Spinal Infections Treatment & Management
- Author: Federico C Vinas, MD; Chief Editor: Jeffrey A Goldstein, MD more...
The combination of mechanical compression of the spinal cord by pus or granulation tissue can result in ischemia with spinal cord infarction, which accounts for the rapid neurologic progression of this disease. Patients with a spinal epidural abscess may progress to complete paralysis within minutes to hours, even while receiving optimal antibiotic therapy. In addition, patients with vertebral osteomyelitis can develop pathological fractures, caused by the softening of the bone, and present with acute spinal cord compression.
Most patients with pyogenic vertebral osteomyelitis respond to medical management. However, surgery may be required if medical management is unsuccessful. Indications for surgery include the following:
Significant osseous involvement
Neurologic deficits - Neurologic deterioration can be caused by significant kyphosis, by infection behind the vertebral body under the posterior longitudinal ligament, or by infection in the epidural space
Septic course with clinical toxicity from an abscess not responding to antibiotics
Failure of needle biopsy to obtain necessary cultures
Failure of intravenous (IV) antibiotics alone to eradicate the infection
Infectious Diseases Society of America guidelines for native vertebral osteomyelitis
The Infectious Diseases Society of America (IDSA) has published clinical practice guidelines for the diagnosis and treatment of native vertebral osteomyelitis (NVO) in adults. Treatment recommendations include the following:
In patients with neurologic compromise with or without impending sepsis or hemodynamic instability, immediate surgical intervention and initiation of empiric antimicrobial therapy are recommended
In patients with normal and stable neurologic examination and stable hemodynamics, hold empiric antimicrobial therapy until a microbiologic diagnosis is established
In patients with hemodynamic instability, sepsis, septic shock, or progressive or severe neurologic symptoms, initiate empiric antimicrobial therapy in conjunction with an attempt to establish a microbiologic diagnosis
A total duration of 6 weeks of parenteral or highly bioavailable oral antimicrobial therapy is recommended for most patients with bacterial NVO
A total duration of 3 months of antimicrobial therapy is recommended for most patients with NVO due to Brucella species
Surgical intervention is recommended in patients with progressive neurologic deficits, progressive deformity, and spinal instability with or without pain despite adequate antimicrobial therapy
Surgical debridement with or without stabilization is recommended in patients with persistent or recurrent bloodstream infection (without alternative source) or worsening pain despite appropriate medical therapy (weak, low)
Recommend against surgical debridement and/or stabilization in patients who have worsening bony imaging findings at 4-6 weeks in the setting of improvement in clinical symptoms, physical examination, and inflammatory markers
The overall treatment plan for a patient with vertebral osteomyelitis must be individualized according to the patient's general medical condition, neurologic status, presence of large associated abscesses, and biomechanical factors. Underlying infections (eg, retropharyngeal, pelvic, decubital) require simultaneous treatment if the vertebral infection is to be cured.
Antibiotic treatment must be tailored to the isolated organism and any other sites of infection. Broad-spectrum antibiotics covering both gram-positive and gram-negative organisms, aerobes and anaerobes, including methicillin-resistant S aureus, are instituted initially until the organism is isolated. Most cases of vertebral osteomyelitis are caused by S aureus, which generally is sensitive to antibiotics. Although rare, spinal tuberculosis or fungal infection must be considered in the face of persistently negative culture findings and lack of response to antibiotics.[2, 41, 42]
Antibiotics are given for variable lengths of time. It appears that 6-8 weeks of parenteral antibiotic therapy is effective in most cases. Before parenteral antibiotics are discontinued, the erythrocyte sedimentation rate (ESR) should have fallen to at least two thirds of the pretherapy level. In addition, the patient should be afebrile, without pain on mobilization, and without any disease-related complications such as neurologic deficits. A persistently high ESR implies continuing infection, and additional IV antibiotics are indicated. In such an instance, an additional biopsy can be taken of the infected vertebra to see if organisms not susceptible to the chosen antibiotics are present.[43, 44]
Bracing is recommended to provide stability for the spine while the infection is healing. The goal of immobilization is to provide opportunity for the affected level to fuse in an anatomically aligned position. Bracing is usually continued for 6-12 weeks, until either bony fusion is seen on radiographs or the patient's pain subsides. A rigid brace works best and need be worn only when the patient is active.
After successful conservative treatment of pyogenic vertebral osteomyelitis and eventual union, some degree of vertebral body collapse may still occur. The greater the amount of bone destruction present before treatment, the greater the likelihood of eventual kyphosis. After antibiotic treatment, therefore, the spine must be monitored using sequential radiographs. Kyphosis formation may lead to eventual neural impingement, and the kyphosis itself may require late surgical correction.
Vancomycin is a potent antibiotic directed against gram-positive organisms and that is active against Enterococcus species. It is useful in the treatment of bloodstream infection and skin-structure infection and is indicated in patients who cannot receive or have failed to respond to penicillins and cephalosporins or have infections with resistant staphylococci.
To avoid toxicity, the current recommendation is to assay vancomycin trough levels after the third dose is drawn one half hour prior to the next dose. Use creatinine clearance (CrCl) to adjust the dose in patients diagnosed with renal impairment. Vancomycin is used in conjunction with gentamicin for prophylaxis in patients who are allergic to penicillin and are undergoing gastrointestinal (GI) or genitourinary (GU) procedures. The adult dosage is 0.5-2 g/day IV; the pediatric dosage is 40 mg/kg/day IV. Vancomycin is a pregnancy category C drug.
Nafcillin is the initial therapy for suspected penicillin G–resistant streptococcal or staphylococcal infections. Use parenteral therapy initially in severe infections, and change to oral therapy as the patient’s condition warrants. Because of the risk of thrombophlebitis, particularly in elderly patients, parenteral administration should continue for only a short period (1-2 days) before being changed to the oral route as clinically indicated.
Adult dosing of nafcillin is 1 g IV or intramuscularly (IM) every 4-6 hours. Neonatal dosing (0-4 kg) is 10 mg/kg IM every 12 hours. Dosing in children who weigh 4-40 kg is 25 mg/kg IM every 12 hours or 50 mg/kd/day orally in four divided doses or, alternatively, 100-200 mg/kg/day IV/IM in four or six divided doses. Nafcillin is a pregnancy category B drug.
Gentamicin is an aminoglycoside antibiotic that has gram-negative coverage. It is used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Consider gentamicin if penicillins or other less toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms. Dosing regimens are numerous; the dosage should be adjusted on the basis of CrCl and changes in volume of distribution. Gentamicin may be given IV or IM.
In adults, dosing of gentamicin for serious infections and normal renal function is 3 mg/kg IV every 8 hours. The loading dose and the maintenance dose are 1-2.5 mg/kg IV and 1-1.5 mg/kg IV, respectively, every 8 hours. The extended dosing regimen for life-threatening infections is 5 mg/kg/day IV/IM every 6 or 8 hours. Follow each regimen by at least a trough level drawn on the third or fourth dose (30 minutes before dosing); a peak level may be drawn 30 minutes after a 30-minute infusion.
In children younger than 5 years, gentamicin dosing is 2.5 mg/kg IV/IM every 8 hours. In those older than 5 years, dosing is 1.5-2.5 mg/kg IV/IM every 8 hours or 6-7.5 mg/kg/day in three divided doses, not to exceed 300 mg/day; monitor as in adults.
Ceftazidime is a third-generation cephalosporin with broad-spectrum, gram-negative activity. It has lower efficacy against gram-positive organisms and higher efficacy against resistant organisms. Ceftazidime arrests bacterial growth by binding penicillin-binding proteins. Adult dosing is 1-2 g IV/IM every 8 or 12 hours. Neonatal dosing is 30 mg/kg IV every 12 hours. In infants and children, dosing is 30-50 mg/kg IV every 8 hours, not to exceed 6 g/day. Ceftazidime is a pregnancy category B drug.
Long-term antibiotic treatment may, in itself, lead to complications such as cranial nerve (CN) VIII and renal toxicity, skin rashes, and other sequelae associated with specific antimicrobials.
Although most patients with pyogenic vertebral osteomyelitis respond to medical management, surgery may be required (see Approach Considerations, Treatment Indications).[2, 45, 46, 27, 28, 29, 30, 31, 47, 48, 49] Goals of surgery include preservation of neural function and achievement of stable bony fusion without severe kyphosis, which itself could lead to neural compromise or disabling radicular pain.
Preparation for surgery
Most patients who need to undergo a surgical procedure for the treatment of a vertebral infection are chronically debilitated and require a careful preoperative evaluation, including a hematologic and coagulation profile, chest radiography, and electrocardiography (ECG). Blood is typically typed and cross-matched.
An accurate preoperative documentation of the patient's neurologic condition is of primary importance. In patients with spinal instability or spinal cord compression, particular care should be taken to avoid unnecessary movement of the spine during transport, induction of anesthesia, endotracheal intubation, and positioning. Patients with a full stomach undergoing emergency surgery should have gastric decompression via a nasogastric tube and suction. Patients with cervical spinal instability or cervical spinal cord compression may benefit from fiberoptic endotracheal intubation while awake.
If antibiotic therapy has not been initiated preoperatively, prophylactic antibiotics are generally administrated after the cultures have been obtained.
Infections located in the vertebral body or spinal cord compression produced by collapse of the vertebral body are best corrected by an anterior or anterolateral surgical approach (see the image below), which allows one to decompress the neural elements and to remove the infected disk and involved vertebral bodies. Patients with extensive vertebral destruction usually require instrumentation and fusion.
In cases of posterior osteomyelitis, especially if a posteriorly placed epidural abscess is present, laminectomy may be indicated. Whether subsequent fusion should be performed depends on the extent of bone removal, the condition of the anterior spinal column, and the likelihood of postoperative spinal instability or deformity.
After the patient is under general anesthesia and the endotracheal tube is secured, the patient's eyes should be well lubricated and taped shut. A Foley catheter is placed, and bilateral thromboembolism-deterrent (TED) hose and sequential compression boots are used. The extremities should be padded carefully to prevent compression-related neural injury.
Patient positioning depends on the particular surgical approach; the preferred position is usually prone for a posterior approach, supine for anterior approaches, and oblique for an anterolateral approach. It is important to avoid applying pressure to the thorax and abdomen so that epidural bleeding can be minimized.
Decompression of the spinal cord and nerve roots with drainage of purulent material and debridement of compressive granulation tissue is central to this procedure. A full set of aerobic, anaerobic, fungal, and acid-fast bacteria cultures should be obtained early in the procedure. Appropriate antibiotics should be administrated at this time. Debridement and drainage should be followed by extensive irrigation with antibiotic solution. In most cases, closure can be done primarily, with a surgical drain left in place.
In some patients, an arthrodesis with internal instrumental fixation may be necessary at the time of decompression. There is strong support in the literature for a staged anterior decompression and strut fusion followed by a second-stage posterior spinal fixation. However, there is growing support in the literature for the view that in selected patients, anterior fixation can be combined with a strut fusion.[45, 46, 50]
Significant postoperative discomfort limits activity for several days in most patients. A morphine patient-controlled analgesia (PCA) pump usually is employed during the first 36-48 hours.
To allow early patient mobilization postoperatively, patients are braced with an appropriate molded orthosis for a variable period, and a physical therapist is consulted.
The antibiotics should be adjusted according to the culture results.
During the postoperative period, patients with neurologic deficits are prone to multiple complications, including skin decubitus, pulmonary problems, DVT, and urinary sepsis.
Once correct treatment is implemented, patients require neurologic monitoring to exclude progressive neurologic deterioration. Home health care may help provide parenteral antibiotics, which typically are given until the infection resolves. Rehabilitation for any residual neurologic deficit may be necessary. This would include restrengthening programs and ambulation retraining.
In addition, follow-up laboratory and radiologic studies are necessary. A falling ESR is consistent with successful treatment. Decreases in serum C-reactive protein (CRP) have been shown to be more sensitive than ESR. Serial radiographic studies are needed to detect bony collapse or deformity.
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