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Y.-W. Wong
65.3 Physical Examination
The most common presentation is pain (Chaps. 11 and 41), and if there is any one
of the following additional features, it should raise the suspicion:
1. Fever of unknown source.
2. Intravenous drug abusers or immunocompromised patients.
3. Elevation of infective markers such as CRP, ESR procalcitonin, and WBC.
4. Radiological features of pyogenic spondylodiscitis.
Pain at rest is the typical complaint of pyogenic spondylodiscitis. In the presence
of fever and back pain, spondylodiscitis should be excluded. There may be local tenderness at the affected segment. Deformity if any is usually not severe especially in
early cases. Detailed neurological assessment is mandatory (Video 65.4). The severe
neurological decit at presentation or deterioration is an indication for surgery. Any
skin lesions or other septic foci should be treated accordingly. At least two sets of
blood cultures (especially when patients have a fever, or chill and rigor) and one midstream urine for urinalysis/culture should be done. Other specimens (sputum, wound
swaps) for culture should also be obtained, if clinically appropriate. Prolonged incubation during culture is needed if low virulence pathogens such as Propionibacterium
and diphtheroids are suspected. Brucella serology must be checked if there is history
of exposure such as farm visit, raw milk, or placenta consumption. Elevation of procalcitonin suggests pyogenic rather than tuberculosis (TB) infection.
65.4 Imaging
Spine radiographs may show decreased intervertebral disc height with adjacent
bony end plate erosion (Fig.65.1). Bony destruction is not apparent in the rst or
second week. The only radiological features may be soft tissue edema and loss of
spinal sagittal alignment due to muscle spasms. In chronic infection, radiographs
may show osteosclerosis and deformity. Clinical diagnosis is usually not difcult
with compatible clinical, serological, and radiographic features. Magnetic resonance imaging is the most useful tool for early diagnosis before radiographic features develop. It also delineates the extent of the disease for surgical planning.
Blood culture can only catch less than 50% of the causative bacteria. Computed
tomography scan or uoroscopy-guided biopsy (Videos 65.7 and 65.8) is frequently
necessary to get the bacteriological diagnosis. If there is a paraspinal abscess, percutaneous drainage can be done at the same time of the biopsy. Specimens should be sent
for aerobic and anaerobic culture, AFB smear and culture, TB PCR, fungal culture, and
histological examination. Special culture may be necessary if rare organisms are
suspected.
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a
b
Fig. 65.1 (a, b) Showing the typical radiological features of destruction of intervertebral disc
space and adjacent vertebral bodies in spondylodiscitis
65.5 Differential Diagnosis
Spinal tumors, both primary and secondary, tend to affect the vertebral bodies alone
without intervertebral disc involvement. TB is a great mimicker that can present
with either spondylitis or spondylodiscitis (Chap. 64). The lymphocyte monocyte
ratio is a cheap and good indicator for differential diagnosis of TB spine and pyogenic spondylodiscitis. The ratio is typically elevated in specic infections like TB.
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Y.-W. Wong
65.6 Treatment Options
Most patients respond well to antibiotic treatment, and surgery is not required for
most patients. Antibiotics are withheld until the bacteriological diagnosis is conrmed. However, empirical antibiotics can be started early after essential diagnostic
workups especially if the patients are septic looking and ill. For community-acquired
infection, cloxacillin 2g IV every 6h will cover the most common organisms such
as methicillin-sensitive staphylococci and streptococci. For hospital-acquired infection or immunocompromised patients, ceftriaxone 1–2g IV daily plus vancomycin
15–20 mg/kg/dose IV every 12 h provides broader coverage including Gramnegative bacilli and MRSA.The subsequent antibiotic regime is adjusted according
to the culture result. Duration of antibiotic treatment varies but normally ranges
from 3 to 12 weeks depending on the clinical, serological, and radiological
responses. Typically, antibiotics can be stopped if patients’ symptoms improve;
infective markers return to normal; radiographs showed evidence of stopping new
vertebral destruction. A regular blood examination is essential, not just to check
infective markers but also to monitor patients’ liver and renal function because of
the prolonged antibiotic treatment. Like other infections, spondylodiscitis is catabolic, and adequate nutritional support promotes early recovery. Spondylodiscitis
may be very painful. Adequate symptomatic treatments including analgesics, corset
or collar, and appropriate rest relieve patients’ suffering.
The sizable paraspinal abscess should be drained, preferably image-guided percutaneous drainage. Loculated abscess or thick pus may need open drainage.
Surgery is generally indicated if there is neurological deterioration, persistent instability, unacceptable deformity, debilitating pain not under control by nonoperative
treatment, an uncertain diagnosis, and unfavorable response to medical treatment.
The aims of treatment are to decompress the spinal cord or nerves, debride necrotic
tissues, drain abscesses, correct deformity, and stabilize the spine.
Anterior or anterolateral approach accesses the infective focus directly and provides wide exposure for thorough debridement and spinal canal decompression.
Reconstruction can be done by autologous iliac crest tricortical, rib, or bular graft.
Alternatively, titanium cage or mesh cage lled with a bone graft can be used.
Anterior instrumentation at the cervical and thoracic spine provides additional stability, while anterior xation at the lumbar spine is less secure, and additional posterior instrumentation may be necessary (Fig.65.2).
The posterior approach alone is effective for decompression of the spinal canal
and allows rigid instrumented fusion (Fig.65.3). It is particularly useful for the
upper thoracic spine since the anterior approach there is difcult (may need split
manubrium approach). However, surgeons cannot normally debride the infective
focus as thoroughly as the anterior approach.
The choice of surgical approaches is dictated by surgeons’ expertise and the
indications for surgery. Regardless of the approaches, metallic cages and implants
can be safely used to reconstruct the spine if patients are covered by adequate antibiotics and the surgical bed is relatively clean. PEEK cages should be avoided
because it is more difcult to eradicate the bacteria on the PEEK surface.
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a
d
b
e
c
f
Fig. 65.2 (a, b) Anteroposterior and lateral radiographs showing the L2/3 spondylodiscitis. (c, d)
T2-weighted sagittal and T1-weighted contrast axial MRI demonstrating the active infection.
Patient did not respond to empirical antibiotics after negative biopsy. (e, f) Radiographs after anterior debridement and fusion followed by posterior stabilization
65.7 Expected Outcomes
Most patients can recover completely with early treatment. The mortality and morbidity rates become higher if the patient has many comorbidities.
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a
d
b
e
c
f
Fig. 65.3 (a, b) Radiographs showing L4/L5 spondylodiscitis. (c) T1-weighted contrast sagittal
MRI demonstrating the extensiveness of the infection. (d) Sagittal CT scan illustrating L4 vertebral body fragmentation. Due to neurological deterioration and poor response to antibiotics, anterior debridement, fusion, and posterior xation via posterior approach alone were done. (e, d)
Postoperative radiographs
65.8 Potential Complications
• Uncontrolled sepsis leading to mortality.
• Neurological deterioration.
• Spinal instability (Chap. 47).
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• Kyphosis.
• Secondary degeneration and chronic pain (Chap. 41).
65.9 What Should Patient andFamily Know?
Prolonged antibiotic treatment and close monitoring of treatment responses are
necessary.
Further Reading
Yee DK, Samartzis D, Wong YW, Luk KD, Cheung KM.Infective spondylitis in Southern Chinese:
a descriptive and comparative study of ninety-one cases. Spine. 2010;35(6):635–41.
Postsurgical Spinal Infection
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66
AlainDimeglio andFedericoCanavese
66.1 Definition
According to the surgical site and the time since surgery, postoperative spine infections can be divided into (a) supercial or deep and (b) acute (early-onset) or chronic
(late-onset). It is also important to distinguish between infections occurring in adult
and pediatric patients.
Supercial infections typically develop above the fascial layer and involve subcutaneous tissues and skin; on the other hand, deep infections do extend below the
fascial layer (lumbodorsal fascia or ligamentum nuchae for posterior surgery and
abdominal fascia or platysma for anterior surgery).
Acute infections are usually diagnosed within 3 to 4 weeks of the procedure,
while chronic infections are diagnosed more than 4 weeks since surgery; for some
authors, the cutoff between acute and chronic infection is 6 weeks. However, it is
important to recognize the very late infection (sometimes years after the index procedure) usually secondary to low-grade pathogens such as Propionibacterium spe-
cies and that can be cured by hardware removal.
Supplementary Information The online version contains supplementary material available at
[https://doi.org/10.1007/978- 3- 030- 80356- 8_66].
A. Dimeglio (*)
Department of Pediatric Orthopedics, Clinique St. Roch, Montpellier, France
Faculty of Medicine, Montpellier University, Montpellier, France
F. Canavese
Department of Pediatric Orthopedic Surgery, Lille University Center, Jeanne de Flandre
Hospital, Lille, France
Faculty of Medicine Henri Warembourg, Nord-de-France University, Lille, France
© 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_66
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66.2 Natural History
The incidence of postoperative spine infection is highly variable; it ranges from 0%
to 18% depending on the type of surgery (surgeries without bone grafting or instrumentation have the lowest rate of infection) and of surgical approach (posterior
cervical fusion>posterior lumbar surgery>anterior surgery).
Overall, the development of a postoperative infection put the patient at increased
risk for pseudoarthrosis, chronic pain, adverse neurological sequelae, return to the
operating room, worsened long-term outcomes, and – in most severe cases –
even death.
66.3 Physical Examination
The typical physical signs of surgical site infection are pain, erythema, swelling of
the incision or wound dehiscence, and purulent drainage from the wound; importantly, wound drainage for more than 1 week is a risk factor for deep infection.
Other signs and symptoms are fever (present in about half of the patients), fatigue,
and, in some cases, weight loss (depending on the chronicity of the infectious
process).
Laboratory Tests: If surgical site infection is suspected, white blood count
(WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) should
be requested by the treating surgeon. However, used in isolation, WBC is a poor
marker, and ESR is a nonspecic marker—though more sensitive than WBC—to
rule out a surgical site infection. CRP is the most sensitive indicator currently available to diagnose postoperative infection. The combination of CRP and ESR values
is the most predictive method for diagnosing and monitoring treatment response of
postoperative spinal infections; however, no laboratory method has demonstrated
excellent specicity/positive predictive value.
The use of procalcitonin (PCT) for the evaluation of spinal infection has shown
lower sensitivity than CRP.Other relatively novel markers such as serum amyloid A
(SAA) and presepsin, although promising, have limited clinical validation and
require to be studied further.
66.4 Imaging
Plain radiographs are of limited use in postoperative spine infection although they
should be obtained to assess for any hardware failure.
Computed tomography (CT) scan is the imaging of choice to evaluate bone, and
it also provides information on soft tissue collections. Early bony changes include
erosion and destructive changes at the level of the end plates and disk space narrowing. CT can identify (earlier than radiographs) lucencies around orthopedic implants.
Magnetic resonance imaging (MRI) with gadolinium contrast is considered to be
the most sensitive modality for the assessment of postoperative infection. MRI
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ndings usually associated with postoperative spine infection are rim-enhancing
uid collections, ascending epidural collections, evidence of bony destruction, and
progressive marrow signal changes; the presence of hardware can create artifacts
making the interpretation of the images more difcult.
Nuclear medicine (gallium-67 or technetium-99) can be used as an adjunct for
the diagnosis of postoperative spine infection although it has limited sensitivity and
is not used regularly in the diagnostic process.
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66.5 Differential Diagnosis
Currently, the gold standard for the diagnosis of postoperative spine infection is a
positive deep culture. Differential diagnosis focuses on the type of pathogen
involved in the infectious process (Videos 66.7 and 66.8).
66.6 Treatment Options
Multiple debridement procedures of necrotic and infected tissue and long-term antibiotics are required for treatment. Exploring below the fascia is recommended for
all but the most supercial infections. Bone graft that is loose at the time of debridement should be removed, but any graft material that is adherent to bony structures
should be left in place; similarly, all necrotic, infected, and foreign material, such as
sutures, must be completely debrided.
For early postoperative infection (acute or chronic <3 months), in cases where
spinal instrumentation is present, the current recommendation is not to remove the
hardware to avoid destabilizing the spine. For late postoperative infection (chronic
>3 months), if fusion has occurred, hardware removal is usually needed to allow
adequate debridement of the wound. The vacuum-assisted closure (VAC) system
can be used in patients with acute infection; it has been shown to be a useful tool in
the armamentarium of the spinal surgeon dealing with patients susceptible to deep
postoperative infections, especially those with neuromuscular diseases (Fig.66.1).
VAC system is changed every 48 to 72h.
Equally important to multiple debridements and lavages is antibiotic therapy.
Importantly, antibiotics should not be administered prior to culture results; if the
patient is septic or unstable, antibiotics should be administered empirically to help
prevent further clinical decline. Broad-spectrum antibiotics should be initiated
prior to obtaining nal culture results and adjusted depending on the results of the
cultures. Although the duration of antibiotic therapy is controversial, short antibiotic course should be reserved only for patients without any hardware in place.
For patients with deep infection and hardware in place, the length of antibiotic
treatment is much longer, including 4 to 6 weeks of IV antibiotics followed by at
least 4 to 6 weeks of oral antibiotics. Postoperative discitis/osteomyelitis is generally treated with >3 months of antibiotics depending on the inammatory markers
(Fig.66.2).
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Fig. 66.1 Deep postoperative infection in a patient with spinal muscular atrophy. Use of VAC
system. Hardware is left in place, and supercial and deep layers are progressively closed
66.7 Expected Outcomes
A high index of suspicion is needed to make an early diagnosis; if treated promptly
through debridement and lavage in association with targeted antibiotic therapy
(according to deep culture results), the outcome is generally good. Older age, presence of comorbidities, smoking history, and obesity can be associated with poorer
outcomes (Table66.1).
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