Vertebral Osteomyelitis complicated with Epidural Absceses

GEORGE SAPKASPROFESSOR AT ORTHOPAEDICS

Metropolitan Hospital

Athens Greece

Cases

1st caseJ. Chr.M 69 – Retired Civil servant

Symptoms Neurologic deficitCervical Pain Low fever

Laboratory Neutroph. ↑SR 40

MRI

Unknown origin

Treatment

Transoral

Pus evacuation

Post op. CT scan

Post op. MRI

Occipito-cervical stabilization

2nd Post op. CT scan

2nd Post op. MRI (6mts)

Post op. 3D scan (3yrs)

Follow up

Culture staphylococous aureous

Antibiotics i-v for 2 mtsorally for 4 mtsFull neurologic recovery

2nd caseMa. Pal.F 56 – Lawyer

Symptoms Neurologic deficitCervical Pain Low fever

LaboratoryNeutroph. ↑SR 50

56X-rays

Unknown origin

MRI

33

MRI

Anterior procedureVertebrectomy - PUS evacuation + Stabilization

Posterior stabilization

2nd Post op. MRI

Follow up

Pus culture (staphylococous aureous)Antibiotics i-v for 2 mts orally for 6 mts

Complete neurologic recovery

3rd caseEV. PY.M 56 – Industrial labor

Symptoms Neurologic deficitThoracic Pain Low fever

LaboratoryNeutroph. ↑SR 45

Unknown Origin

Follow up

Pus culture (staphylococous aureous)Antibiotics i-v for 2 mts orally for 6 mts

Complete neurologic recovery

4th caseD.N.M 61– Cardiologist

Symptoms Severe Neurologic deficit Intensive Thoracic-lumbar Pain High fever

Laboratory Neutroph. ↑ SR 60

PMH Heavy smoker Diabetes melitus Recent Elbow Furuncle (untreated)

Elbow furuncle

33

4 4

04/06/2007

04/06/2007

04/06/2007

13/06/2007

3

4

3

4

13/06/2007

Anterior PUS evacuation

Bilaterally

Laminectomies PUS evacuation

Post posterior PUS evacuation

Follow up

Pus culture (staphylococous aureous)Antibiotics i-v for 2 mts orally for 7 mts

Complete neurologic recovery

Conclusions

Epidural abscesses

Of the spinal column is a rare but potentially devastating disease.When recognized early and treated appropriately the outcome can be excellentHowever the mortality is as high as 20% even in modern series

Surgical therapyDecompression of the neural elements and drainage of purulent material or debridement of granulation tissue is recognized as the best method to prevent neurologic deficits and if performed quickly after the onset of deficits, may allow full recovery.

Delay in surgical drainage and decompression has repeatedly been associated with high morbidity and mortality. Given the life-threatening nature of subdural empyema,decompression of epidural abscess is uniformly considered an emergency.

SPINAL EPIDURAL, AND

SUBDURAL - INTRAMEDULAR ABSCESSES

GEORGE SAPKAS PROFESSOR AT ORHTOPAEDICS

Metropolitan Hospital

Athens Greece

Epidural abscesses

Subdural abscesses

Intramedullar abscesses

Historical review1761 Morgagni first to allude pyogenic infection in the spinal epidural space(Feldenzer et al. Neurosurgery 1987)1820 Bergamaschi first description (Hlavin et al. Neurosurgery 1990)1892 (Unknown) first surgical drainage1901 Barth first successful drainage(Hlavin et al. Neurosurgery 1990)

Epidemiology2 cases per 10.000 hospital admissions per year(Hlavin et al. Neurosurgery 1990)The peak age incidence is in the sixth and seventh decade of life(Danner et al. Rev infection disease 1987)(Wheeler et al. Clin Infect, disease 1992)Rare in the pediatric population(Rubin et al. Pediatric infect disease 1993)

Comorbid conditions

Diabetes mellitusIntravenous drug useChronic renal failureAlcoholism Cancer

(Redekop et al. Can J. Neurol. Sci 1992)

Source of infection

Skin and soft tissue 25% Previous spinal surgery Osteomyelitis Spinal traumaUrinary tractsRespiratory tracts

(Redekop et al. Can J. Neurol. Sci 1992)Unknown and not indentified 16% - 40%

(Hlavin et al. Neurosurgery 1990)(Redekop et al. Can J. Neurol. Sci 1992)

Etiologic agent

(Hlavin et al. Neurosurgery 1990)(Redekop et al. Can J. Neurol. Sci 1992)

Pathophysiology The spinal epidural space is a metameric segmental structure in which some areas are filled with fat and veins and other areas the dura is in direct contact with bone or ligamentIn addition individual metameres are septated preventing free communication between the anterior and posterior epidural space (Redekop et al. Can J. Neurol. Sci 1992)

The majority of epidural abscesses are from hematogenous spread and are localized posteriorly

(Redekop et al. Can J. Neurol. Sci 1992)

Cases associated with: Discitis Vertebral osteomyelitis

typically involve the anterior epidural space

and

cont.

In few cases that are commonly post-surgical, the abscess may be circumferential because of disruption of the normal anatomic septations

The extend of the abscess is usually limited with an average of 3 to 4 vertebral segments

(Del Curling et al. Neurosurgery 1990)(Hlavin et al. Neurosurgery 1990)

Location

Cervical 15%Thoracic 50%Lumbar 34%

Posterior 80%Anterior 20%

The precise pathophysiologic cause of the neurological impairment is not knownRapid and irreversible deterioration

prompted several authors to postulate an ischemic mechanism either from arterial occlusion or venous stasis

(Baker et al. N. Engl J Med 1975)

Recent studies indicate that the progressive neurologic deficits were secondary to compression

(Feldenzer et al. Neurosurgery 1987)(Feldenzer et al. Neurosurgery 1988)

It is most likely that the cause of neurological deficit is multi factorial with compression been the major component

Diagnosis

Onset of symptoms usually occurs within hours to days but may be more chronic in nature, presenting with weeks to months of symptoms. The microbiology often dictates the pace of progression.

If left untreated, the progression of symptoms is usually sequential: back pain (70-100%), radicular irritation (50%), motor weakness (30-40%) sphincter incontinence (30-40%) sensory changes (12%), then paralysis (6-48%) fever is frequently present especially in acute

phases

(Redekop et al. Can J. Neurol. Sci 1992)(Maslen et al. Arch inten Med 1993)

Tuberculous abscesses

The clinical presentation is slightly different Back pain ~ 100%The prodrome is longer Leukocytosis frequently absent Fever - // -The patients are usually younger than

patients with bacterial abscesses

Differential diagnosisSpondylosis or disk syndromesEpidural Hematoma Leptomeningeal Carcinomatosis Metastatic Disease to the SpineSpinal Cord Hemorrhage or InfarctionSubdural Hematoma or EmpyemaHIV-1 Associated Vacuolar MyelopathyTropical Myeloneuropathies Vitamin B-12 Associated Neurological Diseases Alcohol (Ethanol) Related Neuropathy

Laboratory studiesLeukocytosis, (left shift), anemia. In one retrospective analysis, leukocytosis was present in only 60% of patients.Blood cultures positive in 60%. ESR and CRP elevated.Lumbar puncture relatively contraindicated (risk of spreading the bacteria into the subarachnoid space). Usually reveals inflammation, cultures positive in 25% of cases.

Imaging studies

Plain radiographs occasionally demonstrate osteomyelitis but are of almost no utility. Spinal MRI is the procedure of choice (sensitivity 95%, specificity 92%).Gadolinium enhancement increases sensitivity and enables better differentiation between abscess and surrounding neurological structures. CT-guided needle aspiration may be used to obtain material for analysis.

Plain radiographs

MRI

Treatment

Medical therapyMedical management with appropriate antibiotics has been successful in several reportsPotential candidates : Lumbar epidural

abscess with no neurologic deficitand bacteriologic agent has been cultured

(Wheller et al. Clin Inf Des. 1992)

Proposed criteria for exclusive medical treatment in spinal epidural abscesses

Poor surgical candidates because of sever concomitant medical problemsCases in which the abscess involves a considerable length of spinal canal and who have epiduritis from the cervical to the lumbar levelPatients not suffering from severe loss of spinal cord or cauda equina functionPatients with complete paralysis for more 3 days

The length of suggested medical therapy is at least 8 to 12 weeks of intravenous antibioticsfollowed by oral agents

(Leys et al. Ann Neurol. 1985)

Management Initiate empirical therapy; must continue for 3 – 4 weeksCeftriaxone (ROCEPHIN) 2g x 2Ceftazidime (SOLVETAN) 2g x 3Cefazolin (BIOZOLIN) 2g x3

+Meropenem (MERONEM) 1g x 3 (antipseudomonal)

±Metronidazole (FLAGYL) 500mg x 3

±Gentamycin (GARAMYCIN) 80mg x3 in D/W 5% (if post – op or IV drug user or endocarditis)

±Vancomycin (VONCON) 1g x 2 (MRSA)

Operative treatment

Posterior decompression

Posterior decompression and stabilization

Anterior decompression ± stabilization