Introduction

INTRODUCTION

Spinal infections are an uncommon but important

clinical problem that often requires aggressive medical
therapy, and sometimes even surgery. Several terms can
be found in the scientific literature describing infection
of the spine, namely discitis, spondylodiscitis,
spondylitis, vertebral pyogenic osteomyelitis, and
pyogenic spinal infection, creating confusion in the
literature nomenclature. Current data show that in most
cases, the infection involves both the disc space
(discitis) and the adjacent vertebral body, suggesting
that these radiological findings represent the different
stages of the same disease. Therefore, spinal infections
are now more correctly considered as a spectrum of
diseases that include spondylitis, discitis,
spondylodiscitis, and epidural abscess, and will be
generically referred to as spondylodiscitis (SD) (Cramer
et al., 2013).

There are three main contamination routes:

hematogenous spread, external inoculation or
involvement from adjacent tissue. Clinical presentation
can be quite varied, making diagnosis not always
obvious. Local pain in the posterior aspect of the neck
or back in a febrile patient should always be
investigated for spondylodiscitis. Pain is
characteristically mechanical: increased with standing
position and relieved by recumbency; it typically gets
worse with time and at later stages can even be at rest.
Pain can be associated with neurological symptoms
secondary to either direct compression by suppurative

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material or as the result of the posterior dislocation of a

bony fragment into the spinal canal that compresses the
spinal cord and/or the nerve roots. Known risk factors
for SD are advanced age, diabetes mellitus, rheumatoid
arthritis, immunosuppression, alcoholism, long-term
steroid use, concomitant infections, poly-trauma,
malignant tumor, and previous surgery or invasive
procedures (discography, chemonucleolysis, and
surgical procedures involving or adjacent to the
intervertebral disc space (Ozalay et al., 2015).

The incidence of acute pyogenic SD is estimated to

be 5–5.3 per million patients per year with a male
predominance; however, some studies suggest that this
incidence is rising, possibly due to an increase in the
rate of nosocomial infections associated with vascular
devices and other forms of instrumentation and to an
increasing prevalence of intravenous drug abusers. In a
recent study, the incidence of hospital-acquired SD
(following invasive procedures or not) accounted for
more than 50% of cases. Males are more commonly
affected than females in the ratio of 2:1, for unknown
reasons. The average age at clinical presentation is the
fourth to fifth decade. The most common level of
involvement is at the lumbar spine, followed by the
thoracic, cervical and sacral levels: lesions at the
thoracic spine tend to lead more frequently to
neurological symptoms. The aim of the current paper is
to describe current evidence-based standards of therapy
in management of SD by emphasizing pharmacological
therapy and principles and indications for bracing and
surgery (Lim et al., 2008).
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The indications for surgery include one or a

combination of the following pathological changes:
severe destruction of endplates, abscess formation,
chronic osteomyelitis with biomechanical instability,
neurologic deficit, local kyphosis, severe pain, septic
pseudarthrosis or refractoriness to conservative
treatment (Lim et al., 2008).

There is a broad range of options for the surgical

management of spinal infections, which include
anterior, or posterior approach, single-stage or two-stage
surgery, with or without instrumentation. The role of
spinal instrumentation in the presence of active
infection is still controversial (Lim et al., 2008).

Several authors have suggested bed rest and prolonged

external bracing rather than placing spinal
instrumentation (Asamoto et al., 2015).

Others have advocated a staged instrumented operation

with a period of antibiotics therapy after debridement
only surgery (Ozalay et al., 2015).

Numerous reports have demonstrated that stainless steel

and titanium have different biocompatibility
characteristics which consequently could influence
bacterial or cell adhesion and colonization. However,
the results were inconsistent. Some in vivo or in vitro
researches implicated that stainless steel was more
likely to be colonized by microbes, but contradictory
results could also be found in other literature (Haky et
al., 2014).

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But it was not until the 1990s of the last century,

internal fixation started gaining some acceptance in
reconstructive surgery performed in the setting of active
infection, and more and more surgeons reported their
series of surgical treatment of spinal infections with
excellent results (Christodoulou et al., 2011).

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HISTORICAL PERSPECTIVE

Evidence of spinal infection in human's dates back to

before the time of recorded history. Neolithic people (c.
7000 to 300 b.c.) and Egyptian mummies (c. 3000 B.C.)
have been found to have evidence of spinal deformity
believed to be caused by tuberculosis. Hippocrates
described the clinical condition of spinal infection and
noted that the prognosis in this condition, believed to be
tuberculosis, was better when the infection was below
the diaphragm than when above it. In 1779, Pott gave
the first complete report of tuberculous infection of the
spine. According to Wilensky, Nelaton coined the term
osteomyelitis in 1854. The scientific understanding of
osteomyelitis began in 1884, when Rodet described the
development of osteomyelitis after injections of
Staphylococcus aureus into the veins of animals. Early
treatment for spinal infections was limited to abscess
drainage, usually of tuberculous infections; secondary
bacterial infection frequently caused death (Ozalay et
al., 2015).

Before the use of antibiotics, mortality in patients with

infections of the spine and contiguous tissues was 40%
to 70%. Advances in chemotherapy since the 1960s
have dramatically altered the natural history of these
diseases. Today, spinal infections are relatively rare,
accounting for only 2% to 4% of all osteomyelitis
infections, and mortality is estimated to be 1% to 20%,
depending on the patient group and the infecting agent.
Paralysis is reported to occur in 50% of patients with
spinal infections, depending on the patient population

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and the spinal segment involved. The primary problems

today are the delay in diagnosis (estimated to average 3
months), the long recovery period (averaging ≥12
months), and the great cost of treating such infections
(Christodoulou et al., 2011).

Reconstructive surgery for spinal infection required

the development of safe surgical and anesthetic
techniques. In 1911, Hibbs and Albee independently
developed posterior spinal fusion techniques for treating
tuberculous spinal disease; these procedures decreased
the degree of kyphosis and shortened the course of the
disease. Hibbs and Albee each chose the posterior
approach because it avoided involvement of the area of
active infection. Posterior spinal fusion remained the
mainstay of treatment of spinal tuberculous infection
until the advent of antibiotics. With the development of
chemotherapeutic agents, surgical approaches became
more aggressive in the direct treatment of tuberculosis
and other pyogenic infections. In 1956, Hodgson and
Stock pioneered radical anterior decompression for Pott
disease, and this procedure has been used with equal
success in the treatment of other kinds of spinal
infections (Lim et al., 2008).

Today, radical excision of infected bone is

commonplace, provided that ancillary support for such
procedures is adequate, and the use of bone graft in
infected spaces is accepted by most authors. Lim et al.
reported successful treatment of patients with spinal
tuberculosis and human immunodeficiency virus (HIV)
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using radical débridement, fresh frozen allografts, and

18 months of antituberculous drugs without
antiretroviral therapy (Lim et al., 2008).

Rigid internal fixation is being used more frequently

in the treatment of pyogenic and nonpyogenic spinal
infections. Caragee noted a 47% complication rate after
instrumentation, including two instrumentation failures
and one wound dehiscence, in 17 patients with pyogenic
osteomyelitis. Wrobel, Chappell, and Taylor reported
general success after instrumentation in 10 of 23
patients with coccidioidomycosis spinal infection. In a
review of 31 patients with primary spinal infection
treated with internal fixation, Faraj and Webb noted
eradication of the infections; however, one patient died
of infection, three had deep wound infections requiring
further débridement, and one had an implant failure.
Krodel et al. noted no additional risks when posterior
instrumentation was used to augment anterior
decompression and grafting for spinal tuberculosis. The
use of autograft alone has a similar but less frequent
complication rate. Allograft also has been used with
fewer complications as noted by Schuster et al. and
Govender and Parbhoo. Meticulous planning, proper
implant choice, and appropriate long-term antibiotics
are necessary when rigid internal fixation is used for
infections of the spine. Nonpyogenic infections seem to
be less reactive to instrumentation than pyogenic
infections (Lim et al., 2008).

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BIOLOGY OF SPINAL INFECTION

Knowledge of the structure and composition of the

spinal elements is essential to an understanding of spinal
infections. The intervertebral disc previously was
identified as the most commonly infected spinal
element, but more recent evidence points to the
metaphyses and cartilaginous end plates as the starting
areas for blood-borne infections. The disc space now is
considered the primary starting area only for infections
that result from direct inoculation (Gouliouris et al.,
2014).

In 1945, Coventry, Ghormley, and Kernohan

described the microscopic anatomy of the intervertebral
disc and its contiguous structures. They concluded that
in adults older than 30 years the intervertebral disc
receives its nutrition from tissue fluids, rather than from
direct blood supply. They noted multiple holes in the
end plates of the vertebral bodies, which corresponded
with the marrow cavities and were arranged in three
distinct areas: (1) a central zone with numerous small
holes, (2) a peripheral zone with a few large holes, and
(3) an epiphyseal ring surrounding the end plate
(Gouliouris et al., 2014).

The epiphyseal ring overlaps the outer surface of the

vertebral body and joins the more concave surface of
the central and peripheral zones internally. Next to the
bony end plate is the cartilaginous plate, which consists
of hyaline cartilage and forms the inner base between
the bone and the fibrous disc. In 1981, Inoue found that
the disc was firmly adherent to the vertebral end plate:
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two thirds of its fibers were perpendicular to the end

plate in this area. The central portion was less firmly
attached, with fibers parallel to the end plate. This
composition most likely allows the transport of nutrients
through the holes and into the central portion of the disc
without disturbing the structural integrity (Tayles et al.,
2014).

The arterial and venous supply to the vertebrae has

been studied by numerous investigators for more than
100 years. In 1959, Wiley and Trueta found marked
similarities in the arterial and venous supply in humans
and rabbits at the cervical, thoracic, and lumbar levels.
At the level of each vertebra, the vertebral artery,
intercostal artery, or lumbar arteries provide nutrient
vessels that enter the vertebral body (Fig. 40-1).
Posterior spinal branch arteries enter the spinal canal
through each neural foramen. These arteries separate
into ascending and descending branches that
anastomose with similar branches at each level (Fig. 40-
2). This posterior network joins centrally to enter a large
posterior nutrient foramen (Tayles et al., 2014).

Hippocrates was the first to describe

osteomyelitis of the spine in 400 BC.The first account
of pyogenic vertebral osteomyelitis is credited to the
French physician Lannelongue in 1879. The first large
series of pyogenic vertebral infections in the English
literature was published by Kulowski in 1936.
Improvements in surgical and radiological techniques
and the discovery of antimicrobial therapy have

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transformed the outlook for patients with this condition,

but morbidity remains (Gouliouris et al., 2014).

Figure (1 A picture of wooden statue of a man with hunch back

deformity, sharp angulation of spine suggest TB (Egyptian
Museum).

The ancient Egyptians had tried to solve their

medical problem with all resources they had at that
time. Figure (2)

Figure (2) (kumombo temple)Inscription detailing ancient

Egyptian medical instruments, including bone saws, suction cups,
knives and scalpels, retractors, scales, lances, chisels and dental
tools.

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