This document provides information on spinal infections. It discusses two main types of spinal infections - pyogenic and non-pyogenic infections like tuberculosis. Pyogenic infections usually involve the lumbar spine and are caused by bacteria like Staph aureus. Tuberculosis is the most common non-pyogenic infection and usually affects the lower thoracic spine. Clinical features, investigations, management and various surgical approaches for treating spinal infections are described in detail.

1. INFECTIONS OF
SPINE
Dr. Shreekant Dhanani
R3, DR. JVM SIR UNIT

2. Spondylodiscitis
• infection of the
intervertebral disc
Vertebral osteomyelitis
• If infection invades the
endplates or the vertebral
body.
INTRODUCTION
 Spinal infections are basically divided into
two types:
a)Pyogenic
b)Non pyogenic(granulomatous)

3. 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%

4. Routes of
pathogen spread
Hematogenous
Direct external
inoculation
Spread from
contiguous tissues
PATHOPHYSIOLOGY

5. 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

6. 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

7. Irritability,
Refusal to crawl, sit or
walk,
Abdominal pain
PRESENTATION IN CHILDREN

8. LABORATORY INVESTIGATIONS
ESR
 Elevated in 71-97% of patients
 Generally > 50mm/hr
 Elevated after surgery peak at 5 days and
elevated for 4 weeks.
 Persistent elevation after surgery suggestive of
infection
 Remains high even after treatment for prolonged
period of time
CRP
 More sensitive marker
 Peaks within 2 days of surgery and has rapid fall
 Elevation even after a week of surgery suggest of
infection
 Rapidly decline following treatment.
Other tests: CBC: may show leucocytosis
Blood culture- positive in around 60%

9. 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

10. 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

11. 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 showing response to treatment.
• Following treatment soft tissue findings tend to improve while the bony findings like marrow edema remains.
T1 T2

12. 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

13. CT guided
• Minimal invasive
Open biopsy
• If blood cultures and percutaneous
biopsy fail to identify the infecting
organism.
Biopsy
 Best method of determining the infection.

14. Primary and
metastatic
tumours
Infections in
contiguous
structures like that of
psoas, abdomen,
GUT.
Rheumatoid
arthrirtis
Ankylosing
spondylitis
Epidural
infections
DIFFERENTIAL DIAGNOSIS

15. MANAGEMENT
ALGORITHM

16. ESR

18. INDICATIONS FOR SURGERY
• Open biopsy
• Neurological deficit
• Vertebral collapse
• Abscess
• Failure of medical treatment
MANAGEMENT CONTD..
NON OPERATIVE
 Antibiotics chosen according to culture and
sensitivity
 Response to treatment evaluated with serial ESR
and CRP.
 Duration: INTRAVENOUS – FOR 4-6 WEEKS followed
by oral antibiotics based on individual response.

19. 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

20.  Radiography:
 Confirm diagnosis: Titre of brucella >1:80
 Treatment: Antibiotics (rifampicin and
doxycycline) for 4 months
BRUCELLOSIS(contd.)

21. FUNGAL INFECTIONS
Opportunistic infection, common in
immunodeficient
Symptoms develop very slowly. Pain is less
prominent
Most common: Aspergillus> Cryptococcal
Most common involvement is of lumbar
ESR and CRP elevated but WBCs are not
raised
Diagnosis by biopsy

22.  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.
FUNGAL INFECTIONS (contd.)

23. SPINAL
TUBERCULOSIS

24. 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.

25. REGIONAL DISTRIBUTION
SPINE TB
Cervical(12%)
Cervicodorsal(5%)
Dorsal(42%)
Dorso lumbar(12%)
Lumbar(26%)
Lumbosacral(3%)

26. WHY MOST COMMONLY
OCCURS AT DL JUNCTION???
Greater extent of movement
Degree of weight bearing and
microfracture
Large spongy cancellous bone
Proximity to kidney and cistern
chili

27. PATHOGENESIS
 Secondary infection- lung, genitourinary system.
 Spread - hematogenous route- attacks macrophages

29. Constitutional
symptoms(40%)
• Malaise
• Loss of appetite/weight
• Night sweats.
• Evening rise of temperature.
CLINICAL PRESENTATION
 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

30. 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

31. OTHER FEATURES
 KYPHOTIC DEFORMITY
 ENLARGED LYMPH NODE
 NEURAL DEFICIT-20%
 SPASTICITY
 CLONUS
 EXAGGERATED REFLEXES

35. 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

36. 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.
TESTS FROM OBTAINED
SAMPLE

37. PLAIN XRAY
FINDINGS:
Reduced disc space
Blurred paradiscal
margins
Anterior wedging
Psoas abscees

38. CERVICAL
THORACIC
[BIRD NEST]
LUMBAR

40. “SPINE AT RISK” SIGN IN CHILD
Separation of
facet joint
Retropulsion
Lateral
translation
“Toppling
sign”

41. CT SCAN
Pattern of bony
destruction
Calcification in
abscess.
Detects early lesion
before they appear
on xray

42. 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

43. Biopsy
Best method of
obtaining the sample
for microscopy, culture
and Gene Xpert,
histopathology.
Percutaneous CT guided
biopsy is preferred.

44. SITE OF LESION
 • INTRADURAL involvement-very rare
 • Extradural involvement- 4 TYPES [FIGURE]
(m.c) (2nd
m.c) (Rarest)

45. STAGES OF SPINAL TB [KUMAR]

46. COMPLICATIONS OF
SPINAL TUBERCULOSIS
Paraplegia
Cold abscess
Spinal deformity
Secondary infection
Fatality
Amyloid disease

47. Spinal
infection-
pyogenic,
brucellosis,
fungal
Neoplastic-
lymphoma-
metastasis
Degenerativ
e
Neuropathic
spine
DIFFERENTIAL DIAGNOSIS OF
TB SPINE

48. TUBERCULAR
Chronic back pain -Long standing
History of months to years.
Presence of active
pulmonary TB – 60 %
Most common location thoracic
spine
>3 contiguous vertebral body segment
involvement common
Skip lesions- common
Vertebral collapse - 67%
Posterior elements involvement
possible
PYOGENIC
Acute onset : History of days to
months
Not present
Lumbar spine
Mostly involves single level
Rare
Rare –
21%
Rare
Vs.

49. 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”)

50. POTT’S PARAPLEGIA
Incidence : 10 - 30 %
Dorsal spine most common
Motor functions affected before /
greater than sensory.
Sense of position & vibration last
to disappear

51. Secondary
infection
Abscess,
Granulation
tissue
Vertebral
Collapse
Endarteritis
Cord
ischemia
Neural
Deficit
PATHOPHYSIOLOGY

54. BASIC PRINCIPLES OF
MANAGEMENT
Early diagnosis
• Medical Treatment – AKT and
bracing
• Surgery to drain abscess,
debridement and fusion
• Stabilization to Prevent kyphotic
deformity

55. TREATMENT OF TB SPINE
CONSERVATIVE
AKT[18 MONTHS] REST AND BRACE
SURGERY
(DEBRIDEMENT+FIXATION
+FUSION)
ANTERIOR
APPROACH
POSTERIOR
APPROACH
COMBINED
APPROACH

56. AKT GUIDELINES
ENTIRE DUARTION OF CHEMOTHERAPY LASTS FOR
16-18 MONTHS- 2 months intensive phase
+
10-16 months maintenance phase- 2HRZE+10HRE)
•10 MG PYRIDOXINE FOR PREVENTION OF PERIPERAL
NEUROPATHY

57. INDICATIONS FOR SURGERY IN TB SPINE
WITHOUT NEUROLOGICAL DEFICIT
 Diagnosis is uncertain and open biopsy is
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.

58. 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.

59. VARIOUS SURGICAL
APPROACHES

61. • 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.
ALL POSTERIOR

62. ☺ 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.
ADVANTAGES OF ALL POSTERIOR
APPROACH

64. THANK
YOU