Identifying Infections of the S pine Dr Jamie Wilson FRCS - PowerPoint PPT Presentation

Identifying Infections of the S pine Dr Jamie Wilson FRCS (Neurosurgery) BMBCh.BA(OXON) Neurosurgery S pine Fellow, Toronto Western Hospital ymposium 2 nd March 2018 S pine Network S

The Honest Truth  Low Yield: Y ou will investigate many patients who have no evidence of infection  Relatively Rare: Y ou will miss/ diagnose late cases of spine infection

Case 1 Patient A Patient B  40 yo male  40 yo male  Left leg S  Left leg S 1 pain 1 pain  2-3d onset  2-3 d onset  S  Cough 10 days ago ome fever 7-10 d ago  O/ E Depressed left ankle  O/ E Depressed left ankle j erk j erk  Parasthesia left S  Parasthesia left S 1 1

But… .. Patient A Patient B  40 yo male  40 yo male  Left leg S  Left leg S 1 pain 1 pain  IV Drug user  No medical history  S  Blood work normal kin ulcer right foot  WCC 17 CRP 35

Patient B Patient A Case 1

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

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

S pine Infections  Discitis / S pondylitis  S pinal Abscess: Epidural (S ubdural) (Intramedullary)  Post-operative (early vs delayed)

Pathogens  Pyogenic / Bacterial  Granuloma – Fungi  Granuloma –TB  No organism in 30%

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

Work Up  History – Pain, neurology, risk factors  Exam – Complete  Imaging – XR/ CT - MRI with contrast

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)

Indications for surgery  Compressive collection with neurological deficits  Bony destruction / deformity  Failure of non-operative management

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

Case 2  60yo male  10 days intermittent fever  Cough at times  Previous anterior cervical surgery for spinal cord inj ury 8 years ago

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?

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

Case 2

Case 2

Case 2

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

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

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!

Thank Y ou Dr Jamie Wilson is kindly supported by the Dowager Countess Eleanor Peel Trust Travel Grant and the Ethicon Foundation Travel Award.