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40 Discitis inPediatric Spine
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inherited immunity from the mother. Staphylococcus aureus accounts for 80% of
pyogenic spinal infections in infancies less than 6 months old. Other organisms
include coagulase-negative Staphylococcus, alpha-hemolytic Streptococcus,
Streptococcus pneumoniae, and Gram-negative rods. For children between half a
year and 4years old, clinicians should specically look for Kingella kingae, which
is very difcult to be found by traditional culture. Using aerobic blood culture vials
or polymerase chain reaction (PCR) for biopsy specimens is recommended. The
diagnosis is further supported if throat swabs were positive for Kingella kingae. In
the regions where tuberculosis is endemic, an elevation of the procalcitonin points
to a pyogenic infection, since its level should be normal or only slightly increased
in a TB spine.
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40.6 Treatment Options
In principle, antibiotic therapy should be given according to the sensitivity tests of
the causative agent. However, the positive detection rate of blood culture and biopsy
is low. Empirical broad-spectrum antibiotics can be given while waiting for investigation results, and the patient’s response should be closely monitored. For
community- acquired infections, cloxacillin can be used for young children below
6months old, since the most common organism is MSSA.Amoxicillin-clavulanate
is used when the patients are between 6months and 4years old, because it covers
both MSSA and Kingella kingae. Covering Kingella kingae is important if PCR on
throat swabs is positive. For hospital-acquired infections or immunosuppressed
patients, empirical antibiotics, such as vancomycin and third-generation cephalosporin against MRSA and Gram-negative microorganisms, are necessary. If the
patients have a history of visiting farms or consuming unpasteurized milk products,
rifampicin or trimethoprim-sulfamethoxazole are antibiotics of choice. There is no
standard recommendation on the duration of antibiotics for pyogenic infection, but
in general the antibiotics should be given until serum infective markers return to
normal, and there should be a minimum duration of three weeks.
For TB spine, four anti-TB drugs (isoniazid, rifampicin, pyrazinamide, and ethambutol) are given for the rst 8weeks. If the patients are responding well, or the
sensitivity test conrms effective isoniazid and rifampicin, they should be continued
for a total of 9months, and the other two anti-TB drugs can be stopped. Children
with TB spine after adequate antituberculosis treatment should still be carefully followed up for any progression of kyphosis, particularly if multiple apophyseal rings
of vertebral bodies are destroyed. This may lead to the progression of kyphosis during growth. Rajasekaran described four radiological risk features with which
patients may develop progressive kyphotic deformity [3] (Fig.40.1).
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ab cd
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Fig. 40.1 The schematic drawings [3] from Dr. S.Rajasekaran (with permission): (a–d) illustrat-
ing the radiological signs of the high risk of progression of kyphosis. (a) Separation of facet joint
at the apex. (b) Retropulsion of the intervening vertebral bodies posterior to two lines along the
posterior surfaces of the rst upper and lower normal vertebrae. (c) Lateral translation between the
rst lower normal vertebra and the rst upper normal vertebra. (d) Toppling sign. When a line
drawn along the anterior surface of the rst lower normal vertebra intersects higher than the middle
of the anterior surface of the rst normal upper vertebra
Y.-W. Wong
40.7 Expected Outcome
Most pyogenic spinal infections respond to antibiotics alone. It is only very occasionally that surgery is indicated for neurological deterioration. Correction of severe
deformity is mandatory in TB spine to prevent Pott’s paraplegia of late onset.
Surgery for persistent symptoms not responsive to anti-TB treatment also gives
favorable short- and long-term results (Fig.40.2).
In case of established kyphotic deformity with persistent infected tissues or
abscess, anterior debridement and fusion together with posterior instrumented
fusion are indicated.
40.8 Potential Complications
Disseminated pyogenic infections, paraplegia, or spinal instability.
40.9 What Should Patient andFamily Know?
Compliance with antibiotics or anti-TB treatment.
40 Discitis inPediatric Spine
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235
a
c
b
d
e
Fig. 40.2 This 6-year-old patient suffered TB spine. (a) Lateral X-ray showing the complete col-
lapse of L5 and partial collapse of L4. (b) Axial CT scan demonstrating a huge right psoas abscess.
(c) Lateral X-ray after the anterior debridement and fusion L3 to S1 using a bular graft. (d, e)
Standing whole spine X-ray 20 years after surgery. The global spinal alignment was well
maintained
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Y.-W. Wong
Further Readings
1. Principi N, Esposito S. Infectious discitis and spondylodiscitis in children. Int J Mol Sci.
2016;17:539.
2. Dayer R. Spinal infections in children: a multicenter retrospective study. Bone Joint
J. 2018;100-B(4):542–8.
3. Rajasekaran S.The natural history of post-tubercular kyphosis in children. J Bone Joint Surg
Br. 2001;83(7):954–62.
Part IV
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Adult Spine Pathology
Back Pain andIts Generators
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41
PhilipK.Louie andToddJ.Albert
41.1 Definition
Back pain is one of the most common health complaints among adults, resulting in
pain and disability. Musculoskeletal pain in adults ranges from 65% to 85% with
36% to 70% suffering from back pain. The 1-year prevalence of back pain in seniors
(aged 65+) ranged globally from 13% to 50% in population-based studies. Up to
80% of older residents in long-term care facilities experience substantial back pain
which is often underreported and inadequately treated.
41.2 Physical Examination
Research has shown that less than 50% of primary care physicians have strong condence in diagnosing the causes of chronic back pain in adults (Appendix N). A
stepwise approach to history collection can lead to a cost-effective and cost-efcient
process of treating the patient. The clinician must determine whether the pain is
Supplementary Information The online version contains supplementary material available at
[https://doi.org/10.1007/978- 3- 030- 80356- 8_41].
P. K. Louie (*)
Virginia Mason Franciscan Health, Seattle, WA, USA
e-mail: philip.louie@virginiamason.org
T. J. Albert
Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, USA
e-mail: albertt@hss.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spine Surgery,
https://doi.org/10.1007/978-3-030-80356-8_41
239
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Table 41.1 Physical exam: mechanical versus nonmechanical and axial versus radicular
Mechanical Nonmechanical
• Rest improves symptoms
• Pain often worsens progressively
throughout the day
Axial Radicular
•Diffuse
•Referred pain patterns include:
–Cervical spine: scapula or shoulder
– Lumbar spine: buttock or posterior thigh
Table 41.2 Inspection
Coronal plane evaluation Sagittal plane evaluation
–Scoliosis
–Pelvic obliquity
–Shoulder imbalance
–Scapular protuberance
–Rib prominence
Table 41.3 Palpation
Bones Soft Tissue
–Spinous processes
–Posterior superior iliac spines
–Scapula and ribs
–Iliac crests
–Sacrum and coccyx
–Trochanter
–Ischial tuberosity
• Rest/immobilization does not improve
symptoms
• Pain is independent of activity and can be
worse at night
• Dermatomal distribution
• Can present with paresthesia, numbness, or
weakness
• Pain can be associated with tension signs
• Note normal spinal curves
–Cervical lordosis: 20–40°
–Thoracic kyphosis: 20–45°
–Lumbar lordosis: 40–60°
–Trapezius muscle
–Rhomboid/levator muscles
–Gluteus muscles
–Piriformis muscle
–Sciatic nerve
P. K. Louie and T. J. Albert
mechanical or nonmechanical and axial or radicular (Tables 41.1, 41.2, 41.3).
Paresthesia, numbness, or weakness that follows a dermatomal distribution and is
associated with tension signs is more indicative of radicular pain. A comprehensive
physical exam should include inspection, palpation, movement, neurological examination (Video 41.4), and other special exams. While assessing for coronal or sagittal imbalance, also evaluate for walking aids that the patient may use for mobility.
41.3 Imaging
Table 41.4 outlines the indications for imaging during the workup of back pain vary
(Table41.4). Standing plain radiographs of the thoracic and/or lumbar spine are the
initial diagnostic test of choice in the setting of trauma, malignancy, infection,
deformity, and degenerative spine disease and offer many benets due to ease in the
acquisition and relatively low cost. However, plain radiographs are limited in the
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Table 41.4 Indications for imaging of the thoracolumbar spine
Plain radiographs
First diagnostic test of choice
in the setting of trauma,
malignancy, infection,
deformity, and degenerative
spine disease
Back pain that does not
improve with conservative
measures for more than 6
months (all ages)
Evaluate for dynamic
instability of the spine
Assess overall coronal and
sagittal alignment (concern
for deformity)
Evaluate for arthritic changes
in neighboring joints
(sacroiliac, hips, etc.)
MRI
Radicular symptoms (pain,
weakness, and numbness/
tingling which radiates to the
extremities)
Myelopathic signs and
symptoms (altered gait,
difculty with ne motor
tasks, hyperreexia, upper
motor neuron signs)
Neurogenic claudication Assess bone mineral density
Bladder dysfunction (usually
urinary retention or overow
incontinence) with leg pain
and weakness
History or concern for
present malignancy
Infection (both rule out and
assess current status/
progression)
If the back pain is
accompanied by
constitutional symptoms
(such as loss of appetite,
weight loss, fever, chills,
shakes, or severe pain when
at rest)
241
CT
Concern for fracture
History or concern for present
malignancy
Assess status of fusion
Preoperative planning
Acute postoperative evaluation
of hardware placement
Myelography: diagnostic test
of choice in patients unable to
receive an MRI; provides
additional diagnostic
evaluation for foraminal/
lateral recess stenosis and disk
lesions
ability to identify soft tissue, three-dimensional characteristics, and high image
resolutions. Plain radiographs can also evaluate stability and exibility in the form
of exion-extension, sitting, supine, and bending views to provide dynamic
feedback.
Magnetic resonance imaging (MRI) is the diagnostic procedure of choice for
most primary spinal pathologies. MRI provides relatively high sensitivity and specicity for infections, tumors, disk degeneration, pathologic fractures, and herniations. Some visceral pathology may also be initially evaluated. However, MRI is
relatively expensive and has varying degrees of utility in obese, claustrophobic, and
pacemaker-dependent patients.
Computed tomography (CT) provides a more detailed evaluation of the osseous
structures of the spine, largely due to its ability to reconstruct three-dimensional and
multiplanar images. Although not as commonly utilized at this point, CT myelography has some utility to improve the diagnosis of foraminal/lateral recess stenosis
and disk lesions, especially in patients that cannot undergo MRI.
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Discography has largely fallen out of favor due to controversial evidence and
risks associated with the procedure, specically iatrogenically induced disk
degeneration.
Angiography provides clear visualization of specic structures due to variations
in vascular ow. This form of imaging is particularly useful for the characterization
of many spinal tumors and can be applied preoperatively to evaluate vascular
anatomy.
P. K. Louie and T. J. Albert
41.4 Differential Diagnosis
While the vast majority of nonspecic complaints can be self-limited and treated
conservatively, notable ndings can present that aid with diagnosis and may drastically alter the time course of evaluation and treatment, such as weight loss, bowel or
bladder incontinence, saddle anesthesia, weakness, or gait imbalance. A differential
diagnosis of common back pain etiology is listed below.
Nonspecic or mechanical low back pain: Often multifactorial, disk degeneration, facet joint pain, spondylolisthesis, spondylosis, sacroiliac joint disorders, and
myofascial sources.
Radiculopathy or neurogenic claudication (compression of nerve roots): Disk
herniation, lumbar spinal stenosis from secondary to degenerative changes (hypertrophic ligamentum avum, facet arthropathy, disk-osteophyte complexes), and epidural lipomatosis.
Facet joint syndrome: Can also be a source of chronic low back pain in older
individuals. As the degenerative process in the spine progresses, kinematics and
load transmission throughout the motion segments are impacted, which can stimulate nociceptive bers in the facet joints. Studies have not found reliable referral
patterns of facet joint pain. Symptoms can range from local soreness to “pseudoradicular” pain that typically radiates uni- or bilaterally along with lumbar nerve
root distributions without neurological decits.
Trauma/vertebral body fractures: Can be a result of varying impact levels of
trauma or poor bone mineral density.
Scoliosis (previous adolescent idiopathic scoliosis or de novo degenerative lumbar scoliosis): The asymmetric loading on vertebral end plates on the concavity of
the curve may elicit inammatory responses in the end plate and adjacent bone marrow of the vertebral body.
Tumors: Common metastatic sources of LBP are prostate and kidney; however,
primary malignant tumors are also found in older adults (plasmacytoma, lymphoma,
or chordoma). Primary benign tumors (e.g., aneurysmal bone cysts, eosinophilic
granuloma, osteochondroma, osteoma, and osteoblastoma). Clinically, the patient
can describe progressive, unremitting, localized, or radiating pain aggravated by
activity, worse at night, and does not improve with rest.
Visceral disease: Several visceral diseases (e.g., urinary tract infection, prostatitis, dissecting abdominal aortic aneurysm, pelvic inammatory disease, cholecystolithiasis, and nephrolithiasis) can present as back pain.
41 Back Pain andIts Generators
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243
Spinal infection: Bacteria may be disseminated hematogenously from a distant
infected source and multiply at the metaphyseal arterioles of vertebral bone that
causes abscess formation, bone necrosis, and stula within the bone. Specically,
aerobic gram-negative bacilli in men with urinary tract infection may travel to the
lumbar spine through Batson’s plexus. Rarely, tubercular osteomyelitis may occur
in those who have contracted tuberculous infection earlier in life.
41.5 Treatment Options, Expected Outcomes,
andPotential Complications
Treatment options are based on the etiology of the back pain. Ultimately, improper
treatment or nontreatment of adults with back pain may result in impeded cognition,
malnutrition, withdrawal from social and recreational activities, sleep disturbances,
psychological distress, rapid deterioration of functional ability, and falls. Thus, a
comprehensive diagnostic workup is recommended, especially in presentations that
do not directly correlate with symptoms, exam ndings, and early imaging results.
The surgical treatment options for spine-specic pathology will be discussed at
length throughout this book. There are several well-established algorithms and
evidence- based approaches for surgical treatment. However, conservative management for nonspecic back pain can be a bit challenging and nuanced (Table41.5).
Table 41.5 Treatment options
Treatment option Description
Activity modication Common recommendation is to avoid activities that cause
pain (until acute symptoms decrease), but evidence is lacking.
Bed rest no longer indicated. Patients with chronic low back
pain should be encouraged to remain physically active
Exercise/physical therapy The general consensus is that low-impact cardiovascular and
aerobic exercises provide other benets (as no signicant
impact on clinical outcome), such as improved mood,
increased pain tolerance, and prevention of deconditioning.
Symptoms can be improved by a focus on aerobic tness,
restored normal lumbosacral motion, strengthening of trunk
muscles, and emphasis of correct body mechanics
Specic modalities Physical therapists and chiropractors often provide modalities
that include cold packs, supercial heat, short-wave
diathermy, and ultrasound
Education Provide information regarding correct posture, biomechanics
of the spine with activities of daily living, and simple methods
that can reduce symptoms. Inform patients on the expected
outcome and favorable natural history of low back pain
Manipulation/traction There is no evidence that spinal manipulative therapy or
traction is superior to other treatments of patients with acute
or chronic low back pain
(continued)
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