Pyogenic spondylitis cme chitwan 2019

PYOGENIC
SPONDYLITIS:WHEN TO
SUSPECT AND HOW TO
MANAGE?
SURESH PANDEY
CONSULTANT ORTHOPEDIC SURGEON
CHITWAN HOSPITAL
MANAKAMANA HOSPITAL
Spine CME 2019 Chitwan

– Definition
– Epidemiology
– Pathophysiology
– Presentation
– Investigation
– Differential
– Treatment
– Prognosis

What is Pyogenic spondylitis?
– Spondylitis: Inflammation of vertebra
– Pyogenic spondylitis: Osteomyelitic inflammation of vertebra, disc and
paravertebral structures
Includes
vertebral osteomyelitis
disc infection
epidural infection

What is spondylodiscitis?
– Inflammation of both vertebra and
disc
– Inevitable part in pyogenic
spondylitis

Components of spinal infection

Problem magnitude
– Relatively less common but increasing prevalence
– Upto 4% of pyogenic osteomyelitis
– Less common than Tubercular
– M:F 2:1
– 5th decade onward most common

– Common in lumbar spine followed by thoracic and cervical spine
unlike tubercular which is most common in
thoracic/Thoracolumbar junction spine

Causes of Increasing Incidence
– Increased life expectancy
– Immunocompromised such as HIV, chronic steroid use, IV drug
abuse
– Increased rate of spinal surgery/Invasive procedures
– Better diagnostic modality and accuracy

Risk factors
– Immunocompromised state
– Advanced age
– IVDU
– Systemic comorbidities such as CRF, liver failure
– Previous infection: UTI, Skin, OM
– Spinal procedures: surgery and needle biopsy

Microbiology
– Mostly monomicrobial
– Polymicribioal (<10%)
– S aureus is the most common ( upto 84%)
– Streptococci and Enterobacteriae 2nd most common group (7-33%)
– E coli, proteus, klebsiella
– More common gram negative infection with H/O UTI, GI
infection

Pathogens…
– S epidermidis in implant related infection
– Salmonella in sickle cell
– Pseudomonus in IVDU

MRSA
– Increasing (40-57%)
– Male , multiple comorbidities and previous non spine surgery are
risk factors

Pathophysiology
– Haematogenous: Bacteremia from distant site of infection. Most
common
– Nonhaematogenous:
– Direct inoculation due to spinal procedures/surgery or implant
– Contiguous due to spread of infection from adjacent tissue e.g.
retropharyngeal abscess

Pathogenesis…
– Vertebral destruction, end plate erosion
– Disc destruction marked by proteolytic enzyme of pyogenic
bacteria unlike tubercular
– Vertebral destruction, collapse, instability, neural compromise,
paravertebral, epidural abscess

Pathog… children vs adult
– Disc vascular supply persistent
– Disc involvement prominent
– Relative preservation of vertebra
– Vascular network anastomosis in the metaphysis
– Child vs adult vertebra

Path… adult
– Metaphyseal arterioles are end artery
– Mainly body destruction early
– Disc involvement late as compared to children

Tubercular vs pyogenic
– Mainly thru Batson’s plexus i.e. venous channels
– Mainly vertebra and end plate involvement. Disc relative
preservation in the early stage

Presentation
– Lumbar spine more common
– Relatively acute symptoms of short duration
– 2-12 weeks of symtomatology

Pain
– Pain, spasm, tenderness axial region of variable degree
– Most common(90%)
– Upto 80% have severe pain not controlled with analgesics
– Insidious onset
– Weeks to months
– Suspect epid abscess in severe pain with radicular feature

Fever
High to low grade (upto 60%)
May be absent

Constitutional symptoms
– lethargy
– wt loss
– dysphagia
– vomiting

Neurological Involvement
– sensory, motor or bowel bladder function
– Upto 29% present with some form of neurolocal compromise
– 80% of them partial

Look for primary focus
– UTI
– GI
– Respiratory
– Endocarditis
– Present upto 50%

Clinical suspicision when
– 5th decade and onward
– Male
– Relatively short duration and insidious symptoms
– Marked pain, spasm, fever with or without neurological deficit
– Immunocompromised patient
– Source of infection elsewhere in the body

Diagnosis
– Difficult to establish etiological diagnosis due to close resemblance to
tuberculosis spine
– Clinical, imaging, lab data correlation
– Final confirmation with histopath and bacterial growth demonstration

Blood
– CBC: Leukocyte count marginally raised or normal. Hign neutrophils also not
reliable.
– ESR: significantly raised. Sensitive but non specific
– CRP: markedly raised within 6 hours of infection. More sensitive and specific
than ESR
– Monitor treatment response as decreses by 50% in 1 wk if good response

Lab…
– ESR and CRP incresase in many condtions : post op, inflammatory, infection
– ESR peaks apprx 5th day and normalize in 3 wks
– CRP peaks at 2-3 days and normalizein 6-14 days

Culture
– Etiological diagnosis and antibiotics guidance
– Blood culture
send in all patient irrespective of fever
Diagnostic value of 30-70%
May obviate invasive biopsy procedure

Antibiotic and impact on culture
report

X ray Imaging
– Normal in early phase
– End plate erosion and irregularity (2-10 wks of infection)
– Consider deg changes
– Late stage collapse of vertebra
– Loss of disc space
– Fusion
– Soft tissue shadow and abscess

X ray
– Low sensitivity
– Degenerative spine may confuse early findings
– Can help to differentiate from spinal tumor such as MM and mets.

TB spine on X ray
– Rarefaction of vertebrae is present
besides end plate erosion,
irregularity, loss of disc space,
vertebral destruction, deformity,
paravertebral large abscess.

MRI
– Gold standard of imaging
– Better than less sensitive plain radiograph and less specific radioscan of nuclear
medicine

MRI
– Typical findings T1 hypointense and T2 weighted hyperintense vertebra and disc
with contrast enhancement

MRI…
– Pyogenic spondylodiscitis with T1
and T2 image with loss of disc
space , end plate erosion

MRI Pyogenic vs Tumor
– Tumor also shows T1 hypo and T2 hyper intense but disc
is preserved
– Posterior elements involvement
– Possible site of primary
– Mets in the other parts

Year : 2015 | Volume : 6 | Issue : 2 | Page : 388-393
Results: The most common pattern of spinal infection was spondylodiscitis (78% incidence
rate) with epidural extension (86%) and cord compression (64%) being most common
complications observed. Imaging (postcontrast study) and final diagnosis correlated in 93.7%
tubercular (sensitivity of 75% and specificity of 90%) and 75% pyogenic (sensitivity of 90%
and specificity of 83.3%) spondylodiscitis. The patients with tubercular spondylitis had a
significantly (P < 0.05) higher incidence of following MRI findings: A well-defined paraspinal
abnormal signal (80% in TS vs. 40% in PS), a thin and smooth abscess wall (84.2% in TS vs.
10% in PS), presence of intraosseous abscess (35% in TS vs. 0% in PS), focal and heterogenous
enhancement of the vertebral body (75% in TS vs. 20% in PS), vertebral destruction more
than or equal to grade 3 (71.8% in TS vs. 0% in PS), loss of cortical definition (75% in TS vs.
20% in PS), and spinal deformity (50% in TS vs. 5% in PS). Conclusion: Contrast-enhanced
images improve the sensitivity and specificity of detection and differentiation of tubercular
and PS.
Utility of magnetic resonance imaging in the differential diagnosis of tubercular and pyogenic
spondylodiscitis
Ritu Dhawan Galhotra, Tanica Jain, Parambir Sandhu, Vineet Galhotra
Department of Radiodiagnosis, Dyanand Medical College and Hospital, Ludhiana, Punjab, India

MRI evidence of healing and
healed state
– Decreasing contrast enhancement is sign of healing
Healed state
Absence of contrast enhancement
Normal signal pattern

Pyogenic vs Tubercular
– Disc involve early late
– ≤2 vertebra >2 vertebra
– No skip lesion skip lesion
– Paravertebral abscess less common more common
– Small abscess large abscess
– Subligamnetous spread less more
– Body destruction <1/2 >1/2 body destruction common
– Lumbar spine common thoracic or T-L

Pyogenic vs Tubercular
– Abscess intradiscal common intravertebral common
– Abscess wall thick and irregular thin and regular
– Affection anterolateral anterior
– Posterior element rare can involve

Intravertebral abscess in tubercular
with no disc involvement

PS with disc abscess, thick and
irregular abscess wall

Pyogenic spondylodiscitis
following facet joint injection

Post percutaneous discectomy PS

Epidural abscess mimicking
HNP

Pyogenic spondilodiscitis

MRI summary favouring
Tubercular spine
– ≥2 vertebra
– Relative preservation of disc
– Paraspinal shadow/abscess
– Marked vertebral destruction
– Instability
– Intraspinal abscess
– Abscess wall thin and regular
– Heterogenous contrast enhancement of vertebral body

MRI summary favouring
Pyogenic spondylitis
– ≤2 vertebra
– Intradiscal lesion
– Early disc collapse
– Minimal or no paravertebral abscess
– Less vertebral destruction
– Instability none or minimal
– Abscess wall thick and irregular
– Homogenous enhancement of vertebra
– Ill-defined paraspinal contrast enhancement

CT scan
– Can better delineates bony destruction but inferior diagnostic value than MRI
– Routinely not used and useful for CT guided biopsy and where MRI is
contraindicated

PCR
– Tissue subjected to PCR
– High sensitivity
– May be used if available
– Helpful when blood culture, tissue culture and biopsy are inconclusive

Nuclear imaging
– Sensitive but less specific
– 99 Tech: 90% sensitivity but low specificity
– Gallium: sensitivity similar to MRI but low for epid abscess
– Leukocyte labelled: sensitive but less specific
– 18F-fluorodeoxyglucose labelled PET very sensitive and specific if available

Biopsy
– Most sensitive tool for etiological diagnosis and
confirmation
– Indicated when
– Diagnosis is doubtful
– To differentiate from tubercular spine and spinal tumor
– Other investigations are inconclusive such as blood
culture, imaging, nuclear imaging

Biopsy types
– CT/Fluoroscopy guided
percutaneous biopsy: Yield rate
upto 70%
– Open biopsy: better diagnostic
value but cost and morbidity
associated is important
consideration

Diagnostic Value of Biopsy
– Range from 47-100%
– Drainage of pus and culture and biopsy of the same sample is preferred in
epidural, paravertebral or psoas abscess rather than bone or disc biopsy.
– Send for pus cuture, AFB stain, AFB culture, fungal and anaerobe culture
besides histopath examination

Fine needle vs wide bore needle
– 60%:41%

Tissue culture yield
– Meta analysis: 48%
– Prior antibiotic vs no antibiotics:

Closed vs Open biopsy: pros and
cons?

DATA SYNTHESIS: Image-guided biopsy has a yield of approximately 48% (793/1763),
which is significantly lower than the open surgical biopsy yield of 76% (152/201; P .01).
Biopsy in patients with prior antibiotic exposure had a yield of 32% (106/346), which was
not significantly different from the yield of 43% (336/813; P .08) in patients without prior
antibiotic exposure.
Yield of Image-Guided Needle Biopsy for Infectious Discitis: A
Systematic Review and Meta-Analysis X A.L. McNamara, X E.C. Dickerson, X
D.M. Gomez-Hassan, X S.K. Cinti, and X A. Srinivasan

Image-guided biopsy had a significantly higher yield in the
detection of mycobacterium tuberculosis at 71% (97/132;
95% CI, 0.54 –0.84) compared with detection of pyogenic
organisms at 48%
Percutaneous Bx: PS vs TB

Fluoroscopy vs CT guided needle
biopsy
– 55 vs 44%
– Not significant

Biopsy…
– Performed after at least 48 hr after stopping antibiotics
– Antibiotics is not started before biopsy and culture if patient is stable and no
neurological deficit.

D/D
– TB spine
– Spondylosis
– Tm
– Disc herniation
– Osteoporotic fracture

Treatment
– Aim of treatment
– Eradication of infection
– Preservation of spinal structure and stability
– Prevention of neurological deficit
– Pain relief

Conservative management
– Most of the patients can be managed with appropriate
antibiotics, pain management, immobilization and rest
– Consider suitable antibiotic against causative agent with
good bone and disc penetration property with less
systemic side effect

Antibiotics
– Empirically started after sending biopsy and culture except when
patient is unstable
– Cover S aureus, the most common causative agent and gram
negative
– Methicillin sensitive: cephalosporine, cloxacillin, Fluoroquinolones,
clindamycin
– MRSA: vancomycin (500mg IV QID), Daptomycin (6 mg/kg IV OD)
– Change antibiotic as per culture report

Antibiotics
– IV
– 4-6 weeks
– Followed by oral for total of 3 months or till patient recovers
clinicoradiologically and ESR and CRP return to normal
– Monitor renal function to see untoward side effect of long term antibiotics
– Undrained abscess and implant in site may need longer duration

Duration of antibiotics?
Antibiotic treatment for 6 weeks versus 12 weeks in patients with pyogenic vertebral
osteomyelitis: an open-label, non-inferiority, randomised, controlled trial
Prof Louis Bernard, MD Aurélien Dinh, MDIdir Ghout, MScDavid Simo, CRAValerie Zeller,
MDBertrand ssartel, MD et al.
Published:November 04, 201, Lancet
6 weeks of antibiotic treatment is not inferior to 12 weeks of antibiotic treatment with respect to
the proportion of patients with pyogenic vertebral osteomyelitis cured at 1 year, which suggests
that the standard antibiotic treatment duration for patients with this disease could be reduced to
6 weeks.

Practical consideration
– 6 wks (2 wks IV 4 wks oral) in uncomplicated pyogenic spondilodiscitis has
shown no difference in relapse, mortality and failure rate than 12 wks (6-6)
therapy

Organism, antibiotics and
relapse
– Relapse more in S aureus, MRSA and hence recommended for longer duration
antibiotics
– Vancomycin has higher relapse rate than Daptomycin (30%:3%)

Brace
– Initial 6-12 weeks for immobilization in non operative group

Healing
– Observed and monitored by CRP, ESR, clinical recovery and MRI findings
– Radiological recovery lags clinical recovery
– Healing at last can be confirmed by MRI with normal signal and no contrast
enhancement
– Condition with drained abscess heals earlier

Treatment failure
– Failure to respond to 2-4 weeks of IV antibiotics, persistence of fever, pain, non
return of CRP/ESR to normal are indicators of failure of conservative treatment

Antibiotics in children
– No definitive consensus
– 2-3 weeks of IV antibiotics followed by conversion to oral.

Operative
– Only 10%-20% patient may need surgical intervention in adult
– Children rarely require
– Conservative vs operative outcome?

Indication for surgical Treatment
– Cauda equina
– Progressive neurological deficit
– Failure of conservative treatment
– Gross destruction leading to spinal instability
– Large abscess

Aim
– Decompression
– Stabilization
– Evacuation of pus
– Send sample for histopath and microbiological study

Options
– Transpedicular drainage and posterior fixation
– Anterior debridement and anterior fixation with or without posterior fixation
– Combined one stage debridement and fixation
– Sequential debridement and fixation
– Posterior drainage

– Decompression and stabilization
anterior column with cage and
instrumentation

Instrumentation issue in active
Infection
– Biofilm and antibiotic resistance
– Titanium cage has been found with
low recurrence rate and high cure
rate

Optimal timing of surgery
– Emergency surgery for epid abscess compressing cord, cauda equine and
development of neurological deficit
– Posterior laminectomy and abscess drainage enough

Approach
– Anterior: standard as disc and vertebral bodies are the main affection
– Combined: long segment bone destruction and instability
– Posterior: epid abscess

Staged
– Posterior stabilization followed by anterior debridement and stabilization

Algorithm of Surgical Treatment

Prognosis
– Successful healing in upto 91%
– Mortality 2-11% (More so with comorbidities)
– Relapse upto 14%

Take home message
– Relatively uncommon but incidence rising
– Clinical correlation with lab and imaging analysis for accurate diagnosis
– Differentiate from tubercular spine
– Culture and histopath confirm the diagnosis
– Early intervention with suitable antibiotics of prolonged IV and oral course
successful in most of the cases
– Operative decompression with fixation and fusion may be indicated in advanced
cases

Thank you for
your Attention

Pyogenic spondylitis cme chitwan 2019

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