Spinal Infection

Vertebral Osteomyelitis

• Can develop from direct open spinal trauma, infections in adjacent structures, haematogenous spread, or postoperatively
• Left untreated, can lead to permanent neurologic deficits, spinal deformity, or death
• May cause severe neural compression from epidural abscess or pathologic fracture

Discitis

• Inflammation of the vertebral disc space often related to infection
• Almost always present together with vertebral osteomyelitis
• Shares similar pathophysiology, symptoms, and treatment with osteomyelitis

Epidural Abscess

• Most cases arise from haematogenous seeding from distant infection
• Can result from direct extension of spinal or paraspinal infections
• Threatens spinal cord by compression and vascular compromise
• If untreated, can lead to paralysis and death

• Advanced age
• Intravenous drug use
• HIV infection
• Long-term corticosteroid use

• Immunosuppressants
• Diabetes mellitus
• Organ transplantation
• Malnutrition

• Malignancy
• Recent spinal surgery

Vertebral Osteomyelitis

• Progressively severe back pain
• Fever
• Rigors
• Weight loss
• Muscle spasms
• Painful or difficult urination
• Neurological deficits:
  • Weakness/numbness of arms/legs
  • Bowel/bladder incontinence

Discitis

• Initially few symptoms, progressing to severe back pain
• Young children:
  • No fever or apparent pain
  • Refuse to flex spine
• Children 3-9 years:
  • Back pain as predominant symptom

Epidural Abscess

• Severe back pain with fever and spinal tenderness
• Radicular pain and paraesthesia
• Weakness of voluntary muscles
• Sensory loss
• Bowel/bladder dysfunction
• Paralysis

Laboratory Tests

• Blood tests: FBC, CRP/ESR
• Blood cultures
• Urinalysis and culture

Imaging

• Spinal X-ray
  • Findings normal in first 2-4 weeks
  • Later shows disc space narrowing, endplate destruction
  • Limited role in epidural abscess diagnosis
• CT spine
  • Detects osteomyelitis earlier than X-ray
  • Shows hypodensity, lytic fragmentation, gas in vertebra
  • May miss smaller collections
• MRI spine with contrast
  • Gold standard for spinal infection
  • Assesses neural elements

Biopsy

• CT-guided percutaneous biopsy of vertebra/disc space
• Minimally invasive
• Provides histologic confirmation and cultures

Non-surgical Treatment

• Long-term IV antibiotic/antifungal therapy (6-8 weeks minimum)
• Initial broad-spectrum antibiotics covering:
  • Gram-positive and gram-negative organisms
  • Aerobes and anaerobes
  • MRSA coverage
• Immobilization for significant pain or spinal instability

Surgical Indications

• Significant bone destruction causing instability
• Neurological deficits
• Sepsis from abscess unresponsive to antibiotics
• Failed needle biopsy to obtain cultures
• Failed IV antibiotics alone

Surgical Goals

• Debride infected tissue
• Promote adequate blood flow for healing
• Restore spinal stability with instrumentation
• Restore function/limit neurological impairment