spinal infections

1. SPINAL INFECTIONS
DR. VIJAYA ANAND S
Ist year Primary DNB

2. POTT’S SPINE

3. INTRODUCTION
Tuberculosis of the vertebral column , first
described by Percival Pott and since associated
with his name.
Is a slowly developing disease, characterized by
pain, spinal deformity and occasionaly paralysis

4. • Spinal tuberculosis is the commonest form of
skeletal tuberculosis
• About 50% of all cases of tuberculosis of bones
and joints
• Is usually secondary to primary elsewhere

5. ETIOLOGY
CAUSATIVE ORG:
• Mycobacterium tubercule bacilli are gram
positive , acid fast bacilli, aerobic , grows at
temperature between 30 – 40 degree and can be
grown on LJ medium
• Can be killed by heat at 60 degree in 15 to 20
min.
• Survives for many weeks in moist condition.

6. PREDISPOSING FACTORS
• Malnutrition
• Poor sanitation
• Living in crowded areas
• Close contact with TB patients
• Exanthematous fever
• Immunodeficiency states
• Hiv and aids
• Chronic alcoholism

7. PATHOGENESIS
• A minimum of 2 t0 3 years is required between the
primary and skeletal TB
• Hematogenous dissemination from a infected visceral
focus
• Primary focus may be active or quiescent, apparent or
latent
• Either in lungs ,lymph glands , mediastinum,
mesentry,or cervical region or other viscera

8. • The infection reaches the skeletal system through the
vascular channels generally the arteries as a result of
bacillemia or rarely in axial skeleton through bastons
plexus of veins
• The disease begins as infection of a single vertebrae.
• The primary error is a tubercular endarteritis the
marrow is converted into pale myxomatous tissue in the
devitalized tissue, a tuberculous follicle develops until it
is visible to naked eye as a small yellow gray nodule.

9. • The centre of the body being caseous the superimposed
weight of the verterbral column is now borne by fragile
shell of compact bone , which sooner collapses resulting
the angular deformity – kyphus, gibbus or hunch back.
• The IV disc in not involved primarily because it is a
relatively avascular structure
• The involvement of paradiscal bone effects its nutrition
and this altered or necrosed disc may be involved by the
infection later.

10. • The cartilaginous plate which acts a barrier once
destroyed leads to disc invasion and destruction rapidly.

12. Most common level of lesion is lower thoracic and
thoracolumbar region.
Thoracic is most commonly involved because
Incresead stress of weight bearing
Relatively large amount of spongy tissues
Close relationship between cysterna chyli, thoracic duct
and anterior surface of the vertebral body.
Role of trauma- repeated mechanical stress in the mobile
and weight bearing parts of the body results in minor
hematoma or bone marrow edema
Trauma activates the latent tuberculous focus

13. Vertebral lesions

14. TYPES OF VERTEBRAL LESIONS
Paradiscal type:
• Commonest
• Adolescents
• Spreads through epiphyseal arteries
• Involvement of adjacent bodies with decreased
disc space

16. Central type:
• Children
• Either through baston’s plexus or through branches of
posterior vertebral artery
• Normal bony trabecuale lost
• Reduction of disc space is minimal
• Concentric collapse
Anterior type:
• Common in thoracic region
• Begins underneath ALL
• Anterior shallow erosion of vertebral bodies on xray
• Collapse of body and decreased disc space are minimal
• Clinical pictures resembles intraspinal tumor and hence
known as spinal tumor syndrome

17. Posterior type :
• Lesion may be in pedicle, transverse process,
laminae, or spinous process
• Higher incidence of neurological deficits
• Pedicle and post articulation are destroyed as a
result combination of both lateral deviation and
rotation has been observed
• Lateral shift and scoliosis may also be seen

18. Articular type:
• Involves facet joints
• Associated with radiculopathy
• Very less incidence
• Common in elderly

19. CLINICAL FEATURES
• Equal sex predilection
• Common in first three decades
• Insidious in onset
• Back pain is common presenting symptom
• Diffuse later localized
• Stiffness very early symptom
• Is a protective mech wherein the paravertebral
muscles go into spasm to prevent the movement

20. • During sleep the muscle spasm relaxes – night
cries
• Pressure symptoms:dysponea, dysphagia,
hoarness of voice, inability to extend hip(psoas
abscess)
• Deformity:gradually increasing promince of
spine- gibbus

21. • Paraplegia:
• Other constitutional symptoms:
• Weakness, loss of weight, loss of appetite,
evening temp, night sweats.

22. • Signs:
• On general ex:
Signs of anemia, debilities, involvement of lungs,
lymphnodes
Local attitude:
Upper cervical: wry neck
Upper thoracic: militiary position
Lower thoracic:alderman”s gait
Upper lumbar:prominent abdomen
Lower lumbar:increased lordosis

23. Upper cervical Wry neck
Lower cervical The head is thrown backwards and to
one side and may be supported by
hand
Upper thoracic Militiary attitude:
Shoulders are raised and the arms and
shoulders drawn backwards
The head appears sunken, owing to
apparent shortening of the neck
Lower thoracic Alderman”s gait:
Thorax and head thrown backwards
the abdomen is promient
Patient walks with legs apart and
waddles

24. • Gait
• Tenderness : to pressure and percussion at local
site
• Movements: decreased in all directions mostly
forward flexion
• Neurological deficits:paraplegia or quadriplegia
or paresis with or without region of involvement
of bowel and bladder
• Deformity: kyphotic deformity is common

25. Angulation of spine (kyphosis)
• Result of collapse of affected vertebrae
• 1 0r 2 – knuckle
• 3 or more- wedge collapse - angular kyphosis
• Large number- round kyphosis
• Scoliosis
• Lordosis:to compensate the kyphosis

26. COMPLICATIONS
• Cold abscess
• Paraplegia‘
• Sinuses
• Secondary infections
• Amyloid
• fatality

27. Cold abscess
• Commonest complication
• 20 % of all cases
• Body of vertebrae collapses – collection of
tuberculous detritus consists granulation
tissues,caseous matter, disintegrated bone
marrow
• It first collects under ALL – disseminates along
one or other courses
• Superficial abscess –bursts- sinus or ulcer

29. Neurological complications
• Potts paraplegia
• Above L1 high incidence
• Thoracic is common
Classification
• Based on motor involvement(goel , tuli, kumar)
• Progressive severity of neurological deficits due
to cord compression

30. goel , tuli, kumar
stage Clinical features
I negligible Patient unaware of neural deficits, physician detects
plantar extensor
II mild Patient aware of deficit but manages to walk with
support
III moderate Nonambulatory because of paralysis
Sensory deficits less than 50 %
IV severe III + flexor spasms/paralysis in flexion/flaccid/
sensory deficits > 50 % , sphincters involved

31. Cord involvement Better prognosis Poor prognosis
degree partial complete
duration shorter Longer ( >12 months)
type Early onset Late onset
Speed of onset slow rapid
age younger older
General condition good poor
Vertebral disease active healed
Kyphotic deformity < 60 degree > 60
Cord on mri normal myelomalacia
preoperative Wet lesion Dry lesion

32. Investigations
Blood:
• Hb : anemia
• Tc:increased lymphocytes
• Lymphocyte : monocyte ratio:5:1 is favorable
• CRP
Mantoux test:in doubtful cases in children with
negative mantoux rules out TB

55. Radiological techniques:
Xray AP and Lateral views
• Earliset finding is rarefaction present on either side
of IVD space
• Narrowing of disc space
• Lytic destruction of ant vertebral end plate
• Osteolytic destruction of vertebral body
• Pathological collapse
• Spinal deformity
• Sclerosis reactive bone formation
• Abscess shadow varies region of involvement

60. • K is the angle of kyphosis
by the technique of
dickson
• A line drawn from along
the posterior margin of
the bodies of the healthy
vertebrae above and
below the site of disease.
• Angle k increases with
increase in degree of
kyphosis

61. CT- SCAN OF SPINE
• Patterns of bony destruction.
• Calcifications in abscess (pathognomic for TB)
• Regions which are difficult to visualize on plain
films, like :
• 1. Cranio-vertebral junction (CVJ)
• 2. Cervico-dorsal region,
• 3. Sacrum
• 4. Sacro-iliac joints.
• 5. Posterior spinal tuberculosis because lesions less
than 1.5cm are usually missed due to overlapping of
shadows on x rays

62. MAGNECTIC RESONANCE IMAGING
• highly sensitive &specicific for spinal TB
• Spinal cord & soft tissue involvement
• Detect marrow infiltration in vertebral
bodies(EDEMA), leading to early diagnosis
• Skip lesions
• Changes of diskitis (EDEMA)
• Assessment of extradural abscesses /
subligamentous spread
• Poor for calcification

66. MANAGEMENT

67. MEDICAL MANAGEMENT
• There is a lack of consensus regarding the ideal duration
of multidrug chemotherapy for spinal TB.
• WHO recommends nine months of treatment for TB of
bones and joints (2HREZ + 7 HR) because of the serious
risk of disability in addition to difficulties in assessing
treatment response.

68. Current guidelines
• All cases of bone and joint TB – extended ATT
• It includes two months of intensive phase and 10-16
months of continuation phase
For spine
• 2 HRZE and 10 HRE upto 18 months
• Repeat Xray every third month
• MRI at 6 , 9 , 12 , 18 months
• At the end of the treatment, Follow up every six
months for two years

71. MDR TB
• TB is defined as resistance to at least both
Isoniazid and Rifampicin.
• Extensively drug-resistant tuberculosis or XDR-
TB is defined as resistance to any
fluoroquinolone and at least one injectable
second-line antibiotic in addition to Isoniazid
and Rifampicin resistance

72. • primary reasons for the emergence of MDR
strains, unscientific use of multi-drug
chemotherapy by clinicians, making it one of the
most dangerous iatrogenic creations.
• India ranks second amongst the high-burden
MDR-TB countries.

73. • 1. Early detection of MDR and prompt initiation of effective
treatment are important for successful outcomes
• 2. A biopsy is a must, and all efforts must me made to culture
the organism to obtain drug sensitivity testing.
• 3. A lab competent in microbiological testing should be
chosen.
• 4. It is imperative to involve a chest physician or an infectious
disease specialist for treatment.
• 5. Never add a single drug to a failing regimen
• 6. MDR-TB regimen should be composed of at least five drugs
likely to be effective, including four second-line anti-TB drugs
that are likely to be effective plus pyrazinamide

74. Surgical management

75. INDICATIONS
• Paraplegia during conservative treatment (6
weeks)
• Paraplegia worsening during treatment (6
weeks)
• Complete motor loss for 1 month despite of
conservative treatment
• Paraplegia with uncontrolled spasticity
• Severe and rapid onset paraplegia
• Severe flaccid paraplegia/ sensory loss

76. OTHER INDICATIONS:
• Spinal deformity
• Childhood spine tuberculosis
• Disease (Poor response to medical treatment)
• Drug resistance
• Diagnosis in doubt

77. Surgical management
• Anterior spinal cord decompression and
reconstruction
• Posterior instrumentation without
anterior column reconstruction
• Posterior approach with anterior column
reconstruction
• Anterior and posterior approach

78. Anterior spinal cord decompression
and reconstruction
As tuberculosis affects the anterior spinal column, anterior
debridement and fusion has long been the gold standard of
treatment.
It has several advantages, which include direct access to
pathology, safe and effective decompression without
handling of the spinal cord and optimal reconstruction of
the anterior column without damaging intact posterior
elements.

79. • In patients with extensive spinal destruction
(more than 2 VB loss in the thoracic spine and
more than 1 VB loss in thoracolumbar and
lumbar spine) or severe kyphosis, standalone
anterior spinal instrumentation is
biomechanically inferior to posterior
pedicle screw construct

80. • In the past few decades, surgeons have gained
expertise in accessing the anterior column
via the posterior approach, and the
indications for a standalone anterior surgery are
dwindling.

81. Posterior instrumentation without
anterior column reconstruction
• Tuberculosis presents as posterior element
disease with spinal cord compression.
• In these patients, a standalone posterior
approach is an obvious choice
• In patients with less severe anterior column
destruction, a posterior approach to decompress
the spinal cord via transfacetal or transpedicular
approach may be successful

82. •
• As the antibiotics heal the anterior column and
restore its integrity, the posterior
instrumentation helps to maintain spinal
alignment.
• However, frequently the technique of spinal cord
decompression via a posterior approach may
involve excision of anterior column sufficient
enough to warrant grafting of anterior column

83. Posterior approach with anterior
column reconstruction
• This approach is most popular to treat spinal
tuberculosis of the thoracic and lumbar area.
• The posterior approach is the workhorse of a
spinal surgeon, and most surgeons are far more
comfortable with it compared to the anterior
approach

84. • As per necessity, a progressive sacrifice of the
posterior elements can provide increasing access
to the anterior column. (Transfacetal,
transpedicular, extracavitary lateral approach)
• The approach also may involve spinal cord
handling if one is not careful, and frequently a
less experienced surgeon may end up doing a
suboptimal job fearing injuring to the neural
structures.

85. Anterior and posterior approach
• Extensive anterior column destruction (3 or
more vertebral bodies in thoracic spine or more
than 1 vertebral body in the lumbar spine) with
or without severe kyphosis, warrants a global
access to take advantages of both anterior
and posterior approach

87. • Usually, posterior approach is performed first to
correct the alignment and stabilize the spine
followed by anterior spinal cord decompression
• reconstruction using a structural graft or cage.
• A global approach can be morbid and potentially
could be staged to avoid complications.

88. Take home message
• Clinical features can be subtle, and the clinician needs to have a
high degree of suspicion for spinal tuberculosis to be able to
diagnose this infection early.
• There are no radiological features that are pathognomonic for spinal
tuberculosis
• A biopsy is recommended not only for diagnosis but also to treat it
with effective antibiotics.
• New diagnostic tests, such as GeneXpert and LPA, can be used to
diagnose MDR-TB early in the course of treatment
• Surgeons who treat spinal tuberculosis should follow recommended
guidelines when prescribing multi-drug chemotherapy
• It is advisable to involve a chest physician or an infection disease
specialist early in the course of treatment.

89. • Management of MDR-TB is complex and potentially
morbid, and all efforts should be taken not to
generate iatrogenic cases of MDR-TB by prescribing
irrational and unscientific chemotherapy
• Surgical management is reserved for complications
of spinal tuberculosis.
• Childhood spinal TB can have a malignant
progression of deformity, in spite of effective
medical management and these should be identified
early.
• The treating physician or orthopedic surgeon should
be cognisant of the indications for surgery and make
an appropriate referral to a spine surgeon, especially

90. BRUCELLOSIS
• Brucellosis results in a noncaseating, acid-fast–
negative granuloma caused by a gram-negative
capnophilic coccobacillus.
• individuals involved in animal husbandry and
meat processing (workers in abattoirs).
• Symptoms include polyarthralgia, fever, malaise,
night sweats, anorexia, and headache.

91. • Bone involvement, most frequently of the spine,
occurs in 2% to 30% of patients.
• The lumbar spine is the most frequently involved
spinal region.
• Radiographic changes of steplike erosions of the
margin of the vertebral body require 2 months
or more to develop.

92. Brucellosis of lumbar spine. Note vertebral sclerosis, spondylolisthesis,
steplike irregularity in anterior vertebral body,
and anterior osteophytes

93. • Treatment usually consists of antibiotic therapy
for 4 months and close monitoring of the
Brucella titers.
• Nas et al. recommended 6 months of antibiotic
therapy (rifampicin and doxycycline) with
surgery for spinal cord compression, instability,
or radiculopathy.

94. FUNGAL INFECTIONS
• Fungal infections generally are noncaseating,
acid-fast– negative infections.
• They usually occur as opportunistic infections in
immunocompromised patients.
• Symptoms usually develop slowly.
• Pain is less prominent as a physical symptom
• than in other forms of spinal osteomyelitis.

95. • Direct culture by biopsy is the only method of
absolute determination of the infecting organism
• Aspergillus and cryptococcal infections are of
special note with regard to spinal infections.
• predominant lumbar involvement and
neurological involvement.

96. • Pain, tenderness, and an elevated ESR and CRP
are the most common symptoms.
• Cryptococcal infection is a less opportunistic but
more prevalent fungal infection.
• These organisms are found in avian excreta and
usually infect the human respiratory system.

97. • Radiographs show lytic lesions that on biopsy
reveal non–acid-fast, caseating granulomas
without pus.
• The indications for radical surgery are the same
as for tuberculosis.

98. EPIDURAL SPACE INFECTION
• The incidence of this infection is increased in
immunosuppressed patients.
• direct extension from infected adjacent
structure, hematogenous spread, and iatrogenic
inoculation.
• Epidural abscess usually spans three to five
vertebral segments.

99. • Spinal epidural abscess caused by direct
extension from a vertebral osteomyelitis usually
is on the ventral side of the canal anterior to the
thecal sac.
• Clinical findings :
• (1) a more rapid development of neurological
symptoms (days instead of weeks);
• (2) a more acute febrile illness; and
• (3) signs of meningeal irritation, including
radicular pain with a positive straight-leg raising
test and neck rigidity

100. • MRI is crucial to the determination of diagnosis
• A few authors have reported successful
treatment without surgical drainage.
• For selected patients with an epidural abscess
presenting with back pain alone or neurological
symptoms that have been stable for more than
72 hours follow-up is necessary
• any deterioration of the patient’s neurological
status or development of systemic sepsis
requires urgent surgical decompression.

101. • Acute or chronic isolated dorsal (posterior),
lateral, and some ventral (anterior) infections
are best treated with total laminectomy.
• Epidural infections associated with osteomyelitis
are best exposed by anterior or posterolateral
exposures that allow treatment of the
osteomyelitis and the epidural infection.

102. POSTOPERATIVE INFECTIONS
• The rate of postoperative spine infections ranges
from less than 3% in discectomies and
laminectomies to approximately 12% in patients
with instrumented fusions.
• Increased exposure and blood loss, increased
operative time, and increased dead space.
• Age older than 60 years, previous surgical
infection, poorly controlled diabetes, obesity,
alcohol abuse, and smoking.

103. OPERATING ROOM
• Prophylactic antibiotics should be given 30 minutes
• prior to the incision and redose after 3 to 4 hours or
1500-mL blood loss.
• Reduce traffic in and out of the operating room.
• Release soft tissue retraction regularly.
• Irrigate regularly.
• Maintain strict aseptic techniques.
• Close and seal wounds.
• Maintain sterile dressings in the immediate
• Postoperative period unless the wound is chemically
sealed.

104. POSTOPERATIVE MANAGEMENT
• Concomitant infections (e.g., urinary tract
infections, pneumonia) should be aggressively
evaluated and treated.
• Sterile dressings should be maintained for 48
hours.
• Nutritional status of the patient should be
carefully maintained, particularly during the
postoperative period

105. PYOGENEIC VERTEBRAL OSTEOMYELITIS
• Usually caused by s.aureus (hematogenous spread)
• Risk factors: old and debiliated patients , IV drug users
• Recent history of pneumonia, UTI, skin infections,
immunologic compromise,
• Unremitting spinal pain at any level is characteristic
• Neurologic deficits seen around 40 % in older patients, mostly
in cephalic level of spine
• Laboratory studies – elevated ESR, CRP and WBC count

106. Plain radiographs shows
• Osteopenia
• Paraspinous soft tissue swelling
• Erosion of vertebral end plates
• Disc space destruction
• Gadolinium enhances the MRI sensitivity

107. Treatment:
Non operative:
• After tissue diagnosis 6 to 12 weeks of IV antibiotics
is the treatment of choice
Operative:
• Open biopsy indicated when tissue diagnosis has not
made
• Anterior debridement and strut grafting are for
refractory cases.
• May required posterior stabilization

108. osteodiscits
• Blood borne infections can primarily invade the
disc space in children
• S.aureus is the most common offender , gram
negative org are common in older patients
• Children are most common affected
• History – may or may have spinal procedures as
spinal injection

109. • Inability to walk or stand
• Back pain with tenderness
• Restricted range of motion
• Laboratory studies: elevated ESR, CRP, WBC
Imaging:
• Loss of lumbar lordosis
• Disc space
• End plate erosions
• Findings do not occur until 10 days to 3 weeks

110. Treatment:
• Typically medical:
• Obtain percutaneous biopsy if possible
• Targeted antibiotic therapy once culture and
sensitivity completed.

111. Surgical includes :
• Patient medically systemically ill
• Evidence of epidural abscess
• Unable to obtain percutaneous biopsy.