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24 Spinal Infect ions 291
(2) Central (rare): starts within a single vertebral body.
(3) Anterior (rare): starts under the anterior longitudinal ligament.
B. Clin ica l p re se n t at io n / d ia gn o sis .
1. Pain is present with evidence of systemic illness.
a. Fever, malaise, and weight loss.
2. Local tenderness, muscle spasm, and limited range of motion.
3. Tissue biopsy can be di cult because of the long incubation period for
mycobacterium.
a. Fifty percent false-negative rate.
4. Di erential diagnosis:
a. Neoplasms.
b. Sarcoidosis.
c. Charcot spine.
C. Ra d io lo gic a l e va lu at io n .
1. MRI is the modality of choice.
a. Unique characteristics of tuberculosis versus pyogenic infections.
(1) Disk space is often spared.
(2) Involvem ent of anterior bodies over contiguous segm ents.
(3) Paraspinal abscesses and granulom as are distinguished with the use
of gadolinium.
D. Treat m e n t.
1. Conservative management.
a. Antituberculous drugs constitute rst-line treatment.
b. Nine to 12 months of therapy.
c. Successful therapy is associated with a fall in the serial ESR values, a
decrease in pain, and weight gain.
2. Surgical management.
a. Indications:
(1) Failure to respond to antituberculosis therapy.
(2) Neurological comprom ise or evidence of progressive spinal instability.
b. The Hong Kong procedure (Fig. 24.8):
(1) Anterior approach for anterior pathology.
(2) Radical debridement and rem oval of all necrotic tissue.
(3) Strut graft/fusion using autograft or allograft restoring anterior
colum n supp ort.
(4) Posteriorly supplem ented instrum entation in more than tw o levels
anteriorly.
c. Lam inectomy alone is contraindicated.
V. P o s t o p e r a t i v e i n f e c t i o n s .
A. Risk fa c t o r s (Table 24.3).
B. Pr eve n t i o n .
1. Optimization of patient risk factors prior to surgery.
2. Strict sterile technique.
3. Dilute iodine in irrigation solution or dilute iodine wound soak prior to
closure.
292
24 Spinal Infections
ab
cd ef
Fi g . 2 4 . 8 Tu b e r c u l o s i s o f t h e l u m b a r s p i n e . A 5 2 - y e a r - o l d m a n w i t h d i s s e m i n a t e d t u b e r c u l o s i s w a s
treated with 1 year of therapy with three antituberculous drugs. He presented with progressive low
back pain and neurogenic claudication. (a) Anteroposterior and (b) lateral lumbar spine radiographs
show collapse of L2 and L3 with kyphotic deformit y. (c,d) T1-weighted image sagittal magnetic resonance imaging (MRI) sequence demonstrates decreased signal in the bodies of L1 to L4, kyphotic
deform ity, and epidural m ass composed of ne crotic bone, disk, and purulent debris. (e,f) T2 -we igh t e d
sagit tal MRI sequence demonstrates areas of high signal intensity within the L2 and L3 vertebral bodies
and in the anterior paraspinal region.
4. Vancomycin mixed bone graft or pulse lavage.
a. Most recent meta-analyses demonstrate favorable outcomes.
b. Results may depend on the incidence of postoperative spinal infections in
the local population.
(1) Vancomycin mixed bone graft is likely more e cacious if the number
to treat is greater.
Ta b l e 2 4 . 3 Ris k fa c t o rs fo r p o st o p e r at ive in fe c t io n s
Diabet e s m ellitus
Chro n ic co r t ico st e ro id use
Che m o t he ra py
Re v is i o n s u r g e r y
Pro long e d ope rative tim e (> 4 h)
Mo r b id o b esit y
24 Spinal Infect ions 293
Pre o p e rative/ post op e rative infectious condition
To o t h a b s c e s s
Urin a r y t rac t in fe ct io n
Pne u m onia
Open sores
Pro long e d drainage from t he surgical woun d
C. Pr e se n t at io n .
1. Elevated ESR and WBC with concomitant fever and wound drainage are
suspicious signs.
D. Diagn osis.
1. MRI with gadolinium enhancement is the best modality to detect an SSI.
2. Vertebral and soft tissue changes must be di erentiated between normal
postoperative changes and vertebral osteomyelitis.
a. Both states are associated with type 1 end plate changes characterized by
adjacent marrow edem a and hypointense signal on T1 imaging.
b. Gadolinium contrast demonstrates areas of enhancement in the disk
space.
c. Infection is associated with circum ferential disk enhancem ent, w hereas
linear areas of enhancem ent are m ore con sistent with norm al changes.
E. Ea r ly ve r s u s la t e .
1. Early infections are typically recognized by systemic complaints.
a. Fevers, chills, local wound erythema, drainage, increased back pain
2. Late infections:
a. More common, particularly in the presence of instrumentation.
(1) Di cult clinical diagnosis that should be considered if signi cant risk
fact o r s a r e ap pare n t .
294
24 Spinal Infections
F. Su p e r c i a l v e r s u s d e e p .
1. Di cult to di erentiate by physical examination.
a. Irrigation and debridement should include opening the deep fascial layer
to evaluate for the presence of an occult deep wound infection.
G. Man age m en t .
1. The type of postoperative infection dictates management:
a. Super cial SSIs respond to a course of intravenous antibiotics and/or
bedside drainage.
b. Medical therapy alone is unsuccessful with subfascial infections due to
poor antibiotic penetration.
(1) May warrant m ultiple episodes of extensive debridement of infected
and necrotic tissue.
2. Instrumentation should be retained to maintain the stability of the spinal
colum n; however, loosened im plants should be rem oved, an d the patien t
should be monitored closely for pseudarthrosis.
3. Negative-pressure wound therapy:
a. Vacuum-sealed suction device that encloses the surgical wound.
b. Enhances would healing and closure due to the following mechanisms:
(1) Rem oval of interstitial uid that reduces interstitial uid pressure
and enhances blood perfusion.
(2) Negative pressure causes mechanical stimulation that facilitates cell
grow th, increases blood ow, and reduces bacterial load.
Sugg este d Reading
Bo r k h u u B, Bo r o w sk i A, Sh a h SA, Li t t le to n AG, Da b n e y KW , Mille r F. An t ib io t ic - lo a d e d a l-
lograft decreases the rate of acute deep woun d infection after spinal fusion in cerebral
palsy. Spin e 2008;33(2 1):2300–2304
Ca n ave s e F, Gu p t a S, Kr a j b ich JI, Em a ra KM. Vac u u m - a s s ist ed clo su re fo r d ee p in fe ct io n a ft er
spinal instrumentation for scoliosis. J Bone Joint Surg Br 2008;90(3):377–381
Ch ia n g H Y, H e r w a ld t LA, Ble vin s AE, Ch o E, Sch w e iz e r M L. E e c t ive n es s o f lo c al va n co m y-
cin pow der to decrease surgical site infections: a m eta-analysis. Spine J 2014;14(3):
397–407
Olsen MA, Ne p ple JJ, Riew KD, et al. Risk factors for su r gical site in fect ion follow ing or th o -
pae d ic sp in al operat ions. J Bon e Join t Surg Am 2008;90(1):62– 69
Sasso RC, Gar r id o BJ. Po s t op e r at ive sp in a l w o u n d in fect ion s. J Am Aca d Or t h o p Su rg
2008;16(6):330–337
25 Rheumatoid Arthritis
25.1 General Considerations
I. Epid e m io lo g y.
A. Mo st co m m o n d u r in g t h e ft h a n d s ix t h d e ca d e .
B. Fe m a le > m a le (3 : 1 ).
C. Tw e n t y- ve t o 8 0 % o f p a t ie n t s w it h r h e u m a t o id a r t h r it is ( RA) w ill h ave ce r vica l
spine involvem ent.
1. The thoracic and lumbar spine are rarely a ected.
II. Pat h oge n e sis.
A. Co m ple x in te ra ct ion b e t we e n ge n e s an d e nviro n m en t .
1. Genetic component.
a. Increased susceptibility mediated by HLA-DR antigens.
b. Twelve to 15% concordance rate of RA between identical twins.
2. Environmental components.
a. Smoking (strongest evidence).
(1) Increases susceptibilit y 20 to 40 tim es.
(2) Activates in am matory cascade resulting in complement attachm ent
to the tissues.
b. Other environmental components.
(1) Infections (no causal e ect has been proven).
(a) Mycoplasma.
(b) Prot eu s m irab ilis .
(c) Epstein–Barr virus (EBV).
(d) Retrovirus.
(2) Occupation exposure.
(a) Silica.
(3) Alcohol intake.
B. Cellu la r in t e r a ct io n w it h s yn ov ia l t is su e .
1. T lymphocytes.
a. Constitute > 50% of cells in most RA synovium.
b. Activate B cells to increase antibody production.
c. A defect in program med cell death (apoptosis) results in lymphoproliferation.
d. Antigens that can induce a T cell–mediated adaptive immune response:
(1) Type II collagen.
(2) Im m unoglobulin G (IgG).
(3) Citrullinated proteins.
(4) Glycoproteins (secreted by synovial cells and chondrocytes).
2. Angiogenesis and cell migration.
a. New synovial blood vessels are formed.
(1) Increases uid transudations.
295
296
25 Rh eum at oid Arthritis
(2) Promotes transm igration of lymphocytes into the synovium and
polymorphonuclear leukocytes into the synovial uid.
3. Tumor necrosis factor (TNF).
a. Activates production of adhesion cells in newly formed endothelial cells.
b. Helps recruit in ammatory cells into the synovium.
c. Inhibits apoptosis of in am m atory cells.
d. Induces the production of cytokines to propagate the in ammatory
cascade.
4. Cellular components in synovium and synovial uid.
a. Synovium.
(1) T lymphocytes (CD4).
(2) Fibroblast-like synoviocytes.
(a) Mediate initial destruction of cartilage at the cartilage–pannus
junction (periphery of joints).
b. Synovial uid.
(1) T lymphocytes (CD8).
(2) Neutrophils.
III. Clin ical n din gs.
A. In sid iou s o n se t .
B. Co n s t it u t io n al s ym p to m s.
C. Sym m e t r ica l p olya r t h r it is .
1. Morning sti ness.
2. Joint pain and swelling.
3. Wrist and nger involvement (does not a ect distal interphalangeal [DIP]
joint).
4. Axial spine is involved in 20 to 50% of the cases.
D. Ext ra-ar t icu lar involvem en t .
1. Subcutaneous nodules.
2. Pleuropericarditis.
3. Episcleritis.
E. Va r ia b le clin ica l co u r se .
1. Spontaneous exacerbations and decrease in symptoms.
2. Structural damage is cumulative and irreversible.
IV. Laboratory n dings.
A. Sy n ovia l u id a s p ir at e (r ar e ly ob t ain ed in p r act ice ).
1. In ammatory e usion.
3
2. Leukocyte count 1,500 to 25,000/mm
.
3. Predominance of polymorphonuclear (PMN) cells.
B. Se r o lo g ic a l t e s t s.
1. Not used for screening purposes.
2. Rheumatoid factor (RF) (75–85%).
3. Anticitrullinated peptide antibodies (ACPA) (> 95%).
4. Positive serological ndings can be present as early as 10 years prior to any
symptoms.
5. Both RF and ACPA are associated with a higher risk of developing erosive
joint dam age and functional impairm ent.
C. Ot h e r h e m a t o lo gic n d in gs .
1. Anemia of chronic disease.
2. Elevated ESR and CRP.
V. R a d i o g r a p h i c s t u d i e s .
A. All RA p a t ie n t s s h ou ld h ave ce r v ical sp in e e xa m in at ion .
1. Plain lm radiographs.
a. Helps determine atlantoaxial instability.
b. Used to predict risk of paralysis.
2. Magnetic resonance imaging (MRI).
a. Useful in visualizing spinal cord compression due to odontoid pannus
(space available for the cord [SAC]).
25 Rheumatoid Arthritis 297
3. Computed tomographic (CT) scan.
a. Provides excellent bony detail.
b. Excellent ability to detect spinal cord compression from synovial pannus
if perform ed w it h intrath ecal contrast.
c. Reserved for patients with contraindication to MRI (e.g., pacem akers).
VI. Ce r vica l s p in e d efo r m it y.
A. In st ab ilit y d ep e n d s o n t h e s e ve rit y o f t h e d is e a s e p r o ce ss .
B. Su b lu x a t io n a p p e a r s 1 d e ca d e a ft e r t h e d is e a s e o n s e t .
C. Ra d io gr ap h ic p r ogr e s sio n o f s u b lu x a t io n h a s b e e n o b se r ve d in 3 5 t o 8 0 % o f p at ie n t s.
1. Seven to 34% will develop a neurological de cit.
2. Recent evidence has demonstrated that aggressive early medical treatment
with disease-modifying antirheumatic drugs (DMARDs) can signi cantly
decrease the risk of cervical spine atlantoaxial disorders.
D. At lan toaxial in st abilit y (or su blu xat ion ) (Fig. 25.1):
1. Most comm on cervical spine abnormality in RA (49%).
2. Results from erosive synovitis in the following joints:
a. Atlantoaxial.
b. Atlanto-odontoid.
c. Atlanto-occipital.
3. Radiographic ndings.
a. Anterior atlantodens interval (AADI):
(1) Distance between the posterior margin of C1 to the anterior surface
of the odontoid:
(a) The norm al distance is 3 mm in adults and 4.5 mm in children.
(2) AADI is an unreliable predictor of paralysis because of poor
correlation bet w een the AADI an d the degree of cord com pression as
shown by magnetic resonance imaging (MRI).
(a) AADI ≥ 8 mm has a positive predictive value (PPV) of 61% and a
negative predictive value (NPV) of 56%.
b. The posterior atlantodens interval (PADI) has been demonstrated as a
better predictor of paralysis.
(1) The interval between the posterior dens and the anterior margin of
the lamina at C1 is measured in a lateral plain lm radiograph.
(a) An interval ≤ 14 mm has a PPV of 69% and an NPV of 94% with
regard to predicting paralysis.
(b) Preferred screening test .
298
25 Rh eum at oid Arthritis
Fi g . 2 5 . 1 Sa g it tal T2 -we ig h t e d m ag netic resonance imaging taken of the
patient demonstrating that the spinal
cord is decompressed in extension.
(2) Limitations:
(a) Retro-odontoid synovial pannus m ay occupy as much as 3 mm of
space.
(b) May not represent th e tr ue SAC.
(c) PADI < 14 mm on lateral plain lm radiograph warrants MRI.
i. PADI ≥ 13 mm measured on MRI represents spinal cord
compression.
4. Clinical symptoms.
a. Neck pain.
b. Headache.
c. Vertigo.
d. Myelopathy.
(1) Paresthesias.
(2) Abnorm al gait.
(3) Bowel/bladder di culties.
(4) Di culty with ne m otor control.
E. Atla n toa xia l im p a ct io n o r b a s ila r in va gin at io n (Fig. 25.2):
1. Second most common cervical spine abnormality in RA (38%).
2. Characteristics:
a. Superior migration of the odontoid (SMO).
b. Vertical subluxation of the axis.
c. Pseudobasilar invagination.
3. Synovitis and cartilage destruction of the occipitoatlantal and atlantoaxial
joints.
25 Rheumatoid Arthritis 299
a
b
Fi g . 2 5 . 2 ( a ) Illust ra t ion and (b) radiograph demonstrating the measurem ent s of t he skull, including
McRa e ’s lin e, Cha m b erla in’s lin e , Wa cke nh e im ’s lin e , a nd Ran awa t’s lin e . (Fig . 2 5. 2 b fro m Boh n do rf
K, I m h o f H , P o p e T H Jr . M u s c u l o s k e l e t a l I m a g i n g : A C o n c i s e M u l t i m o d a l i t y Ap p r o a c h . S t u t t g a r t , G e r many: Georg Thieme Verlag; 2001: Fig. 9.105. Reproduced with permission.)
4. Symptoms include occipital headache, myelopathy, or brain stem
compression signs.
5. Radiographic measurements (Table 25.1) (Fig. 25.3):
a. Used to identify the degree of odontoid encroachment on the spinal cord.
b. Most are di cult to reproduce.
300
25 Rh eum at oid Arthritis
Ta b l e 2 5 . 1 Ra d io g r a p h ic lin e s t o m e a s u r e su p e r io r m ig r a t io n o f t h e o d o n t o id
Nam e Measure m e nt s Characte rist ic Re sults
McGre go r lin e Lin e co nn e ct ing
posterior margin of
the hard palate to the
most caudal point of
the occiput
Re d lu n d – Jo h n e l l
line
Dist ance be t we en
the midpoint of the
infe rior m arg in o f t he
body of the axis to the
McGre go r lin e
Ra n a w a t in d e x Dis t a n c e b e t w e e n t h e
center of the pedicle
Mo s t co n sis t e n t
reference
Me a su re s t he
occiput to C2
complex
Ev a l u a t e s t h e
C1 – C2 se gm e n t
Ve r t i c a l s e t t l i n g i s
de ned as migration
of odontoid > 4.5 mm
In cre as e d r is k o f
neurological injury
with values < 34 mm
for m e n and < 2 9 m m
for wo m e n
< 1 3 m m is diagno st ic
of vertical settling
of the axis and the
transverse axis of the
atlas
McRae lin e Con n e ct s t he a nt e r io r
and the posterior
margins of the
fora m en m a g num
Th e t ip o f t h e
odontoid should lie
1 cm below this line
ab
Fi g . 2 5 . 3 La t e r a l p l a i n l m r a d i o g r a p h d e m o n s t r a t i n g t h e a n a t o m i c a l l a n d m a r k s u s e d t o d r a w t h e
(a) McGre g or line (McG), Re dlun d – Johne ll line (RJ), McRae line (McR), and (b) t he Ranawat inde x. HP,
hard palate; TA, transverse axis of atlas; CP, center of pedicle of axis.
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