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Spinal Infection
Aka: Spinal Infection, Spinal Cord Infection, Spinal Osteomyelitis, Spinal Epidural Abscess, Epidural Abscess, Discitis, Diskitis
- See Also
- Osteomyelitis
- Vertebral Osteomyelitis
- Acute Spinal Cord Compression (includes Spinal Cord Syndrome)
- Epidemiology
- Incidence: 0.2 to 2.8 cases per 10,000 per year
- Most common in ages 31 to 70 years old (peak Incidence ages 60-70 years old)
- Also occurs in children <5 years old
- Gender predominance: Males by a ratio >2:1
- Precautions
- Spinal Epidural Abscess is frequently misdiagnosed on initial presentation
- Be alert for red flag presentations (esp. with back pain)
- Unexplained fever (present in 86% of cases)
- Focal neurologic deficits with progressive or disabling symptoms (present in 82% of cases)
- References
- Bhise (2017) Am J Med 130(8): 975-81 +PMID: 28366427
- Types: Spinal Infection
- Spinal Epidural Abscess (SEA) - typically the primary infection site
- Infection in the space between the Dura Mater and the adjacent Vertebral Column
- Of the Spinal Infections, SEA is the most acute of presentations with fever, neurologic deficits and spinal pain
- Disc space infection (Discitis)
- Vertebral infection
- Spondylitis
- Osteomyelitis
- Pathophysiology: Sources of Spinal Infection
- Hematogenous spread (50%)
- Contiguous spread (33%)
- Retropharyngeal Abscess
- Psoas Abscess
- Direct introduction of infection
- Spinal injection
- Spinal surgery
- Pathophysiology: Sites of Spinal Infection
- Most cases involve thoracolumbar spine
- Anterior Epidural Abscess (20%)
- Associated infections
- Disk space infection (Discitis)
- Vertebral Osteomyelitis
- Blunt Trauma and associated hematoma infection
- Direct extension from adjacent infection
- Retropharyngeal Abscess
- Retroperitoneal abscess
- Posterior Epidural Abscess (80%)
- Distant source (Cellulitis, dental, Pharyngitis)
- Causes
- Acute Infection (within 5-10 days)
- Staphylococcus aureus (most common)
- Actinomycosis (rare)
- Chronic Infection (within 3-6 months)
- Other indolent infections
- Fungus
- Tuberculosis (Pott's Disease)
- Vertebral collapse
- Sharply angulated spinal deformity
- Risk Factors
- Idiopathic without risk factors in 20% of cases
- Intravenous Drug Abuse
- Back pain in IVDA is a Spinal Infection until proven otherwise
- Immunodeficiency
- AIDS
- Chronic Renal Failure (esp. Dialysis)
- Diabetes Mellitus
- Alcoholism
- Malignancy
- Recent spinal procedure
- Spinal surgery
- Epidural Anesthesia
- Recent back Trauma
- Concurrent infectious sources
- Genitourinary infection
- Skin Infection
- Poor Dentition (Associated with Actinomyces)
- Symptoms
- Back pain (70-90% of cases)
- Associated with secondary Muscle spasm
- Severe localized back pain not relieved with rest
- Pain provoked by standing and bearing weight
- Children may limp or refuse to crawl or walk
- Systemic symptoms
- Fever (30-60% of cases)
- Rigors
- Malaise
- Neurologic compromise (70% of cases, but often subtle)
- Bowel or Bladder dysfunction
- Extremity weakness
- Signs
- Focal tenderness at involved spinous process (60-70% of cases)
- Precautions
- Keep a high index of suspicion
- Classic triad of back pain, fever and neurologic symptoms occurs in <37% of patients
- Avoid Lumbar Puncture
- Not diagnostic
- Risk of contiguous seeding of subarachnoid space (and secondary Meningitis)
- Disposition to rapid intervention at time of diagnosis
- Delays result in greater risk for neurologic injury
- Abscess results in direct mechanical compression of the spinal cord
- Local infection may result in ischemic injury to the cord via thrombosis of vessel Occlusion
- Labs
- Complete Blood Count
- Leukocytosis (30% of cases)
- Acute phase reactants (increased in 95% of cases)
- Erythrocyte Sedimentation Rate (ESR) increased
- C-Reactive Protein (C-RP) increased
- Blood Cultures
- Identify responsible organism in 60% of cases
- Imaging
- Gadolinium-enhanced Spine MRI (preferred)
- Test Sensitivity >90%
- Enhancing Lesion seen in T2-Weighted Images
- Differentiates Diskitis from Vertebral Osteomyelitis
- CT with Myelography
- Management
- Emergent Neurosurgery Consultation
- Surgical decompression (first-line, preferred management)
- Open decompression (preferred)
- May be performed with endoscopy-assisted surgery
- Percutaneous drainage
- Aspiration under CT guidance is performed in some cases
- Empiric Antibiotics
- Start early empiric therapy and modify based on culture results
- Discuss with neurosurgery (in some cases, may ask to withhold antibiotics until surgical culture obtained)
- Typical IV antibiotic duration: 6 weeks
- Drug 1: MRSA Coverage (Staphylococcus aureus is most common cause, used with drug 2 below)
- Vancomycin 15-20 mg/kg IV every 8-12 hours (dosing must be calculated based on weight, levels)
- Alternatives: Linezolid, Daptomycin
- Drug 2: Gram Negative Coverage, esp. IVDA, Immunosuppression, UTI (used in combination with MRSA Drug 1 coverage)
- Gram Negative Coverage without Pseudomonas coverage
- Ceftriaxone 2 g IV every 24 hours
- Cefepime 2 g IV every 8 hours
- Levofloxacin 750 mg IV every 24 hours
- Gram Negative Coverage With Pseudomonas coverage as indicated (e.g. IV Drug Abuse, recent hospitalization)
- Ceftazidime 1-2 g IV every 8-12 hours
- Ciprofloxacin 400 mg IV every 12 hours
- Piperacillin-Tazobactam 4.5 g IV every 6 to 8 hours
- Meropenem 1 g IV every 8 hours
- Other modified antibiotic coverage
- Mycobacterium tuberculosis suspected
- Prognosis: Positive prognostic indicators
- Intact or only mild neurologic symptoms prior to intervention
- Most accurate prognostic indicator
- Age under 60 years
- Cord symptoms (e.g. Bladder dysfunction) <24 hours
- No comorbid conditions
- Thecal sac compression <50%
- Complications
- Cauda Equina Syndrome
- Results from direct mechanical compression of cord
- Meningitis (or overwhelming Sepsis)
- Results from spread into subarachnoid space
- Mortality
- Mortality rate: 5-23%
- References
- Dasburg (2020) Crit Dec Emerg Med 34(6): 28-9
- Della-Giustina (2014) Crit Dec Emerg Med 28(3): 2-9
- Chao (2002) Am Fam Physician 65(7):1341-6 [PubMed]
- Tompkins (2010) J Emerg Med 39(3): 384-90 [PubMed]