IWAN SETIAWAN

FAK.KEDOKTERAN UMS
 ETIOLOGY
1) PYOGENIC SPINE INFECTION:
- OSTEOMYELITIS OF THE SPINE
- DISCITIS

2) NON PYOGENIC (GRANULOMATOUS)

SPINE INFECTION:
- TUBERCULOUS SPINE INFECTION
 PYOGENIC
SPINE INFECTION
 EPIDEMIOLOGY
• Rare: 1/100 000 population in developed countries
 + vague s/sx : lead to delayed diagnosis

• ↑ incidence rate : ↑ use of intravascular device

: ↑ IVDU

• Male:Female = 2:1

• Age: peak in 5th decade

• Risk factor: immunosuppressive state

 ETIOLOGY
• Bacterial : Staph aureus (70 %)
: Streptococcus sp.
: E.coli
: Pseudomonas  IVDU

• Location: Lumbar spine

: Thoracic spine ↑ vascularity
: Cervical spine
 PATHOPHYSIOLOGY
ROUTES OF INFECTION SPREAD:
 HEMATOGENOUS SPREAD

1) Differences in blood supply in children and adult:

2) Blood supply of the vertebrae:

Batson’s plexus
 CLINICAL PRESENTATION
• Back / neck pain RED FLAG OF BACK PAIN:

• Constitutional symptoms • AGE <15 OR >55

• THORACIC BACK PAIN
– Fever / malaise / anorexia • NIGHT PAIN
•CONSTANT & PROGRESSIVE
• Neurological deficit: S/SX
•FOCAL NEUROLOGICAL
– according to the level of vertebra DEFICIT
•HX OF MALIGNANCY
• Non specific in children • IVDU
• IMMUNOCOMPROMISED
• o/e: tenderness, limited ROM
 INVESTIGATION
• Aim of investigation
• Laboratory investigation:
– FBC: ↑ WCC
: anemia of chronic disease
– BLOOD C&S
– ESR: > 50 mm/hr
– CRP
– LIVER FUNCTION TEST
– RENAL PROFILE
• Radiological investigation:
a) Plain x-ray:

Narrowing of
intervertebral space

Destruction of
vertebral body
b) CT scan:

Axial view of cervical vertebra:

Destruction of vertebral body
c) MRI with contrast enhancement:

Retropulsed bony fragment

Collapse of vertebral body compressing the spinal cord
 TREATMENT

MEDICAL: SURGICAL:
• CRIB • Indications:
• Analgesia • Failed medical treatment
• Intravenous abx 4-6/52 • Presence/development of
neurological signs
↓ improvement
• Drainage of soft tissue
• Oral abx 6-8/52
abscess
• Spinal brace • Methods:
• Decompression
• Stabilization
 DISCITIS
• Routes of infection spread:
– Iatrogenic: following procedure eg discectomy  adult
– Non iatrogenic: blood-borne  children
• Clinical presentation:
– Acute back pain / muscle spasm / systemic features
• Destruction of vertebral end plate  spread to v/body
• Raised ESR
• Management:
– Iatrogenic: prevention!!
: broad spectrum abx
– Non iatrogenic: usually self limiting
 NON PYOGENIC
SPINE INFECTION:
(TUBERCULOUS SPONDYLITIS)
 EPIDEMIOLOGY
• Extrapulmonary Tb: 20-25 % of reported case

• Skeletal Tb: 1-3 %, with spine preference

• M. Dharmalingam. Tuberculosis of the spine—the Sabah

experience. Epidemiology, treatment and results.
Tuberculosis (Edinb). 2004;84(1-2):24-8.
– 33 patient (24 Males, 9 Females)
– Peak incidence: 20s
– Prior hx of pulmonary Tb: 66.6 %
– Vertebral involvement: thoracic ( 30.3 %) > lumbar (27.2 %)
PATHOPHYSIOLOGY

Abscess
 Collapse of
vertebral body

Preservation of
intervertebral disc
Rarefaction the
anterior aspect of
vertebral body
 CLINICAL PRESENTATION
• Long h/o backache
• Prior h/o pulmonary Tb or
exposure to Tb patient
• Deformity
• Cold abscess
• Paresthesia / weakness
• On examination:
- Pulmonary signs
-Angular thoracic
kyphos
- Local tenderness
- Gibbus
- Limited ROM
- Neurological exam
 POTT’S DISEASES
• Pott disease or Pott's disease is a form of
tuberculosis that occurs outside the lungs
whereby disease is seen in the vertebrae.
• Tuberculosis can affect several tissues outside
of the lungs including the spine, a kind of
tuberculous arthritis of the intervertebral
joints
 POTT’S PARAPLEGIA
• Neurologic abnormalities occur in 50% of cases and
can include spinal cord compression with paraplegia,
paresis, impaired sensation, nerve root pain, and/or
cauda equina syndrome
• Early onset
• paresis:Weakness of Lower Limb, UMN features, sensory
dysfunction
• Due to pressure by the abscess/caseous material/ bony
fragment
• Late onset:
• Due to deformity/reactivation of the disease/cord ischemia
 INVESTIGATION
a) Laboratory investigation: b) Radiological investigation:
– Plain x-ray:
– FBC
• Narrowing of i/vertebral
– BLOOD C&S
space
– ESR & CRP
• Fuzziness of end plates
– LFT
• Collapse of adjacent
– RP vertebral body
– Mantoux test • Paraspinal soft tissue
shadow

– CT scan & MRI

• Cord compression
 Narrowing of T9 Soft tissue
intervertebral disc shadow
Soft tissue
mass
Destruction of
vertebral body
 TREATMENT
• Aim of treatment:
– To eradicate or at least arrest the disease
– To prevent or correct deformity
– To prevent or treat complication – paraplegia

• Medical treatment:
– Anti-Tb chemotherapy 9/12
– Continuous bed rest

• Surgical treatment:
– To drain abscess
– To correct deformity
TB DRUGS
(first Line)
Extra notes: red flag of back pain
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