Infection of the Spine

276
Infections of the Spine
Dennis G. Vollmer I Nitin Tandon
cally needed to cure osteomyelitis than an infection of the disk or the epidural space, the
role of surgical intervention, the inci- dence of neurological deficits, and the chance of
failure with maximal medical management are poorly predicted by these tra- ditional
anatomy-based descriptors. Instead, we find it more useful to categorize these infections by
the neurological condi- tion of the patient (presence or absence of deficits) and by the
vertebral level affected by the infection. A classification based on these descriptors is
concordant with the biology of these infec- tions and facilitates decisions determined on the
basis of the patients clinical condition and the radiographic findings rather than on an
arbitrary anatomic label.
Epidemiology
The incidence and demographics of pyogenic spinal infections (PSIs) have been
significantly influenced by social changes, advances in medical technology, and the
acquired immunodefi- ciency syndrome (AIDS) pandemic. The incidence of spinal
infections appears to be on the rise.
11,12
In years past, the inci- dence of epidural abscess was
estimated to be around 0.2 to 2 per 10,000 hospital admissions,
4,7
but most recent authors
have cited higher rates.
13-16
The annual incidence of all PSIs is now probably between 5 and
10 cases per million individuals, with a male pre- ponderance.
11,17-19
Older series describe
two age-related spikes, one during the first decade of life and the second around the fifth or
sixth decade,
20,21
which reflects the proclivity of the very young and the older population to
acquire such infections. Infections still occur in these demographic groups, perhaps with no
change in frequency,
22
but are overshadowed in number by those that occur in adults with
frequent bacteremia, significantly impaired host defenses, or both.
13,23-26
Intravenous drug
abuse and AIDS, the most common risk factors for PSI,
16,27-32
have reached epi- demic
proportions in modern times.
33,34
Medical advances have led to an increased prevalence of
individuals who are susceptible to spinal infection. Patients with diabetes, end-stage renal
disease, and cirrhosis live longer than in years past.
35
Immunosuppression of transplant
recipients,
36
long-term steroid therapy for autoim- mune diseases, chemotherapy, chronic
indwelling catheters for venous access,
37
splenectomy, genitourinary instrumentation, and
other medical interventions also unfortunately enhance a patients risk for contracting an
infection of the spine.
23,28,38-40
In suscep- tible patients, remote pyogenic infections (e.g.,
skin, genitouri- nary tract, lungs, gastrointestinal tract) can result in bacterial seeding of the
spine. Spontaneous bacteremia with the potential to inoculate the spine is probably a
relatively common event that is ordinarily rendered inconsequential by competent immune


Infections of the spinal axis have been recognized throughout history. Evidence of
tubercular disease of the spine has been found in Egyptian
1
and South American mummies.
2
Social changes and advances in medical technology have changed the spectrum of
causative organisms and the characteristics of patients who acquire these infections.
However, the uneven nature of these socioeconomic changes across the globe, combined
with variations in the endemic microbial flora, has led to regional variability in the
epidemiology of spinal infections. The growth of medical technologies has enhanced the
ease of detection and the options for definitive management of spinal infections. Ironi-
cally, technologic advances have also promoted the development of spinal infections by
increasing the number of patients with iatrogenic immunosuppression, thereby enhancing
the life expec- tancy of patients with chronic medical illness, and by increasing the
complexity of spinal procedures and thus the potential for infectious complications.
3

From a neurosurgical perspective, infections can be subdi- vided into three broad
categoriesspontaneous pyogenic infec- tions, iatrogenic infections, and infections caused
by mycobacteria, fungi, unusual bacteria, and parasites. We use the term pyo- genic
restrictively to refer to bacterial infections that produce a predominantly neutrophilic
infiltrate and purulence. Although mycobacteria, Actinomyces, Nocardia, and certain fungal
infections can produce purulence, this is a lymphocyte-predominant immune response, the
so-called cold pus. The clinical behavior and management of such infections differ enough
from that of pyogenic infections to merit discussion in a separate section.
SPONTANEOUS PYOGENIC SPINE
INFECTIONS
Traditionally, categorization of spinal infections has been based on the anatomic locus of
the infection. The terminology used osteomyelitis, diskitis, and epidural abscess
suggests that the infection is more or less limited to a particular anatomic struc- ture.
Advanced evaluation with magnetic resonance imaging (MRI) has made it clear that such
terminology often does not accurately depict the nature of the infection. Most spinal infec-
tions spread to involve more than one of these anatomic struc- tures and, not uncommonly,
affect all of them.
4-10
In addition, all three subcategories of infection share similar
epidemiology, risk factors, and clinical findings and are diagnosed with the same laboratory
tests and imaging studies. Furthermore, a classifica- tion based on these anatomic
boundaries does not contribute much to determining the optimal management for an
individual patient. Although a longer duration of antibiotic therapy is typi-
CHAPTER

2831
2832 SECTION X SPINE
mechanisms. A Danish database of all patients with staphylococ- cal bacteremia in that
country suggests that hematogenous ver- tebral osteomyelitis developed in 145 patients
roughly 1% of all those who had clinically apparent bacteremia.
13
In some patients with
predisposing conditions for PSI, no overt source of primary infection is found. The same
can also be said of patients in whom infections occur in the absence of any particular risk
factors. Increased awareness of spinal infections as a cause of fevers of unknown origin and
the widespread availability of MRI scanners may both have contributed to the increase in
the rate of diagnosis of this condition and hence a greater reported incidence.
Pathogenic Mechanisms
Infective organisms can be carried to the spine by four routes: via the arterial blood supply,
retrograde by the vertebral venous plexus,
41,42
by direct inoculation (a contaminated surgical
instrument/needle or a penetrating injury), or by direct extension from an adjacent nidus of
infection (e.g., pulmonary abscess or sacral decubitus ulcer). In adults, the nutrient artery of
the metaphyseal end plate is an end artery derived from the periosteal arteries. Infected
thrombi that lodge in this nutrient artery, the metaphyseal artery, produce avascular
necrosis of a portion of the metaphysis, which in turn creates a sizable nidus for infection.
43
Small anastomotic arteries that do branch off from the metaphy- seal arteries are unable to
supplant the blood flow to an ischemic metaphysis. These connect the metaphyseal plates at
opposite ends of a vertebra and are the probable pathway for spread of the infection to
transequatorial metaphyses while sparing the inter- vening equatorial region of the
vertebra.
44
The equatorial region of the vertebra is supplied by multiple branches from the
main segmental artery, thus making it very vascular and relatively resis- tant to the
processes that result in infarction of the metaphysis. In addition to devitalization of the
metaphyseal bone, thrombosis of the metaphyseal artery gives rise to ischemia of the
interver- tebral disk, which results in an infection of the disk, as well as chronic aseptic
necrosis. This leads to gradual loss of disk height and, occasionally, the production of frank
pus in the disk space. Purulence in the disk or the bone can result in septic thrombosis of
draining veins, which in turn relay the infection to the epidural venous plexus, thereby
leading to the formation of an epidural abscess.
The constellation of findings of an infection of the vertebral body, disk, and epidural space
is seen commonly but not con- stantly, and the relative predominance of infection in a
single region has been the basis for the traditional categorization of these lesions. The
microvascular anatomy of the vertebrae and disk is slightly different in children, as a
consequence of which the predominant type of infection in children tends to be limited to
the disk space, as discussed in the later section on pediatric spinal infections.
Not all infections arrive in the spine through an arterial routetransvenous dissemination
may also occur, somewhat akin to metastasis of genitourinary and gastrointestinal
malignancies to the spine. Infections involving the left kidney may be more likely to spread
to the spine because the left renal vein often communicates with Batsons plexus.
40
Occasionally, infection may be restricted to the epidural veins, which act as a portal to the
spine and can result in the production of contiguous or hetero- topic epidural abscesses over
multiple spinal segments without significant involvement of the bony or cartilaginous
components of the spine.
6
Similar mechanisms may be involved in the infre- quent
occurrence of infections arising within the posterior elements of the spine.
45-47
Less than 5%
of spinal infections are isolated to the posterior spinal elements.
6,48,49

Bacteria can also reach the spine through contaminated needles or other instruments used
during diskography, epidural
anesthesia, or surgery; by contiguous spread from surrounding infected tissues; and by
penetrating injuries or after cutaneous breakdown (especially over the sacrum and lower
lumbar region). The clinical findings and management of such infections are addressed in a
subsequent section.
Neurological deficits develop as a result of compression or ischemia (or both) of the spinal
cord or cauda equina in 5% to 50% of all patients with PSI.
27,28,48,50-52
Such compression and
ischemia can be caused either by an expanding epidural abscess or, more commonly, by
kyphosis of the spine as a result of the loss of bone integrity and subsequent bony
compression and distortion of neural elements. The lumbar spinal canal is some- what
capacious relative to the space requirement of the cauda equina. This allows the
accommodation of sizable epidural col- lections and retropulsed bony fragments in the
lumbar spinal canal in comparison to the cervical or thoracic spinal canal, where very little
spare room is available around the cord. For this reason, even though PSI affecting the
lumbar region is relatively common,
27,53,54
spinal infections that produce neurological defi-
cits are seen predominantly with infections of the cervical and thoracic regions.
6,51,55
In
addition, neurological deficits are more likely to develop in immunocompromised patients
as a conse- quence of a spinal infection.
27

Microbiology
The most common organism causing PSI is Staphylococcus aureus.
4,6,8,9,25,30,38,52-54,56-60
S.
aureus together with other gram- positive organisms such as Staphylococcus epidermidis,
Streptococcus viridans, Streptococcus pneumoniae, Streptococcus faecalis (enterococ-
cus), Propionibacterium, and diphtheroids account for the vast majority of PSIs. Gram-
negative organisms such as Escherichia coli, Pseudomonas, Salmonella, Enterobacter,
Klebsiella, Haemophilus, and Proteus are less frequent and may be associated with gastro-
intestinal or genitourinary sources of infection.
15,50,60,61
Infections in intravenous drug
abusers are most likely to be caused by staphylococcal species as well,
14,59,62,63
but
Pseudomonas infection may be relatively more common in this patient group.
27,29,55,62,64
Rarely, anaerobes such as Peptostreptococcus and Bacteroides may cause spinal
infections,
4,65
also with relatively greater frequency in intravenous drug abusers. Anaerobic
infections are more likely than aerobic infections to be polymicrobial. Care should be taken
to process all material submitted for culture, both aerobically and anaerobically.
66

Clinical Findings
The diagnosis of PSI can easily be missed unless a high index of suspicion is maintained.*
Given the large number of visits to emergency departments for complaints of back pain,
recognizing this comparatively rare, sometimes subtle, but treatable condition is
challenging. Additionally, patients with a history of substance abuse, who are especially
prone to the development of such infec- tions, can be poor historians and manifest drug-
seeking behavior, thereby further confounding matters.
62

Early in the course of their disease, patients typically have isolated back pain
27,53
that they
may relate to strenuous activity or a minor injury. Systemic signs of infection such as fever
or an elevated leukocyte count may be absent. Such patients may be discharged from
emergency departments or physicians offices without a definitive diagnosis, only to return
later with progres- sive symptoms, deformity, or neurological deficits.
Heusner described the clinical evolution of epidural abscess in four stages: pain,
radiculopathy, weakness, and paralysis.
7
In practice, however, such distinct progression of
the infection rarely occurs. Patients can be seen anywhere along a spectrum
*See references 4, 15, 20, 22, 26, 28, 30, 51, 61, 63.

that ranges from predominantly local manifestations of focal spinal or radicular pain at one
end to systemic manifestations of infection (e.g., fevers, chills, malaise, and night sweats)
at the other end. The presence of systemic manifestations may herald bacteremia and is an
opportune time to obtain blood for culture. Unusual characteristics of the back pain, such as
a midline loca- tion over the thoracic or upper lumbar spine that worsens with recumbency,
especially at night, and the association of a thoracic radiculopathy should prompt
consideration of a nondegenerative cause of the pain. Careful screening for risk factors such
as intra- venous drug abuse, AIDS, diabetes, recent steroid therapy, or the presence of other
immunocompromised states helps detect patients who merit further evaluation.
Neurological symptoms are more commonly seen with infections of the cervical and
thoracic spine than with infections in the lumbar region. The rate of progression of
infection and neurological deficits is variable some infections are relatively indolent,
whereas others can pro- gress rapidly and result in profound neurological deficits in just a
matter of hours.
On examination, there is usually exquisite tenderness with percussion of the affected spinal
segment. When the infection has a prominent bone component, a gibbus deformity may be
clinically obvious. A dermatomal level of sensory, motor, or com- bined deficits is
common in patients with deficits. The examina- tion is usually consistent with an acute
spinal cord injury with bladder and bowel involvement. Measurement of postvoid bladder
residual followed by bladder catheterization provides an objective measure of the urologic
dysfunction and prevents sec- ondary injury of the detrusor muscle. Rarely, with relatively
indo- lent infections, chronic compression of the spinal cord may occur and long-tract signs
may be present.
67

Occasionally, patients may initially be seen with florid sepsis
68
and an altered level of
consciousness and be unable to provide any history. This is somewhat more common in
immunoincom- petent patients, those in whom medical attention is delayed, and those with
a previous, more rostral spinal cord injury who are insensate to the pain and have no
neurological function below the infected level.
69
In such cases, the diagnosis of PSI may be
delayed for hours or days until the patient is stable enough to undergo MRI.
Diagnosis
Laboratory Markers
The diagnosis of PSI is suggested by the clinical features described earlier. Laboratory
markers of acute inflammationleukocyte count, erythrocyte sedimentation rate (ESR),
and C-reactive protein (CRP)are helpful in screening patients for further evaluation and
in establishing the diagnosis in cases in which the imaging changes are nondiagnostic. Of
these markers, the leuko- cyte count is the least commonly affected,
11,27,53,70
whereas the
ESR is usually affected, often in dramatic fashion.
6,16,20,50,53,56,70,71
According to Carragee and
colleagues, the ESR is elevated in more than 90% of patients with spinal infections.
70
Measurement of the ESR is inexpensive and reasonably sensitive, although nonspecific. It
is an excellent parameter to monitor in determin- ing the response to therapy and should be
measured at the initial evaluation even if the diagnosis is already clear. Given its lack of
specificity, the ESR should always be interpreted in the context of the patients overall
condition. This lack of specificity is espe- cially an issue in the management of patients
with PSI and a preexisting elevated baseline ESRsuch as those with cirrhosis in which
the elevated ESR is refractory to treatment of the infec- tion and it is hard to determine
whether the infection is responding. The diagnosis of spinal infection is also strongly
suggested by a persistently elevated CRP. Measurement of CRP
FIGURE 276-1 Paraspinous muscle involvement in a patient with a pyogenic spine
infection as seen on an abdominal computed tomo- graphic scan obtained after
the administration of contrast material.
may be useful in detecting early infections because serum levels may increase within hours
of a bacterial infection.
72,73
Although both the ESR and CRP will become elevated after
elective spine surgery, CRP normalizes postoperatively much more quickly than the ESR
does, thus making it potentially more useful in the evaluation of postoperative patients.
74

Imaging
The diagnosis of PSI requires that the physician first establish the presence of the infection
and, second, arrive at a bacteriologic diagnosis. The first of these goals is dependent on
adequate imaging data. The imaging diagnosis is usually established by MRI. Plain
radiographs and computed tomography (CT) can also play a role in the diagnosis.
Occasionally, MRI is either not feasible or is nondiagnostic. In such cases, the diagnosis
needs to be made by an overall interpretation of the patients clinical picture, laboratory
parameters, and radiographic findings. Additional imaging data such as radionuclide scans
may be useful in such cases.
Plain radiography and CT typically show few if any changes during the very early stages of
infection.
26
These imaging modali- ties, however, are valuable in the evaluation of more
advanced infections in which bone changes are apparent and in the evalu- ation of vertebral
bony integrity and spinal stability in patients in whom surgical management is being
considered. Changes that are seen on plain radiographs several weeks after onset of the
infection increasingly consist of prevertebral and paravertebral soft tissue volume, loss of
disk height, trabecular erosion, and, eventually, destruction of the entire vertebral end plate
on either side of a disk. Vertebral collapse, loss of normal lordosis around the affected
level, and the development of a kyphotic deformity occur with advanced infection.
75,76

CT is generally more sensitive and specific than plain radio- graphs. Contrast-enhanced CT
reveals inflammation of the pre- vertebral and paravertebral soft tissues (Fig. 276-1),
visible as stranding and loss of the normal tissue planes, in infections that have been
present for several days. Enhancing epidural collec- tions may also be visible on a high-
quality, contrast-enhanced CT of the spine. CT is an appropriate modality for the detection
and percutaneous management of psoas abscesses and paravertebral abscesses that result
from unchecked progression of the prever- tebral and paravertebral components of a PSI.
CT guidance is useful for percutaneous aspiration of disk spaces, paravertebral
CHAPTER 276
Infections of the Spine 2833

2834 SECTION X
SPINE

FIGURE 276-2 Gadolinium-enhanced T1-weighted imaging with fat suppression in a
patient with L4-5 diskitis. There was no osteomyelitis or epidural involvement. The
patient was treated with intravenous antibiotics, which led to resolution of all the
symptoms.
fluid collections, and necrotic bone and to provide specimens for a bacteriologic diagnosis.
Myelography followed by CT provides another means of visualizing spinal cord or cauda
equina com- pression in situations in which MRI cannot be performed.
MRI is the diagnostic test of choice for the detection of PSI and should be performed in all
patients unless contraindicated. Imaging should be carried out without and with the
administra- tion of paramagnetic contrast agents. Unenhanced T1-weighted images reveal a
hypointense signal in the vertebral body, espe- cially at the end plates; the normal
hyperintense fat signal in the vertebral bone marrow is lost. Disk height is reduced and may
be markedly diminished. T2-weighted imaging reveals high signal (edema) in the disk
space and occasionally in the bone and paravertebral soft tissues.
8,57,77
Gadolinium-enhanced
T1-weighted imaging is perhaps the most diagnostic MRI sequence (Fig. 276-2)
enhancement of the vertebral end plates, the vertebral
body, the prevertebral and paravertebral soft tissues, and the epidural space can be seen.
76
The entire spine should be imaged if an infection is detected because much like metastatic
tumors, spinal infections can occasionally be multifocal (Fig. 276-3 to 276-5).
78,79

Occasionally, it is not feasible to evaluate patients with MRI because of the presence of
incompatible devices such as cardiac pacemakers, ferromagnetic aneurysm clips, or
shrapnel, which constitute absolute contraindications. Other problems such as patient size,
claustrophobia, ongoing mechanical ventilation, or other monitoring may render the
performance of high-quality MRI difficult or time-consuming. Furthermore, MRI may be
less specific in patients with extensive or pronounced spondylosis or in those who have
suffered recent trauma. Finally, the scans of some patients with MRI-compatible, metallic
implants are affected by sufficient artifact to render them nondiagnostic. In all cases in
which MRI is either not possible or not diagnostic, CT myelography and nuclear medicine
scans should be considered.
Radionuclide studies have a high degree of sensitivity in early infection. Gallium 67 and
technetium 99 both have reasonable sensitivity for the detection of PSI. Gallium binds to
iron-binding proteins at the site of inflammation, whereas technetium reflects blood flow to
the bone. Gallium scans are therefore more specific than technetium scans for PSI, but both
of these scanning methods are not very specific.
80
Focal uptake can be seen with
spondylosis, after trauma, and in tumors. In comparison, scans using white blood cells
tagged with radionuclide are more specific for the detection of infection, but their
sensitivity is much lower.
81
Leukocytes from the buffy layer of the patients blood are
tagged with indium 111 and reinjected into the patient (Fig. 276-6). These labeled cells
localize to sites of ongoing inflammation; focal uptake in the spine strongly suggests the
diagnosis of a PSI, although false-positive results can occasionally be seen with a few
conditions such as tumors, especially hematogenous malignancies involving the spine.
Chronic infections can occasionally lead to false-negative results with indium scanning.
Fluoro-2-deoxy-d- glucose (FDG)-labeled positron emission tomography (PET) has proved
to be highly sensitive for spinal infections, although it is also relatively nonspecific.
82-84
Recently, scans using indium- labeled biotin have been used for the diagnosis of osseous
infec- tions.
85
Biotin, a growth factor widely used by bacterial species, shows early promise
as a more specific indicator of infection. Various other potential peptide markers are being
investigated to aid in early diagnostic imaging.


AB
FIGURE 276-3 A and B, Axial and sagittal magnetic resonance images of a patient
with a large, dorsal epidural abscess that extended from T11 to the sacrum. The
patient complained of urinary retention and back pain. The abscess, which grew
coagulase-positive staphylococci, was drained via laminectomy.
DE
FIGURE 276-4 Typical findings of a spinal infection with osseous involvement as seen
on magnetic resonance imaging. There is hypointense signal in the vertebral body
on T1-weighted images (A and D) and enhancement of the vertebral end plates,
prevertebral and paravertebral soft tissues, and epidural space after the
administration of contrast material (B and E). T2-weighted imaging reveals
increased signal (edema) within the disk space, bone, and paravertebral soft
tissues (C).
FIGURE 276-5 A and B, Magnetic resonance image of T8-9 diskitis and destruction of
the adjacent end plates. Computed tomography directed biopsy was positive for
Enterococcus species.
CHAPTER 276 Infections of the Spine 2835

ABC


AB
2836 SECTION X SPINE

A B FIGURE 276-6 A, Magnetic resonance imaging was not diagnostic of a
pyogenic spine infection. B, The diagnosis was made with an indium

111tagged white blood cell scan that revealed focal uptake.
Bacteriologic Diagnosis
The second component of the diagnostic evaluation is bacterio- logic characterization of the
infection. As noted earlier, the spine may be hematogenously seeded from other sites of
infection such as the respiratory tract, urinary tract, or an endovascular source. Cultures of
urine and sputum should be performed in patients with these potential sources. The
causative organism is typically isolated from either blood or spinal tissue. Blood should be
obtained for culture in all cases, and if possible, multiple sets should be collected to
coincide with spikes in the patients tem- perature. If the blood cultures are positive, the
causative organ- ism is identified in 25% to 59% of cases.
86
Appropriate therapy may be
started without the need for further, more invasive testing. Unfortunately, blood cultures are
negative in 40% to 75% of cases, possibly because some infections are indolent, although
most commonly in patients who have received antibiotics before blood is drawn for culture.
In such cases, biopsy of the vertebra or the disk space under CT or fluoroscopic guidance
has a higher rate of success in culturing the organism. This may need to be repeated if no
growth results from culturing the aspirate. A larger bore needle that obtains a core of tissue
may yield microbiologic results superior to that of aspirates of fluid from bone. The use of
a nucleotome for percutaneous suction-aspiration of the infected disk space has also been
described.
86,87
Biopsy specimens consisting of a core of tissue can also be submitted for
histopatho- logic analysis to confirm the diagnosis. Closed biopsy techniques have reported
accuracy rates ranging from 60% to 100%. If these measures fail and the imaging diagnosis
is reasonably definitive for PSI, open biopsy may be necessary. This is best done in an
operating suite under fluoroscopic guidance. A bacteriologic diagnosis is made in about
80% of open biopsies.
86

It is difficult to establish a bacteriologic diagnosis if empirical antibiotic therapy is begun
before obtaining blood for culture. It
is important to exert restraint and withhold the administration of antibiotics until it is clear
that an organism has been cultured, unless the patient is septic or has major systemic
manifestations, in which case delaying therapy may be inappropriate.
61
Even a single dose
of a broad-spectrum intravenous antibiotic may sig- nificantly decrease the probability of
culturing an organism. In patients with neurological deficits, antibiotics should be withheld
until specimens are collected intraoperatively. If antibiotic treat- ment is initiated before a
bacteriologic diagnosis is established in patients who are neurologically intact, it may be
reasonable to terminate this empirical therapy and obtain fresh samples for culture without
the influence of antimicrobials. In a small number of cases, no organism can be cultured
despite multiple attempts.
6,87
Mycobacterial or fungal infections should be considered in
such cases. Once this possibility is reasonably excluded, empirical anti- biotic therapy is the
only option. Patients treated empirically with antibiotics need to be monitored closely to
confirm a response to the treatment being administered.
Diagnosis of Associated Conditions
Patients with PSI are at risk for concomitant pyogenic infections elsewhere in the body.
Because the risk for bacterial endocarditis is especially high, patients should be examined
for cardiac murmurs and evidence of embolization to the retina and the skin. If endocarditis
is suspected, echocardiography, preferably via a transesophageal route, should be
performed to look for valvular vegetations.
Frequently, a cutaneous pyogenic lesion that represents the index location of the infection
is still present when the patient is evaluated by a neurosurgeon.
88
Such lesions can often be
used to obtain material for culture to make a bacteriologic diagnosis. Patients should also
undergo assessment for risk factors respon- sible for the infection. Certain risk factors may
be obvious,
whereas others may be discovered only after careful evaluation. For instance, patients may
be reluctant to admit to intravenous drug abuse. In some cases of indolent infection, the
drug abuse may even have occurred several months previously. It is reason- able to offer
intravenous drug abusers testing for human immu- nodeficiency virus (HIV) and type B
and C viral hepatitis, as well as appropriate counseling together with such testing.
It should be emphasized that evaluation of a PSI is incom- plete unless the patient is
assessed for extraspinal manifestations of the infection. Infections can track along fascial
planes adja- cent to the infected vertebrae and result in psoas abscess, para- spinous muscle
abscess, empyema, sympathetic pleural effusion, and retropharyngeal abscess.
89
Infections
can breach the dura spontaneously or with the unintended assistance of a biopsy or lumbar
puncture needle. Changes in mental status, nuchal rigid- ity, or emesis in a patient with a
known or suspected PSI should lead to the consideration of meningitis or parameningeal
inflam- mation as a diagnostic possibility. The diagnosis of concomitant meningitis is best
confirmed by obtaining cerebrospinal fluid (CSF) from a cisternal rather than a lumbar
punctureunless the locus of spine infection is clearly remote from the site of the
puncture.
62

Differential Diagnosis
Occasionally, patients with severe back pain and laboratory studies consistent with acute
inflammation have spinal MRI scans that fail to reveal changes diagnostic of a PSI. In such
cases it is prudent to wait for definitive imaging changes to develop or to obtain
radionuclide scans if the diagnosis of a PSI is strongly suspected. It is also essential to
consider alternative diagnoses that can mimic PSI.
Conditions that can have clinical findings similar to PSI but can be differentiated with
imaging include pyogenic arthritis of the hip, septic or autoimmune sacroiliitis,
pyelonephritis, primary psoas abscess, autoimmune spondylitis, spinal trauma, osteopo-
rotic compression fractures, spinal epidural hematoma, spon- taneous spinal subarachnoid
hemorrhage, and leptomeningeal metastatic disease. Certain conditions may occasionally
be a little harder to distinguish with imaging alone. Nonpyogenic (tuber- cular or fungal)
spinal infections can occasionally mimic PSI rather closely, as can tumors metastatic to
adjacent vertebral levels. Involvement of the vertebral body more than the disk space and
the development of paravertebral abscesses rather early in the course of the infection
suggest a tubercular rather than a pyogenic etiology.
70
A definitive diagnosis can usually be
estab- lished by needle biopsy in such cases. Tubercular infection and lymphomas should
always be considered in the differential diag- nosis in patients with AIDS.
90
The
degenerative changes seen in patients with advanced spondylosis
91
can at times be confused
with infections because both are preferentially localized to the vertebral end plates. They
can generally be differentiated from infection; a degenerated disk is usually dehydrated and
therefore hypointense, whereas an infected disk is hyperintense on T2-weighted imaging.
Enhancement of the disk itself is also indicative of PSI, but enhancement of vertebral bone
can be seen with either entity. The presence of gas within the disk, the vacuum disk
phenomenon, is much more suggestive of degenera- tion than infection.
76
A rare entity that
may mimic PSI is avas- cular necrosis of the vertebral body, which is usually associated
with significant collapse of the vertebral body and intravertebral vacuum clefts. Changes in
the intravertebral vacuum clefts are seen as a consequence of spinal loading and unloading.
T2-weighted imaging performed immediately after the patient lies supine on the scanner
reveals a hypointense signal because of the presence of air, but as fluid enters the cleft, this
signal becomes hyperintense.
92,93

CHAPTER 276 Infections of the Spine 2837 Management
Once a diagnosis of PSI has been established, an important deci- sion to be made is whether
operative intervention is indicated. Although all patients need antibiotic therapy, the term
medical management in the present context refers to the use of antibiot- ics without
planned surgical dbridement at the site of infection. Surgical management, in contrast,
implies operative interven- tion consisting of dbridement of necrotic tissue, decompression
of neural elements, correction of deformity, fusion, and instru- mentation as indicated by
the clinical situation, along with appro- priate antimicrobials.
Surgical Treatment
The decision to proceed with surgery should be made after con- sideration of the patients
neurological status, vertebral level of involvement, extent of vertebral destruction, and
findings on MRI. In the past, the decision to undertake emergency surgery was often made
solely on the basis of an enhancing epidural component. The guiding principle has been
that an epidural abscess constitutes a neurosurgical emergency. It has become increasingly
clear that there is heterogeneity in the composition of epidural collections. Entirely liquid
abscesses are rare, and in most cases a phlegmon with minimal, if any, liquid abscess is
seen (Fig. 276-7). Such heterogeneity also applies to the clinical manifestations of epidural
collectionssome produce rapidly progressive neurological deficits, whereas others
produce no defi- cits. Furthermore, as discussed in the section on the pathogenesis of PSI,
neurological deficits occur more often as a result of spinal instability or deformity than as a
result of compression of the cord or cauda equina by an abscess component. Thus, there is
often poor correlation between an imaging diagnosis of epidural abscess and the
development of neurological deficits. This lends further credence to the notion that
management decisions in PSI are best made by taking into account multiple clinical and
imaging criteria rather than a simple anatomic classification of the infection.
The presence of neurological deficits is the most important of these criteria. Emergency
surgical intervention should be consid- ered in all patients with neurological deficits,
regardless of the duration of the weakness, unless the deficits are minimal (e.g.,
radiculopathy) or the patients medical comorbid conditions (coagulopathy, sepsis)
preclude rapid surgical intervention. If a patient has minimal neurological deficits and it is
decided to proceed with nonsurgical management, the patient must be care- fully monitored
to detect any early progression. Deficits may sometimes progress rapidly in a few hours.
Surgical intervention for neurological deficits needs to address the location of the
compressive lesion, such as ventral or dorsal to the spinal cord or cauda equina. Simplistic
though this sounds, ignoring this principle may result in destabilization of an already
compromised spine, with worsening deficits.
39,49,51,94
The nature of the compressive lesion
liquid pus versus a mass of granula- tion tissue or retropulsed boneis also an important
consider- ation in determining the optimal surgical approach. Although pus may be
accessed and drained by various routes, simple laminec- tomy does not adequately afford
decompression of a solid ven- trally situated extradural lesion and can exacerbate the
deficits produced by a kyphotic deformity. Finally, the various anatomic regions of the
spine dictate the potential approaches available and the likelihood of postoperative
instability.
In the cervical spine, the surgical approach usually coincides with the location of the
compressive lesion (i.e., an anterior approach for ventral compression and a posterior
approach for dorsal compression).
9,55
An exception may be cited for ventral abscesses
without major bone involvement extending over more than two or three levels. In these
cases, pus can usually be drained
2838 SECTION X SPINE


ABC
FIGURE 276-7 A-C, Osteomyelitis of C5 and C6 in a 51-year-old woman with neck
pain of 2 weeks duration and quadriparesis. Magnetic reso- nance imaging shows
a prevertebral abscess and cord compression from a ventral phlegmon. Anterior
dbridement and reconstruction with an expandable cage, allograft, and an
anterior plate resulted in solid fusion with complete resolution of the neurological
symptoms.
from a posterior approach without the morbidity of multilevel corpectomy and fusion.
Infections of the odontoid, though rare, have been reported. If deemed to have produced
instability, they are best managed by occipitocervical fusion and a transoral biopsy or
decompression of the thecal sac. Stable lesions at this level can be managed medically.
95,96
At the cervicothoracic junction and in the upper thoracic spine, anterior lesions may be
difficult to access from a ventral approach because of the presence of the great vessels.
Although partial sternotomy or manubrial resection may provide adequate access in such
cases, technical challenges with dbridement and reconstruction of the anterior column
remain. Furthermore, a kyphotic deformity produced by the infection can make access to
the apex of the deformity via an anterior approach more difficult. Transpedicular, lateral
extra- cavitary,
97-99
or periscapular
100,101
approaches may be used in these cases. These
approaches can be used to decompress the ventral aspect of the spinal cord, and potential or
apparent segmental instability can be addressed by concurrent posterior thoracic fusion
with instrumentation.
39,49,94
Recent technologic advance- ments have increased the options
available for fixation over the cervicothoracic junction.
Surgical approaches for treating PSI of the midthoracic spine are best tailored to the site of
compression. Thoracotomy approaches offer excellent visualization of the ventral and ven-
trolateral aspects of the spinal canal. Anterior reconstruction after vertebrectomy is readily
performed via this exposure. Alterna- tively, the lateral extracavitary approach
97-99
or the
retropleural approach
101
can be used. The temptation to perform a laminec- tomy for ventral
disease in the thoracic spine, other than liquid pus, should be resisted because it can result
in the cord being draped over the compressive lesion along with concomitant loss of the
stability offered by the posterior tension band.
49,51,94
The extent of spinal instrumentation
required to restore stability is a function of the number of segments involved, the degree of
kyphotic deformity, the patients bone stock, and the integrity of the posterior tension band.
In the lower thoracic and upper lumbar spine, anterior dbridement via a thoracoabdominal
approach affords excellent exposure for resection of the involved vertebral bodies and
recon- struction of the anterior and middle columns.
22,27,56
When the posterior elements are
intact, an anterior approach alone may suffice. Anterior dbridement and fusion followed
by posterior instrumentation and posterolateral fusion
102,103
may be an option
in selected patients in whom concern for appropriate placement of instrumentation from the
anterior approach used for the decompression is especially high. Infections of the middle
and lower lumbar spine may be approached through either a retro- peritoneal or a
transperitoneal approach for dbridement and anterior reconstruction. Below the conus, a
posterior approach can be used to decompress the neural elements; however, recon-
struction of the anterior and middle columns is difficult with this approach. Transpedicular
instrumentation can provide a measure of stability in such cases, but it may occasionally
fail if anterior column reconstruction is not performed. After fusion and instru- mentation
for spinal infections, an external orthotic device appropriate for the level in question should
be prescribed for approximately 3 months.
In addition to the treatment of patients with neurological deficits, surgical intervention is
also indicated for the manage- ment of those who have failed medical therapy, the
treatment of chronic pain after medical management, and the treatment of patients with
prominent deformity or overt instability.
6,32,104
Relapses of infection can be treated either
with a second course of antibiotics or by surgery, depending on the clinical scenario and the
patients preference. It has been postulated that relapses occur because of the presence of
necrotic bone (sequestra) within a vertebral body that lacks blood supply and thus provides
a nidus for persistent infection. Surgical treatment in these cases there- fore includes
dbridement of the vertebral body that is infected (i.e., corpectomy), followed by
reconstruction (Figs. 276-8 and 276-9). Finally, some surgeons tend have a bias toward
immediate surgical management of patients with a prominent bony compo- nent of their
infection because they believe that bacteriologic cure rates are then higher and thus a cure
is effected earlier. This bias still remains to be validated by clinical trials. However, the fact
that aggressive dbridement eliminates a sizable portion of infected and necrotic bone lends
credence to this viewpoint.
Timing of Surgery
Surgery needs to be performed on an emergency basis in patients with rapidly progressive
neurological deficits.
58
In cases in which the deficits have been slowly progressive or the
patient has sig- nificant medical comorbidity (septicemia, coagulopathy, endocar- ditis with
cardiac failure), the timing of surgical intervention should be more carefully considered.
Surgery can be carried out
AB
CD
FIGURE 276-8 A-C, Destruction of the third and fourth cervical vertebrae by an
Enterobacter cloacae infection in an intravenous drug abuser. The spine was
grossly unstable, and C3-4 corpectomy was performed, followed by fusion with an
iliac crest autograft and an anterior cervical plate. The postoperative radiograph
(D), which was obtained at 2 years, demonstrates some subsidence but solid
incorporation of the graft and a stable spine.
CHAPTER 276 Infections of the Spine 2839



on an elective basis in patients with no deficits, in whom the goal is to stabilize the spine or
dbride a necrotic focus of infection.
The role of steroids, at dose levels used for the acute manage- ment of spinal cord
injury,
105,106
is questionable in that there are no prospectively collected data to address the
issue, nor are there likely to be any given the relatively small numbers of such cases seen at
any one institution. Our experience, though anecdotal, suggests that the use of steroids at
high doses in patients with a significant neurological deficit is safe in the perioperative
period.
Implantation of Bone Grafts and Hardware
The surgical wound created during the operative management of PSI is heavily
contaminated by the organisms responsible for the infection. Yet the spine in such cases is
often unstable and some method of spinal reconstruction is essential. In years past, the
implantation of devitalized bone or metal into such a field was considered contraindicated.
Recent clinical experience by mul- tiple groups has tended to refute this viewpoint. Many
studies have shown that if the necrotic bone and soft tissue are adequately dbrided, the
implantation of bone graft (allograft or autograft) and instrumentation in patients who
receive an appropriate post- operative course of antibiotics is safe and
effective.
6,30,32,39,68,88,107-111

Follow-up of patients over time reveals that the implantation of hardware and bone grafts is
remarkably effective in producing bony union at the site of infection. This may be partly
due to the enhanced vascularity of the region with the infection. Implanted hardware and
bone graft seldom become secondarily infected as long as the necrotic bone is well
dbrided and the patient receives an appropriate course of antibiotics. Given that inadequate
dbridement is frequently the cause of a recrudescence of infec- tion and that placement of
hardware is safe if the dbridement is adequate, thorough dbridement is an important goal
of surgical intervention in patients with PSI.
Management of Epidural Abscesses
Management of epidural abscesses merits a separate discussion given the controversies that
surround it. There are no prospec- tively collected data that address the surgical versus
medical man- agement of these lesions. Because patients with true abscesses are at some
risk for acute neurological deterioration and fatality, an observation that dates back to
Dandy,
112
the prevailing recom- mendation has been to treat all abscesses
surgically
7,14,35,113
ubi pus, ibi evacua. A review of the existing literature and our own
experience in dealing with such lesions suggests that carefully
2840 SECTION X SPINE

AB
FIGURE 276-9 A and B, Pyogenic infection caused by Staphylococcus aureus at T9-
10 in a 38-year-old man with paraparesis. Treatment con- sisted of anterior
dbridement, T9 and T10 corpectomy, and reconstruction with a Harms cage,
autograft, and a Kaneda-type construct.
selected patients have an excellent outcome with medical man- agement
alone.
16,25,29,31,49,58,114,115
The clinical condition of the patient and the imaging characteristics
of the epidural collection are the determining factors that direct decisions on management.
Careful evaluation of the MRI characteristics of epidural lesions can determine their fluid
versus formed nature and prevent unnecessary, potentially harmful intervention. A
collection that enhances only peripherally, has a central nonenhancing portion, and is
hyperintense on T2-weighted images is very likely to be fluid and easily drainable. Lesions
that are homogeneously enhancing and isointense or hypointense on T2-weighted images
probably represent a phlegmona collection of granulation tissue. Such collections need to
be addressed surgically only if they are responsible for the production of neurological
deficits. An area of controversy lies in patients with a fluid abscess but no detectable
deficits. If an organism is identified from such patients and they can be monitored closely,
they may be managed medi- cally. If a bacteriologic diagnosis is not forthcoming, the
symp- toms persist or worsen despite medical therapy, or there is any difficulty in obtaining
reliable serial neurological assessments, surgical intervention is desirable.
104
Epidural
abscesses of the cervical and thoracic spine are at higher risk for the sudden onset of
neurological deficits than are similar lesions below the conus and therefore justify a lower
threshold for surgical intervention. The presence of an epidural abscess over several
segments or paralysis of more than 3 days duration does not present a con- traindication to
surgical intervention.
25,115
Good outcomes can be obtained by decompression over
discontinuous segments, and patients with relatively long-standing deficits may
occasionally improve neurologically with surgical intervention. Finally, it cannot be
overemphasized that patients with epidural abscesses who are managed conservatively need
to be carefully and serially monitored with regard to their neurological status.
Medical Management
The management strategy in patients without neurological defi- cits or sepsis involves
immobilization of the affected vertebral levels and administration of appropriate
intravenous antibiotics.
22

Medical management should be initiated as soon as an organism has been isolated or after
cultures have been initiated in patients who are seen in septic extremis. The goal of therapy
is to effect sterilization of the infected vertebral levels, prevent the occur- rence of a
neurological deficit, and prevent the formation of a painful deformity as the infection
clears. The duration of therapy may be dependent in some measure on the extent of bone
involve- ment seen on MRI. The duration of antibiotic therapy remains controversial, with
no prospective clinical trials having addressed length of therapy. Relapses occur in 0% to
15% of patients and usually occur within 6 months of treatment.
116
In patients with a
minimal amount of bone infection and a competent immune system, the duration of therapy
can be restricted to 6 weeks. In patients with a prominent osteomyelitis component
extending over multiple segments or in immunocompromised patients (AIDS, cirrhosis,
poorly controlled diabetes), an 8-week-long course of antibiotic therapy may be more
effective in preventing a relapse of infection.
26
The efficacy of medical management can be
gauged by diminishing pain, malaise, and fevers and a decrease in the ESR. In all patients
in whom there are no other unrelated coexisting causes of the persistent elevation, the ESR
should be monitored closely to determine the effect of treatment. Unfor- tunately, however,
the response of the ESR to appropriate treat- ment is unpredictable. Although a significant
decrease in the ESR within a few weeks of treatment usually augurs a good prognosis,
sustained elevations do not in themselves imply a failure of therapy.
70
The ESR should be
viewed in context of the patients overall clinical picture. If the decrement in the ESR takes
far longer than expected, consideration should be given to extending the duration of
antibiotic therapy. If after several weeks of therapy there is no significant alteration in the
ESR and the patient con- tinues to be symptomatic, consideration should be given to rees-
tablishing the radiobacteriologic diagnosis.
20,117

Antibiotic therapy is guided by the in vitro sensitivity of the organism that is isolated.
Given that staphylococcal and streptococcal species account for the vast majority of PSI,
-lactamspenicillin and oxacillin/methicillin/nafcillinthe ureidopenicillins (ticarcillin
and piperacillin), the cephalo- sporins, and vancomycin are the most commonly prescribed
antibiotics. The addition of an aminoglycoside, trimethoprim- sulfamethoxazole, a
fluoroquinolone, or rifampin as a second agent may have a synergistic effect in vivo and
should be consid- ered in patients with extensive bone involvement because vanco- mycin
and certain cephalosporins may penetrate poorly into devascularized bone and the disk.
118
The addition of fusidic acid to the treatment regimen of penicillinase-stable penicillins
appears to decrease the chance of failure of medical therapy.
26
Newer agents such as
linezolid and daptomycin have not demonstrated superiority over standard therapies.
119,120
The increasing prevalence of methicillin resistance and the decreas- ing susceptibility to
vancomycin warrant careful assessment of the response to therapy.
Patients in whom no causative organism is isolated after mul- tiple attempts or in whom
empirical treatment was started before a full microbiologic work-up need to be monitored
especially closely. Recommendations for empirical antibiotics vary some- what with the
epidemiologic factors involved. Intravenous drug abusers may tend to have a relatively
greater proportion of infec- tion with Pseudomonas.
27,29,55,62
Failure of empirical therapy
should prompt consideration of unusual pathogensfungi and mycobac- teria (see later).
Additionally, patients need monitoring for adverse effects of the drugs used, antibiotic
levels as appropriate, and man- agement of the predisposing factors and associated
complications. In addition to antibiotics, patients are prescribed about 2 weeks of bed rest
and are fitted with an orthosis appropriate to the spinal level of infection to prevent the
occurrence of a deformity or to help correct a mild deformity present at the time of
diagnosis.
The role of oral antibiotics in treating PSI is poorly defined. The practice of initiating oral
agents
59,113,121
after a prolonged course of intravenous antibiotics is widespread for
osteomyelitis in various locations yet finds little support from any comparative analysis of
their efficacy in treating spinal infections.
11
It is unlikely that any residual infection after an
appropriate course of intravenous antibiotics would be cleared by oral antibiotics, which
may serve simply to suppress recrudescence of the infec- tion rather than effect sterilization
of the infective nidus.
Infections isolated to the facet joints are rare.
46,47
They are usually well managed by medical
treatment, with surgery being reserved for patients with neurological compromise. A dorsal
approach for dbridement is usually adequate in these cases, and disruption of a single facet
does not generally compromise stabil- ity in an otherwise intact motion segment.
Outcomes
Patients with PSI and incomplete neurological deficits of recent onset can have surprisingly
good neurological recoveries, pro- vided that timely, aggressive surgical therapy is
instituted.
16,39,51,55,68
The prognosis is more guarded in patients with profound deficits and in
those in whom diagnosis or treatment is delayed. None- theless, some of these patients may
show substantial improve- ment in neurological function over time, thus justifying an
aggressive therapeutic stance even when severe deficits are encountered.
It is our experience that neurological outcomes in patients with deficits secondary to PSI
exceed those seen after the treat- ment of other acute or subacute causes of myelopathy,
such as traumatic spinal cord injury or metastases. The outcomes are probably better
because the compressive forces acting on the spinal cord in PSI develop slowly, are
gradually progressive, and are most likely smaller in magnitude than those with traumatic
spinal cord injury. In some cases, however, the deficits associated with PSI are the result of
related vascular events such as venous or arterial thrombosis with infarction. In these
circumstances, recovery would be less dramatic.
An analysis of outcome in patients with epidural abscesses suggests that older patients and
those with sepsis, neurological
deficits of longer than 72 hours duration, or significant compres- sion of the spinal cord on
imaging studies are more likely to have a poor outcome than patients without these
characteristics.
58,122

In patients managed medically, the prognosis depends to some extent on the patient age, the
rate of decrease in the ESR, and whether the patients were substantially
immunocompromised. An immunocompromised state and infections caused by virulent
organisms such as S. aureus (as opposed to S. epidermidis or Pro- pionibacter) may be
associated with higher mortality rates.
27
Advanced age may be an independent indicator of a
bad outcomestudies have suggested that the elderly have a poor outcome,
27,58
but with
aggressive surgical management, they may fare rather well.
22,23

Serial plain radiographs may be considered in patients with a prominent bony component of
the infection and for the early detection of vertebral body collapse or the development of a
deformity. Successful treatment of the infection is seen radio- graphically as incorporation
of the bone graft (if the patient was managed surgically) or sclerosis of the vertebral end
plates on plain radiographs and CT. In patients with prominent disk space or bone
infection, spontaneous fusion at the affected level may occur. MRI shows resolution of the
typical changes, with the vertebral body tending to have a fat-like signal quality. Serial
MRI is not indicated unless a relapse of infection is suspected on clinical grounds.
Radiographic findings respond very slowly to successful treatment, in contrast to the
clinical response, and are therefore not immediately useful in assessing the response to
therapy.
57

PYOGENIC SPINE INFECTIONS IN CHILDREN
Pyogenic infections of the spine in young children are more common than expected. Those
affected usually have no risk factors for infection other than their age. Infections have been
reported in neonates
123
and infants
124,125
and occur throughout childhood into early
adolescence. The predilection for these infections appears to be a result of the frequent
bacteremia that occurs in childhood. The distinct pattern of infection is thought to result
from the peculiarities of the pediatric spinal vascular anatomy.
Until the age of about 7 years, profuse anastomoses exist between the intraosseous spinal
arteries and thereby prevent devascularization and infarction of large portions of the
metaphy- sis when septic emboli occlude a metaphyseal artery. This tends to limit the
extent of metaphyseal and osseous infection to the cartilaginous end plate at either end of
the vertebra. Hence, hematogenous spread to the pediatric spine tends to be limited more to
the disk space. Additionally, the pediatric disk retains vascularity, unlike disks in adults,
and occasionally blood-borne pathogens may lodge directly in the disk space in children
without any involvement of the metaphyseal end plates.
126

There is controversy regarding whether pediatric diskitis can exist without the presence of
an infection. It has been postulated that some cases may occur secondary to partial
dislocation of the epiphysis as a result of a hyperflexion injury.
127
Indeed, the rate of
culturing organisms from the disk in young children with radiographic changes consistent
with an infection is lower than that in adults.
75,128,129
Other studies, however, support the
notion that these are true infections and are best treated by intravenous antibiotic therapy.
10

Young children may be unable to provide an accurate history or accurately describe their
symptoms, so the diagnosis should be considered whenever a child with fevers refuses to
bear weight or assumes postures that avoid bending of the spine. The dif- ferential
diagnosis includes the conditions that may mimic PSI in adults, but idiopathic intervertebral
disk calcification, urinary tract infections, and appendicitis must also be considered in the
pediatric population. The clinical and radiographic disease in
CHAPTER 276 Infections of the Spine 2841
2842 SECTION X SPINE
children may often be milder than that seen in adults. In patients in whom no organisms are
isolated, management with immobi- lization alone may be reasonable, but patients managed
in this way should be monitored closely for clinical and radiographic evidence of
deterioration. In all cases in which infection is sus- pected or confirmed, appropriate
antibiotic therapy based on the results of culture should be initiated. Surgical intervention is
only rarely indicated, usually if there is a significant epidural extension of the infection
leading to neural compromise.
130
Patients appear to do well with relatively short courses of
antibiotic therapy and immobilization. In the long term, these patients may be at high risk
for the development of block vertebrae and vertebrae magnae.
124,131

IATROGENIC INFECTIONS
Infections of the spine can occur after a variety of invasive diag- nostic and therapeutic
procedures, notably surgical procedures on the spine. The true scope of the term
iatrogenic also includes infections resulting from hematogenous inoculation of the spine
precipitated by the manipulation of a remotely contaminated or infected site, such as dental
manipulation, urologic instrumenta- tion, or drainage of a noncontiguous abscess.
Infections resulting from such iatrogenic bacteremia are similar in most aspects to
spontaneous pyogenic infections, which are discussed in the first section of this chapter.
The present discussion deals specifically with infections that result from direct spinal
interventions. These procedures can render the spine susceptible to infection by the
implantation of instrumentation, devascularized bone graft, suture, or hematoma and by the
creation of ischemic or necrotic tissue through dis- section and retraction.
Postoperative Spinal Infections
Postoperative spinal infections can occasionally be catastrophic events that result in
prolonged (and expensive) hospital stays and significant long-term disability.
132,133
In the
pre-antibiotic era, the rate of infection after spinal operations was about 0.9% to 4.6%. In
series reported after the advent of Harrington instrumenta- tion, the infection rate rose to
between 1% and 12%, with an average of 6%.
134
Today, however, postoperative infection
rates have decreased substantially despite the increased complexity of surgical procedures.
Currently, the average rate of infection after spinal procedures is around 2%. Of course,
rates vary by procedure and are affected by a variety of factors. Contamination of the
surgical wound by skin commensals occurs in as many as half of all surgical cases.
135
The
host response to this contamination plays a significant role in determining whether an
infection develops. Patient factors that predispose to infection include previous surgery,
previous irradia- tion, preexisting neoplasm, chronic steroid therapy, diabetes, malnutrition,
paraplegia, smoking, rheumatoid arthritis, nutri- tional state, and intercurrent infection.
136-138
In addition, there are numerous technical factors that influence the risk for infection;
examples include the duration of surgery, the length of the wound, the duration and force of
retraction used, the presence of a CSF leak, the use of antibiotic irrigation solutions, and the
implantation of instrumentation. Prophylactic administration of antibiotics in the
perioperative period is probably useful in pre- venting colonization of the wound and, if
used for appropriate durations, is not associated with the development of infection by
resistant organisms.
139-142
Double gloving is another practice that may reduce the risk for
infection. The use of Bovie monopolar cauterization has been implicated in an increased
risk for postop- erative infection.
143
Interestingly, the level of experience of the surgeon is
not a factor; for instance, residents and fellows in training do not seem to increase the risk
for infection.
144
For
diskectomy procedures, the risk for postoperative spondylodiski- tis may be reduced by
placement of a gentamicin-impregnated collagen sponge in the disk space
145,146
and adding
bacitracin to the irrigation fluid used during surgery.
147
This seeming efficacy of locally
delivered antibiotics finds support from studies that show unreliable and poorly sustained
levels of antibiotics in the disk space after systemic administration.
148,149
Microneurosurgical
approaches for diskectomy may also be associated with a lower risk for infection than
traditional laminectomy and diskectomy.
150

Potential infections that can occur after spinal surgery include superficial wound infections,
deep infections (below the fascia), spondylodiskitis, epidural abscess, and meningitis. The
occur- rence and management of most of these infections are signifi- cantly affected by
whether instrumentation and bone grafting were carried out.
Infections after Surgery without Instrumentation
or Bone Grafts
The incidence of infection after lumbar laminectomy or diskec- tomy is approximately
1%.
151
Postoperative diskitis occurs in about 0.1% to 5% of patients after lumbar
diskectomy.
145,152
The incidence is similar for posterior cervical operations but may be
slightly lower when an anterior approach to the cervical spine is used. Infection usually
occurs after intraoperative contamina- tion,
147
and the typical causative organisms are skin
flora commonly S. aureus and S. epidermidis. Rarely, however, gram-negative organisms
and anaerobes may produce fulminant infections in the surgical bed.
153
The typical scenario
is recur- rence of symptoms in a patient who initially experienced good relief of
preoperative symptoms (e.g., radiculopathy) immediately after surgery. The surgical
incision may appear to be healing uneventfully. A history of a small amount of drainage
soon after surgery is occasionally obtained. The diagnosis is strongly sug- gested by a
persistently elevated ESR
145,154
or CRP and by typical changes on MRI. However, both the
acute-phase reactants and the imaging changes need to be distinguished from the expected
postoperative changes. The ESR generally returns to normal levels within 2 weeks after
uncomplicated surgery. Measurement of CRP, which returns to normal sooner, may be
useful in detect- ing early infections, but given the individual variability in CRP values, it is
most useful when a baseline value is also available. Measurement of a specific acute-phase
reactant, such as elastase
1
-proteinase inhibitor, potentially allows the detection of an
infection even earlier, but it has not been shown to be relevant outside of a research
setting.
155
MRI with contrast enhancement almost always reveals changes suggestive of
postoperative spon- dylodiskitis, but it may yield false-positive results
152,156
and needs to be
evaluated in the context of the patients clinical picture and laboratory data.
Depending on the number of levels operated on and the size of the postoperative fluid
collection, the infection can be managed either with antibiotics alone or with surgical
dbridement in addition.
157
Because there is little devascularized tissue or foreign material
in such wounds, antibiotic penetration is usually excel- lent, and these infections can often
be eradicated by a few weeks of intravenous therapy alone.
Infections after Surgery with Instrumentation
and Bone Grafts
Modern management of spinal disorders often includes the use of instrumentation to
facilitate fusion. Instrumentation provides immediate spinal stabilization, early
mobilization of the patient, and a higher rate of bone fusion. However, the use of instru-
mentation clearly increases the risk for postoperative infectious
complications. Data demonstrating the effect of instrumentation on the risk for
postoperative infection first became available with the series of Harrington rod
instrumentation.
158
Recent estimates of infection risk in instrumented patients range from
2% to 8.5%.
136,137,159,160
Infections associated with spinal instrumentation are far more
common after posterior or posterolateral approaches to the spine than after anterior cervical
or anterior thoracolumbar instrumentation.
136
This is presumably related to an increase in
necrosis of the paraspinous muscles and other soft tissues because of the devascularization
that results from dissection and ischemia from prolonged retraction. Prolonged retraction is
known to cause disruption of normal muscle physiology and compromise of perfusion, so
the duration and extent of retraction should be minimized.
161,162
In addition to frank tissue
necrosis, ischemia can promote the formation of a large seroma in the wound, a fertile
ground for colonization by multiple organisms.
133

Infections after spinal instrumentation can become manifested in either acute or delayed
fashion.
163
Patients with acute infec- tions are usually seen between 2 and 8 weeks after the
initial surgery with erythema of the wound, partial wound dehiscence, and drainage of
seropurulent fluid.
136
Fever and leukocytosis may or may not be present, although the ESR
is generally elevated. The causative organism can usually be cultured from the wound if
material for culture is obtained before starting antibiotic therapy.
Distinction needs to be made between early infections that are limited to the skin and
subcutaneous tissue and those that extend below the fascia. Superficial infections generally
occur in obese patients with large amounts of subcutaneous fat and in those with impaired
wound healing. These infections can either be closed after thorough dbridement and
irrigation, if there is minimal necrosis, or be managed with sterile dressing changes and
delayed secondary closure if there is more substantial soft tissue loss. Early infections after
instrumentation are usually caused by S. aureus, sometimes a strain resistant to the
antibiotic administered perioperatively. Such infections necessitate thorough dbride- ment
of the wound, removal of suture material and necrotic tissue, and intravenous antibiotic
therapy. They can generally be managed without removal of the implants.
133,136
A concern in
the management of deep infections after instrumentation has been the ability to deliver
bactericidal concentrations of antibiotics to potentially devascularized regions. To
accomplish this, some sur- geons advocate the use of continuous suction-irrigation systems
to deliver antibiotics to the wound.
133,136,164
Others prefer to augment local bacterial control
at the surgical site of grafting by implanting material that releases antibiotics locally over
an extended period.
165
However, Rath and colleagues stated that if the delivery vehicle used
is an acrylic implant, it may allow the infective foci to persist.
39
Many other surgeons,
including us, prefer multiple dbridements or serial open packing of the wound until all
necrotic tissue is removed and delayed secondary closure can be performed. Occasionally,
catastrophic mixed infections by organisms that can cause a synergistic necrotizing fasciitis
or gangrene can complicate dbridements, but fortunately they are rare.
166

Because hardware removal in the context of early infections may pose a significant risk for
spinal instability, most surgeons attempt to dbride the wound and remove loose bone graft
and devitalized tissue with retention of the implants. This approach is frequently successful,
although long-term oral suppressive anti- biotic therapy may be necessary.
Delayed infections are manifested several months after the initial operation. Such infections
are almost always attributable to indolent organisms such as Propionibacterium acnes, S.
epider- midis, or Corynebacterium. If enough time has elapsed since bone grafting and
rigid bone fusion is found at surgery, a case can be made for removal of the infected
hardware.
160,167
Dubousset and associates have argued that these delayed infections are not
indeed true infections but may reflect a fretting corrosion of the metal implant
168
that results
in a seemingly sterile chronic inflam- mation surrounding the instrumentation. It has been
shown, however, that if the intraoperative tissue cultures are maintained in the laboratory
for at least 7 days, slow-growing organisms such as the ones listed earlier can be
isolated.
160,169
These infections probably result from intraoperative contamination of the
instru- mentation by organisms that multiply slowly.
167
The instrumen- tation is coated with
an avascular exopolysaccharidethe glycocalyxproduced by these bacteria that prevents
the bodys immune mechanisms and antibiotics from eradicating them. Additionally, the
glycocalyx prevents truly representative organ- isms from detaching in sufficient numbers
to be detected by simple aspiration and culture. Because such infections usually occur late,
removal of the instrumentation may not compromise the bony fusion. Hardware removal is
the most effective way of eradicating the glycocalyx and thereby the nidus of the infection.
This forms the basis for the recommendation by some authors for hardware removal.
160,167
After hardware removal and adequate dbridement and intravenous antibiotics for about 4
weeks, these infections are generally eliminated.
Infections after Diskography
Infections develop after diskography in about 0.16% to 3% of disks injected.
170-173
Although
the most common infectious com- plication is diskitis, an epidural abscess
170,174
or even a
subdural abscess can result after diskography. Patients usually have severe local pain a few
days after the diskogram. The hematologic markers of acute inflammation
175
are
significantly elevated. The diagnosis is made by MRI without and with contrast enhance-
ment. Management is chiefly medical, with antibiotics tailored to the staphylococcal
species, the most common causative organ- isms, or to the culture results if an organism
can be aspirated from the disk. The risk for spinal infection after diskography can be
minimized by the administration of a broad-spectrum antibi- otic either intravenously or
mixed with the contrast dye.
176
The use of styletted needles and a double-needle technique
as recom- mended by Fraser and coworkers may also aid in the prevention of iatrogenic
contamination of the disk space.
171

Infections after Placement
of Epidural Catheters
Epidural catheters used for pain control can occasionally provide a track for the entry of
infection into the epidural space. The usual pathogenic organisms are S. epidermidis and S.
aureus, which probably reflect contamination of the catheter by skin flora.
177
The reported
incidence of such infections is widely variable from approximately 1 infection per 2000
catheter placements
178
to a 12% infection rate. Much of this variability appears to origi- nate
from the duration for which epidural catheterization was used; when the incidence is
expressed as the number of infections per catheter-days, there is much more homogeneity
in the risk for infection. The incidence stated in this way appears to be between 0.2 and
0.77 per 1000 catheter-days.
179-181
This seeming dichotomy in the incidence of infections
relates to the rise in infection risk with the duration of catheterization.
178
Long-term epidural
anesthesia is used for the management of cancer pain, and the risk for infection per
patient is higher.
181
Given the wide use of epidural anesthesia during parturition, the large
majority of reports of infection of these catheters come from the obstetric literature. Factors
that appear to correlate with the occurrence of catheter infection include a prolonged time
of catheter insertion, an immunocompromised state, and recent trauma.
179,182,183
Early
warning signs of the presence of infection include focal pain around the site of insertion of
the catheter,
CHAPTER 276 Infections of the Spine 2843
2844 SECTION X SPINE
superficial infection of the catheter entry site, and catheter dys- function.
180,181
These early
signs can progress to the rapid devel- opment of neurological deficits.
181
MRI with contrast
enhancement provides a reliable diagnosis in most cases.
181,184
Management depends on the
condition of the patient at the time of evaluation. If the infection is detected early, it can
usually be treated by removal of the catheter followed by appropriate antibiotic therapy.
Patients in whom deficits have developed should be evaluated for urgent surgical
intervention.
182,184
Surgical interven- tion can improve the chance of neurological recovery
in patients in whom deficits develop, but many patients may not improve despite aggressive
intervention.
183
Culture of the catheter after its removal will generally identify the causative
organism, and antimicrobial therapy can be tailored accordingly. In patients with chronic
pain who are debilitated, sepsis may occur after development of the epidural abscess and
may result in death.
181
Tunneling the catheter for a distance before exiting the skin may help
in reducing the risk for infection.
185

The use of 0.5% chlorhexidine in 80% ethanol rather than 10% povidone-iodine for
decontamination of the skin before insertion of an epidural catheter has been promoted by
some as a method of preventing catheter infections.
186
It finds support in the scientific
literature, where chlorhexidine solutions have been shown to be more effective than
povidone-iodine in decreasing the number of bacterial colonies cultured from the skin
187-189
and in preventing vascular catheter-related infections.
190-193
The latter set of studies has been
used by some as an analogous situation to catheterization of the epidural space because of
similarities in the risk factors for colonization of the catheters. However, two pro- spective
randomized studies comparing the use of chlorhexidine and povidone-iodine for skin
preparation before the placement of epidural catheters failed to agree with each other, with
one study showing a beneficial effect of using chlorhexidine in a pediatric population and
the other study showing no difference in an adult population.
194,195

Infected Kyphoplasty and Vertebroplasty
Percutaneous vertebroplasty and kyphoplasty have become widely accepted modalities for
the treatment of refractory pain after thoracic or lumbar compression fractures. Recently,
these procedures have been used for the management of pathologic fractures resulting from
metastasis, myeloma, lymphoma, and hemangioma of bone. Injection of polymethyl
methacrylate cement by means of either technique is associated with high rates of pain
relief in otherwise refractory patients.
196,197
Recent studies have reported that 90% of
patients experience pain relief within 24 hours after treatment.
198
Clinical series have
reported low rates of complications, most of which result from cement migration.
199
Infections have generally been thought to be uncommon. With broader use of these
techniques, reports of osteomyelitis have begun to emerge.
200-202

Walker and coauthors reported two such cases in 2004 and noted that both patients had a
history of previous infection.
201
They recommend careful preprocedure screening to
minimize infectious complications. Findings on postvertebroplasty imaging may be
atypical and infections difficult to diagnose radiographi- cally. Intervertebral clefts may be
seen adjacent to the cement. Percutaneous, CT-guided aspiration may yield an organism,
although inability to culture an organism is not uncommon.
202

Late recurrence of refractory pain after kyphoplasty/ vertebroplasty is concerning for
adjacent fracture or potential infection. Clinical assessment is similar to that for other spinal
infections and includes laboratory investigations, radionuclide scans, spinal CT, and MRI.
In the cases reported, treatment has generally involved exten- sive anterior dbridement
with removal of the cement and recon- struction with anterior or posterior instrumentation.
Other Iatrogenic Infections
Spinal infections may develop after other minimally invasive pro- cedures on the spine.
The risk for infections developing after the placement of epidural spinal cord stimulators
203
and after intra- discal electrothermy
204
is extremely low. The use of careful sterile technique
and periprocedural antibiotics minimizes these risks. Early detection and aggressive
medical therapy are usually ade- quate for the management of infections in this setting,
with surgi- cal intervention being reserved for patients with neurological deficits or infected
nonbiologic material.
UNUSUAL BACTERIAL PATHOGENS
As noted previously, the vast majority of spinal infections are caused by gram-positive
organisms, with staphylococcal species predominating. Other common pathogens such as
enterococci, E. coli, Pseudomonas species, and Proteus species make up most of the
remainder. Infections caused by uncommon organisms such as Nocardia species and
Actinomyces have been described sporadically.
Actinomycosis and Nocardiosis
Actinomyces species are gram-positive, filamentous bacteria that are most commonly
associated with chronic draining infections. The presence in the drainage of sulfur
granules, discrete yellow particulate material that consists of clumps of the organism
itself, is pathognomonic of Actinomyces infection. Common sites of infection include the
oral cavity and paranasal sinuses with exten- sion into the soft tissues of the face or neck.
Spinal involvement is rare and generally the result of contiguous spread from adjacent sites
of infection, especially the lungs and the sinuses.
205,206
Ver- tebral destruction with
deformity is uncommon with Actinomyces infection. Neurological compromise is usually
due to extensive spread of the infection to the epidural space. The first-line treat- ment of
Actinomyces osteomyelitis is intravenous penicillin G. Ciprofloxacin and rifampicin are
also effective in eradicating ver- tebral infections.
207
Surgical intervention is rarely indicated
and should generally be reserved for patients with neurological compromise.
208

Nocardia species are filamentous, branching, gram-positive aerobic bacteria. They are
normally found in the soil and are primarily associated with pulmonary infection in
immunocom- promised patients. Spinal involvement is rareabout a dozen cases have
been reported in the literature
209-211
and it occurs through both direct extension of
intrathoracic infections and hematogenous spread. Most reported infections have been
caused by asteroides species. Treatment consists of sulfonamides, cepha- losporins,
aminoglycosides, or synthetic penicillins. Although a prolonged course of antibiotics may
be required for cure of osteo- myelitis, elimination of the infection occurs in most patients.
Surgery is generally reserved for stabilization and correction of deformity.
Brucellosis
Although infection with Brucella species in humans is uncommon in the United States and
northern and central Europe, this group of pathogens continues to pose a significant
problem in many underdeveloped regions of the world. Endemic areas include the
Mediterranean region, the Middle East, and Central and South America. Most human
infections are associated with contact with livestock or products related to livestock such as
untanned hides or unpasteurized milk.
Osteoarticular complications of infection with Brucella species are common and occur in
about 25% of cases.
212
Spinal involve- ment, perhaps the most common bony infection,
accounts for
about half of the cases of osteoarticular extension. Vertebral infection occurs in about 6%
to 12% of cases of brucellosis.
213,214
The initial signs and symptoms of spinal brucellosis are
nonspe- cific and similar to other forms of spinal osteomyelitis.
215
The onset of symptoms
of spinal brucellosis tends to be subacute, and the radiologic manifestations are nonspecific
and bear some simi- larity to cases of tuberculosis (TB). However, the proliferative changes
associated with bone repair seen in brucellosis are not found in tuberculous infection, and
deformities of the spine, although common in TB, are rarely seen with brucellosis. Radio-
nuclide bone scans are highly sensitive in demonstrating areas of involvement in patients
with Brucella infections who have mus- culoskeletal complaints.
216

Antimicrobial therapy is effective in most cases, with a cure possible in approximately 90%
of patients with skeletal brucel- losis, although there is some evidence that spinal infections
may be more refractory. A number of antibiotics in various combina- tions have been used
to treat Brucella osteomyelitis, including tetracyclines, trimethoprim-sulfamethoxazole, and
aminoglyco- sides. Surgical intervention in these cases is less frequent and is typically
reserved for patients in whom a bacteriologic diagnosis is not possible by other means, for
decompression of the neural elements when necessary, and occasionally, for correction of
deformity.
Tuberculosis
TB is perhaps the most lethal infectious disease worldwide; it accounts for nearly 3 million
deaths per year.
217
More than 1.5 billion people either are presently infected or have had
tubercu- lous infection in the past. The AIDS pandemic has been cited as being responsible
for the recent resurgence in the reported cases of TB, especially in regions of eastern and
central Africa, where the incidence of HIV infection is especially high. In the western
world as well, there is evidence of an increase in cases of tuber- culous infection in high-
risk groups, especially those with immu- nosuppression or immunodeficiency syndromes,
substandard nutrition and living conditions, and the extremes of age. It has been estimated
that more than 2 million individuals have spinal TB worldwide.
Osseous and articular involvement is a common manifestation of well-established
mycobacterial disease and occurs in approxi- mately 3% to 5% of patients. Interestingly,
the incidence of skeletal involvement in patients with concurrent HIV infection rises to
60%. The most common site of skeletal involvement is the spine, and nearly half of all
cases of osseous TB are spinal. Spinal infections also typically have the most serious conse-
quences, with severe deformity and paraplegia being the most significant. Although
tuberculous involvement can be seen at any spinal level, the frequency of involvement
varies widely, with the peak levels being at the thoracolumbar junction and decreasing
frequencies occurring at more rostral and caudal levels. Overall, the cervical spine accounts
for about 10% of cases, the thoracic spine 50%, and the lumbar spine 40% of all cases of
tuberculous spondylitis.
212
Although spinal involvement may result from direct extension
from adjacent structures (e.g., lung and pleural cavity), it is more common for spread to the
vertebral column to be through a vascular route. Work by Hodgson in the 1960s and 1970s
suggested that a major mechanism for spread of infection is via Batsons venous plexus.
The strong association of spinal involvement with intra-abdominal infection such as renal
TB is consistent with this hypothesis.
The nature of tuberculous spinal infection is somewhat dif- ferent from the pyogenic
infections of the spine described in the preceding sections. First, TB tends to become
manifested in a more indolent fashion. It more commonly exhibits concurrent involvement
of the posterior elements and the vertebral body and is therefore more likely to induce
deformity. Because of the slow
rate of development, these deformities may frequently be observed without severe
neurological compromise. The disks are often relatively preserved, and there are frequent
associated para- spinous masses of inflammatory tissue or abscesses (or both). The
appearance of tuberculous infection on imaging may be more difficult to distinguish from
neoplastic processes as a result. The actual nature of the pathology is dependent on the
stage of the disease process. The initial inflammatory changes are followed by abscess
formation. Occasionally, a large amount of liquid pus will be present and may cause a mass
effect on the neural ele- ments and a neurological deficit. As the infection evolves, the
formation of caseous material ensues. Necrosis of bone with erosion and loss of
ligamentous integrity contributes to the devel- opment of angulation and deformity.
Retropulsion of sequestered bone into the spinal canal may cause acute deficits. With
resolu- tion of the acute infectious process, a more chronic situation may develop in which
formation of fibrous scarring takes place and serves to restore relative stability.
Calcification and ultimately ossification may occur and can in some cases produce cord
com- pression as a chronic process.
Diagnosis
The diagnosis of spinal TB requires a high level of suspicion. In the absence of a history of
active pulmonary or renal TB, the initial symptoms overlap with a variety of spinal
disorders, depending on the level of involvement. The course of symptoms may be more
suggestive of neoplasm than infection, and the systemic complaints of a patient with active
TB may be mistaken for signs of disseminated cancer. Patients with concurrent AIDS and
pediatric patients may have greater acuity. The initial evalu- ation usually consists of plain
radiographs, MRI with and without contrast enhancement, blood culture, urine culture, and
percuta- neous biopsy or aspiration (or both). CT may supplement the other imaging
modalities by better defining the degree of bone destruction and the likelihood of segmental
instability. Open biopsy is infrequently necessary to obtain satisfactory diagnostic material,
although surgical intervention is primarily reserved for therapeutic purposes, as discussed
later.
Treatment
Chemotherapy
The mainstay of treatment of spinal TB, as with other sites of infection, is effective
antituberculous chemotherapy. Modern methods of characterizing TB strains with
polymerase chain reaction have provided clues to the prospective determination of possible
drug resistance. Standard antituberculous therapy involves multiple agents administered for
protracted periods. Drug therapy with isoniazid, rifampin, and pyrazinamide is a frequently
used regimen. The duration of therapy is often debated, but the incidence of relapse of bony
infection may be unacceptable with less than 12 months of treatment with triple- drug
therapy. Longer durations may be required in patients who are slow to respond.
Adjunctive Treatment
The role of bed rest or orthoses in the management of spinal TB is not well defined. Some
authors have advocated an early period of recumbency at the beginning of drug treatment in
the rationale of decreasing the development of deformity. Others have tended to use
orthoses and continue the patients ambulatory status. Many of the larger studies of therapy
for tuberculous spondylitis are derived from underdeveloped coun- tries, where difficulty in
providing for prolonged recumbency
CHAPTER 276 Infections of the Spine 2845
2846 SECTION X SPINE
or problems in fitting and maintaining appropriate orthoses may have made positive results
from these measures unlikely. Nonetheless, the presence of significant instability or
deformity would probably best be treated by surgical means if other patient factors allow.
Surgery
Surgical treatment is considered in patients with spinal instability or progressive
neurological symptoms and evidence of cord com- pression or deformation. In the past,
surgical drainage of large paraspinal cold abscesses was advocated on the grounds that
this maneuver accelerates improvement. More recent practice in centers with a large
volume of spinal TB, however, has suggested that routine drainage of these extraspinal
collections may have little or no impact on outcome. Similarly, it has been held that
surgical dbridement of involved bone and soft tissue may have utility in the clearance of
infection. There is good evidence, however, that simple dbridement of the infected focus
may have little to add to effective chemotherapy. Nonetheless, when defor- mity,
neurological deficit, or instability exists, the role of decom- pression, dbridement of
affected tissues, reconstruction, and stabilization seems clear. As with other types of spinal
infection, most of the involvement centers in the vertebral bodies. As a result, the surgical
approaches for decompression, dbridement, and reconstruction of the affected anterior and
middle columns require anterior or anterolateral approaches. For cervical lesions, the
standard approaches for multilevel anterior disease are appli- cable. In patients with
considerable deformity that cannot be completely corrected from a frontal approach,
additional poste- rior fixation may need to be considered.
The thoracic levels are generally accessed through a thora- cotomy approach, which is
sufficient to allow anterior dbride- ment, anterior reconstruction with an allograft strut or
cylindrical cage and autograft, and placement of an anterior internal fixation device. If the
posterior elements are intact and kyphosis is not marked, this is usually sufficient.
Alternatively, if there is more pronounced kyphosis with cord compression in the thoracic
region (T4-L1), a lateral extracavitary approach (Larson) may be quite effective in
affording visualization for spinal cord decom- pression and allowing a long posterior
construct for correction of deformity through a single operative field. Anterior recon-
struction with autologous rib or an allograft strut or cage can generally be performed with
this approach. Finally, planned ante- rior and posterior surgery carried out sequentially in a
single session may be required to achieve optimal dbridement, correc- tion of deformity,
and long-term stability.
FUNGAL INFECTIONS
Fungal infections of the spine are infrequent and tend to occur in patients with predisposing
conditions or rarely as a conse- quence of iatrogenic interventions. Examples of comorbid
condi- tions usually seen in patients with fungal spine infections include prolonged
corticosteroid administration, immunosuppression after organ transplantation, and severe
systemic illness associated with malnutrition and multiple antibiotic use, HIV infection,
diabetes, alcohol or intravenous drug abuse, and parenteral nutrition.
Candida species have become some of the most common noso- comial pathogens in
critically ill patients. Osteoarticular involve- ment can be expected to increase as the overall
incidence of disseminated candidiasis increases. Certain endemic pathogens such as
Coccidioides and Blastomyces may involve the spine as a consequence of dissemination.
Recognition of the possibility of these infections in their various endemic regions is a key
to diag- nosis. Because bacterial infection is much more prevalent, a high degree of clinical
suspicion, especially in patients with the types
of risk factors noted earlier, is critical to making the appropriate diagnosis and initiating
effective antifungal therapy.
Aspergillosis
Spinal infection with Aspergillus species is rare in immunocom- petent patients.
Predisposing factors that have been described in clinical reports include systemic
corticosteroid therapy, immuno- suppression, chemotherapy, hematologic malignancy, and
pro- longed neutropenia. Aspergillus typically invades the spine from a contiguous site of
infection (usually pulmonary), but it can also be spread hematogenously. Intravenous
amphotericin B is the primary therapeutic agent. Surgical dbridement may be indi- cated
for patients with abscess formation, vertebral destruction, or neurological deficits.
Blastomycosis
North American blastomycosis is predominantly a granuloma- tous cutaneous or
respiratory infection. It is endemic to the southeastern and midwestern United States. Males
are more sus- ceptible to infection than females, and blacks are more commonly affected
than whites. All ages can be affected, but the disease appears to have a predilection for the
second through the fifth decades. The infection may be self-limited or may progress to
dissemination. Disseminated disease produces generalized symp- toms of fever, malaise,
anorexia, and night sweats. Secondary osseous involvement is common, with the spine
being a prime target. Vertebral involvement produces a destructive lesion that is often
associated with a large paraspinous mass. The diagnosis is typically made through positive
cytology or histologic exami- nation. A high index of suspicion is justified in endemic areas
and in immunocompromised or otherwise susceptible hosts. Similar to most fungal
osteomyelitis, standard treatment consists of amphotericin B, although newer azole
antifungals (e.g., itracon- azole) may be effective, with surgery being reserved for spinal
instability or neurological deterioration.
Candidiasis
Candida species are common opportunistic infectious agents in patients with various forms
of immunocompromise, including diabetes, systemic malignancy, HIV infection, prolonged
antibi- otic administration, or bone marrow or organ transplantation.
28
Intravenous drug
abuse is also an important factor in dissemi- nated candidiasis. Vertebral involvement as a
consequence of disseminated infection is relatively uncommon; however, the increase in
numbers of susceptible individuals will result in an increased number of cases. Non-
albicans species such as Candida glabrata, Candida tropicalis, and Candida dubliniensis
are assuming greater importance as opportunistic pathogens. This is significant because
there is an increase in resistance to antifungal chemo- therapy in many of these
nontraditional species. The diagnosis of Candida osteomyelitis is supported by an
elevated ESR. Posi- tive blood cultures are obtained in about 50% of patients. Culture and
histologic evaluation of vertebral biopsy specimens are both useful in confirming the
correct diagnosis.
Amphotericin B is the standard form of medical therapy, although newer antifungal agents
may be successful with lower rates of toxicity. According to Sugar and associates,
218
fluconazole may be effective when administered on a continuous basis for prolonged
periods. Variations in drug sensitivity must be consid- ered when planning therapy. The
ESR can be useful in assessing the response to treatment. As with other forms of infection,
surgical dbridement, fusion, and instrumentation are required for patients with advanced
deformity, neurological compromise, and instability. Overall, at least 85% of patients will
respond to treatment with cure of the osteomyelitis. Because of the
significance of comorbid conditions, however, mortality rates in patients with Candida
spinal osteomyelitis remain high.
Coccidioidomycosis
Coccidioidomycosis is endemic to the southwestern United States, Mexico, and Central and
South America. Infection with Coccidioides immitis may be benign and localized to the
respiratory tract, or in susceptible individuals, it may become disseminated via
hematogenous spread to involve multiple loci, including the spine. Spinal infections usually
involve the vertebral body, are destructive, and like other granulomatous infections, are
rela- tively sparing of the disk. Multifocal spinal involvement is not uncommon. Treatment
is primarily medical with intravenous antifungal agents such as amphotericin B. Surgery is
generally reserved for patients with overt deformity, instability, or neural compression.
PARASITIC INFECTIONS
Parasitic infections of the spine are rare except in areas where parasitic infestation is
endemic and a significant proportion of the population is infected. In these regions a
relatively larger incidence of parasitic involvement of the spine is seen. Organisms that
have been implicated with some regularity as being causative of spinal infection include
Echinococcus granulosus (hydatid disease); Schistosoma haematobium, Schistosoma
mansoni, and Schistosoma japonicum (bilharziasis); Taenia solium (cysticercosis); and
Dracunculus medinensis (guinea worm infection). Of these, echinococcal
219-221
and
dracuncular infections
222,223
can occasion- ally result in what are truly extra-axial lesions that
compress the
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