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Spinal infection
Spinal infection
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Spine infection

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Spine infection

  1. 1. SPINE INFECTION NOOR HAFIZAH BINTI HASSAN 2007287236
  2. 2. CONTENTS: <ul><li>PYOGENIC SPINE INFECTION: </li></ul><ul><li>- OSTEOMYELITIS OF THE SPINE </li></ul><ul><li>- DISCITIS </li></ul><ul><li>2) NON PYOGENIC (GRANULOMATOUS) </li></ul><ul><li>SPINE INFECTION: </li></ul><ul><li>- TUBERCULOUS SPINE INFECTION </li></ul>
  3. 3. <ul><li>PYOGENIC </li></ul><ul><li>SPINE INFECTION </li></ul>
  4. 4. EPIDEMIOLOGY
  5. 5. AETIOLOGY <ul><li>Bacterial : Staph aureus (70 %) </li></ul><ul><li> : Streptococcus sp. </li></ul><ul><li> : E.coli </li></ul><ul><li> : Pseudomonas  IVDU </li></ul><ul><li>Location: Lumbar spine </li></ul><ul><li> : Thoracic spine </li></ul><ul><li> : Cervical spine </li></ul><ul><li> </li></ul>↑ vascularity
  6. 6. PATHOPHYSIOLOGY <ul><li>ROUTES OF INFECTION SPREAD: </li></ul>
  7. 7. HEMATOGENOUS SPREAD <ul><li>1) Differences in blood supply in children and adult: </li></ul>
  8. 8. 2) Blood supply of the vertebrae: Batson’s plexus
  9. 9. CLINICAL PRESENTATION <ul><li>Back / neck pain </li></ul><ul><li>Constitutional symptoms </li></ul><ul><ul><li>Fever / malaise / anorexia </li></ul></ul><ul><li>Neurological deficit: </li></ul><ul><ul><li>according to the level of vertebra </li></ul></ul><ul><li>Non specific in children </li></ul><ul><li>o/e: tenderness, limited ROM </li></ul><ul><li>RED FLAG OF BACK PAIN: </li></ul><ul><li>AGE <15 OR >55 </li></ul><ul><li>THORACIC BACK PAIN </li></ul><ul><li>NIGHT PAIN </li></ul><ul><li>CONSTANT & PROGRESSIVE S/SX </li></ul><ul><li>FOCAL NEUROLOGICAL DEFICIT </li></ul><ul><li>HX OF MALIGNANCY </li></ul><ul><li>IVDU </li></ul><ul><li>IMMUNOCOMPROMISED </li></ul>
  10. 10. INVESTIGATION <ul><li>Aim of investigation </li></ul><ul><li>Laboratory investigation: </li></ul><ul><ul><li>FBC: ↑ WCC </li></ul></ul><ul><ul><ul><li> : anemia of chronic disease </li></ul></ul></ul><ul><ul><li>BLOOD C&S </li></ul></ul><ul><ul><li>ESR: > 50 mm/hr </li></ul></ul><ul><ul><li>CRP </li></ul></ul><ul><ul><li>LIVER FUNCTION TEST </li></ul></ul><ul><ul><li>RENAL PROFILE </li></ul></ul>
  11. 11. <ul><li>Radiological investigation: </li></ul><ul><li>a) Plain x-ray: </li></ul>Narrowing of intervertebral space Destruction of vertebral body
  12. 12. <ul><li>b) CT scan: </li></ul>Axial view of cervical vertebra: Destruction of vertebral body
  13. 13. <ul><li>c) MRI with contrast enhancement: </li></ul>Collapse of vertebral body Retropulsed bony fragment compressing the spinal cord
  14. 14. TREATMENT <ul><li>MEDICAL: </li></ul><ul><li>CRIB </li></ul><ul><li>Analgesia </li></ul><ul><li>Intravenous abx 4-6/52 </li></ul><ul><li> ↓ improvement </li></ul><ul><li>Oral abx 6-8/52 </li></ul><ul><li>Spinal brace </li></ul><ul><li>SURGICAL: </li></ul><ul><li>Indications: </li></ul><ul><ul><li>Failed medical treatment </li></ul></ul><ul><ul><li>Presence/development of neurological signs </li></ul></ul><ul><ul><li>Drainage of soft tissue abscess </li></ul></ul><ul><li>Methods: </li></ul><ul><ul><li>Decompression </li></ul></ul><ul><ul><li>Stabilization </li></ul></ul>
  15. 15. DISCITIS <ul><li>Routes of infection spread: </li></ul><ul><ul><li>Iatrogenic: following procedure eg discectomy  adult </li></ul></ul><ul><ul><li>Non iatrogenic: blood-borne  children </li></ul></ul><ul><li>Clinical presentation: </li></ul><ul><ul><li>Acute back pain / muscle spasm / systemic features </li></ul></ul><ul><li>Destruction of vertebral end plate  spread to v/body </li></ul><ul><li>Raised ESR </li></ul><ul><li>Management: </li></ul><ul><ul><li>Iatrogenic: prevention!! </li></ul></ul><ul><ul><li> : broad spectrum abx </li></ul></ul><ul><ul><li>Non iatrogenic: usually self limiting </li></ul></ul>
  16. 17. <ul><li>NON PYOGENIC </li></ul><ul><li>SPINE INFECTION: </li></ul><ul><li>(TUBERCULOUS SPONDYLITIS) </li></ul>
  17. 18. EPIDEMIOLOGY <ul><li>Extrapulmonary Tb: 20-25 % of reported case </li></ul><ul><li>Skeletal Tb: 1-3 %, with spine preference </li></ul><ul><li>M. Dharmalingam. Tuberculosis of the spine—the Sabah experience. Epidemiology, treatment and results. Tuberculosis (Edinb). 2004;84(1-2):24-8. </li></ul><ul><ul><li>33 patient (24 Males, 9 Females) </li></ul></ul><ul><ul><li>Peak incidence: 20s </li></ul></ul><ul><ul><li>Prior hx of pulmonary Tb: 66.6 % </li></ul></ul><ul><ul><li>Vertebral involvement: thoracic ( 30.3 %) > lumbar (27.2 %) </li></ul></ul>
  18. 19. PATHOPHYSIOLOGY Abscess
  19. 20. Preservation of intervertebral disc Collapse of vertebral body Rarefaction the anterior aspect of vertebral body
  20. 21. CLINICAL PRESENTATION <ul><li>Long h/o backache </li></ul><ul><li>Prior h/o pulmonary Tb or exposure to Tb patient </li></ul><ul><li>Deformity </li></ul><ul><li>Cold abscess </li></ul><ul><li>Paresthesia / weakness </li></ul><ul><li>On examination: </li></ul><ul><li>Pulmonary signs </li></ul><ul><li>Angular thoracic kyphos </li></ul><ul><li>Local tenderness </li></ul><ul><li>Gibbus </li></ul><ul><li>Limited ROM </li></ul><ul><li>Neurological exam </li></ul>
  21. 22. POTT’S PARAPLEGIA <ul><li>The most feared complication </li></ul><ul><li>Early onset paresis: </li></ul><ul><ul><li>Weakness of LL, UMN features, sensory dysf(x) </li></ul></ul><ul><ul><li>d/t pressure by the abscess/caseous material/ bony fragment </li></ul></ul><ul><li>Late onset: </li></ul><ul><ul><li>d/t deformity/reactivation of the disease/cord ischemia </li></ul></ul>
  22. 23. INVESTIGATION <ul><li>Laboratory investigation: </li></ul><ul><ul><li>FBC </li></ul></ul><ul><ul><li>BLOOD C&S </li></ul></ul><ul><ul><li>ESR & CRP </li></ul></ul><ul><ul><li>LFT </li></ul></ul><ul><ul><li>RP </li></ul></ul><ul><ul><li>Mantoux test </li></ul></ul><ul><li>Radiological investigation: </li></ul><ul><ul><li>Plain x-ray: </li></ul></ul><ul><ul><li>Narrowing of i/vertebral space </li></ul></ul><ul><ul><li>Fuzziness of end plates </li></ul></ul><ul><ul><li>Collapse of adjacent vertebral body </li></ul></ul><ul><ul><li>Paraspinal soft tissue shadow </li></ul></ul><ul><ul><li>CT scan & MRI </li></ul></ul><ul><ul><li>Cord compression </li></ul></ul>
  23. 24. T9 Narrowing of intervertebral disc Soft tissue shadow
  24. 25. Soft tissue mass Destruction of vertebral body
  25. 26. TREATMENT <ul><li>Aim of treatment: </li></ul><ul><ul><li>To eradicate or at least arrest the disease </li></ul></ul><ul><ul><li>To prevent or correct deformity </li></ul></ul><ul><ul><li>To prevent or treat complication – paraplegia </li></ul></ul><ul><li>Medical treatment: </li></ul><ul><ul><li>Anti-Tb chemotherapy 9/12 </li></ul></ul><ul><ul><li>Continuous bed rest </li></ul></ul><ul><li>Surgical treatment: </li></ul><ul><ul><li>To drain abscess </li></ul></ul><ul><ul><li>To correct deformity </li></ul></ul>
  26. 27. FIRST LINE TB DRUGS
  27. 30. THANK YOU <ul><li>REFERENCES: </li></ul><ul><li>1. Spinal infections. Jonathan A Clamp and Michael P Grevitt. Elsevier Ltd. </li></ul><ul><li>2. Theodore Gouliouris , Sani H. Aliyu , and Nicholas M. Brown . Spondylodiscitis: update on diagnosis and management. </li></ul><ul><li>J. Antimicrob. Chemother. (2010) 65 (suppl 3): iii11-iii24. </li></ul><ul><li>3. Peter Martin.Pyogenic osteomyelitis of the spine. British Medical Journal, Nov 9 1946. </li></ul>
  28. 32. Extra notes: red flag of back pain
  29. 33. Continue..

Editor's Notes

  • Batson’s plexus: valveless venous system Venous drainage of the spine: internal plexus  external plexus  IVC  rt atrium Batson’s plexus communicate with venous drainage from the pelvic, abdominal n thoracic Y communicate? If any obstruction to IVC in abdominal level, venous blood from lower xtrmities can still travel back to the heart. That’s y gut bacteria can be one of the etiology
  • Improvement: falling ESR, WCC return to normal. Important to assess pt CLINICALLY !!!
  • Note the spread of the infection anteriorly to, rather than thru the vertebral body.
  • Liver enzymes inducer: P C B R A S (pyrazinamide, carbamazepine, barbiturate, rifampicin, alcohol, sulphonylurea) Liver enzymes inhibitor: SICK FACES.COM (sodium valproate, isoniazid, cimetidine, ketoconazole, fluconazole, alcohol, CMC, erythromycin, sulfonamides, ciprofloxacin, omeprazole, metronidazole)
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