Infections Infections of the Spineof the Spine

F ihF ih Od hOd h Ab HAb HFreihFreih OdehOdeh Abu HassanAbu HassanF.R.C.SF.R.C.S.(.(Eng.), F.R.C.S.(Tr.&Eng.), F.R.C.S.(Tr.& Orth.).Orth.).F.R.C.SF.R.C.S.(.(Eng.), F.R.C.S.(Tr.&Eng.), F.R.C.S.(Tr.& Orth.).Orth.).

Professor Professor of Orthopedicsof OrthopedicsUniversity of Jordan Hospital University of Jordan Hospital -- AmmanAmman

1/15/2011 1Professor Freih Abu hassan -University of Jordan

Hematogenous spread :g pEndarteriolar circulation at the vertebral endplates is an areavertebral endplates is an area predisposed to hematogenous seeding.

in the lumbar spine followed by the thoracic spine.

1/15/2011 2Professor Freih Abu hassan -University of Jordan

1/15/2011 3Professor Freih Abu hassan -University of Jordan

1/15/2011 4Professor Freih Abu hassan -University of Jordan

1-Paraspinal abscess2-Extraspinal abscesses.

Paralumbar abscesses may point in theA Fl k t P tit' t i lA- Flank at Petit's triangle, B- Groin, C-Buttock,D- Popliteal fossa,D Popliteal fossa, E-Perirectal area.

1/15/2011 5Professor Freih Abu hassan -University of Jordan

1 S ti f ( ki it i1-Septic focus (e.g skin, genitourinary. 2-Invasive procedures.2 Invasive procedures. 3-Patients with spinal cord injury , due to chronic UTI and skin ulcersdue to chronic UTI and skin ulcers. 4- immunocompromised . p5-Penetrating trauma, spinal surgery, 6 Diabetes Rh A steroid use old age6-Diabetes, Rh.A,steroid use, old age,

1/15/2011 6Professor Freih Abu hassan -University of Jordan

A- S aureus 50%A S. aureus. 50% . B- Gram-negative Escherichia coli and

P d d P t iPseudomonas and Proteus species.C-Anaerobic organisms. g

1/15/2011 7Professor Freih Abu hassan -University of Jordan

1-(ESR) and (CRP) high in 90% of patients.1 (ESR) and (CRP) high in 90% of patients. 2- Needle biopsies guided by (CT) or fluoroscopy. Cultures are positive in 68% to 86% of cases. When negative

3- Open biopsy, positive in greater than 80% of cases.

samples sent for pathology to exclude Malignancy Stains for AFB fungal organismsMalignancy,Stains for AFB, fungal organisms, and pyogens.

1/15/2011 8Professor Freih Abu hassan -University of Jordan

ImagingImaging 1-Plain radiographsThe findings lag 2 to 3 weeks behind theThe findings lag 2 to 3 weeks behind the onset of symptoms.

A- Osteolysis in the ant. vertebral metaphyseal region, B- Loss of disk space height, C- End plate blurringC- End plate blurring, D- Subchondral reactive bone formation .

1/15/2011 9Professor Freih Abu hassan -University of Jordan

1/15/2011 10Professor Freih Abu hassan -University of Jordan

Long-standing disease causesLong standing disease causes

Vertebral destruction,Vertebral destruction, collapse, kyphosis, and abscess formation

1/15/2011 11Professor Freih Abu hassan -University of Jordan

2- Technetium bone scan86% in diagnosing vertebral osteomyelitis86% in diagnosing vertebral osteomyelitis.

3 CT scans3- CT scans Enhanced CT scans provide a useful view of th i l l id tif i f l lthe spinal canal, identifying areas of localneurologic compromise.

1/15/2011 12Professor Freih Abu hassan -University of Jordan

4-MR is the imaging 95% (modality of choice for spinal infections)

T1 loss of details of the nucleus pulposus, the vertebral end plates, and the associated metaphyseal region.

T2 hyperintensity of the disk space and possibly associated epidural abscesses.

1/15/2011 13Professor Freih Abu hassan -University of Jordan

T12-L1 disk space and the entire L1 body have decreasedsignal and the end plates are indistinct.

1/15/2011 14Professor Freih Abu hassan -University of Jordan

Vertebral osteomyelitisVertebral osteomyelitis

High signal is seen in the T12-L1 disk space and the L1 vertebral body on the T2-weighted sagittal sequence.

1/15/2011 15Professor Freih Abu hassan -University of Jordan

1/15/2011 16Professor Freih Abu hassan -University of Jordan

P t ti di kiti d t litiPostoperative diskitis and osteomyelitis

1/15/2011 17Professor Freih Abu hassan -University of Jordan

6 W I.V antibiotics + oral antibiotics there after.

Molded total contact braces for the lumbar and low thoracic spine.lumbar and low thoracic spine.

If cervical osteomyelitis is to beIf cervical osteomyelitis is to be treated non surgically, a halo vest h ld b id dshould be considered.

1/15/2011 18Professor Freih Abu hassan -University of Jordan

(1) Open biopsy (2) Neurologic deficit(2) Neurologic deficit (3) Vertebral collapse esp. C. spine (4) Ab(4) Abscess (5) Failure of medical treatment. ( )

1/15/2011 19Professor Freih Abu hassan -University of Jordan

Paraspinal abscessParaspinal abscess

1/15/2011 20Professor Freih Abu hassan -University of Jordan

Paraspinal abscessParaspinal abscess 1/15/2011 21Professor Freih Abu hassan -

University of Jordan

Brucellosis of lumbar spine

1/15/2011 22Professor Freih Abu hassan -University of Jordan

The principal mode of spread is hematogenous.The primary focus lung GIT or GUTThe primary focus lung, GIT, or GUT

1/15/2011 23Professor Freih Abu hassan -University of Jordan

= Slowly progressive spinal pain Slowly progressive spinal pain

S t f h i ill= Symptoms of a chronic illness, fever,malaise, Wt loss,anorexia . e e , a a se, oss,a o e a

1/15/2011 24Professor Freih Abu hassan -University of Jordan

1/15/2011 25Professor Freih Abu hassan -University of Jordan

1/15/2011 26Professor Freih Abu hassan -University of Jordan

1/15/2011 27Professor Freih Abu hassan -University of Jordan

Radiological presentationRadiological presentation

Active & large lesion with abscess.Multiple levels.Healing & activity together withHealing & activity together with sclerotic lesion.Epidural abscess.Neurological impairment withoutNeurological impairment without obvious discrible vertebral lesion.

1/15/2011 28Professor Freih Abu hassan -University of Jordan

Radiographs= As vertebral osteomyelitis .

E tensi e dest ction= Extensive destruction There is also a tendency towards preservation of the intervertebral disks until late in the diseaseof the intervertebral disks until late in the disease.

T.B tends to involve more levels of the spineT.B tends to involve more levels of the spinethan pyogenic processes, and the abscessestend to be more extensive.tend to be more extensive.

1/15/2011 29Professor Freih Abu hassan -University of Jordan

1/15/2011 30Professor Freih Abu hassan -University of Jordan

CT scans = Extent of vertebral involvement &= Extent of vertebral involvement &

associated soft-tissue masses .

= CT scans cannot distinguish granulation tissue from abscess formation.o at o

1/15/2011 31Professor Freih Abu hassan -University of Jordan

MRI scans modality of choice.y

excellent definition ofexcellent definition of 1-The extent of vertebral involvement,2-Spinal canal compromise,2 Spinal canal compromise, 3-Abscess formation .4-Distinguish abscesses from granulation T.st gu s abscesses o g a u at o

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Laboratory findings are nonspecificLaboratory findings are nonspecific.

Most patients ha e an ele ated ESRMost patients have an elevated ESR; the WBC count is highly variable.

1/15/2011 33Professor Freih Abu hassan -University of Jordan

TREATMENTTREATMENTTREATMENTTREATMENT

Chemotherapy is the mainstay, particularly for early disease, but increasing resistant to therapy isincreasing resistant to therapy is a cause of concern.

1/15/2011 34Professor Freih Abu hassan -University of Jordan

O ti t t tO ti t t tOperative treatmentOperative treatmentS i l t &Surgery is complementary & supplementary to chemotherapy.pp y py

Indications Neurological deficitIndications -Neurological deficit-Large abscessP i d i &-Progressive destruction &

KyphosisI bili-Instability

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SurgerySurgerySurgerySurgery

EarlierEarlier-Only focal debridement and-Only focal debridement and

drainage of abscessdrainage of abscess-Long bed restg

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SurgerySurgery

CurrentlyCurrently-Radical debridement & reconstruction-Prevention & correction of kyphosis-InstrumentationInstrumentation-Give stability for early mobilisation

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INSTRUMENTATIONINSTRUMENTATIONINSTRUMENTATIONINSTRUMENTATION(Newer concept)(Newer concept)

AnteriorP t iPosteriorCombined

adv:-(1)Protect graft(2)Encourage fusion( ) g(3)Prevent & correct kyphosis(4)Gives stability(4)Gives stability(5)Early mobilisation

1/15/2011 38Professor Freih Abu hassan -University of Jordan

Anterior InstrumentationAnterior InstrumentationAnterior InstrumentationAnterior Instrumentation(One stage surgery)(One stage surgery)

After radical debridementWith graft or cage

Indications2 segment involved with kyphosis(P t El t h ld b i t t)(Post. Element should be intact)

1/15/2011 39Professor Freih Abu hassan -University of Jordan

Posterior InstrumentationPosterior Instrumentation((one stage surgery)one stage surgery)

Indications:- Post.elelment involvement- Epidural abscessEpidural abscess- Tuberculoma- Both element involvement

(postero-lat approach)(postero-lat approach)

1/15/2011 40Professor Freih Abu hassan -University of Jordan

Posterior fusion and instrumentation stabilized the spine after anterior L1 corpectomy and T12-L2 strut graft for the patient with L1 osteomyelitis

1/15/2011 41Professor Freih Abu hassan -University of Jordan

T.B.of spine in childenT.B.of spine in childenpp(Newer concept)(Newer concept)

Early surgical intervention-* Children bet. 5-15 yearsy* >2 segment involvement* Preexisting kyphosis > 30* Preexisting kyphosis > 30

Surgery-Surgery-Anterior surgery with fusion and second stage post fusion with/second stage post.fusion with/without instrumentation

1/15/2011 42Professor Freih Abu hassan -University of Jordan

Tuberculosis of spine in 13-year-old girl.

1/15/2011 43Professor Freih Abu hassan -University of Jordan

Late casesLate casesLate casesLate cases(Newer concept)(Newer concept)

Reconstruction of ant. column with ftgraft

Shortening of posterior column with fusionfusion

P t i i t t tiPosterior instrumentation

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Endoscopic spine surgeryEndoscopic spine surgeryEndoscopic spine surgeryEndoscopic spine surgery(Newer concept)(Newer concept)

MINIMALLY INVASIVE

* Debridement Debridement* Decompression* Interbody fusion* Instrumentation ???* Instrumentation ???

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USG guided procedureUSG guided procedure

USG guided drainage of abscess it b tti th tcavity by putting catheter

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MMMessageMessage

Be radical where indicated for

* Prevention of deformity Prevention of deformity* Prevention of complications* Early mobilisation with help of current conceptscurrent concepts

1/15/2011 47Professor Freih Abu hassan -University of Jordan

1/15/2011 48Professor Freih Abu hassan -University of Jordan