7/19/2017 Spinal Infections: Background, Anatomy, Pathophysiology

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Spinal Infections
Updated: Dec 22, 2015
Author: Federico C Vinas, MD; Chief Editor: Jeffrey A Goldstein, MD more...

OVERVIEW

Background
Pyogenic vertebral osteomyelitis is the most commonly encountered form of vertebral infection. It can
develop from direct open spinal trauma, from infections in adjacent structures, from hematogenous
spread of bacteria to a vertebra, or postoperatively. Left untreated, vertebral osteomyelitis can lead to
permanent neurologic deficits, significant spinal deformity, or death. [1, 2, 3, 4, 5, 6, 7] It can result in
severe compression of the neural stuctures due to formation of an epidural abscess or due to a
pathologic fracture resulting from bone softening.

Evidence of vertebral osteomyelitis has been found in Egyptian mummies. Hippocrates first described
the infection of the vertebral column. Later on, Galen related this infectious process to spinal
deformity. Before the development of antibiotics and bacteriology, little knowledge was added to the
basic understandings of the Hippocratic school until Servino and Potts characterized and described
the pathology of tuberculosis infection of the spine. In 1879, Lannelonge described bacterial
osteomyelitis as we recognize it today.

Although successful treatment of spinal abscess with surgical drainage was reported early on, the
high complication rate from secondary infection caused this surgery to remain in poor favor. Following
the introduction of antisepsis, surgical intervention for spinal infections became feasible.

The initial procedure introduced for the surgical treatment of spinal infections was a laminectomy.
However, this procedure did not allow access to anterior abscesses and contributed to spinal
instability, which often resulted in progressive deformity. Ito et al first described the anterior approach
to the spine. Later, Hodgson and Stock extensively reported this procedure in the treatment of
tuberculosis of the spine. Late spinal deformity was prevented with spinal fusion and instrumentation.
While Hodgson and Stock performed fusions from the anterior approach, Hibbs and Albee
independently presented techniques for posterior spinal fusion in the treatment of tuberculosis of the
spine.

In the future, the introduction of newer, more effective antibiotics may contribute to the treatment of
these infections. For patients requiring a fusion, the use of growth factors for the induction of spinal
fusions is a theoretically attractive approach. Numerous studies have shown that viral vectors can be
used to implant osteoinductive growth factor genes directly into the paraspinal muscles or into cells
that can subsequently be implanted next to the spine. These osteoinductive factors enhance the
activation and differentiation of pluripotent stem cells to develop into mature bone.

Anatomy
The anatomy of the spine includes the vertebral bodies, intervertebral disks, and associated joints,
muscles, tendons, ligaments, and neural elements.
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The intervertebral disk is a fibrocartilaginous remnant of the embryonic notochord, which provides the
spine with strength, mobility, and resistance to strain. It consists of the following three parts:

Annulus fibrosus
Nucleus pulposus
Cartilaginous endplates

The annulus fibrosus is made up of type I collagen fibrils, which are arranged in 15-20 concentric
lamellae brought together into parallel bundles. These bundles are firmly attached to the vertebral
bodies and are arranged in layers to provide strength and limit vertebral movement when the disk is
compressed. The nucleus pulposus is composed of type II collagen and represents 30-60% of the
disk volume. The nucleus pulposus is supplied with blood vessels through small perforations in the
central cartilaginous endplates.

The cervical spine consists of the first seven vertebrae in the spinal column (C1-7). Typically, these
vertebrae are small and possess a foramen on the transverse process for the vertebral artery. The
thoracic spine consists of the next 12 vertebrae (T1-12) and is stabilized by the attached rib cage and
intercostal musculature. The lumbar spine consists of a mobile segment of five vertebrae (L1-5),
located between the relatively immobile segments of the thoracic and sacral segments.

The lumbar vertebrae are particularly large and heavy in comparison with the cervical and thoracic
vertebrae. The bodies are wider and have shorter and heavier pedicles, and the transverse processes
project somewhat more laterally and ventrally than the other spinal segments. The laminae are
shorter vertically than the bodies and are bridged by strong ligaments. The spinal processes are
broader and stronger than those in the thoracic and cervical spine.

Pathophysiology
Approximately 95% of pyogenic spinal infections involve the vertebral body, and only 5% involve the
posterior elements of the spine. This disparity has been attributed in part to the voluminous blood
supply to the vertebral body and its rich, cellular marrow.

Bacteria circulating through the blood may enter a vertebra or a disk space via its arterial blood supply
or via the venous system. In the typical case, bacteria enter the vertebral body through small
metaphyseal arteries arising from larger primary periosteal arteries that, in turn, branch from the spinal
arteries. In adults, blockage of metaphyseal arteries by septic thrombi may infarct relatively large
amounts of bone. Subsequently, bacteria can readily colonize a large bony sequestrum adjacent to
the disk.

In the adult, after bacterial colonization of the metaphyseal region, the avascular disk is secondarily
invaded by bacteria from the endplate region. Intermetaphyseal communicating arteries allow the
spread of septic thrombi from one metaphysis to the other in a single vertebral body without
involvement of the midportion of the vertebra.

Although the arterial route is the usual route of bacterial spread to a vertebra, another proposed route
of infection is the retrograde seeding of venous blood via the Batson plexus. During periods of
increased intra-abdominal pressure, venous blood is shunted toward the vertebral venous plexus.
Some authors have proposed that the venous system may be the route of bacterial spread from
genitourinary tract infections.

Another possible means of infection is by the spread of contiguous infection into the vertebrae and
disk (eg, from a retropharyngeal abscess or a retroperitoneal abscess), resulting in osteomyelitis and
diskitis. [8]

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Etiology
Presumably, a distant focus of infection provides an infective nidus from which bacteria spread by the
bloodstream to the spinal column. The skin and the genitourinary tract are common antecedent sites,
but a review of the literature reveals multiple foci, such as septic arthritis, sinusitis, subacute bacterial
endocarditis, and respiratory, oral, or gastrointestinal infection. [9, 10, 11, 12] Approximately 30-70% of
patients with vertebral osteomyelitis have no obvious prior infection.

Risk factors for developing osteomyelitis include conditions that compromise the immune system,
such as the following:

Advanced age [13]

Intravenous (IV) drug use [14]
Congenital immunodepression
Long-term systemic administration of steroids
Diabetes mellitus [15]
Organ transplantation
Malnutrition
Cancer

IV drug abuse is a growing cause of spinal infections. Typically, the organism most likely to infect the
spine is Staphylococcus aureus; however, in IV drug users, Pseudomonas species are also a
common cause. [16] Nonpyogenic osteomyelitis can be caused by tuberculosis, fungus, yeast, or
parasitic organisms. [17, 18, 19, 20, 21]

Surgical site infection (SSI) can result as an adverse event after a spinal procedure. Timing of
preoperative antibiotic prophylaxis as well as careful aseptic technique can reduce the incidence of
SSIs during spinal procedures. [22, 23]

Fungal infections of the spine are rare and generally occur in patients who are debilitated or have
diabetes or a compromised immune system. Patients with acute leukemia, alcoholics, patients with
lymphoma, recipients of organ transplants, and those receiving chemotherapy are particularly
susceptible to fungal infections.

Most vertebral body infections occur in the lumbar spine because of the blood flow to this region of the
spine. Tuberculosis infections have a predilection for the thoracic spine, and IV drug abusers are more
likely to contract an infection of the cervical spine.

Epidemiology
Vertebral osteomyelitis is considered uncommon, with an incidence of 1 case per 100,000-250,000
population per year. However, some reviews suggest that the incidence of spinal infections is now
increasing. This increase may be secondary to increased use of vascular devices and other forms of
instrumentation and to increasing rates of IV drug abuse. [24] Because of its rarity and vague initial
signs and symptoms, diagnosis is often delayed.

No specific predilection for a particular race has been noted. Osteomyelitis has a predilection for
males. A bimodal age distribution occurs in diskitis. Diskitis and osteomyelitis peak in pediatric
patients; the incidence of spinal infections then decreases until middle age, when a second peak in
incidence is observed at approximately age 50 years. [25] Some authors argue that childhood diskitis
is a separate disease entity and should be considered independently.

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In developed nations, the incidence of spinal osteomyelitis is similar to that in the United States.
However, in less developed nations, infectious osteomyelitis is more common. In some areas of
Africa, a reported 11% of all patients seen for back pain were diagnosed with diskitis and
osteomyelitis.

Prognosis
Both bony and neural status must be considered in the evaluation of treatment outcome. [26] Most
patients can be cured by a treatment protocol that includes antibiotics alone or in combination with
surgery. [27, 28] For patients with an incomplete neurologic compromise, several studies indicate that
with aggressive antibiotic and surgical therapy, paresis may improve or resolve. [29, 30, 31] Only 15% of
patients experience permanent neurologic deficits. Recrudescence of infection occurs in 2-8% of
patients.

In a retrospective cohort study, Gupta et al assessed 260 patients with pyogenic vertebral
osteomyelitis, of whom 27% acquired the infection after an invasive spinal procedure, 40% had S
aureus as the cause of the infection, and 49% underwent spinal surgery as part of initial therapy. [32]
The estimated cumulative probability of treatment failure-free survival was 72% at 2 years, 69% at 5
years, and 69% at 10 years. On multivariate analysis, the factors associated with greater likelihood of
treatment failure were (1) a longer duration of symptoms before diagnosis and (2) an infection caused
by S aureus.

Clinical Presentation

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Media Gallery

Spinal infections. Lateral plain radiographs of Patient A with diskitis at C4-5. Note the severe
disk space narrowing and subluxation seen at C4-5.
Spinal infections. T2-weighted MRI of Patient A. Evidence of osteomyelitis and diskitis, as well
as a small epidural abscess, is present. The patient underwent a C4-5 anterior cervical
diskectomy and arthrodesis using autologous iliac crest bone graft and instrumental fixation with
a titanium plate and screws.
Spinal infections. A 47-year-old woman (Patient B) who presented with intractable back pain.
Radiographs reveal significant collapse and destruction of the L4 vertebral body. An MRI of the
lumbar spine was ordered.
An MRI of Patient B reveals an enhancing mass affecting the L4 vertebral body with
compromise of the spinal canal. The patient underwent several blood cultures and a CT-guided
trocar biopsy; culture results were negative. A surgical procedure was necessary.
Spinal infections. Patient B developed lower extremity weakness, and follow-up studies reveal
further compression of L4 and compromise of the canal. An anterolateral approach was
performed with a corpectomy, decompression of the spinal canal, restoration of the anterior
column support, and arthrodesis with a titanium cage and autologous iliac crest bone graft. The
pathology and Gram stain revealed some hyphae. Culture findings were positive for Aspergillus
species. The patient underwent a full course of amphotericin B and completely recovered.

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Contributor Information and Disclosures

Author

Federico C Vinas, MD Consulting Neurosurgeon, Department of Neurological Surgery, Halifax

Medical Center

Federico C Vinas, MD is a member of the following medical societies: American Association of

Neurological Surgeons, American College of Surgeons, American Medical Association, Florida
Medical Association, North American Spine Society, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

J Richard Rhodes, MD Orthopedic Surgeon, Atlantic Orthopaedics, PA, and Coastal Medical
Research

J Richard Rhodes, MD is a member of the following medical societies: Florida Medical Association,
Florida Orthopaedic Society

Disclosure: Nothing to disclose.

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Amy L Stumpf, PA-C, MPH Clinical Director, Assistant Professor, Physician Assistant Program, Nova
Southeastern University

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical
Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

William O Shaffer, MD Orthopedic Spine Surgeon, Northwest Iowa Bone, Joint, and Sports Surgeons

William O Shaffer, MD is a member of the following medical societies: American Academy of

Orthopaedic Surgeons, American Orthopaedic Association, Kentucky Medical Association, North
American Spine Society, Kentucky Orthopaedic Society, International Society for the Study of the
Lumbar Spine, Southern Medical Association, Southern Orthopaedic Association

Disclosure: Received royalty from DePuySpine 1997-2007 (not presently) for consulting; Received
grant/research funds from DePuySpine 2002-2007 (closed) for sacropelvic instrumentation
biomechanical study; Received grant/research funds from DePuyBiologics 2005-2008 (closed) for
healos study just closed; Received consulting fee from DePuySpine 2009 for design of offset
modification of expedium.

Chief Editor

Jeffrey A Goldstein, MD Clinical Professor of Orthopedic Surgery, New York University School of
Medicine; Director of Spine Service, Director of Spine Fellowship, Department of Orthopedic Surgery,
NYU Hospital for Joint Diseases, NYU Langone Medical Center

Jeffrey A Goldstein, MD is a member of the following medical societies: American Academy of

Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, AOSpine,
Cervical Spine Research Society, International Society for the Advancement of Spine Surgery,
International Society for the Study of the Lumbar Spine, Lumbar Spine Research Society, North
American Spine Society, Scoliosis Research Society, Society of Lateral Access Surgery

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for:
Medtronic, Nuvasive, NLT Spine, RTI, Magellan Health<br/>Received consulting fee from Medtronic
for consulting; Received consulting fee from NuVasive for consulting; Received royalty from Nuvasive
for consulting; Received consulting fee from K2M for consulting; Received ownership interest from
NuVasive for none.

Additional Contributors

James F Kellam, MD, FRCSC, FACS, FRCS(Ire) Professor, Department of Orthopedic Surgery,
University of Texas Medical School at Houston

James F Kellam, MD, FRCSC, FACS, FRCS(Ire) is a member of the following medical societies:
American Academy of Orthopaedic Surgeons, Orthopaedic Trauma Association, Royal College of
Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

http://emedicine.medscape.com/article/1266702-overview 10/10