Spine conference on spinal infections Dec 2018

1. Union Memorial
Spine Conference
Spinal Epidural Abscess
December 22, 2018

2. 56 year old man with lower thoracic pain
HPI: Onset of thoracic pain 5 weeks ago pain in the lower thoracic area with radiation to the B flanks to anterior chest. patient had difficulty sleeping and
would sleep on couch.The patient thought he had the flu 4 weeks ago with anorexia, sweats and hot/cold sensations. H/O right foot cellulitis onset
several days later while helping daughter at home with a construction project. Patient went to ER for right foot cellulitis. Was given 10 days bactrim and
foot cellulitis completely resolved. Patient started eating again but back pain worsened. now back pain contant and severe. Saw PCP MRI was ordered
which showed findings at T8T9. no fevers. No extremity sx
SH: computer science chief network manager
Exam: nonfocal. No deficits. Normal.

3. T8T9

7. Wbc 10.5
IgA 546 (70-400)
Free K 34.99 (3-19)
Free lambda 31.73 (5-26)
ESR 115
CRP 67 (0-3)
Globulin 4.9 (1-4.7)
Skeletal survey negative
Bone scan neg
CT : small B apical nodule left lung mass 2.7 x 1.7 cm

8. biopsy :few pmn, moderate , positive cocci in pairs
MRSA

9. The slide “A” demonstrates reactive bone formation with associated reactive vascular tissue and inflammatory cells and debris
at the left side of the slide.

10. Slide “B” shows the interface between the existing bone and the inflammatory/reactive tissue with multinucleated osteoclasts. The
bone is a little out of focus in the upper left of the photo.

11. Slide “C” is higher magnification of the interface in “B”, more clearly showing the osteoclasts.

12. Slide “D” is the interface between the inflamed and edematous granulation tissue and cartilage. You can see the irregularity of the interface as
the inflammation eats into it.

14. initial 2 weeks
Abx

15. HOW?

26. Clinical Features
• Signs:
• back pain 86%
• Fever 40%
• Tests:
• Blood Cx 47%
• CRP
• Biopsy: open/CT

27. Organism
• None 7%
• Multiple 10%
• Virulent 60%:
• Low Virulent 48%
staph aureus 36%
staph epidermidis 10%
beta hem strep 10%,
E Coli/ Strep Viridans 7%

28. Non-operative
candidates
• Age<60
• Immune status
• Staph aureus
• Decreasing
ESR

29. Co-morbitidities
• Diabetes
• Corticosteroids
• Malignancy/chemo
• Rheum/Immuno
• Renal/Hepatic Failure
• Malnutrition
• myelodysplasia

30. Source
• Urine 19%
• Resp 7%
• Oral
• i.v. line
• Foot ulcer
• Wound
• Operative site
• Endocarditis

31. Imaging
• Xray
• CT
• MRI
• Bone Scintigraphy
• Leukocyte
Scintigraphy
• Gallium Scintigraphy
• Fluorodeoxyglucose
Positron Emission
Tomography (PET)

33. 73 woman LBP urosepsis

37. 63 year old woman
Cc:neck pain, HA, chest
and back pain 4 days
HPI: L LE weakness 6
months, worse in last 4
days
ED visit downtown ER 1-2
days after onset of sx CT
C4C5 deg
PMH: metastatic
endometrial ca, HLD<
HTN, chronic
lymphedema, DM A1C
10.7
Permanent central port
2012 for magnesium
Exam: LUE motor 2/5
biceps, delt
4/5 wrist flex/ext
RUE 5/5
Hoffmans –ve
BLE 4/5
CT Head/aorta echo neg
WBC 28k 89%PMN, esr
122, crp 318 glu random
345, bac in urine, blood cx
MRSA

39. L1

40. T12

41. • C2T2, T6T7,
T11L1 MRSA

43. ld man with neck pain and right hand numbness. constant right hand numbness that is always present 5 months now. Sometimes
nd becomes numb off and on. At night pain in anterior chest wall just inferior to her clavicle area. pain in neck and bilateral shoulders
ter than left over her deltoid areas. no pain past shoulders. numbness in her right hand specifically her right thumb right index finger
le finger right ring finger. no symptoms on the left
d with severe back pain and therefore an MRI of the cervical thoracic and lumbar spine were performed. toe infection which 2 weeks
ed the right shoulder which required incision and drainage type surgery.

44. flex
ext

45. left

46. 5 months ago

48. c2 c3c4
c4c5
c7t1

49. now

51. c2c3 c3c4
c4c5
c5c6 c6c7
c7t1 t2 t2t3
t4

52. Univ of Washington Seatle 128 spontaneous SEA, f/u mean 8 months, 2005-
2011
51 patients: Abx, 41% failed due to pain or weakness,
77 patients: surgery
Predictors for failure: DM, CRP>115, WBC>12.5,positive blood cx
No predictors: 8.3% failure of abx only
1 predictor :35%, 2:40%, 3 or more: 77%
Early surgery improves neurologic outcome compared with trial of antibiotics
and delayed surgery

56. 52 yo aa female with cc: LBP
pain for 2-3 months presented 9/1/9
PMH: sarcoidosis
SH: clerical govt married

60. T100

61. L1

62. L1

63. L4L5

64. L4L5

66. Macrophage

67. Granuloma non-caseating sarcoid

68. Caseating granuloma: infection TB

69. Lung Biopsy non-caseating granulo

70. Spine Biopsy:
caseating
granuloma

71. Spine Biopsy:
caseating
granuloma

72. High power spine biopsy AFB

73. Mycobacterium tuberculosis
The main cause of TB is Mycobacterium tuberculosis, a small, aerobic, nonmotile
bacillus.[9] The high lipid content of this pathogen accounts for many of its unique clinical
characteristics.[17] It divides every 16 to 20 hours, which is an extremely slow rate
compared with other bacteria, which usually divide in less than an hour.

77. initial 2 weeks
Abx

82. CW DOB 3/30/18
• 93 year old man CC: thoracolumbar back pain and inability to walk for 1-2
weeks
• MRI 6/17/03 for low back pain L4L5 spondylolisthesis
HPI:
• inItial fx Jan 2011 from xray 1/9/11 L1 superior endplate fx
• Urosepsis with MRSA with diagnosis of spine infection 5/23/11
• Negative biopsy CT guided 5/26/11
• MRI 6/6/11 osteomyelitis T12L1 treated with iv Vanco
• MRI 8/22/11 now epidural abscess surrounding dura

83. June 2003 LBP

84. Mri from ER
visit 6-17-03
L3
pedicle
L3L4 disc
space

85. Mri 1-9-11
L1 superior
endplate fx
following fall

86. Jan 10,
2011 L1
Fx

87. MRI 5-23-11
WORSENING LBP
WITH H/0
UROSEPSIS IN
MARCH 2011

89. MRI 6-6-11

90. MRI 8-22-11

91. 8-22-11

92. problem list
• T12L1 osteomyelitis probable MRSA
• T12L1 kyphosis and collapse of T12
• L3L4 stenosis
• L4L5 spondylolisthesis
• Nonagenarian
• Patient’s pain is so severe it is not
controlled with high dose opiates and self
imposed bed rest

99. L3L4

100. Pain
dramatically
improved
but could
not
ambulate,
failure to
thrive, sent
to hospice
after one
month, died

101. Thanks!

106. Monoclonal proliferation of Plasma cells
WBC secrete Ab
Bone marrow

107. • stem cell 2011

110. ll study in the Lancet 2005 revealed spinal cord compression from metastatic disease
42/50, 84%) than in the radiotherapy group (29/51, 57%) were able to walk after
treatment (odds ratio 6.2 [95% CI 2.0-19.8] p=0.001). Patients treated with surgery
also retained the ability to walk significantly longer than did those with radiotherapy
alone (median 122 days vs 13 days, p=0.003). 32 patients entered the study unable
to walk; significantly more patients in the surgery group regained the ability to walk
than patients in the radiation group (10/16 [62%] vs 3/16 [19%], p=0.01). The need for
corticosteroids and opioid analgesics was significantly reduced in the surgical group.

112. 2:1 black:white
7th decade of life most common
60% are 65 and older
27k/year in the US 2015
11k died in 2015 US
More common in men

113. 70% have bone pain

114. fatigue

115. neuropathy
Henry Bence
Jones (1813-1871)
English physician
Described proteins
In 1847

116. Bone Marrow Aspirate

119. Bone marrow aspirate >10% plasma cells

121. Peripheral smear shows rouleaux formation of RBC

122. LABS

126. Bence Jones proteins in urine
M spike in blood SPEP

127. Skeletal met of unknown origin
85% diagnosis prior to biopsy and biopsy gave Dx in 8%
Rougraff BT, Kneisl JS, Simon MA: Skeletal
metastases of unknown origin: A prospective
study of a diagnostic strategy. J Bone Joint Surg
Am 1993; 75(9):1276-1281.
Workup includes skeletal survey, CT?, labs

128. End Organ Damage
C: hypercalcemia
R: renal
A: anemia
B: bone lesions

129. Monoclonal gammopathy
Uncertain significance
smouldering

132. Ninlaro is an oral formulation of
velcade
Approved Nov 2015; $8k/4 weeks
Approved 11/2105
$23k/month
Approved 11/2105; $10k/mo
$6k/mo

133. EXTERNAL BEAM RADIATION
XRT

135. 5 year survival has increased dramatically
In the last 10 years, patients can live around
7 years after diagnosis

137. JL
• 56 wm cc: LBP increased in the last 2-3 days
• HPI: admitted 1-11-10 bacteremia (MRSA), LLL pneumonia
• PMH: L3L5 laminectomy 2003 with chronic LBP on disability, IDDM, charcot
arthropathy with foot ulcer, PVD, TIA, CAD, HTN, cardiac stent
• Hospital course: L psoas I&D 1-15-10
• Xray: 7-5-03
• CT myelogram: 1-30-04
• Xray: 1-26-06
• Xray: 1-11-10
• MRI Lumbar: 1-13-10
• MRI: 1-29-10

138. JL
• 56 wm cc: LBP increased in the last 2-3 days
• HPI: admitted 1-11-10 bacteremia (MRSA), LLL pneumonia
• PMH: L3L5 laminectomy 2003 with chronic LBP on disability, IDDM, charcot
arthropathy with foot ulcer, PVD, TIA, CAD, HTN, cardiac stent
• Hospital course: L psoas I&D 1-15-10
• Xray: 7-5-03
• CT myelogram: 1-30-04
• Xray: 1-26-06
• Xray: 1-11-10
• MRI Lumbar: 1-13-10
• MRI: 1-29-10