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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6025_Библиотеки_им_академика_М_И_Перельмана
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24 Spinal Infect ions 281
Fi g . 2 4 . 1 Sag it t a lly se c t ion e d hu m a n fe t al sp e cim en (26 we eks gest at io n ), inje ct e d, clea re d, an d
transilluminated, showing cartilage canals and absence of vessels in nucleus pulposus. (A) Cartilage
canal; (B) nucleus pulposus; (C) hyaline cartilage; (D) ossi ed vertebral body.
(2) Vertebral metaphysis is a low- ow environment that may allow for
the direct spread of bacteria into and across the intervertebral disk.
2. Spread to the intervertebral disks.
a. Bone/disk destruction (Fig. 24.2).
(1) Bacteria produce enzym es that digest disk tissue.
(2) Bone resorption by osteoclasts is activated by various in am m atory
mediators.
3. Soft tissue extension.
a. Psoas abscess.
b. Paraspinal muscle abscess.
c. Epidural abscess.
(1) May result in neurological comprom ise secondary to direct
compression of the spinal cord an d nerve roots.
D. Clin ical n dings.
1. Delay in diagnosis is common.
2. Back or neck pain is the most common presenting complaint (90%).
a. Symptoms are typically present for more than 3 months in 50% of
patients.
b. Acute presentation with septicemia and toxemia is extremely rare.
3. Localized pain and tenderness with a decreased range of motion are the
most consistent ndings.
4. History of fever > 100°F (w ith or w ith out chills) is p resent in over 50% of
patients.
5. In children, a limp and refusal to walk are characteristically present.
282
24 Spinal Infections
ab
c
d
Fi g . 2 4 . 2 A 76-year-old wom an with rheumatoid arthritis and a T12–L1 diskitis/L1 osteom yelitis.
Re s u l t s o f t h r e e n e e d l e b i o p s i e s w e r e n e g a t i ve . (a,b) Anteropost erior and lat eral radiographs dem onstrated a diskitis at T12–L1 with dest ruction of the L1 vertebral body. (c) T1-weighted sagittal magnetic resonance imaging (MRI) sequence shows decreased signal throughout and across the T12–L1
disk space. The end plates are blurred and indistinct. (d) T2-weighted sagittal MRI sequence shows
high signal wit hin the T12–L1 disk and the L1 vertebral body.
E. La b or at or y n d in gs (Table 24.1).
F. Ra d i o g r a p h i c i m a g i n g s t u d i e s (Table 24.2).
G. Treat m en t .
1. Goals.
a. Establish a tissue diagnosis and identify the organism.
b. Eradicate the infection.
c. Provide long-term pain relief.
d. Prevent or relieve any neurological de cits.
e. Restore spinal stability/alignment.
24 Spinal Infect ions 283
ef
g
h
Fi g . 2 4 . 2 (Cont inu ed) A 76-year-old wom an with rheumatoid arthritis and a T12–L1 diskitis/ L1 osteo -
myelitis. Results of three needle biopsies were negative. (e) T1-weighted sagit tal MRI sequence with
gadolinium shows enhancement of the T12–L1 disk space and L1 vertebral body. There is a slight
amount of enhancing tissue in the anterior epidural space without compression of the conus medullaris or cauda eq u in a . (f) T1-weighted axial MRI sequence with gadolinium shows enhancement of
the T12–L1 disk space. (g,h) Anteroposterior and lateral radiographs taken 6 months after surgery
demonstrating incorporation of the bone graft anteriorly with solid xation posteriorly.
2. Principles.
a. Medically optimize the patient.
(1) Nutritional supplem entation.
(2) Correct any laboratory abnorm alities.
b. Treat extraspinal sources of infection.
(1) Urinary tract.
(2) Cardiovascular (infected throm bus).
(3) Gastrointestinal.
c. Broad-spectrum antibiotics should be started, and then antibiotic
therapy should be speci c to the organism identi ed.
284
24 Spinal Infections
Ta b l e 2 4 . 1 La b o r a t o r y m a r k e r s i n s p i n a l i n f e c t i o n s
Te s t F i n d i n g s
ESR Ele v a t e d a t p r e s e n t a t i o n in m o r e t h a n 8 0 % o f c a s e s
ESR n o r m a liz e s in t w o - t h ir d s o f p a t ie n t s a d e q u a t e ly t r e a t e d
3
WBC > 10,0 0 0 / m m
in m ore than 50% of cases
WBC count has a low sensitivity for diagnosis
CRP Mo re se n s it ive a n d sp e ci c t h a n ESR fo r m o n it o rin g p ost o p era t ive
spine infections
Blo o d c u lt u r e s Mo s t u s e f u l in c h il d r e n w it h ve r t e b r a l p yo g e n ic o s t e o m ye lit is
Only positive in ~ 35% of patie nts
Re l ia b le in d e t e c t in g t h e o e n d i n g o r g a n i s m
Nee d le b iopsy False -negat ive e xam inations are com m o n when pat ient is o n antibiotics
Open biopsy Indicated if needle biopsy is negative, nondiagnostic, or both despite
high clinical suspicion
Lo w e r f a l s e - n e g a t i v e r a t e t h a n c l o s e d b i o p s y
Ab b r e v i a t i o n s : CRP, C-react ive protein; ESR, erythrocyte se d imentat ion rate; WBC, white
blood cell count.
d. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels
are useful to obtain prior to therapy.
(1) May be followed as an indication of treatm ent e cacy.
3. Operative treatment.
a. Indications.
(1) Cases that have failed nonoperative managem ent.
(2) Progressive neurological de cit.
(a) Due to direct compression from the infection.
(b) Due to progressive deform it y or instabilit y.
(3) Abscess or granulom a form ation.
(a) Antibiotics are ine ective.
(4) Intractable pain not responsive to conservative measures.
b. Technique (Fig. 24.3).
(1) Anterior approach is the m ost useful for vertebral body debridem ent
(corpectomy).
(a) Lam inectomy alone for decompression is contraindicated
because of the potential for spinal destabilization.
24 Spinal Infect ions 285
Ta b l e 2 4 . 2 Diag n o st ic im ag ing in spinal infect ions
Im a g i n g s t u d y Fin d in g s
Plain radiographs – Findings lag beh ind clinical presentation (at least 2 we e ks
from the on set of infect ion)
– Disk space narrowing with erosive changes (75%)
– Osteolysis, di use osteopenia, focal defect
– 50% trabecular bone destruction before radiographic
evidence is noted
– Osteosclerosis (11%)
– Chronic cases may reveal spontaneous bone fusion (50%)
Nuclear im ag ing – E ective as an initial screening tool
– Earlier detection and localization when compared with
plain lms
– Combination of gallium (in ammatory) and technetium
(bone) scans provides > 90% accuracy in diagnosis
– Indium-111-labeled leukocyte (white blood cell) scans are
not sensitive in the spine
– High false-negative rate may be related to leukopenia
Co m pu t e d t o m o g ra p hy – Be st m o d alit y fo r id en t ifyin g b o ne d es t ru ct io n
Mag n e t ic re so na n ce
im agin g
– Imaging modality of choice for spine infections
– T1-weighted images—decreased signal around adjacent
– T2-weighted images—high signal intensity in bodies near
adjacent end plates and disk space end plates and disk space
– Loss of end plate de nition
– Involved portions of disks and vertebral bodies enhance
with gadolinium
– Allows for visualization of soft tissue involvement
(paraspinal, psoas abscess)
– Best imaging modality to di erentiate infection versus tumor
(2) Autogenous bone graft is the gold standard for reconstruction (iliac
crest, rib, or bula).
(a) However, autograft- lled titanium cages and cortical strut
allograft have demonstrated good clinical results.
(b) Titan ium alloys have dem onst rated lower bacterial adhesion th an
stainless steel alloys and are now commonly used in the setting
of anterior corpectomies.
(c) More recently, polyetheretherketone (PEEK) interbody devices
(expandable) have been successfully used in the setting of a
corpectom y for a spinal infection.
(3) Thoracic and lumbar vertebral osteomyelitis m ay be treated by
a single posterior approach (debridement and xation) using an
interbody technique.
286
24 Spinal Infections
a
Fi g . 2 4 . 3 ( a ) A co r p e c t o m y p r o c e d u r e .
II. Epid u r a l a b sce ss.
A. Et io log y.
1. Associated with vertebral pyogenic osteomyelitis in 28% of cases.
2. S. au reus m ost com m on causative organ ism (~ 60%).
3. Regional or location frequencies:
a. Thoracic (50%).
(1) Neurological de cits are more com mon.
b. Lumbar (35%).
c. Cervical (14%).
4. Most cases are in adults (rare in children).
a. Postoperative (16%).
B. Cli n ica l p re s e n t a t io n .
1. Highly variable, leading to misdiagnosis and delayed treatment in > 50% of
patients.
2. Localized spine tenderness is more common.
3. Nuchal rigidity and other meningeal signs are possible.
4. With or without neurological de cit.
C. Diag n o s is .
1. ESR is elevated in > 98% of cases.
2. White blood cell count (WBC) is unreliable.
24 Spinal Infect ions 287
b
Fi g . 2 4 . 3 (Continued) (b) Incorporat ion of an e xpandab le cage.
3. Magnetic resonance imaging (MRI) is the imaging modality of choice (Fig. 24.4
and Fig. 24.5).
a. Intense focal signal on T2.
b. Epidural metastasis and subdural abscess should be considered in the
di erential.
D. Treat m e n t.
1. Epidural abscess requires urgent surgical attention.
2. Epidural abscess in the presence of a worsening neurological de cit is a
surgical emergency.
a. Exceptions.
(1) Nonoperative treatm ent consisting of antibiotic therapy with close
monitoring may be considered if surgery would endanger the
patient’s life.
III. Disk sp a ce in fect io n s.
A. Ep id em io lo gy / e t io lo g y.
1. May occur as a result of direct inoculation.
a. Surgical procedures.
(1) Diskogram.
(2) Diskectomy.
(3) Intradiskal electrotherm al therapy (IDET).
288
24 Spinal Infections
Fi g . 2 4 . 4 Sa g it tal T2 -we ight e d m a g ne t ic re so nance image demonstrating increased signal intensit y of the intervertebral disks and vertebral bodies
between L2–L5 suggestive of vertebral osteomyelitis with disk involvement . (From Im hof H, ed. Spinal
Im a gin g ( Dire c t Dia g n o sis in Ra dio lo g y). St u t t ga rt ,
Ge rm an y: Ge org Thie m e Ve rla g ; 20 0 8 : Fig. 4 .46.
Re p r o d u c e d w it h p e r m is s i o n . )
Fig . 2 4 . 5 Sag it t al T2-we igh t ed m ag ne t ic re so n ance im ag in g
of a subdural abscess versus epidural metastases in the cervical
spine. (From Uhlenbrock D. MR Im aging of the Spine and Spinal Cord. Stuttgart, Germany: Georg Thieme Verlag; 2004: Fig.
6.50. Reproduced with permission.)
2. Hematogenous spread:
a. This is the route most commonly encountered in the pediatric
population.
(1) Blood supply from the disk is from the surface of the adjacent
vertebral bodies.
3. The lumbar spine is most commonly involved.
B. Cl in ic a l n d in gs .
1. The typical patient is between 2 and 7 years of age.
a. Patients may not complain of back pain.
b. Limping, refusal to walk, or hip pain m ay be presenting symptoms.
2. ESR and WBC are elevated.
3. MRI or bone scan is positive early in the disease (Fig. 24.6).
a. Plain radiographs may demonstrate narrowing of the intervertebral
space, sclerosis, or bony erosion.
C. Tre at m e n t .
1. Surgery is rarely indicated or needed.
24 Spinal Infect ions 289
2. Immobilization with a brace.
3. Antibiotic therapy.
4. Biopsy is indicated if antibiotics are not e ective.
IV. Tubercu losis of t he sp in e.
A. Ep id em io log y / e t io lo g y.
1. Most common granulomatous infection in the world.
2. Hematogenous spread is the most common source (pulmonary or
gastrointestinal infection s).
ab
Fi g . 2 4 . 6 ( a , b ) Sa g it tal T1 -we ig h t ed m ag n et ic re sona n ce im ag ing de m on st rat in g d ecrease d sign a l
int e nsit y, e p idura l co lle ct ion, and irre g u la rit y o f t he ce rvical sp in e su g g est ive o f ve rt ebra l o st e om ye litis. (From Uhlenbrock D. MR Imaging of the Spine and Spinal Cord. Stuttgart, Germany: Georg Thieme
Ve r l a g ; 2 0 0 4 : F i g . 6 . 4 8 . Re p r o d u c e d w i t h p e r m i s s i o n . )
290
24 Spinal Infections
3. The spine is the most common source of skeletal involvement.
a. Most cases involve the anterior spine.
b. Involvement of adjacent levels from expansion through the disk space.
c. Fifty percent of infections are localized and can be categorized (Fig. 24.7).
(1) Peridiskal (most comm on): starts in the metaphysis and spreads
under the anterior longitudinal ligament.
ab
d
c
Fi g . 2 4 . 7 Ra d io g r a p h ic f e a t u r e s o f t h e t h r e e t yp e s o f t u b e r cu lo u s s p o n d y lit is . (a,b) Pe rid iska l invo lve -
ment is charact erized by disk-space narrowing followed by variable bone destruction. The radiograph
on the left is early in the disease. The radiograph on the right is after resolution of the disease with
minor deformity. (c) Anterior m ultilevel disease is distinguished by scalloped erosions of the anterior
aspect of several adjacent vertebrae (T11, T12, L1). (d) Central involvement resembles a tumor with
central body rarefaction and bone destruction followed by collapse (L1 and L2).
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