Subscribe to RSS
DOI: 10.1055/s-2000-13227
INFECTIONS OF THE LUMBAR SPINE-TREATMENT OPTIONS
Publication History
Publication Date:
31 December 2000 (online)

ABSTRACT
With advances in antimicrobial therapy, diagnostic techniques, and operative intervention, the overall morbidity and mortality associated with spine infections has been greatly reduced. These infections can be devastating, as the population most at risk are the elderly and/or immunocompromised. Given the poor prognosis without appropriate therapy and the relative rarity of these disorders, a high index of suspicion is paramount to facilitate early diagnosis and expeditious treatment. Current concepts in the management of both pyogenic vertebral osteomyelitis and spinal epidural abscess are reviewed in this article with a special emphasis on the lumbar spine.
KEYWORD
Lumbar spine infection - pyogenic vertebral osteomyelitis - iatrogenic spine infection
REFERENCES
- 1 Currier B L, Eismont F J. Infections of the Spine. In: Rothman RH, Simeone FA (eds) The Spine, vol. 2. Philadelphia: WB Saunders 1999: 1207-1258
- 2 Muscher D M, Thorsteinsson S B, Minuth J N, Luchi R J. Vertebral osteomyelitis. Arch Intern Med . 1976; 136 105-110
- 3 Albee F H. Transplantation of a portion of the tibia into the spine for Pott's disease: a preliminary report. JAMA . 1911; 57 885-886
- 4 Hibbs R A. An operation for progressive spinal deformities. NY State Med J . 1911; 93 1013-1016
- 5 Menard V. Causes de paraplegie dans le mal de pott. Son traitement chirurgical par l'ouverture directe du foyer tuberculeux des vertebres. Rev Orthoped . 1984; 5 47-64
- 6 Ito H, Tsuchiya J, Asami G. A new radical operation for Pott's disease: a report of ten cases. J Bone Joint Surg . 1934; 16 499-515
- 7 Hodgson A R, Skinsnes O K, Leong C Y. The pathogenesis of Pott's paraplegia. J Bone Joint Surg . 1967; 49A 1147-1156
- 8 Hodgson A R, Stock F E. Anterior spinal fusion: a preliminary communication on the radical treatment of Pott's disease and Pott's paraplegia. Br J Surg . 1956; 44 266-275
- 9 Hodgson A R, Stock F E. Anterior spinal fusion for the treatment of tuberculosis of the spine: the operative findings and results of treatment in the first one hundred cases. J Bone Joint Surg . 1960; 42A 295-310
- 10 Hodgson A R, Stock F E, Fang H SY. Anterior spinal fusion: the operative approach and pathological findings in 412 patients with Pott's disease of the spine. Br J Surg . 1960; 48 172-178
- 11 Hodgson A R, Yau A, Kwon J S. A clinical study of one hundred consecutive cases of Pott's paraplegia. Clin Orthop . 1964; 36 128-150
- 12 Hodgson A R, Yau A M C C. Anterior surgical approaches to the spinal column. Recent Adv Orthop . 1969; 1 289-323
- 13 A controlled trial of plaster-of-Paris jackets in the management of ambulant outpatient treatment of tuberculosis of the spine in children on standard chemotherapy. A study in Pusan, Korea. Second report of the Medical Research Council Working Party on Tuberculosis of the Spine. Tubercle . 1973; 54 261-282
- 14 A controlled trial of ambulant out-patient treatment and in-patient rest in bed in the management of tuberculosis of the spine in young Korean patients on standard chemotherapy. A study in Masan, Korea. First report of the Medical Research Council Working Party on Tuberculosis of the Spine. J Bone Joint Surg . 1973; 55 678-697
- 15 A controlled trial of anterior spinal fusion and debridement in the surgical management of tuberculosis of the spine in patients on standard chemotherapy. A study in two centres in South Africa. Seventh Report of the Medical Research Council Working Party on tuberculosis of the spine. Tubercle . 1978; 59 79-105
- 16 A five-year assessment of controlled trials of in-patient and out-patient treatment and of plaster-of-Paris jackets for tuberculosis of the spine in children on standard chemotherapy. Studies in Masan and Pusan, Korea. Fifth report of the Medical Research Council Working Party on tuberculosis of the spine. J Bone Joint Surg . 1976; 58B 399-411
- 17 Five-year assessments of controlled trials of ambulatory treatment, debridement and anterior spinal fusion in the management of tuberculosis of the spine. Studies in Bulawayo (Rhodesia) and in Hong Kong. Sixth report of the Medical Research Council Working Party on Tuberculosis of the Spine. J Bone Joint Surg . 1978; 60B 163-177
- 18 A 10-year assessment of a controlled trial comparing debridement and anterior spinal fusion in the management of tuberculosis of the spine in patients on standard chemotherapy in Hong Kong. Eighth Report of the Medical Research Council Working Party on Tuberculosis of the Spine. J Bone Joint Surg . 1982; 64 393-398
- 19 A 10-year assessment of controlled trials of inpatient and outpatient treatment and of plaster-of-Paris jackets for tuberculosis of the spine in children on standard chemotherapy. Studies in Masan and Pusan, Korea. Ninth report of the Medical Research Council Working Party on Tuberculosis of the Spine. J Bone Joint Surg . 1985; 67 103-110
- 20 Upadhyay S S, Saji M J, Sell P, Sell B, Hsu L C. Spinal deformity after childhood surgery for tuberculosis of the spine. A comparison of radical surgery and debridement. J Bone Joint Surg Br . 1994; 76 91-98
- 21 Upadhyay S S, Sell P, Saji M J, Sell B, Hsu L C. Surgical management of spinal tuberculosis in adults. Hong Kong operation compared with debridement surgery for short and long term outcome of deformity. Clin Orthop . 1994; 173-182
- 22 Boachie-Adjei O. Tuberculosis of the spine. Orthop Clin North Am . 1996; 27 95-103
- 23 Fang D, Cheung K M, Dos Remedios D I, Lee Y K, Leong J C. Pyogenic vertebral osteomyelitis: treatment by anterior spinal debridement and fusion. J Spinal Disord . 1994; 7 173-180
- 24 Collert S. Osteomylelitis of the spine. Acta Orthop Scand . 1997; 48 283-290
- 25 Rezai A R, Woo H H, Errico T J, Cooper P R. Contemporary management of spinal osteomyelitis. Neurosurgery . 1999; 44 1018-1026
- 26 Sapico F L, Montgomerie J Z. Vertebral osteomyelitis. Infect Dis Clin North Am . 1990; 4 539-550
- 27 Sampath P. Spinal epidural abscess: a review of epidemiology, diagnosis, and treatment. J Spinal Disord . 1999; 12 89-93
- 28 Hlavin M L, Kaminski H J, Ross J S, Ganz E. Spinal epidural abscess: a ten-year perspective. Neurosurgery . 1990; 27 177-184
- 29 Wheeler D, Keiser P, Rigamonti D, Keay S. Medical management of spinal epidural abscesses: case report and review [see comments]. Clin Infect Dis . 1992; 15 22-27
- 30 Cahill D W, Love L C, Rechtine G R. Pyogenic osteomyelitis of the spine in the elderly [see comments]. J Neurosurg . 1991; 74 878-886
- 31 Holzman R S, Bishko F. Osteomyelitis in heroin addicts. Ann Intern Med . 1971; 75 693-696
- 32 Levi A DO, Dickman C, Sonntag V KH. Management of postoperative infections after spinal instrumentation. J Neurosurg . 1997; 86 975-980
- 33 Sapico F L, Montgomerie J Z. Pyogenic vertebral osteomyelitis: report of nine cases and review of the literature. Rev Infect Dis . 1979; 1 754-776
- 34 Kulowski J. Pyogenic osteomyelitis of the spine. An analysis and discussion of 102 cases. J Bone Joint Surg . 1936; 18 343-364
- 35 Bonfiglio M, Lange T A, Kim Y M. Pyogenic vertebral osteomyelitis: disc space infections. Clin Orthop . 1973; 96 234-247
- 36 Robinson B HB, Lessof M H. Osteomyelitis of the spine. Guy Hosp Rep . 1961; 110 303-318
- 37 Waldvogel F A, Medoff G, Swartz M N. Osteomyelitis: a review of clinical features, therapeutic considerations, and unusual aspects (first of three parts). N Engl J Med . 1970; 282 198-206
- 38 Wilensky A O. Osteomyelitis of the vertebrae. Ann Surg . 1929; 89 561-570
- 39 Digby J M, Kersley J B. Pyogenic non-tuberculous spinal infection: an analysis of thirty cases. J Bone Joint Surg . 1979; 61 47-55
- 40 Carragee E J. Pyogenic vertebral osteomyelitis [see comments]. J Bone Joint Surg Am . 1997; 79 874-880
- 41 Griffiths H E, Jones D M. Pyogenic infection of the spine. A review of twenty-eight cases. J Bone Joint Surg . 1971; 53 383-391
- 42 Levi A DO, Sonntag V KH. Pyogenic vertebral osteomyelitis. In: Osenbach RK, Zeidman SM (eds). Infections in Neurological Surgery Philadelphia: Lippincott-Raven 1999: 257-263
- 43 Frederickson B, Yuan H, Olans R. Management and outcome of pyogenic vertebral osteomyelitis. Clin Orthop . 1978; 131 160-167
- 44 Garcia A, Grantham S A. Hematogenous pyogenic vertebral osteomyelitis. J Bone Joint Surg . 1960; 42A 429-436
- 45 Genster H G, Andersen M J. Spinal osteomyelitis complicating urinary tract infection. J Urol . 1972; 107 109-111
- 46 Koppel B S, Tuchman A J, Mangiardi J R, Daras M, Weitzner I. Epidural spinal infection in intravenous drug abusers. Arch Neurol . 1988; 45 1331-1337
- 47 Ross P M, Fleming J L. Vertebral body osteomyelitis: spectrum and natural history. A retrospective analysis of 37 cases. Clin Orthop . 1976; 190-198
- 48 Hitchon P W, Osenbach R K, Yuh W T, Menezes A H. Spinal infections. Clin Neurosurg . 1992; 38 373-387
- 49 Sapico F L. Microbiology and antimicrobial therapy of spinal infections. Orthop Clin North Am . 1996; 27 9-13
- 50 Peronne J, Saba Z, Behloul D. Pyogenic and tuberculous spondylodiskitis (vertebral osteomyelitis) in 80 adult patients. Clin Infect Dis . 1994; 19 746-750
- 51 Hatch E S. Acute osteomyelitis of the spine: report of case with recovery. Review of the literature. N Orleans Med Surg J . 1931; 83 861-873
- 52 Sapico F L, Montgomerie J Z. Vertebral osteomyelitis in intravenous drug abusers: report of three cases and review of the literature. Rev Infect Dis . 1980; 2 196-206
- 53 Ariza J, Gudiol F, Valverde R. Brucellar spondylitis: a detailed analysis based on current findings. Rev Infect Dis . 1985; 7 656-664
- 54 Edwards J E, Turkel S B, Elder H A. Hematogenous candida osteomyelitis: report of three cases and review of literature. Am J Med . 1975; 59 89-94
- 55 Gathe J C, Harris R L, Garland B. Candida osteomyelitis: report of five cases and review of the literature. Am J Med . 1987; 82 927-937
- 56 Lifesco R M, Harder E, McCorkell S J. Spinal brucellosis. J Bone Joint Surg . 1985; 67B 345-351
- 57 Redfern R M, Cottam S N, Phillipson A P. Proteus infection of the spine. Spine . 1988; 13 439-441
- 58 Schofferman L, Schofferman J, Zucherman J. Occult infections causing persistent low-back pain. Spine . 1989; 14 417-419
- 59 Carvell J E, Maclarnon J C. Chronic osteomyelitis of the thoracic spine due to Salmonella typhi: a case report. Spine . 1981; 6 527-530
- 60 Incavo S J, Muller D L, Krag M H. Vertebral osteomyelitis caused by Clostridium difficile: a case report and review of the literature. Spine . 1988; 13 111-113
- 61 Stone D B, Bonfiglio M. Pyogenic vertebral osteomyelitis: a diagnostic pitfall for the internist. Arch Intern Med . 1963; 112 491-500
- 62 Eismont F J, Bohlman H H, Soni P L, Goldberg V M, Freehafer A A. Pyogenic and fungal vertebral osteomyelitis with paralysis. J Bone Joint Surg . 1983; 65 19-29
- 63 Carragee E J, Kim D, van der Vlugt T, Vittum D. The clinical use of erythrocyte sedimentation rate in pyogenic vertebral osteomyelitis. Spine . 1997; 22 2089-2093
- 64 Rawlings C E, Wilkins R H, Gallis H A, Goldner J L, Francis R. Postoperative intervertebral disc space infection. Neurosurgery . 1983; 13 371-376
- 65 Grollmus J, Perkins R K, Russel W. Erythrocyte sedimentation rate as a possible indicator of early disc space infection. Neurochirurgia . 1974; 17 30-35
- 66 Kapp J P, Sybers W A. Erythrocyte sedimentation rate following uncomplicated lumbar disc operations. Surg Neurol . 1979; 12 329-330
- 67 Rothman S L. The diagnosis of infections of the spine by modern imaging techniques. Orthop Clin North Am . 1996; 27 15-31
- 68 Palestro C J. Radionuclide imaging in orthopedic infections. Semin Nucl Med . 1997; 27 334-345
- 69 Whalen J L, Brown M L, McLeod R, Fitzgerald Jr H R. Limitations of indium leukocyte imaging for the diagnosis of spine infections. Spine . 1991; 16 193-197
- 70 Wukich D K, Van Dam E B, Abreu S H. Preoperative indium-labeled white blood cell scintigraphy in suspected osteomyelitis of the axial skeleton. Spine . 1988; 13 1168-1170
- 71 Post M J, Sze G, Quencer R M, Eismont F J, Green B A, Gahbauer H. Gadolinium-enhanced MR in spinal infection. J Comput Assist Tomogr . 1990; 14 721-729
- 72 Carragee E J. The clinical use of magnetic resonance imaging in pyogenic vertebral osteomyelitis. Spine . 1997; 22 780-785
- 73 Cotty P, Fouquet B, Pleskof L. Vertebral osteomyelitis: value of percutaneous biopsy. 30 cases. J Neuroradiol . 1988; 15 13-21
- 74 Armstrong P, Green G, Irving J D. Needle aspiration/biopsy of the spine in suspected disc space infections. Br J Radiol . 1978; 51 333-337
- 75 Ghelman B, Lospinuso M F, Levine D B, O'Leary P F, Burke S W. Percutaneous computed-tomography-guided biopsy of the thoracic and lumbar spine. Spine . 1991; 16 736-739
- 76 Eismont F J, Wiesel S W, Brighton C T, Rothman R H. Antibiotic penetration into rabbit nucleus pulposus. Spine . 1987; 12 254-256
- 77 Gibson M J, Karpinski M R, Slack R C, Cowlishaw W A, Webb J K. The penetration of antibiotics into the normal intervertebral disc. J Bone Joint Surg . 1987; 69 784-786
- 78 Patzakis M J, Rao S, Wilkins J, Moore T M, Harvey P J. Analysis of 61 cases of vertebral osteomyelitis. Clin Orthop . 1991; 264 178-183
- 79 Stauffer R N. Pyogenic vertebral osteomyelitis. Orthop Clin North Am . 1975; 6 1015-1027
- 80 Ozuna R M. Pyogenic vertebral osteomyelitis and postsurgical disc space infections. Orthop Clin North Am . 1996; 27 87-94
- 81 Carragee E J. Instrumentation of the infected and unstable spine: a review of 17 cases from the thoracic and lumbar spine with pyogenic infections. J Spinal Disord . 1997; 10 317-324
- 82 Kemp H B, Jackson J W, Jeremiah J D, Cook J. Anterior fusion of the spine for infective lesions in adults. J Bone Joint Surg . 1973; 55 715-734
- 83 Wisneski R J. Infectious disease of the spine. Diagnostic and treatment considerations. Orthop Clin North Am . 1991; 22 491-501
- 84 Bohlman H H, Eismont F J. Surgical techniques of anterior decompression and fusion for spinal cord disorders. Clin Orthop . 1981; 154 57-67
- 85 Dietze Jr D D, Fessler R G, Jacob R P. Primary reconstruction for spinal infections. J Neurosurg . 1997; 86 981-989
- 86 Wiltberger B R. Resection of vertebral bodies and bone grafting for chronic osteomyelitis of the spine. A case report. J Bone Joint Surg . 1952; 34 215-218
- 87 Rajasekaran S, Soundarapandian S. Progression of kyphosis in tuberculosis of the spine treated by anterior arthrodesis. J Bone Joint Surg . 1989; 71 1314-1323
- 88 Bradford D S, Daher Y H. Vascularized rib grafts and stabilization of kyphosis. J Bone Joint Surg . 1986; 68B 357-361
- 89 Emery S E, Chan D P, Woodward H R. Treatment of hematogenous pyogenic vertebral osteomyelitis with anterior debridement and primary bone grafting. Spine . 1989; 14 284-291
- 90 Dickman C A, Fessler R G, MacMillan M, Haid R W. Transpedicular screw-rod fixation of the lumbar spine: operative technique and outcome in 104 cases [see comments]. J Neurosurg . 1992; 77 860-870
- 91 Rath S A, Neff U, Schneider O, Richter H P. Neurosurgical management of thoracic and lumbar vertebral osteomyelitis and discitis in adults: a review of 43 consecutive surgically treated patients. Neurosurgery . 1996; 38 926-933
- 92 Redfern R M, Miles J, Banks A J, Dervin E. Stabilisation of the infected spine. J Neurol Neurosurg Psychiatry . 1988; 51 803-807
- 93 Versca J M, Leung K Y, Wagner T A. Primary infections of the spine treated surgically: instrumented versus noninstrumented, 10th Annual Meeting of the North American Spine Society, Washington, DC. 1995
- 94 Horwitz N H, Curtin J A. Prophylactic antibiotics and wound infections following laminectomy for lumber disc herniation. J Neurosurg . 1975; 43 727-731
- 95 El-Gindi S, Aref S, Salama M, Andrew J. Infection of intervertebral discs after operation. J Bone Joint Surg . 1976; 58 114-116
- 96 Cruse P J, Foord R. A five-year prospective study of 23,649 surgical wounds. Arch Surg . 1973; 107 206-210
- 97 Capen D A. Perioperative risk factors for wound infections after lower back fusions. Orthop Clin North Am . 1996; 27 83-86
- 98 Rimoldi R L, Haye W. The use of antibiotics for wound prophylaxis in spinal surgery. Orthop Clin North Am . 1996; 27 47-52
- 99 Rubinstein E, Findler G, Amit P, Shaked I. Perioperative prophylactic cephazolin in spinal surgery. A double-blind placebo-controlled trial. J Bone Joint Surg Br . 1994; 76 99-102
- 100 Kayvanfar J F, Capen D A, Rimoldi R L. Wound infections after instrumented postero-lateral spine fusion in adults. American Academy of Orthopedic Surgeons, Orlando, FL 1995
- 101 Schulitz K P, Assheuer J. Discitis after procedures on the intervertebral disc. Spine . 1994; 19 1172-1177
- 102 Seabold J E. Imaging techniques for evaluation of postoperative orthopedic infections. Q J Nucl Med . 1999; 43 21-28
- 103 Baker A S, Ojemann R G, Swartz M N. Spinal epidural abscess. N Engl J Med . 1975; 293 463-468
- 104 Danner R L, Hartman B J. Update on spinal epidural abscess: 35 cases and review of the literature. Rev Infect Dis . 1987; 9 265-274
- 105 Del Curling Jr O, Gower D J, McWhorter J M. Changing concepts in spinal epidural abscess: a report of 29 cases. Neurosurgery . 1990; 27 185-192
- 106 Kaufman D M, Kaplan J G, Litman N. Infectious agents in spinal epidural abscesses. Neurology . 1980; 30 844-850
- 107 Gardner R D, Cammisa F P, Eismont F J. Nongranulomatous spinal epidural abscesses. Orthop Trans . 1989; 13 562-563
- 108 Russell N A, Vaughan R, Morley T P. Spinal epidural infection. Can J Neurol Sci . 1979; 6 325-328
- 109 Feldenzer J A, McKeever P E, Schaberg D R, Campbell J A, Hoff J T. The pathogenesis of spinal epidural abscess: microangiographic studies in an experimental model. J Neurosurg . 1988; 69 110-114
- 110 Dandy W E. Abscesses and inflammatory tumors in the spinal epidural space (so-called pachymeningitis externa). Arch Surg . 1926; 13 477-494
- 111 Sandhu F S, Dillon W P. Spinal epidural abscess: evaluation with contrast-enhanced MR imaging. Am J Neuroradiol . 1991; 12 1087-1093
- 112 Garrido E, Rosenwasser R H. Experience with the suction-irrigation technique in the management of spinal epidural infection. Neurosurgery . 1983; 12 678-679
- 113 Hulme A, Dott N M. Spinal epidural abscess. Br Med J . 1954; 1 164-168
- 114 de Villiers C J, de Cluver F P. Spinal epidural abscess in children. S Afr J Surg . 1978; 16 149-155
- 115 Carden E, Nanulescu M. Epidural lavage for extensive epidural suppuration. Anesthesia . 1987; 42 1023
- 116 Heusner A P. Nontuberculous spinal epidural infections. N Eng J med . 1948; 239 845-8541