SLIDE 1 Identifying Infections of the S pine
Dr Jamie Wilson FRCS (Neurosurgery) BMBCh.BA(OXON) Neurosurgery S pine Fellow, Toronto Western Hospital
S pine Network S ymposium 2nd March 2018
SLIDE 2 The Honest Truth
Low Yield:
Y
- u will investigate many patients who have
no evidence of infection
Relatively Rare:
Y
- u will miss/ diagnose late cases of spine
infection
SLIDE 3 Case 1
Patient A
40 yo male Left leg S
1 pain
2-3d onset S
O/ E Depressed left ankle
j erk
Parasthesia left S
1 Patient B
40 yo male Left leg S
1 pain
2-3 d onset Cough 10 days ago O/ E Depressed left ankle
j erk
Parasthesia left S
1
SLIDE 4 But… ..
Patient A
40 yo male Left leg S
1 pain
IV Drug user S
kin ulcer right foot
WCC 17 CRP 35
Patient B
40 yo male Left leg S
1 pain
No medical history Blood work normal
SLIDE 5
Case 1
Patient A Patient B
SLIDE 6 Outcomes
Patient A:
Blood cultures identified S taph Aureus IV antibiotics / Debridement of Leg Ulcer Did NOT require any surgical treatment
Patient B:
Temporary improvement with nerve root block L5/ S 1 Discectomy
SLIDE 7
Lessons from Case 1
Identifying risk factors is key Low threshold to investigate Most infections of the spine require a period of hospital
treatment
S
urgery is not always required
SLIDE 8
S pine Infections
Discitis / S
pondylitis
S
pinal Abscess: Epidural (S ubdural) (Intramedullary)
Post-operative (early vs delayed)
SLIDE 9
Pathogens
Pyogenic / Bacterial Granuloma – Fungi Granuloma –TB No organism in 30%
SLIDE 10
Risk Factors
Haematogenous S pread vs direct inoculation
Previous S
pinal S urgery
S
epsis from other source
IVDU Immunocompromised / Diabetes / S
teroids
Age / High or Low BMI Exposure to TB
SLIDE 11 Work Up
History – Pain, neurology, risk factors Exam – Complete Imaging – XR/ CT
SLIDE 12
Goals for Treatment
Identify organism IV antibiotics (6 weeks or more, 1 year + for
TB)
Close observation of neurology and/ or
deformity
Follow up – clinical / imaging (XRs / MRI)
SLIDE 13
Indications for surgery
Compressive collection with
neurological deficits
Bony destruction / deformity Failure of non-operative management
SLIDE 14
When to refer urgently?
Back / Neck / Limb pain is common!
New neurological or sphincter deficits Risk factors for infection (inc TB) Fever or abnormal blood work Prolonged sepsis from another source New deformity on XR History of S
pine surgery – recent or not
SLIDE 15
Case 2
60yo male 10 days intermittent fever Cough at times Previous anterior cervical surgery for spinal
cord inj ury 8 years ago
SLIDE 16
Case 2
Increasing respiratory difficulty Generalised weakness / unable to walk Admitted to hospital for LRTI / S
epsis
S
tarted on IV antibiotics
S
eems appropriate?
SLIDE 17
Case 2
Family reported new right arm and leg
weakness
3 days after admission continued fever WCC and CRP no response 1-2/ 5 paralysis of right side
SLIDE 18
Case 2
SLIDE 19
Case 2
SLIDE 20
Case 2
SLIDE 21
SLIDE 22
Outcome
Intubated on ICU with initial neurological recovery Underwent further posterior C2-T2 fixation and
decompression
Recovered power on right side to 3-4/ 5, left 4/ 5 Tracheostomy Died 20 days post admission
SLIDE 23
Lessons from Case 2
Previous surgery is an important risk factor (even if not
recent!)
Any neurological deterioration requires urgent
investigation
S
pinal infections can be rapidly progressive, and can cause irreversible neurological deficits/ death, if not appropriately identified
SLIDE 24
S ummary (S potting the Zebra)
Identify Risk Factors early Low Index of S
uspicion
Investigate Thoroughly Treat for an adequate duration Follow Up Appropriately Refer to S
pine S urgeon Early!
SLIDE 25 Thank Y
Dr Jamie Wilson is kindly supported by the Dowager Countess Eleanor Peel Trust Travel Grant and the Ethicon Foundation Travel Award.
