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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 topic
      • 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
        • refractory cases
        • neurologic deficits
        • progressive deformity & gross spinal instability
      • 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
 

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(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

QID: 1686
FIGURES:
1

Physical therapy with supportive therapy

1%

(20/2660)

2

IV antibiotics

25%

(672/2660)

3

Open surgical decompression and biopsy

5%

(139/2660)

4

CT-guided closed biopsy

68%

(1814/2660)

5

Repeat MRI in 6 weeks

0%

(3/2660)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(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

QID: 3359
FIGURES:
1

Discharge from the ER with a course of oral antibiotics

2%

(44/2088)

2

Admission to the hospital with empirical IV antibiotics

7%

(155/2088)

3

Admission, blood cultures, and MRI of the lumbar spine with and without gadolinium

87%

(1813/2088)

4

Nuclear medicine bone scan

0%

(7/2088)

5

Renal ultrasound

3%

(60/2088)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(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

QID: 4392
FIGURES:
1

CT guided biopsy

14%

(581/4047)

2

Referral to an orthopaedic pathologist

1%

(21/4047)

3

Organism specific intravenous antibiotics

79%

(3192/4047)

4

Posterior lumbar debridement

1%

(47/4047)

5

Anterior lumbar debridement

5%

(192/4047)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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