent disc, making
the margin between the two
structures indistinct.
 MRIT2-weighted sequences:
 the signal intensity of the vertebral
bodies and the involved disc is
higher than normal
 generally an absence of the
intranuclear cleft normally seen
within the adult disc
 xxx

 MRI- gadolinium contrast
enhancement:
 The extent of the infection is
best seen
 The disc and the involved
portions of the vertebral bodies
reveal a marked increased signal
intensity that delineates the
margins of the infection
 xxx

 (1) degree of bone destruction:
 30% severe vertebral body destruction.
 (2) degree of disc Preservation:
 3% preserved disc space
 (3) paraspinal abscess appearance
 ill-defined areas of enhancement
 (4) abscess with postcontrast rim
enhancement:
 discreet rim enhancement intraosseous
abscess was never observed
 (5) post contrast enhancement
pattern of the vertebral body:
 diffuse and homogeneous.
 (1) degree of bone destruction:
 82% had near complete destruction of at
least one vertebral body
 (2) degree of disc Preservation:
 57% disc was preserved
 (3) paraspinal abscess appearance
 well-defined rim-enhancing lesions
 (4) abscess with postcontrast rim
enhancement:
 rim enhancing abscesses
 (5) post contrast enhancement
pattern of the vertebral body:
 always focal and heterogeneous, with.
degree of bone destruction
30% severe vertebral body destruction 82% had near complete destruction of at least one
vertebral body
degree of disc Preservation
3% preserved disc space 57% disc was preserved
paraspinal abscess appearance
ill-defined areas of enhancement well-defined rim-enhancing lesions
abscess with postcontrast rim enhancement
discreet rim enhancement intraosseous abscess was
never observed
rim enhancing abscesses
postcontrast enhancement pattern of the vertebral body
diffuse and homogeneous always focal and heterogeneousRothman-simeone. The Spine, 6th ed.2011

 A definite diagnosis is
possible by closed-needle
biopsy in 68% - 86% of cases
 cc

 Blood cultures are positive in
24% to 59%
 Biopsy

 Tuberculosis
 fungal infections
 metastatic carcinoma,
 multiple myeloma
 localized Scheuermann disease,
 trauma,
 degenerative disease,
 epidural abscess
 Fractures associated with
osteoporosis
 Less common disorders
 leukemia,
 perinephric abscess,
 neuropathic spinal arthropathy
 sarcoidosis
 xxxx

 The goals of treatment:
 are to establish tissue and
bacteriologic diagnoses
 prevent or reverse neurologic
deficits
 Relieve pain
 establish spinal stability
 correct symptomatic spinal
deformity
 eradicate the infection
 prevent relapses
 xxxx

 choice of antibiotics should be
based on the culture and
sensitivity test
 Recommended that parenteral
antibiotic therapy be used in
maximal dosage for 6 weeks and
followed with an oral course of
antibiotics until resolution of the
disease.
 It may be reasonable to switch
from parenteral to oral therapy
at 4 weeks
 xxx

 Patients should be immobilized
for pain control and prevention
of deformity or neurologic
deterioration
 The length of time a patient
should remain at bed rest, the
type of orthosis, and the
duration of its use all depend on
 the location of the infection in the
spine
 the degree of bone destruction
and deformity
 response to treatment.
 xxx

 (1) to obtain a bacteriologic diagnosis
when closed biopsy is negative or deemed
unsafe;
 (2) when a clinically significant abscess is
present (spiking temperatures and septic
course);
 (3) in cases refractory to prolonged
nonoperative treatment, where the ESR
and/or CRP remain high or pain persists;
 xxx

 (4) in cases with spinal cord
compression causing a
neurologic deficit;
 (5) in cases with significant
deformity or with significant
vertebral body destruction,
especially in the cervical spine.
 xxx

 In most cases the spine should
be approached anteriorly
because this allows direct access
to the infected tissues and
adequate débridement.
 Anterior exposure allows
stabilization of the spine by
bone grafting, which promotes
rapid healing without collapse
and assists rehabilitation
 xxx

 Laminectomy without
anterior débridement and
reconstruction is
contraindicated in most cases
because it may lead to
neurologic deterioration and
increased instability
 xxx

Banal vs tb infection of spine team viii

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