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Other spine infections
The document discusses various types of spine infections including pyogenic osteomyelitis, discitis, fungal spine infections, and parasitic infections. It covers the definition, etiology, risk factors, clinical features, investigations, and management for each type. Key points include that pyogenic osteomyelitis most commonly affects the elderly or immunocompromised, discitis usually results from invasive procedures, fungal infections occur in immunocompromised patients, and echinococcus granulosus is a common parasitic infection in sheep-raising areas. Treatment involves antibiotics, surgery if needed, and addressing any underlying risks.
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Other spine infections
- 1. OTHER SPINE INFECTIONS NUR FARRANAJWA BINTI ABDUL AZIM 082015100035
- 2. LEARNING OBJECTIVES By theend of seminar, students should be able to explain • Definition • Etiology • Risk factor • Clinical feature • Management 1. Pyogenic osteomyelitis 2. Discitis 3. Fungal spine infection 4. Parasitic infection
- 3. INTRODUCTION • The axialskeleton cases of osteomyelitis is 2-7 %. • Predisposing factors – Diabetes mellitus – Malnutrition – Substance abuse – Human immunodeficiency virus (HIV) infection – Malignancy – Long-term use of steroids – Renal failure – Septicaemia.
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- 5. INTRODUCTION • Acute pyogenicinfection of the spine is uncommon • Predisposing factor – The elderly – Chronically ill and immuno-deficient patients
- 6. PATHOLOGY • Staphylococcus aureus(50–60%) • Immunosuppressed patients – Gram negative organisms • E. coli and pseudomonas • Sources of infection are – Haematogenous spread from a distant focus of infection – Inoculation during invasive procedures
- 7. Infection begins inthe vertebral endplates 1) Secondary spread to the disc and adjacent vertebra 2) Spread along the anterior longitudinal ligament to an adjacent vertebra 3) Outwards into the paravertebral soft tissues
- 9. Cont. • Spinal canalis rarely involved – Once infected, form an epidural abscess (surgical emergency!) • Even rapid surgical decompression, – some degree of permanent paralysis present From the thoracic spine along the psoas to the groin From the lumbar region to the buttock, the sacroiliac joint or the hip. 3) Outwards into the paravertebral soft tissues
- 11. SPINAL DECOMPRESSION SURGERY •A general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression, on the spinal cord and/or nerve roots, ex, – a corpectomy, – a diskectomy, – a laminotomy, – a foraminotomy, – or osteophyte removal.
- 12. CLINICAL FEATURES • History –Invasive spinal procedure – A distant infection during the preceding few weeks • A careful history and general examination to exclude a focus of infection – Skin, ENT, chest, pelvis.
- 13. Cont.Localized pain (the cardinal symptom) Intense Unremitting Associated with musclespasm and restricted movement Point tenderness over the affected vertebra. Intercostal neuralgia is a frequent symptom with thoracic spine involvement. Systemic sign pyrexia and tachycardia.
- 14. IN CHILDREN The diagnosisis difficult Awkward gait with a stiff spine If lumbar spine is involved they can present with abdominal symptoms and signs
- 15. IMAGING • X-rays – Nochange for several weeks; – Delayed diagnosis, the examination should be repeated. • Early signs are – Loss of disc height – Irregularity of the disc space – Erosion of the vertebral end-plate – Reactive new bone formation – Soft-tissue swelling may be visible • The early loss of disc height distinguishes vertebral osteomyelitis from metastatic disease, where the disc can remain intact despite advanced bony destruction.
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- 18. Cont. • Radionuclide scanningwill show increased activity at the site but this is non-specific. • MRI may show characteristic changes in the – Vertebral end-plates, intervertebral disc and paravertebral tissues; – This investigation is highly sensitive but not specific. – Similar features may be seen in discitis. • Needle biopsy may help with diagnosis, but often no organism is found.
- 19. Cont. • Other investigations –The white cell count – C-reactive protein (CRP) level – Erythrocyte sedimentation rate (ESR) – Anti-staphylococcal antibodies – Agglutination tests for salmonella and brucella (endemic regions). – Blood culture is essential in patients who are febrile though it is often negative in the early stages of infection.
- 20. TREATMENT • If theblood culture is negative a closed needle biopsy is performed • Treatment is started – Basis of a clinical diagnosis of infection – Includes bed rest, pain relief and intravenous antibiotic administration • The duration of antibiotic treatment depends on the – Clinical, haematological and radiological findings. • Intravenous antibiotics – For 4–6 weeks; – If there is a good response – Oral antibiotics are then used for a further 6– 8 weeks and the patient is mobilized in a spinal brace. • As methicillin-resistant staphylococcus aureus (MRSA) – Vancomycin or linezolid may be required. • During this period nutritional support and management of co- morbidities
- 21. OPERATIVE TREATMENT • Seldomneeded • The indications for an open biopsy and decompression are – Failure to obtain a positive yield from a closed needle biopsy and a poor response to conservative treatment – The presence of neurological signs – The need to drain a soft-tissue abscess • An anterior approach is preferred – Necrotic and infected material is removed – If necessary, the cord is decompressed – The anterior column defect is reconstructed with rib or iliac grafts • For a primary epidural abscess, laminectomy is indicated.
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- 23. Cont. • In theelderly and in immuno-compromised patients – posterolateral extraplueral /retroperitoneal decompression and instrumentation is effective. • Unstable spine – posterior fixation may be necessary • Postoperatively – spine is supported in a brace until healing occurs. • Spontaneous fusion of infected vertebrae is a common radiological feature of healed staphylococcal osteomyelitis.
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- 25. INTRODUCTION • Infection limitedto the intervertebral disc is rare • Usually due to direct inoculation – Following discography – Chemo-nucleolysis – Discectomy • The vertebral end-plates are rapidly attacked and the infection then spreads into the vertebral body
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- 28. CLINICAL FEATURES • Directinfection – History of some invasive procedure. • History of – Flu-like illness followed by – Back pain, muscle spasm and severe limitation of movement. • Systemic features – Mild, but the ESR is elevated. • In children the infection : blood borne.
- 29. INVESTIGATIONS • X-rays, radioscintigraphyand MRI show the same features as in pyogenic spondylitis.
- 30. RADIOGRAPHIC FEATURES PLAIN RADIOGRAPHCT • Insensitive to the early changes of diskitis/osteomyelitis, • Normal appearances being maintained for up to 2-4 weeks. • CT findings are similar to plain film • More sensitive to earlier changes. • Thereafter disc space narrowing and irregularity or ill definition of the vertebral endplates can be seen. • Additionally, surrounding soft tissue swelling, intervertebral disc enhancement with contrast, collections • In untreated cases, bony sclerosis may begin to appear in 10-12 weeks.
- 31. TREATMENT PREVENTION IS ALWAYSBETTER THAN CURE • After an injection into the disc – Broad-spectrum antibiotic should be administered intravenously. • Non-iatrogenic discitis – Self-limiting • Acute stage – Bed rest and analgesics are essential • If symptoms do not resolve rapidly – Needle biopsy is advisable • Only if there are signs of abscess formation or cord or nerve root pressure – Surgical evacuation or decompression indicated.
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- 33. INTRODUCTION • These areopportunistic infections occurring in an immuno-compromised host however, may also affect a normal host • Air-borne fungi that initially affect the lungs – Ex: Aspergillosis and Cryptococcus – Spine is involved by haematogenous spread. • In children with chronic granulomatous disease, – Thoracic spine involvement is due to contiguous spread from the lungs.
- 34. CLINICAL PRESENTATION, CLINICAL FINDINGSAND RADIOGRAPHIC FEATURES • May mimic those of TB. • The chest x-ray may show – A fungal ball or pneumonia. • The diagnosis by – Sputum examination and bronchoscopy. • The immuno-diffusion test is specific for Aspergillosis and the latex agglutination test for Cryptococcus. • A biopsy is performed to confirm the diagnosis.
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- 37. TREATMENT • Neurological deficitis an indication for operative decompression. • Specific treatment includes – 5-flucytosine and Amphotericin B – Synthetic oral antifungals. • Concurrent treatment of the underlying immuno-comprised state is essential
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- 39. INTRODUCTION • The commonestparasitic infestation of spine due to – Echinococcus granulosis • It is encountered in areas where sheep are raised – Australasia, South America, Parts of Africa, Wales and Iceland.
- 40. DEINITIVE HOST Dogand as well as other canine animals. INTERMEDIATE HOST Dog and humans MODES OF INFECTION Enters the human host by being either ingested through faecal contamination or by inhalation of dessicated particles in dust. LIFE CYCLE The embryos come to lodge in the liver and the lungs. Dissemination to other sites, including the bones (mainly the spine, skull and long bones) where hydatid cysts develop in about 1 per cent of cases. Hydatid disease is usually picked up in childhood but it may be many years before the diagnosis is made.
- 41. CLINICAL PRESENTATION AND CLINICALFEATURES • Similar to those of other forms of spondylitis. • X-rays may – Reveal a translucent area with a sclerotic margin in the affected vertebral body • In untreated cases – Lead to bone destruction • Significant morbidity and mortality due to – Neurological deficit – The difficulty in eradicating the disease – The tendency to recurrence make for
- 42. http://www.jotr.in/article.asp?issn=0975- 7341;year=2017;volume=9;issue=2;spage=134;epage=138;aulast=Jain Figure 1: Anteroposterior(a) and lateral (b) lower dorsal spine radiographic views of the patient showing paraspinal fusiform swelling from D6 to D11, along with the right hemicollapse of D9 and reduced D9–D10 intervertebral disc space
- 43. Figure 2: SagittalT2 (a) and T1 (b) with coronal T2 (c) and transverse (d and e) magnetic resonance images dorsolumbar spine of the patient showing two oval cysts measuring 10 cm × 9 cm × 5 cm contained multiple round grape bunch-like daughter cysts, in the right pre- and para-vertebral region along with erosion of the right half of D8 and D9. The cysts are hypointense in T1 and hyperintense in T2 sequences http://www.jotr.in/article.asp?issn=0975- 7341;year=2017;volume=9;issue=2;spage=134;epage=138;aulast=Jain
- 44. Figure 3: Coronal(a) and transverse (b and c) computer tomographic views of patient showing the normal liver and chest with long two well-circumscribed hypoattenuating cystic lesions in the posterior mediastinum with multiple daughter cysts with erosion of D9 vertebra http://www.jotr.in/article.asp?issn=0975- 7341;year=2017;volume=9;issue=2;spage=134;epage=138;aulast=Jain
- 46. Cont. • Systemic treatment –Albendazole – Which is active against the larvae and the cysts – Three cycles of 25 days each is the usual recommendation. • Operative treatment to achieve spinal decompression may be called for – Spillage of cyst contents must be avoided.
- 47. SUMMARY Definition Etiology Risk factor Clinical feature Management Pyogenic osteomyelitis Discitis Fungal spine infection Parasitic infection
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