INFECTIONS OF

SPINE
 INTRODUCTION

Spinal infections are basically divided into

two types:
a) Pyogenic
b) Non pyogenic(granulomatous)

Spondylodiscitis
• infection of the
intervertebral disc
Vertebral osteomyelitis
• If infection invades the
endplates or the vertebral
body.
 PYOGENIC INFECTION

Represents 2-7% of all pyogenic

osteomyelitis
Bimodal distribution: First peak in children
and other around 50.
Site of involvement: >Lumbar spine- 50-
60% >Thoracic 30-40%
 PATHOPHYSIOLOGY
Hematogenous

Routes of Direct external

pathogen spread inoculation

Spread from
contiguous tissues
 Etiology
Predisposing factors:
Septic focus(skin, Genitourinary tract, etc.)
Invasive procedures
Immunocompromised
Diabetes
Steroid use
Old age
Spine surgery
Most common organism – Staph. Aureus(50%)>
Gram negative(E.coli)> Anaerobes
 CLINICAL PRESENTATION

Nonspecific local pain – first presenting feature

Pain more during night.
Constitutional symptoms like night sweats, anorexia,
low grade fever are less common but more
commonly seen in TB spine.
Most common SIGN is Tenderness at local site.
Sustained paraspinal muscle spasm is noted
Abscess formation – rare presentation
Complication: Neurological deficit - suggestive of
abscess compressing over the cord
PRESENTATION IN CHILDREN

Irritability,

Refusal to crawl, sit or

walk,
Abdominal pain
LABORATORY INVESTIGATIONS
ESR CRP

Elevated in 71-97% of patients

Generally > 50mm/hr

Elevated after surgery peak at 5 days and

elevated for 4 weeks. More sensitive marker
Persistent elevation after surgery suggestive of Peaks within 2 days of surgery and has rapid fall
infection
Elevation even after a week of surgery suggest of
Remains high even after treatment for prolonged infection
period of time
Rapidly decline following treatment.

Other tests: CBC: may show leucocytosis

Blood culture- positive in around 60%
 XRAY
Findings lag 2-4 weeks behind onset of symptoms
May show: Narrowing of disc space
Vertebral plate irregularity
Late findings include- Destruction of vertebral body, bony
ankylosis
 CT SCAN

Beneficial over radiograph –

more sensitive to earlier changes
Identifies soft tissue and
paraspinal mass easily
Findings- > lytic defects in
subchondral bone
> Multiple holes seen in cross
sectional views
 MRI

T1 IMAGES: Low density changes in bone and disc

T2 IMAGES: High density changes in bone and disc. Abscess are areas with very high uptake.
• Using serial MRI helps in sho wing response to treatment.
• Following treatment soft tiss ue findings tend to improve while the bony findings like marrow edem a remains.

T1 T2
 RADIONUCLEIDE SCANNING

Radionuclide scans with

technetium-99m become
positive long before plain
film changes are evident
Gadolinium is a good
adjunct. Combination of
Tc99m and Ga67 is used-
shows increased uptake
at the site of infection
 Biopsy
Best method of determining the infection.

CT guided
•Minimal invasive
Open biopsy
• If blood cultures and percutaneous
biopsy fail to identify the infecting
organism.
DIFFERENTIAL DIAGNOSIS

Primary and
metastatic
tumours
Infections in
contiguous
Epidural
structures like that of
infections psoas, abdomen,
GUT.

Ankylosing Rheumatoid
spondylitis arthrirtis
MANAGEMENT
ALGORITHM
ESR
 MANAGEMENT CONTD..
Antibiotics chosen according to culture and
sensitivity
NON OPERATIVE Response to treatment evaluated with serial ESR
and CRP.
Duration: INTRAVENOUS – FOR 4-6 WEEKS followed
by oral antibiotics based on individual response.

INDICATIONS FOR SURGERY

• Open biopsy
• Neurological deficit
• Vertebral collapse
• Abscess
• Failure of medical treatment
 BRUCELLOSIS
Brucella melitensis - organism
Consumption of unpasteurized milk
and soft cheeses made from the
milk of infected animals
Symptoms: polyarthralgia, night
sweats, anorexia, headache.
Psoas abscess is found in 12% of
patients
Lumbar spine most commonly
involved
 BRUCELLOSIS(contd.)

Radiography:

Confirm diagnosis: Titre of brucella >1:80

Treatment: Antibiotics (rifampicin and
doxycycline) for 4 months
 FUNGAL INFECTIONS
Opportunistic infection,
common n
i immunodeficient
Symptoms develop very slowly. Pain is less
prominent
Most common: Aspergillus> Cryptococcal
Most common involvement is of lumbar
E S R and CRP elevated but WBCs are not
raised
Diagnosis by biopsy
FUNGAL INFECTIONS (contd.)
How to differentiate?
MRI: serrated margins of vertebral endplates without
severe VB destruction
Disc space: Typically spared; lack of T2 hyperintensity

Treatment: conservative by antifungal chemotherapy.

 SPINAL
TUBERCULOSIS
 INTRODUCTION
Tuberculosis - oldest disease afflicting humans.
Among overall cases:
- 10% involve musculoskeletal system
- 50% of them involves spine.
Always secondary: follows Tb of other sites
Predisposing Factors:• Malnutrition.
• Over crowding.
• Close contact with TB
patient.
• Immunodeficiency state.
 REGIONAL DISTRIBUTION
SPINE TB

Cervical(12%)
Cervicodorsal(5%)
Dorsal(42%)
D o r s o lumbar(12%)
Lumbar(26%)
Lumbosacral(3%)
WHY MOST COMMONLY
OCCURS AT DL JUNCTION???

Greater extent of movement

D e g r e e of weight bearing and
microfracture
Large spongy cancellous bone
Proximity to kidney and cistern
chili
 PATHOGENESIS
Secondary infection- lung, genitourinary system.
Spread - hematogenous route- attacks macrophages
 CLINICAL PRESENTATION
•
Constitutional • Loss of appetite/weight
symptoms(40%) •
• Evening rise of temperature
Presentation depends on the site and stage of disease:
Patient gives h/o of back ache
- Slight pain and stiffness are earliest complaints
-Pain is initially localized, dull aching brought down by jarring or movement of
spine
REFERRED PAIN : depending on the nerve root involvement
CERVICAL LESION - pain over occiput, ear, jaw, upper limb
UPPER THORACIC - intercostal neuralgia
THORACO-LUMBAR - girdle pain or epigastric pain
LUMBAR - Hips and legs
 GAIT
Patient is very cautious and avoids jarring of
spine and walks with HEAD AND CHEST THROWN
BACKWARD AND legs apart and waddles - so
called “ALDERMAN’S GAIT”

SEEN IN TB OF LOWER DORSAL AND UPPER

LUMBAR
 OTHER FEATURES
KYPHOTIC
DEFORMITY

ENLARGED LYMPH NODE

NEURAL DEFICIT-20%
SPASTICITY
CLONUS
EXAGGERATED REFLEXES
 INVESTIGATIONS
1)CBC:
Decreased Hb, Lymphocytosis
2) ESR & CRP-
>Raised in active stage of the disease.
>Used as an aid for diagnosis and monitoring of treatment
response.
>Normal ESR for 3 months suggest patient is in recovery phase.
3) MONTOUX/TUBERCULIN SKIN TEST
Positive test can be observed 1 to 3 months after infection.
4)Other tests: HIV
IFN –Gamma release assays
 TESTS FROM OBTAINED
SAMPLE
5) Z-N STAINING : Detects acid fast bacilli
- Positive only 50% cases.
6) ELISA- antibody detection
7) PCR- TB Gene expert (from sample)
- result within 4-6 hr
- Ripampicin resistance detected.
8) Culture- Growth often can be detected
within 2 weeks. Typical hold periods are for
4–6 weeks- allows drug succeptibility
assessment.
 PLAIN XRAY

FINDINGS:
Reduced disc space
Blurred paradiscal
margins
Anterior wedging
P s o a s abscees
 THORACIC LUMBAR
[BIRD NEST]
 “SPINE AT RISK” SIGN IN CHILD

Separation of Lateral “Toppling

Retropulsion
facet joint translation sign”
 CT SCAN
Pattern of bony
destruction
Calcification i
nabscess.
Detects early lesion
before they appear
on xray
 MRI
Spinal cord involvement
Changes of discitis
Detect marrow infiltration
in vertebral bodies
Extent of disease
Helps in differentiating
intradural from extradural
lesions
Skip lesions-17% incidence
Abscess
 Biopsy
Best method of
obtaining the sample
for microscopy, culture
and Gene Xpert,
histopathology.
Percutaneous CT guided
biopsy is preferred.
 SITE OF LESION
• INTRADURAL involvement-very rare
• Extradural involvement- 4 TYPES [FIGURE]

(m.c) (2nd
m.c) (Rarest)
STAGES OF SPINAL TB [KUMAR]
 COMPLICATIONS OF
SPINAL TUBERCULOSIS

Paraplegia
C o l d abscess
Spinal deformity
Secondary infection
Fatality
Amyloid disease
DIFFERENTIAL DIAGNOSIS OF
TB SPINE

Spinal
infection-
pyogenic,
brucellosis,
fungal
Neoplastic-
Neuropathic lymphoma-
spine metastasis

Degenerativ
e
TUBERCULAR Vs. PYOGENIC
Chronic back pain -Long standing Acute onset : History of days to
History of months to years. months

Presence of active
Not present
pulmonary TB – 60 %

Most common location thoracic

Lumbar spine
spine

>3 contiguous vertebral body segment

Mostly involves single level
involvement common

Skip lesions- common Rare

Rare –
Vertebral collapse - 67%
21%

Posterior elements involvement

Rare
possible
DD- NEOPLASTIC LESIONS
In early stages of central type of
tuberculosis of spine, there is no
involvement of intervertebral disc thereby
mimicking neoplastic lesion.
However, in chronic tubercular lesion
intervertebral disc is involved making it
easy to differentiate from neoplastic
lesion
Hence the term : “Good disc, bad news;
Bad disc, good news”)
POTT’S PARAPLEGIA
Incidence : 10 - 30 %
Dorsal spine most common
M o t o r functions affected before
/greater than sensory.
S e n s e of position & vibration last
to disappear
 PATHOPHYSIOLOGY

Abscess, Endarteritis
Secondary Vertebral Neural
Granulation Cord
infection Collapse Deficit
tissue ischemia
 BASIC PRINCIPLES OF
MANAGEMENT

Early diagnosis
• Medical Treatment – AKT and
bracing
• Surgery to drain abscess,
debridement and fusion
• Stabilization to Prevent kyphotic
deformity
 TREATMENT OF TB SPINE

SURGERY
CONSERVATIVE (DEBRIDEMENT+FIXATION
+FUSION)

ANTERIOR POSTERIOR
AKT[18 MONTHS] REST AND BRACE APPROACH APPROACH

COMBINED
APPROACH
 AKT GUIDELINES
ENTIRE DUARTION OF CHEMOTHERAPY LASTS FOR
16-18 MONTHS- 2 months intensive phase
+
10-16 months maintenance phase- 2HRZE+10HRE)
• 1 0 MG PYRIDOXINE FOR PREVENTION OF PERIPERAL
NEUROPATHY
INDICATIONS FOR SURGERY IN TB SPINE
WITHOUT NEUROLOGICAL DEFICIT

Diagnosis is uncertain and open biopsy si

indicated
Mechanical instability – panvertebral disease
Suspected drug resistance –inadequate clinical
improvement or deterioration on ATT
Spinal deformity – severe kyphotic deformity at
presentation, or in
Children at high risk of progression of
kyphosis-”SPINE AT RISK SIGNS” with growth
after healing of disease.
INDICATIONS FOR SURGERY IN TB SPINE
WITH NEUROLOGICAL DEFICIT

Neural complications developing or getting worse

or remaining stationary during the course of non-
operative treatment (3–4 weeks)
Paraplegia of rapid onset
Spinal tumour syndrome
Severe paraplegia – flaccid paraplegia, paraplegia
in flexion, complete sensory loss and complete
loss of motor power for more than 6 months
Painful paraplegia in elderly patients.
VARIOUS SURGICAL
APPROACHES
ALL POSTERIOR
This figure shows
temporary fixation
with one side rod and
resection of the
spinous process, facet
joint on one side and
the lower
costotransverse joint
with a small fragment
of rib.
 This figure shows
implantation of
specially constructed
titanium mesh cages
into the interbody via
posterior approach
only.
 ADVANTAGES OF ALL POSTERIOR
APPROACH
☺ Effective to remove disease process
☺ Safe
☺ Excellent in correcting and maintaining
kyphosis
☺ Beneficial for patient in terms of less
blood loss, less operative time and short
duration of hospitalization compared to
combined approach.
THANK
YOU