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Spinal Infections for Postgraduate Orthopaedic Exams
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Spinal Infections for Postgraduate Orthopaedic Exams
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Segment:0 .
We have Nicky today who is working in Lancaster, and she has done the exam. Some time ago and she's been a mentor for some time. She will be talking about spinal infections without any further ado, this is. Thank you, so. Good evening, everyone, and the topic I'd like to talk about this evening is spine infections for the forex exam.
And this is one of the sparks critical conditions. I'd like to recommend these papers, so the first three are quite recent reviews on the management of spinal infection. OK so the first three papers are available on free access, and they provide a very good summary of the latest thinking with regard to spine infections.
I also would like to acknowledge Mr. Phillips, who's a consultant spine surgeon in Leicester, who did a presentation at the e-4 conference last week, and this is available on the effort website. They're looking at some definitions infection in the spine could consist of infection of the virtual body, the virtual end plates, the disk and of spinal tissues, as well as epidural abscesses and spinal lesions.
It represents about to 7% of all musculoskeletal infections, and it's got an incidence between 1 and 100,000 to 1 in 250,000. It's slightly more common in males than females, with a ratio of 21 to 5 to one, depending on which paper you read. There is a bimodal distribution, so generally the young under the age of 20 and the more elderly people between the ages of 50 and 70, the mortality rates are between 2 and 20% worldwide, and the incidence has been increasing in the last decade.
Some ideas of to why this is happening have improved have included our improved diagnostics. Older patients with chronic disease increased intravenous drug users and an overall increase in spinal surgery and instrumentation. So this is a Fox critical case. Critical condition.
Which means its past failed. And when it comes to your exam, the important thing is to have a high index of suspicion. A lot of these patients have a non-specific presentation and the diagnosis is often delayed. By approximately 1 to three months or 2 to six months in some papers, they may require emergency treatment and the outcome may be catastrophic if the diagnosis is missed.
There is no definitive local time for diagnosis and treatment in these cases, and there are significant medical legal outcomes. The mortality, as I said before, is between 2 and 4. Patients can range from being acute severe back pain with neurological deficit and a patient in septic shock to someone that's just gently mobilizing around no fevers. Just got a little bit of back pain that doesn't seem to be getting any better.
The problem with spine infections is this delay in diagnosis, which on average is between 1 and 3 months, and it's 2 to 6. In some papers, some of these patients may need emergency treatment, and if it goes unrecognized without treatment, the outcomes can be catastrophic. Unfortunately, there's no definitive logarithm for diagnosis and treatment that we can all follow. So a lot of the studies tend to be cohort studies, level 3 and four, and a lot of expert testimony.
Really, it does have important medical legal complications, and it's got a mortality of 3% to 4% So these are some of the risk factors. So age, we've got this bimodal distribution, the young and the old chronic disease. So diabetes, renal failure, alcoholism and cirrhosis seems to come up very often in these papers. Rheumatologic diseases and obviously oncological diseases are estrogenic causes, so spinal or epidural injections, spinal surgery and instrumentation.
And there's one paper that suggests that long surgical time, a lumbar posterior approach more than an anterior cervical approach is more likely to result in an infection, multiple procedures and obese patients. And there is actually a paper that classifies the obesity on the amount of subcutaneous fat that needs to be closed. Obviously, immunosuppression, whether it's host related or from chemo or radiotherapy or steroids, intravenous drug users.
So geographical regions, you would think of rarer causes such as brucellosis and TB. And obviously, we need to consider that in our local population in the UK, where we may have a high immigrant population and obviously trauma. So there's three major agents. The main ones are the bacteria usually cause of biogenic infection, and the main one is sartorius, with E coli probably secondary to AUT coming in second in some areas.
MRNA is also a problem. The granulomatous infections, such as TB and fungi and less common would be parasites. So as I said before, depending on the population that you're dealing with, TB may be a very high consideration in your patients and propionibacterium. This causes a non-pathogenic infection.
It does cause infections in shoulder surgery and also in young girls following scoliosis surgery, particularly if they've got a lot of acne. So this is a classification system which is described by falgout in 1991, which is quite a while ago, and the aim of it was to gauge post-op spine infections split into group one, group two, group three, depending on the pathogens and then subgroups, which are dependent on the type of patient.
So routes of infection, the main one would be hematologists affects the lumbar spine more than the thoracic and more than the cervical TB would preferentially affect the thoracic spine in general. And this is often related to the vascular supply, which we'll touch on in a moment. Direct external inoculation so typically surgery, spinal anesthetics, lumbar punctures and then contiguous spread, which in the literature is described as rare.
So they've put down infected aortic implants, esophageal rupture, Elisabeth's abscess. I put query inflammatory bowel disease because where I'm working currently, we've actually had two patients, one who had ulcerative colitis and another one who had Crohn's disease, who were under the general surgeons and subsequently developed back pain. Both of these patients ended up with what had an epidural abscess, which needed to be drained, and the other one had quite severe spondylitis, situs with progressive deformity and progressive neurology.
So I think anything within the abdomen that can. Get towards the spine. We need to be. We need to have it in the back of our minds. So this is the vascular supply, so the arterial supply. And is shown is shown there, and as we know, the arterial supply reaches the end plate but doesn't cross into the disk. In children, there's still some vascular channel, so in children, any infection in the virtual body can go directly to the disk straight into the center of the disk, which is a vascular in adults and cause the disk itis in adults tends not to be as common.
And then the other theory about infection is the bostons plexus and whether you can get infection via this plexus from an alternative source in the body. So presentation, as I said, it can be nonspecific. Somewhere between 85% and 90% will have some kind of axilo pain, whether it be back, chest or neck pain.
Obviously, the problem is with chest pain, it could be cardiac, it could be pulmonary, it could be upper GI. Typically, the pain is unremitting and it's worse at NIPE and the patients are reluctant to mobilize. About 15% will have neurological symptoms, which could be ridiculous, including chest and abdominal pain or related to cord compression.
And leg weakness, numbness, incontinence. About half of the patients with a biogenic bundle oocytes will have a fever. Only about 17% will in TB. Things to consider or dysplasia and talk to us if you've got cervical disease. And a lot of the time and very early, most patients don't. Sorry, 30% to 70% of patients don't show any signs of an infection.
So examination? So I'm just moving this other way. The temperatures may be normal. We need to look at the markers such as pulse, blood pressure, respiratory rate, examine the spine, do they have a high fatigue deformity? Are there any areas of swelling or tenderness within the spine? Are there any neurological deficits, any signs of cord compression?
And then we're looking at things that could be a red flag, which would be things like cardiac new heart murmur, peripheral stigmata of bacterial endocarditis, such as ginawa lesions. And 30% of people with a biogenic gram, positive spondylitis situs have infective endocarditis, so these patients, you need to get sorry, I would consider an echocardiogram in these patients.
And then pediatrics can be difficult because the signs are nonspecific. Typically, you've got a child, it's a bit irritable, refuses to crawl or walk, may have abdominal pain, may have incontinence. Fever is rare, and the most common sign is a loss of their lumbar low doses. So investigations, essentially CRP is the mainstay of investigations, it's elevated in about 90% load disguised as cases, and it's a very good marker to assess your response to treatment.
The ESR is also a sensitive marker, but it's not a specific the White cell count is. Not very specific procalcitonin, it's not very useful blood cultures, so you want at least three sets of blood cultures, and the literature says up to 59% of blood cultures will identify the causative organism in a microbial sundalo disk itis urine cultures. If you're considering hematology to spread and interferon gamma release assays can give you a result for TB in 24 hours.
If their available acid fast bacilli smear and culture takes six to eight weeks and has a sensitivity of 59 percent, which is increased if you use the IGRA. So what can we do for imaging? Well, our first line is always X-rays. So X-rays have got a relatively low specificity, at least in the early stages. So in someone that's under three weeks, you may not see anything on the X-rays round about three to four weeks.
If you look at this picture here, you might see some irregularity of the end plates and a little bit of sclerosis, as well as some narrowing of the discrete disk space. You also might see a little bit of deformity in here the be flattening of the limb below dosis and then long term, you may see this picture where you've got obliteration of the disk space and at least pseudo unconsciousness.
Ct scan, so CT scan can be useful if you've got a patient that can't have an MRI scan, and what they do is they will show you the bony changes very well. So in this case, you've got destruction of the inferior plate and the superior plates with some sclerosis around here.
And the same on this just the same picture, but at a different cut showing the defect in the vertebrae you can't see. I can't see any soft tissue swelling on those, but sometimes you can. So the gold standard is an MRI scan with gadolinium. It's got a high sensitivity and a high specificity. So on the T1 images, you'll see a low signal and on the T2 images or the enhanced images, you'll see this, which is a high signal within the vertebral bodies.
And on this particular one, you can see. This area of high signal here, which represents an epidural abscess, the. MRI scan is good for. Looking for any collections, whether they're a postage of the vegetable bodies or in the posterior part of the spinal canal and. They can differentiate between biogenic sponsor bas status TB and other pathologies, such as degenerative changes or tumors.
So this is just a table to show the difference between MRI findings in a biogenic sponge Lo bas status versus a TB. So in a hygienic most often affects the lumbar region, whereas TB tends to prefer the thoracic anthrax lumbar region, the virtual body is involved in pathogenic and the. Sorry, the disk space is involved in biogenic, whereas in TB.
You tend to get disk space bearing early on in the disease, and you tend to get a spread of the disease beneath the anterior longitudinal ligament, which jumps the disk and goes to the next vertebrae and produces scalloping of the anterior border of the vertebrae. If you are looking in a pair of spinal and epidural space, then you may find small abscesses with a thick and irregular rim enhancement.
In TB. You'll have large spinal absences with a thin and smooth women huntsman, the posterior elements are typically not involved in biogenic but can be involved in TBE a spread is uncommon, but it's quite common in TB and can be more extensive than the vertical involvement with regard to the virtual destruction you get in place. Destruction in cryogenic bungalow bas status and you get a lot of bone destruction destruction in TB.
It's uncommon to have level lesions in biogenic spondylitis sites, but not if you've got an epidural abscess, whereas in TB you often see lesions. So all the other types of imaging, which are mentioned, but not very often you so you can use a CT SPECT with gadolinium or a bone scan with sequential and gallium images.
They can be used in patients that don't have that are not able to have an MRI scan, but they're not as specific as an MRI scan, a PET scan if you have it available. Can be used in the absence of spinal instrumentation, and the advantage of it is, is that you don't get the intense fg uptake in degenerative changes and fractures only in the signs of infection and flexion extension X-rays may have a role in diagnosing instability.
So overall, as far as imaging goes, MRI is the gold standard. So how are we going to make this diagnosis? Well, we've got to have a clinical suspicion. Based on our history and our examination findings were then going to do our preliminary investigations. Including white cell count, CLP and ESR. Three sets of blood cultures, urine cultures and an MRI scan.
Now if we have positive MRI and positive clinical findings, then we have an option. If it's stable, then we can go to a biopsy and mobilization intravenous antibiotics and continually reevaluate if it's unstable, either the patient unstable or the spine alignment unstable, then we may need to go to surgery for an open biopsy drainage plus or minus decompression.
And usually at least some form of stabilization at the initial. Surgery again, intravenous antibiotics. So if we go back and we've got a negative scan and we're not sure about our clinical findings, then we need further investigations and we need to re-evaluate the situation. So our treatment plan is always antibiotics, and I'll talk about them a little bit more later on the mobilization with a brace or a halo.
The idea behind that being pain relief and to reduce any further deformity. Bed rest is in some of the older papers, but I don't think it's practiced very much anymore. Biopsy so the important thing is that you need to obtain a definitive causative organism. So that you can direktor antibiotic treatment if the patient is stable enough. That you don't need to start antibiotic treatment straightaway, then you should at least try and get a biopsy before you start the antibiotics.
Obviously, if the patient is septic, we need to start the antibiotics and then go on to do a biopsy later. And then there are indications for surgery, diprivan and decompression of the spinal canal. Maybe you need to get an open biopsy, and you may need fixation to preserve or restore the spinal structure and stability. The important thing about these patients is whatever treatment you start, you need to monitor their response and you need to frequently reevaluate them.
So somebody who you initially think is stable and can be managing on operatively, you need to keep a close eye on them because in two weeks it may be that they've got a progressive spinal deformity developing neurological symptoms and are actually not responding as well to the antibiotics as what you would hope. So I'll put this in here.
So this is the epidural abscess, and these are the ones that we need to pick up straight away because they can be life threatening and they've got a high mortality rate between 5 to 16% They can be secondary to a standalone bas status, or they can be iatrogenic after surgery or an epidural catheterization. Lumbar is more commonly affected than the thoracic and cervical area.
They can be multi segmental, and they do need urgent decompression. So the top MRI scan shows. An epidural abscess. It's around the posterior elements, and you can see the thick enhancement with the gadolinium and the subsequent spinal cord compression. And if we look at the other diagram, this is again an epidural abscess, which?
Is form post-june again, you can see the rim enhancement, and this has gone over multiple segments. And you can see that the spinal cord has been significantly compressed. So antibiotics, this is a bit controversial, if controversial, as in the choice of antibiotics, not as to whether you should use them or not. If you patient stable, you would want to try and get a biopsy first, and you can do this by CT guided biopsy if your service operates it, or you may need to do an open biopsy.
Essentially, we want to cover staph aureus and E coli, which are the main pathogens plus or minus MRSA, depending on your area. There's different recommendations as to the types of antibiotics you should use, and in what combination. And what I would suggest is that you look at your own trust guidelines. So these are what so my guidelines in Lancaster are clindamycin and ciprofloxacin, and some of the other guidelines in different countries are attacks.
Himanshu clock, Cicilline vancomycin, if it's indicated if you're in an area of MRSA and the American Society of infectious diseases suggests you keep the levels above the trough levels above 15 grams. And what I would say in the exam is. You would liaise with your microbiology team to suggest the most appropriate antibiotics, we wouldn't routinely cover TB and brucellosis unless we have positive findings for that.
The current recommendations are two to 6 weeks of IV therapy, followed by 6 weeks of oral therapy. The decision to change from intravenous to oral depends on the response. So your clinical response and your CRP. So Phillips says if the CRP. Drops below 50, you can consider changing from Ivy to oral. With regard to the duration of antibiotics.
We tend to do 12 weeks in total. But the literature doesn't necessarily support this and again are be guided by your local microbiology consultants. The only randomized controlled trial doesn't show any difference between 6 weeks and 12 weeks of treatment with regard to TB. Again, you're looking at treatment for at least a year on the four drugs isoniazid rifampicin.
The person in March and Ethan Buteau for two months, followed by another 10 months of isoniazid and rifampicin, again, I'd be guided by your microbiologists. The problem is that there's no clear evidence in the literature to support which antibiotic for what duration. So biopsy, this depends on how stable your patient is and what your trust offers, so CT guided just some only need a local anesthetic.
It depends on where the radiologist is happy to do it or not, and it depends on the stability of your patient. In our situation, we probably need to transfer to a spinal center because our radiology department wouldn't do this. An open biopsy, if you've got an unstable or deteriorating patient, you can do an open biopsy and that gives you the advantage of being able to decompress and the bride at the same time, as well as providing some instrumentation.
And the recommendation is three core biopsies, one for histology and 2 for microbiology. So non operative treatment. This depends on you having stable patient. So antibiotics, which we've talked about, if you have a patient that doesn't need urgent surgery, it's reasonable to do at least a trial of antibiotics after you've got your biopsy, but you need to keep reevaluating them.
Also, see so a color halo or a torso. But again, if you're using authorities rather than spinal instrumentation, you've got a higher rate of nonunion bedrest, as I said earlier, not used very often anymore. You need to monitor them for deterioration. And you can consider CT guided percutaneous drainage if you've got a very, very sick patient who's not fit for surgery.
So surgery, your indications, definite indications would be neurological deficit or progressive change in the neurological state, sepsis, spinal instability due to the bone destruction, severe kyphosis and canal spinal lesion with a mass effect on the cord failure of your conservative treatment or an epidural abscess.
And your surgical goals are to decompress the spinal canal, stabilize the involved segments, aggressive tissue debridement and biopsy. So this is a picture of this gentleman. Is about 43, 53 years old, he's an IV drug user, and he developed sponsor disclosures in the slap axilo cervical spine. This is Mr s&ls patient.
He presented to Mr celan. I had urgent anterior decompression and fixation. He then went in a little while later, I think he said, about two or three weeks and did posterior stabilization to augment the initial anterior stabilization. And the guy did very well. He's still an IV drug user, but the extra for X-rays are 14 years after his surgery, and he does have a little bit of a chaotic deformity developing, but functionally, he's managing quite well.
So a little note on TB. So this is the difference with TB in that you give developed this a abscess with scalloping of the vertebrae and it spreads underneath the anterior longitudinal ligament. The disk is being destroyed in this diagram, but it's relatively preserved on the other side. Your anterior longitudinal ligament is raised and it spreads from one vertebrae at a the other down the anterior aspect, and it causes a kiprotich deformity.
So it's typically in the thoracic spine and. You get a progressive, chaotic deformity, which eventually causes spinal cord compression. So in summary, your indications for surgery are going to be an acute or progressive neurological deficit and interest, spinal lesion instability or ineffective conservative therapy, antibiotic therapy in all cases, immobilization, regular review, high suspicion and the important thing is to get a biopsy.
Ideally, before you start the antibiotics. That's it. Thank you, KneeKG. That was well presented and well prepared, and I think it is very thorough. I have some questions. Before we ask these guys if any one of you has any questions, please write them down so that we can type them so that you can direct them to KneeKG or to dementors.
So I have a couple of questions from Mahmoud. The first question is, if the disk is a vascular, why is this kite is more common than vertebral osteomyelitis? So this is what happened on this slide. I think what happens is. That you get the destruction of the end plates, and once you go through the end plates go straight into the disk, which is a vascular, so the infection will sit within the disk space.
It tends to be well. We're just trying to think tends to be a spread from the adjacent vertebrae rather than the disk itself, unless you've had some kind of direct inoculation or you've got local spread. That's my understanding of it. I'm got. So there are two theories.
These are usually the majority of these cases. They usually start there, spread the hemorrhaging spread is either from the arterial or from the venous from if it's from the arteriole is usually start as vertebral in the metastasis of the vertebral body, and these are usually start as vestibular osteomyelitis rather than the slightest. And then they come on to progress to this test later on.
And usually there are a couple of studies saying that the majority of these are start as you can see them as the change is in MRI. As model one model type one, you can see a lot of reports in the radiology report. They say model type 1 and these model type one, these are usually some people they are. Now it as early early discounts or particular osteomyelitis. It's very hard to distinguish, which is which.
Usually they start as metaphysical, particular osteomyelitis, and then they progress later on as this guidance. What about the whole spine to look for escape completions as well? So, you know, I'm just thinking, what would be the answer? Should I just focus on the, let's say, the lumbar spine or the side of tenderness? Or should I am, Ah, the whole spine?
And I would say am, while the whole spine, because the problem is you unless you don't quite know what you're dealing with, that's the problem with spine infection. So if you do have a disguise or a vertical osteomyelitis, then you don't know if you've got. You could have an epidural abscess, but then it could spread further up. TB can have lesions.
So based on what I've read through the literature and talking to Mr selle, I would say I would MRI the whole spine, because if you've got hematology spread at one level, you can easily have it another level. I think if you just said lumbar spine because it's the most common, I think they trip you up and give you something in the thoracic spine. So I think the safest thing to say in an exam is our MRI, the whole spine.
Thank you. I think that makes a lot of sense. Any other questions, guys? OK, if we have no questions that, we will wrap the presentation up. Thank you very much, KneeKG. Don't leave, guys, because there will be some survivor questions if we have.
Segment:0 .
We have Nicky today who is working in Lancaster, and she has done the exam. Some time ago and she's been a mentor for some time. She will be talking about spinal infections without any further ado, this is. Thank you, so. Good evening, everyone, and the topic I'd like to talk about this evening is spine infections for the forex exam.
And this is one of the sparks critical conditions. I'd like to recommend these papers, so the first three are quite recent reviews on the management of spinal infection. OK so the first three papers are available on free access, and they provide a very good summary of the latest thinking with regard to spine infections.
I also would like to acknowledge Mr. Phillips, who's a consultant spine surgeon in Leicester, who did a presentation at the e-4 conference last week, and this is available on the effort website. They're looking at some definitions infection in the spine could consist of infection of the virtual body, the virtual end plates, the disk and of spinal tissues, as well as epidural abscesses and spinal lesions.
It represents about to 7% of all musculoskeletal infections, and it's got an incidence between 1 and 100,000 to 1 in 250,000. It's slightly more common in males than females, with a ratio of 21 to 5 to one, depending on which paper you read. There is a bimodal distribution, so generally the young under the age of 20 and the more elderly people between the ages of 50 and 70, the mortality rates are between 2 and 20% worldwide, and the incidence has been increasing in the last decade.
Some ideas of to why this is happening have improved have included our improved diagnostics. Older patients with chronic disease increased intravenous drug users and an overall increase in spinal surgery and instrumentation. So this is a Fox critical case. Critical condition.
Which means its past failed. And when it comes to your exam, the important thing is to have a high index of suspicion. A lot of these patients have a non-specific presentation and the diagnosis is often delayed. By approximately 1 to three months or 2 to six months in some papers, they may require emergency treatment and the outcome may be catastrophic if the diagnosis is missed.
There is no definitive local time for diagnosis and treatment in these cases, and there are significant medical legal outcomes. The mortality, as I said before, is between 2 and 4. Patients can range from being acute severe back pain with neurological deficit and a patient in septic shock to someone that's just gently mobilizing around no fevers. Just got a little bit of back pain that doesn't seem to be getting any better.
The problem with spine infections is this delay in diagnosis, which on average is between 1 and 3 months, and it's 2 to 6. In some papers, some of these patients may need emergency treatment, and if it goes unrecognized without treatment, the outcomes can be catastrophic. Unfortunately, there's no definitive logarithm for diagnosis and treatment that we can all follow. So a lot of the studies tend to be cohort studies, level 3 and four, and a lot of expert testimony.
Really, it does have important medical legal complications, and it's got a mortality of 3% to 4% So these are some of the risk factors. So age, we've got this bimodal distribution, the young and the old chronic disease. So diabetes, renal failure, alcoholism and cirrhosis seems to come up very often in these papers. Rheumatologic diseases and obviously oncological diseases are estrogenic causes, so spinal or epidural injections, spinal surgery and instrumentation.
And there's one paper that suggests that long surgical time, a lumbar posterior approach more than an anterior cervical approach is more likely to result in an infection, multiple procedures and obese patients. And there is actually a paper that classifies the obesity on the amount of subcutaneous fat that needs to be closed. Obviously, immunosuppression, whether it's host related or from chemo or radiotherapy or steroids, intravenous drug users.
So geographical regions, you would think of rarer causes such as brucellosis and TB. And obviously, we need to consider that in our local population in the UK, where we may have a high immigrant population and obviously trauma. So there's three major agents. The main ones are the bacteria usually cause of biogenic infection, and the main one is sartorius, with E coli probably secondary to AUT coming in second in some areas.
MRNA is also a problem. The granulomatous infections, such as TB and fungi and less common would be parasites. So as I said before, depending on the population that you're dealing with, TB may be a very high consideration in your patients and propionibacterium. This causes a non-pathogenic infection.
It does cause infections in shoulder surgery and also in young girls following scoliosis surgery, particularly if they've got a lot of acne. So this is a classification system which is described by falgout in 1991, which is quite a while ago, and the aim of it was to gauge post-op spine infections split into group one, group two, group three, depending on the pathogens and then subgroups, which are dependent on the type of patient.
So routes of infection, the main one would be hematologists affects the lumbar spine more than the thoracic and more than the cervical TB would preferentially affect the thoracic spine in general. And this is often related to the vascular supply, which we'll touch on in a moment. Direct external inoculation so typically surgery, spinal anesthetics, lumbar punctures and then contiguous spread, which in the literature is described as rare.
So they've put down infected aortic implants, esophageal rupture, Elisabeth's abscess. I put query inflammatory bowel disease because where I'm working currently, we've actually had two patients, one who had ulcerative colitis and another one who had Crohn's disease, who were under the general surgeons and subsequently developed back pain. Both of these patients ended up with what had an epidural abscess, which needed to be drained, and the other one had quite severe spondylitis, situs with progressive deformity and progressive neurology.
So I think anything within the abdomen that can. Get towards the spine. We need to be. We need to have it in the back of our minds. So this is the vascular supply, so the arterial supply. And is shown is shown there, and as we know, the arterial supply reaches the end plate but doesn't cross into the disk. In children, there's still some vascular channel, so in children, any infection in the virtual body can go directly to the disk straight into the center of the disk, which is a vascular in adults and cause the disk itis in adults tends not to be as common.
And then the other theory about infection is the bostons plexus and whether you can get infection via this plexus from an alternative source in the body. So presentation, as I said, it can be nonspecific. Somewhere between 85% and 90% will have some kind of axilo pain, whether it be back, chest or neck pain.
Obviously, the problem is with chest pain, it could be cardiac, it could be pulmonary, it could be upper GI. Typically, the pain is unremitting and it's worse at NIPE and the patients are reluctant to mobilize. About 15% will have neurological symptoms, which could be ridiculous, including chest and abdominal pain or related to cord compression.
And leg weakness, numbness, incontinence. About half of the patients with a biogenic bundle oocytes will have a fever. Only about 17% will in TB. Things to consider or dysplasia and talk to us if you've got cervical disease. And a lot of the time and very early, most patients don't. Sorry, 30% to 70% of patients don't show any signs of an infection.
So examination? So I'm just moving this other way. The temperatures may be normal. We need to look at the markers such as pulse, blood pressure, respiratory rate, examine the spine, do they have a high fatigue deformity? Are there any areas of swelling or tenderness within the spine? Are there any neurological deficits, any signs of cord compression?
And then we're looking at things that could be a red flag, which would be things like cardiac new heart murmur, peripheral stigmata of bacterial endocarditis, such as ginawa lesions. And 30% of people with a biogenic gram, positive spondylitis situs have infective endocarditis, so these patients, you need to get sorry, I would consider an echocardiogram in these patients.
And then pediatrics can be difficult because the signs are nonspecific. Typically, you've got a child, it's a bit irritable, refuses to crawl or walk, may have abdominal pain, may have incontinence. Fever is rare, and the most common sign is a loss of their lumbar low doses. So investigations, essentially CRP is the mainstay of investigations, it's elevated in about 90% load disguised as cases, and it's a very good marker to assess your response to treatment.
The ESR is also a sensitive marker, but it's not a specific the White cell count is. Not very specific procalcitonin, it's not very useful blood cultures, so you want at least three sets of blood cultures, and the literature says up to 59% of blood cultures will identify the causative organism in a microbial sundalo disk itis urine cultures. If you're considering hematology to spread and interferon gamma release assays can give you a result for TB in 24 hours.
If their available acid fast bacilli smear and culture takes six to eight weeks and has a sensitivity of 59 percent, which is increased if you use the IGRA. So what can we do for imaging? Well, our first line is always X-rays. So X-rays have got a relatively low specificity, at least in the early stages. So in someone that's under three weeks, you may not see anything on the X-rays round about three to four weeks.
If you look at this picture here, you might see some irregularity of the end plates and a little bit of sclerosis, as well as some narrowing of the discrete disk space. You also might see a little bit of deformity in here the be flattening of the limb below dosis and then long term, you may see this picture where you've got obliteration of the disk space and at least pseudo unconsciousness.
Ct scan, so CT scan can be useful if you've got a patient that can't have an MRI scan, and what they do is they will show you the bony changes very well. So in this case, you've got destruction of the inferior plate and the superior plates with some sclerosis around here.
And the same on this just the same picture, but at a different cut showing the defect in the vertebrae you can't see. I can't see any soft tissue swelling on those, but sometimes you can. So the gold standard is an MRI scan with gadolinium. It's got a high sensitivity and a high specificity. So on the T1 images, you'll see a low signal and on the T2 images or the enhanced images, you'll see this, which is a high signal within the vertebral bodies.
And on this particular one, you can see. This area of high signal here, which represents an epidural abscess, the. MRI scan is good for. Looking for any collections, whether they're a postage of the vegetable bodies or in the posterior part of the spinal canal and. They can differentiate between biogenic sponsor bas status TB and other pathologies, such as degenerative changes or tumors.
So this is just a table to show the difference between MRI findings in a biogenic sponge Lo bas status versus a TB. So in a hygienic most often affects the lumbar region, whereas TB tends to prefer the thoracic anthrax lumbar region, the virtual body is involved in pathogenic and the. Sorry, the disk space is involved in biogenic, whereas in TB.
You tend to get disk space bearing early on in the disease, and you tend to get a spread of the disease beneath the anterior longitudinal ligament, which jumps the disk and goes to the next vertebrae and produces scalloping of the anterior border of the vertebrae. If you are looking in a pair of spinal and epidural space, then you may find small abscesses with a thick and irregular rim enhancement.
In TB. You'll have large spinal absences with a thin and smooth women huntsman, the posterior elements are typically not involved in biogenic but can be involved in TBE a spread is uncommon, but it's quite common in TB and can be more extensive than the vertical involvement with regard to the virtual destruction you get in place. Destruction in cryogenic bungalow bas status and you get a lot of bone destruction destruction in TB.
It's uncommon to have level lesions in biogenic spondylitis sites, but not if you've got an epidural abscess, whereas in TB you often see lesions. So all the other types of imaging, which are mentioned, but not very often you so you can use a CT SPECT with gadolinium or a bone scan with sequential and gallium images.
They can be used in patients that don't have that are not able to have an MRI scan, but they're not as specific as an MRI scan, a PET scan if you have it available. Can be used in the absence of spinal instrumentation, and the advantage of it is, is that you don't get the intense fg uptake in degenerative changes and fractures only in the signs of infection and flexion extension X-rays may have a role in diagnosing instability.
So overall, as far as imaging goes, MRI is the gold standard. So how are we going to make this diagnosis? Well, we've got to have a clinical suspicion. Based on our history and our examination findings were then going to do our preliminary investigations. Including white cell count, CLP and ESR. Three sets of blood cultures, urine cultures and an MRI scan.
Now if we have positive MRI and positive clinical findings, then we have an option. If it's stable, then we can go to a biopsy and mobilization intravenous antibiotics and continually reevaluate if it's unstable, either the patient unstable or the spine alignment unstable, then we may need to go to surgery for an open biopsy drainage plus or minus decompression.
And usually at least some form of stabilization at the initial. Surgery again, intravenous antibiotics. So if we go back and we've got a negative scan and we're not sure about our clinical findings, then we need further investigations and we need to re-evaluate the situation. So our treatment plan is always antibiotics, and I'll talk about them a little bit more later on the mobilization with a brace or a halo.
The idea behind that being pain relief and to reduce any further deformity. Bed rest is in some of the older papers, but I don't think it's practiced very much anymore. Biopsy so the important thing is that you need to obtain a definitive causative organism. So that you can direktor antibiotic treatment if the patient is stable enough. That you don't need to start antibiotic treatment straightaway, then you should at least try and get a biopsy before you start the antibiotics.
Obviously, if the patient is septic, we need to start the antibiotics and then go on to do a biopsy later. And then there are indications for surgery, diprivan and decompression of the spinal canal. Maybe you need to get an open biopsy, and you may need fixation to preserve or restore the spinal structure and stability. The important thing about these patients is whatever treatment you start, you need to monitor their response and you need to frequently reevaluate them.
So somebody who you initially think is stable and can be managing on operatively, you need to keep a close eye on them because in two weeks it may be that they've got a progressive spinal deformity developing neurological symptoms and are actually not responding as well to the antibiotics as what you would hope. So I'll put this in here.
So this is the epidural abscess, and these are the ones that we need to pick up straight away because they can be life threatening and they've got a high mortality rate between 5 to 16% They can be secondary to a standalone bas status, or they can be iatrogenic after surgery or an epidural catheterization. Lumbar is more commonly affected than the thoracic and cervical area.
They can be multi segmental, and they do need urgent decompression. So the top MRI scan shows. An epidural abscess. It's around the posterior elements, and you can see the thick enhancement with the gadolinium and the subsequent spinal cord compression. And if we look at the other diagram, this is again an epidural abscess, which?
Is form post-june again, you can see the rim enhancement, and this has gone over multiple segments. And you can see that the spinal cord has been significantly compressed. So antibiotics, this is a bit controversial, if controversial, as in the choice of antibiotics, not as to whether you should use them or not. If you patient stable, you would want to try and get a biopsy first, and you can do this by CT guided biopsy if your service operates it, or you may need to do an open biopsy.
Essentially, we want to cover staph aureus and E coli, which are the main pathogens plus or minus MRSA, depending on your area. There's different recommendations as to the types of antibiotics you should use, and in what combination. And what I would suggest is that you look at your own trust guidelines. So these are what so my guidelines in Lancaster are clindamycin and ciprofloxacin, and some of the other guidelines in different countries are attacks.
Himanshu clock, Cicilline vancomycin, if it's indicated if you're in an area of MRSA and the American Society of infectious diseases suggests you keep the levels above the trough levels above 15 grams. And what I would say in the exam is. You would liaise with your microbiology team to suggest the most appropriate antibiotics, we wouldn't routinely cover TB and brucellosis unless we have positive findings for that.
The current recommendations are two to 6 weeks of IV therapy, followed by 6 weeks of oral therapy. The decision to change from intravenous to oral depends on the response. So your clinical response and your CRP. So Phillips says if the CRP. Drops below 50, you can consider changing from Ivy to oral. With regard to the duration of antibiotics.
We tend to do 12 weeks in total. But the literature doesn't necessarily support this and again are be guided by your local microbiology consultants. The only randomized controlled trial doesn't show any difference between 6 weeks and 12 weeks of treatment with regard to TB. Again, you're looking at treatment for at least a year on the four drugs isoniazid rifampicin.
The person in March and Ethan Buteau for two months, followed by another 10 months of isoniazid and rifampicin, again, I'd be guided by your microbiologists. The problem is that there's no clear evidence in the literature to support which antibiotic for what duration. So biopsy, this depends on how stable your patient is and what your trust offers, so CT guided just some only need a local anesthetic.
It depends on where the radiologist is happy to do it or not, and it depends on the stability of your patient. In our situation, we probably need to transfer to a spinal center because our radiology department wouldn't do this. An open biopsy, if you've got an unstable or deteriorating patient, you can do an open biopsy and that gives you the advantage of being able to decompress and the bride at the same time, as well as providing some instrumentation.
And the recommendation is three core biopsies, one for histology and 2 for microbiology. So non operative treatment. This depends on you having stable patient. So antibiotics, which we've talked about, if you have a patient that doesn't need urgent surgery, it's reasonable to do at least a trial of antibiotics after you've got your biopsy, but you need to keep reevaluating them.
Also, see so a color halo or a torso. But again, if you're using authorities rather than spinal instrumentation, you've got a higher rate of nonunion bedrest, as I said earlier, not used very often anymore. You need to monitor them for deterioration. And you can consider CT guided percutaneous drainage if you've got a very, very sick patient who's not fit for surgery.
So surgery, your indications, definite indications would be neurological deficit or progressive change in the neurological state, sepsis, spinal instability due to the bone destruction, severe kyphosis and canal spinal lesion with a mass effect on the cord failure of your conservative treatment or an epidural abscess.
And your surgical goals are to decompress the spinal canal, stabilize the involved segments, aggressive tissue debridement and biopsy. So this is a picture of this gentleman. Is about 43, 53 years old, he's an IV drug user, and he developed sponsor disclosures in the slap axilo cervical spine. This is Mr s&ls patient.
He presented to Mr celan. I had urgent anterior decompression and fixation. He then went in a little while later, I think he said, about two or three weeks and did posterior stabilization to augment the initial anterior stabilization. And the guy did very well. He's still an IV drug user, but the extra for X-rays are 14 years after his surgery, and he does have a little bit of a chaotic deformity developing, but functionally, he's managing quite well.
So a little note on TB. So this is the difference with TB in that you give developed this a abscess with scalloping of the vertebrae and it spreads underneath the anterior longitudinal ligament. The disk is being destroyed in this diagram, but it's relatively preserved on the other side. Your anterior longitudinal ligament is raised and it spreads from one vertebrae at a the other down the anterior aspect, and it causes a kiprotich deformity.
So it's typically in the thoracic spine and. You get a progressive, chaotic deformity, which eventually causes spinal cord compression. So in summary, your indications for surgery are going to be an acute or progressive neurological deficit and interest, spinal lesion instability or ineffective conservative therapy, antibiotic therapy in all cases, immobilization, regular review, high suspicion and the important thing is to get a biopsy.
Ideally, before you start the antibiotics. That's it. Thank you, KneeKG. That was well presented and well prepared, and I think it is very thorough. I have some questions. Before we ask these guys if any one of you has any questions, please write them down so that we can type them so that you can direct them to KneeKG or to dementors.
So I have a couple of questions from Mahmoud. The first question is, if the disk is a vascular, why is this kite is more common than vertebral osteomyelitis? So this is what happened on this slide. I think what happens is. That you get the destruction of the end plates, and once you go through the end plates go straight into the disk, which is a vascular, so the infection will sit within the disk space.
It tends to be well. We're just trying to think tends to be a spread from the adjacent vertebrae rather than the disk itself, unless you've had some kind of direct inoculation or you've got local spread. That's my understanding of it. I'm got. So there are two theories.
These are usually the majority of these cases. They usually start there, spread the hemorrhaging spread is either from the arterial or from the venous from if it's from the arteriole is usually start as vertebral in the metastasis of the vertebral body, and these are usually start as vestibular osteomyelitis rather than the slightest. And then they come on to progress to this test later on.
And usually there are a couple of studies saying that the majority of these are start as you can see them as the change is in MRI. As model one model type one, you can see a lot of reports in the radiology report. They say model type 1 and these model type one, these are usually some people they are. Now it as early early discounts or particular osteomyelitis. It's very hard to distinguish, which is which.
Usually they start as metaphysical, particular osteomyelitis, and then they progress later on as this guidance. What about the whole spine to look for escape completions as well? So, you know, I'm just thinking, what would be the answer? Should I just focus on the, let's say, the lumbar spine or the side of tenderness? Or should I am, Ah, the whole spine?
And I would say am, while the whole spine, because the problem is you unless you don't quite know what you're dealing with, that's the problem with spine infection. So if you do have a disguise or a vertical osteomyelitis, then you don't know if you've got. You could have an epidural abscess, but then it could spread further up. TB can have lesions.
So based on what I've read through the literature and talking to Mr selle, I would say I would MRI the whole spine, because if you've got hematology spread at one level, you can easily have it another level. I think if you just said lumbar spine because it's the most common, I think they trip you up and give you something in the thoracic spine. So I think the safest thing to say in an exam is our MRI, the whole spine.
Thank you. I think that makes a lot of sense. Any other questions, guys? OK, if we have no questions that, we will wrap the presentation up. Thank you very much, KneeKG. Don't leave, guys, because there will be some survivor questions if we have.
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