Introduction Vertebral osteomyelitis, also known as spondylodiskitis Epidemiology demographics usually seen in adults (median age for pyogenic osteomyelitis is 50 to 60 years) location 50-60% of cases occur in lumbar spine 30-40% in thoracic spine ~10% in cervical spine risk factors include IV drug abuse diabetes recent systemic infection (UTI, pneumonia) obesity malignancy immunodeficiency or immunosuppressive medications malnutrition (serum albumin < 3 g/dL indicative of malnutrition) trauma smoking Pathophysiology pathogens staph aureus most common (50-65%) staph epidermidis is second most common cause gram negative infections increasing over last decade and often associated with gram negative infections of the GU and respiratory tract pseudomonas seen in patients with IV drug use salmonella seen in patients with sickle cell disease inoculation hematogenous seeding generally agreed that inoculation likely occurs through hematogenous seeding (arterial or venous) of the endplates and intervertebral discs endplates contain area of low-flow vascular anastomosis that may provide an environment suited for inoculation involvement of one endplate leads to direct extension into intervertebral discs, followed by direct extension into the second endplate direct inoculation can occur after penetrating trauma, open fractures, and following surgical procedure contiguous spread from local infection most commonly associated with retropharyngeal and retroperitoneal abscesses neurologic involvement neurologic deficits present in 10-20% results from direct infectious involvement of neural elements compression from an epidural abscess compression from instability of the spine Associated conditions epidural abscess defined as a collection of pus or inflammatory granulation tissue between dura mater and surrounding adipose tissue epidemiology usually associated with vertebral osteomyelitis present in ~18% of patients with spondylodiskitis 50% of patients with an epidural abscess will have neurologic symptoms Presentation History history of UTI, pneumonia, skin infection, of organ transplant are common Symptoms fever is only present in 1/3 of patients pain pain is often severe and insidious in onset pain is usually worse with activity and unrelenting in nature pain that awakens patients at night should raise concern for malignancy and infection neurologic symptoms present in 10-20% radiculopathy myelopathy Physical exam perform careful neurological exam Imaging Radiographs findings are usually delayed by weeks findings include paraspinous soft tissue swelling (loss of psoas shadow) seen if first few days disc space narrowing and disc destruction seen at 7-10 days remember disc destruction is atypical of neoplasm endplate erosion or sclerosis seen at 10-21 days local osteopenia CT useful to show bony abnormalities, abscess formation, and extent of bony involvement MRI MRI with gadolinium contrast indications gold standard for diagnosis and treatment sensitivity and specificity most sensitive (96%) and specific (93%) imaging modality for diagnosis of spinal osteomyelitis also most specific imaging modality to differentiate from tumor findings include paraspinal and epidural inflammation disc and endplate enhancement with gadolinium T2-weighted hyperintensity of the disk and endplate rim enhancing Bone scan Technetium Tc99m bone scans indications patients who can not obtain an MRI sensitivity and specificity 90% sensitive but lack specificity combined Technetium Tc99m and gallium 67 scan is both more specific and more sensitive than Technetium Tc99m alone indium 111 labeled scan not recommended due to poor sensitivity (17%) Studies Laboratory WBC elevated only in ~ 50% not a sensitive indicator for early infection ESR elevated in 90% of cases can be monitored serially to track success of treatment, however is considered less reliable than CRP CRP elevated in 90% of cases can be monitored serially to track success of treatment and is considered more reliable than ESR Blood cultures identification of organism is mandatory for treatment least invasive method to determine a diagnosis sensitivity & specificity ~33% (reports show 25%-66%) of patients with spondylodiskitis have positive blood cultures when positive 85% are accurate for isolating the correct organism blood culture yield is improved by withholding antibiotic and obtaining cultures when patient is febrile CT guided biopsy indications in patients who do not have indications for immediate open surgery and blood cultures are negative sensitivity & specificity can provide diagnosis in 68-86% of patients technique can be guided by fluoroscopy or by CT scan cultures should be sent for aerobic anaerobic fungal acid-fast cultures Open biopsy indications when tissue/organism diagnosis can not be made with noninvasive techniques technique anterior, costotransversectomy, or transpedicular approach used Differential Spinal Tumors MRI is the most specific imaging modality to differentiate from tumor features that weigh towards an infection include disc space involvement end-plate erosion significant inflammation Types of Spinal Osteomyelitis Bacterial Viral Tuberculosis Fungal Treatment Nonoperative bracing and long term antibiotic (6-12 weeks) indications most cases bracing helps improve pain and prevent deformity rigid cervicothoracic orthosis or halo required for cervical osteomyelitis antibiotics indications once organism has been identified via blood culture or biopsy if patient is septic or critically ill then start broad spectrum antibiotics immediately which include vancomycin for pencicillin-resistant and gram-positive bacteria third-generation cephalosporin for gram-negative coverage technique once organism has been identified usually treated with IV culture directed antibiotics until signs of improvement (~ 4-6 weeks) and then converted to PO antibiotics resistant strains new antibiotic-resistant strains of microorganisms are becoming more common and failure to diagnose can have negative consequences organisms include MRSA (methicillin-resistant Staph aureus) VRSA (vancomycin resistant Staph aureus) VRE (vancomycin resistant enterococcus) treatment newer generation antibiotics for antibiotic resistant organisms include linezolid and daptomycin outcomes successful in 80% Operative neurologic decompression, surgical debridement, and spinal stabilization indications progressive neurologic deficits progressive deformity & gross spinal instability refractory cases technique dictated by characteristics of pathology anterior debridement and strut grafting, +/- posterior instrumentation considered to be gold standard posterior debridement and decompression alone usually ineffective for debridement may be indicated in some cases Techniques Anterior debridement and strut grafting, +/- posterior instrumentation goals identify organism eliminate infection prevent or improve neurologic deficits maintain spinal stability techniques strut graft selection autogenous tricortical iliac crest, rib, or fibula strut grafts have proven safe and effective in presence of acute infection allograft being used with good results, but autogenous sources theoretically have better incorporation a recent study showed improved deformity correction with titanium mesh cages filled with autograft (followed by posterior instrumentation) instrumentation spinal instrumentation in presence of active infection is controversial some advocate I&D followed by staged instrumentation some advocate a single procedure with bone graft and instrumentation in the presence of an active infection titanium is preferred over stainless steel posterior instrumentation posterior instrumentation indicated when severe kyphotic deformity or a multilevel anterior construct required posterior instrumentation can be performed at same time or as a staged procedure
QUESTIONS 1 of 9 1 2 3 4 5 6 7 8 9 Previous Next You have 100% on this question. Just skip this one for now. Take This Question Anyway (OBQ17.113) Of the magnetic resonance images provided in Figures A-E, which circumstance would be most indicated for anterior and posterior approaches with spinal stabilization and fusion? The primary symptoms on presentation are described below:Figure A: A 65-year-old diabetic presents with rapidly progressive gait instability. Serum labs show an elevated WBC, CRP, and ESR.Figure B: A 72-year-old male presents with slowly progressive gait instability over the last 5 years.Figure C: A 42-year-old male presents with the acute onset of left arm pain and triceps weakness.Figure D: A 72-year-old active female who plays golf on a regular basis presents with severe neck pain 3 weeks after falling down the stairs. Figure E: A 37-year-old female presents with vertigo and bilateral upper extremity weakness that has presented intermittently over the last 5 years. Review Topic | Tested Concept QID: 210200 FIGURES: A B C D E Type & Select Correct Answer 1 Figure A 74% (1439/1937) 2 Figure B 12% (236/1937) 3 Figure C 9% (180/1937) 4 Figure D 2% (38/1937) 5 Figure E 1% (10/1937) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 You have 100% on this question. Just skip this one for now. Take This Question Anyway (OBQ13.274) A 60-year-old female presents with a 2 week history of low back pain. The pain is described as a dull, persistent ache and radiates down to her buttocks but not past the horizontal gluteal crease. She has a history of Type 2 diabetes mellitus and urinary incontinence. Examination reveals loin tenderness, paravertebral muscle spasm and diminished reflexes but full strength and sensation in the lower extremities. T2-, T1-weighted, and T1 contrast enhanced sagittal MRI images are shown in Figures A through C, respectively. What is the most likely diagnosis and most appropriate treatment plan Review Topic | Tested Concept QID: 4909 FIGURES: A B C Type & Select Correct Answer 1 These are Modic Type I changes and treatment will involve NSAIDS, a short period of bed rest and physical therapy 6% (231/4142) 2 These are Modic Type I changes and treatment will involve a lumbar corset and physical therapy 2% (87/4142) 3 This is spondylodiscitis and treatment will involve intravenous antibiotics and a thoracolumbosacral orthosis (TLSO). 12% (484/4142) 4 This is spondylodiscitis and treatment will involve needle biopsy, intravenous antibiotics and a thoracolumbosacral orthosis (TLSO). 74% (3066/4142) 5 This is spondylodiscitis and treatment will involve anterior decompression and stabilization, and intravenous antibiotics. 6% (247/4142) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (SBQ12SP.20) Amphotericin B is most appropriate for the treatment of which type of spine infection? Review Topic | Tested Concept QID: 3718 Type & Select Correct Answer 1 Fungal osteomyelitis 96% (3584/3729) 2 Bacterial osteomyelitis with a gram-positive organism 0% (6/3729) 3 Bacterial osteomyelitis with a gram-negative organism 1% (20/3729) 4 Tuberculous osteomyelitis 3% (101/3729) 5 Viral meningomyelitis 0% (8/3729) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 You have 100% on this question. Just skip this one for now. Take This Question Anyway (OBQ12.32) A 69-year-old male presents to the emergency room with low back pain for 1 week duration. His past medical history is significant for diabetes and coronary artery disease that was treated with stenting 7 years prior. Recently he was hospitalized for a urinary tract infection which was treated with oral antibiotics. On physical exam he is afebrile and has no neurologic deficits in his lower extremity. Laboratory studies show a white blood cell count of 10,300/mm3, an erythrocyte sedimentation rate of 35 mm/h (reference range, 0-25 mm/h), and C-reactive protein of 13 mg/L (reference range, 0-5.0 mg/L). A radiograph and MRI are performed and shown in Figure A and B respectively. Repeat blood cultures x2 are performed and both show methicillin-sensitive Staphylococcus aureus. What is the most appropriate next step in treatment. Review Topic | Tested Concept QID: 4392 FIGURES: A B Type & Select Correct Answer 1 CT guided biopsy 14% (658/4683) 2 Referral to an orthopaedic pathologist 1% (27/4683) 3 Organism specific intravenous antibiotics 79% (3703/4683) 4 Posterior lumbar debridement 1% (53/4683) 5 Anterior lumbar debridement 5% (223/4683) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (OBQ10.271) A 45-year-old female IV drug user presents to the emergency department with a chief complaint of severe focal low back pain that has progressed over the past 10 days. She now reports the pain is severe enough that it is difficult for her to walk. She reports night sweats, fluctuating fever, and a loss of appetite. Physical exam shows exquisite pain with flexion and extension of the lumbar spine. Routine urinalysis by the ER physician shows evidence of a urinary tract infection. Her blood leukocyte count is 12,600 per mm3, and erythrocyte sedimentation rate is 78 mm/h. A lateral radiograph is shown in Figure A. Which of the following would be the most appropriate next step in treatment? Review Topic | Tested Concept QID: 3359 FIGURES: A Type & Select Correct Answer 1 Discharge from the ER with a course of oral antibiotics 2% (48/2650) 2 Admission to the hospital with empirical IV antibiotics 7% (177/2650) 3 Admission, blood cultures, and MRI of the lumbar spine with and without gadolinium 88% (2343/2650) 4 Nuclear medicine bone scan 0% (8/2650) 5 Renal ultrasound 2% (61/2650) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 You have 100% on this question. Just skip this one for now. Take This Question Anyway (SBQ06SN.1) A 33-year-old man with a history of IV drug abuse presents with low back pain of increasing intensity. His neurologic examination is intact. Laboratory studies reveal a WBC count of 11,000/mm3 and erythrocyte sedimentation rate of 82 mm/h. Blood cultures are negative x 3. Plain radiographs are shown in Fig A. An MRI T1-weighted images and a post gadolinium fat-suppressed T1-weighted images are shown in Fig B. Initial management should consist of: Review Topic | Tested Concept QID: 1686 FIGURES: A B Type & Select Correct Answer 1 Physical therapy with supportive therapy 1% (24/3242) 2 IV antibiotics 26% (829/3242) 3 Open surgical decompression and biopsy 5% (164/3242) 4 CT-guided closed biopsy 68% (2209/3242) 5 Repeat MRI in 6 weeks 0% (3/3242) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4
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