Adult Pyogenic Vertebral Osteomyelitis - Spine - Orthobullets.

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Adult Pyogenic Vertebral Osteomyelitis
Author: Derek Moore
Topic updated on 05/05/13 1:40pm
Introduction
G Vertebral osteomyelitis, also known as spondylodiskitis
G Epidemiolgoy
H demographics
I usually seen in adults with a median age for
pyogenic osteomyelitis is 50 to 60 years
H location
I 50-60% of cases occur in lumbar spine
I 30-40% in thoracic spine
I ~10% in cervical spine
H risk factors include
I IV drug abuse
I diabetes
I obesity
I malignancy
I immunodeficiency or immunosuppressive medications
I malnutrition (serum albumin < 3 g/dL indicative of malnutrition)
I recent systemic infection (UTI, pneumonia)
I trauma
I smoking
G Pathophysiology
H pathogens
I staph aureus is most common (50-65%)
I staph epidermidis is second most common cause
I pseudomonas seen in patients with IV drug use
I salmonella seen in patients with sickle cell disease
I gram negative infections increasing over last decade and often associated with
gram negative infections of the GU and respiratory tract
H innoculation
I hematogenous seeding
I generally agreed that inoculation likely occurs through hematogenous
seeding (arterial or venous) of the endplates and intervertebral discs
I endplates contain area of low-flow vascular anastomosis that may
provide an environment suited for inoculation
I involvement of one endplate leads to direct extension into
intervertebral discs, followed by direct extension into the second
endplate
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I direct inoculation
I can occur after penetrating trauma, open fractures, and following surgical
procedure
I contiguous spread from local infection
I most commonly associated with retropharyngeal and retroperitoneal
abscesses
H neurologic involvement
I results from
I direct infectious involvement of neural elements
I compression from an epidural abscess
I epidural abscess present in ~18% of patients with spondylodiskitis
I 50% of patients with an epidural abscess will have neurologic
symptoms
I neural compression caused by instability of the spine
G Associated conditions
H epidural abscess
I defined as a collection of pus or inflammatory granulation tissue between dura
mater and surrounding adipose tissue
I usually associated with vertebral osteomyelitis
I present in ~18% of patients with spondylodiskitis
I 50% of patients with an epidural abscess will have neurologic symptoms
Presentation
G History
H history of UTI, pneumonia, skin infection, of organ transplant are common
G Symptoms
H fever is only present in 1/3 of patients
H pain
I pain is often severe and insidious in onset
I pain is usually worse with activity and unrelenting in nature
I pain that awakens patients at night should raise concern for malignancy
and infection
H neurologic deficits present in 10%
I radiculopathy
I myelopathy
G Physical exam
H 17% present with neurologic deficits
Imaging
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G Radiographs
H findings are usually delayed by weeks
H findings include
I paraspinous soft tissue swelling (loss of psoas shadow) seen if first few
days
I disc space narrowing and disc destruction (remember disc destruction is
atypical of neoplasm) seen at 7-10 days
I endplate erosion or sclerosis seen at 10-21 days
I osteopenia
G CT
H useful to show bony abnormalities, abscess formation, and extent of bony
involvement
G MRI
H MRI with gadolinium contrast most sensitive (96%) and specific (93%) imaging
modality for diagnosis of spinal osteomyelitis
I also most specific imaging modality to differentiate from tumor
H findings include
I paraspinal and epidural inflammation
I disc and endplate enhancement with gadolinium
I T2-weighted hyperintensity of the disk and endplate
H MRI is the most specific imaging modality to differentiate from tumor
I features that weigh towards an infection include
I disc space involvement
I end-plate erosion
I significant inflammation
G Bone scan
H Technetium Tc99m bone scans are 90% sensitive but lack specificity
H combined Technetium Tc99m and gallium 67 scan is both more specific and
more sensitive than Technetium Tc99m alone
H indium 111 labeled scan not recommended due to poor sensitivity (17%)
Studies
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G Laboratory
H WBC
I often normal and not a sensitive indicator for early infection
I elevated in ~ 50%
H ESR
I elevated in 90% of cases
I can be monitored serially to track success of treatment, however is considered less
reliable than CRP
H CRP
I elevated in 90% of cases
I can be monitored serially to track success of treatment and is considered more
reliable than ESR
H Blood cultures
I identification of organism is mandatory for treatment
I least invasive method to determine a diagnosis
I 33% (reports show 25%-66%) of patients with spondylodiskitis have positive
blood cultures which are 85% accurate for isolating the correct organism
I blood culture yield is improved by withholding antibiotic and obtaining cultures
when patient is febrile
G CT guided biopsy
H indications
I in patients who do not have indications for immediate open surgery and blood
cultures are negative
H can provide diagnosis in 68-86% of patients
H can be guided by fluoroscopy or by CT scan
H cultures should be sent for
I aerobic
I anaerobic
I fungal
I acid-fast cultures
G Open biopsy
H indicated when tissue/organism diagnosis can not be made with noninvasive techniques
H anterior, costotransversectomy, or transpedicular approach used
Differential
G Spinal Tumors
Treatment
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G Nonoperative
H bracing and long term antibiotic (6-12 weeks)
I indications
I in most cases and successful in 80%
I bracing
I helps improve pain and prevent deformity
I rigid cervicothoracic orthosis or halo required for cervical osteomyelitis
I antibiotics
I if patient is septic or critically ill then start antibiotics immediately,
otherwise hold until organism identified
I usually treated with IV antibiotics until signs of improvement (~ 6 weeks)
and then converted to PO antibiotics
I use broad spectrum antibiotics until organism is identified
I vancomycin for pencicillin-resistent and gram-positive bacteria
I third-generation cephalosporin for gram-negative coverage
I new antibiotic-resistant strains of microorganisms are becoming more
common and failure to diagnose can have dire consequences. Organisms
include
I MRSA (methicillin-resistent Staph aureus)
I VRSA (vancomycin resistant Staph aureus)
I VRE (vancomycin resistant enterococcus)
I newer generation antibiotics for antibiotic resistant organisms include
linezolid and daptomycin
G Operative
H anterior debridement and strut grafting, +/- posterior instrumentation
I usually procedure of choice for refractory cases
I indications
I neurologic deficits
I progressive deformity
I gross spinal instability
I persistent infection
H posterior debridement and decompression
I indications
I posterior surgery usually ineffective for debridement
Techniques
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G Anterior debridement and strut grafting, +/- posterior instrumentation
H goals
I identify organism
I eliminate infection
I prevent or improve neurologic deficits
I maintain spinal stability
H techniques
I strut graft selection
I autogenous tricortical iliac crest, rib, or fibula strut grafts have proven safe
and effective in presence of acute infection
I allograft being used with good results, but autogenous sources theoretically
have better incorporation
I a recent study showed improved deformity correction with titanium mesh
cages filled with autograft (followed by posterior instrumentation)
I instrumentation
I spinal instrumentation in presence of active infection is controversial
I some advocate I&D followed by staged instrumentation
I some advocate a single procedure with bone graft and
instrumentation in the presence of an active infection
I titanium is preferred over stainless steel
I posterior instumentation
I posterior instrumentation indicated when severe kyphotic deformity or a
multilevel anterior construct required
I posterior instrumentation can be performed at same time or as a staged
procedure
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