Spondylodiscitis: diagnosis and treatment

Surgical Neurology 64 (2005) 103 – 108 www.surgicalneurology-online.com

Spine

Spondylodiscitis: diagnosis and treatment Shunji Asamoto, MD, PhDa,T, Hiroshi Doi, MD, PhDa, Nobusuke Kobayashi, MD, PhDa, Takahiro Endoh, MD, PhDa, Hajime Sakagawa, MD, PhDb, Yoichi Iwanaga, MD, PhDc, Masahiro Ida, MD, PhDd, Hiroyuki Jinbo, MD, PhDe Departments of aNeurosurgery, bOrthopedics, cOphthalmology, and dRadiology, Tokyo Metropolitan Ebara Hospital, 145 0065 Tokyo, Japan e Department of Neurosurgery, Ikegami General Hospital, 145 0065 Tokyo, Japan Received 16 September 2004; accepted 27 November 2004

Abstract

Background: We present our experience in the diagnosis and treatment of spondylodiscitis. Methods: 27 patients with spondylodiscitis were studied. There were 15 men and 12 women, with ages ranging from 26 to 85 years. Of the 27 cases, there were 21 patients with pyogenic spondylodiscitis, 6 patients with tuberculosis spondylodiscitis, and 8 patients with diabetes mellitus complication. Two patients presented with tetraparesis, 13 with paraparesis, and 1 with hemiparesis. Seventeen patients underwent surgical treatment, among whom surgical intervention with instrumentation was performed on 5 patients, and emergency operation was performed on 6 patients. Results: Fourteen patients were judged as bexcellent,Q 8 patients as bgood,Q and 4 patients as bno change.Q One patient died because of infection by penicillin-resistant Staphylococcus pneumoniae. Conclusion: It is very difficult to diagnose spondylodiscitis at the first medical examination. Most spondylodiscitis patients often first visit a department of internal medicine. We strongly recommend that all doctors, especially doctors examining diabetes mellitus patients daily, should be well informed of spondylodiscitis in order to improve its diagnosis. D 2005 Elsevier Inc. All rights reserved.

Keywords:

Spondylodiscitis; Diagnosis; Therapy; Diabetes mellitus

1. Introduction It is very difficult to diagnose spondylodiscitis at the first medical examination; most patients who are referred to our neurosurgical department already have some neurological findings. Based on our experience, we examined a possible method of improving the rate of diagnosis of spondylodiscitis and its treatment. 2. Materials and methods We present 27 patients with spondylodiscitis. The epidemiological and clinical data of the patients are outlined in Table 1. All patients underwent magnetic resonance and CT scanning. There were 15 men and 12 women, with ages Abbreviations: CT, computed tomography; DM, diabetes mellitus. T Corresponding author. Tel.: +81 3 5734 8000; fax: +81 3 5734 8023. E-mail address: [email protected] (S. Asamoto). 0090-3019/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.surneu.2004.11.034

ranging from 26 to 85 years (mean age 64.1 years). Among various primary symptoms distinctly observed in these patients, an episode of pain was the most frequently encountered symptom in 24 patients, followed by fever in 12 patients. The duration from onset of disease to first examination was evident in 25 patients and ranged from 8 days to 2 years (Table 1). The departments first visited by a patient with some symptom were of internal medicine by 18 patients; orthopedics by 5 patients; and neurology, surgery, and neurosurgery by 1 patient, respectively (Table 1). Among those who first visited a department of orthopedics, 1 patient was examined in our hospital (Table 1, case no. 23). Another patient who first visited a department of neurosurgery was diagnosed as spondylodiscitis while in the hospital for treatment of cerebral infarction (Table 1, case no.15). Only 2 patients were diagnosed as spondylodiscitis at the first examination, one of whom was diagnosed in the department of orthopedics (Table 1, case no. 23) and the other in the department of neurosurgery of our hospital

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Table 1 Summary of all cases of spondylodiscitis at our institute Sex (M/F)

Age (y)

Initial department

Second department

1 2 3 4 5

F F M M F

68 67 69 84 55

Orthopedics Internal medicine Internal medicine Internal medicine Internal medicine

Neurosurgery Surgery Neurosurgery Neurology Orthopedics

6 7 8 9 10 11 12

F M F M M F M

26 85 51 43 61 60 55

Orthopedics Internal medicine Neurology Internal medicine Emergency medicine Orthopedics Internal medicine

Neurosurgery Orthopedics Orthopedics Orthopedics Neurosurgery Neurosurgery Orthopedics

13 14 15 16 17

F M M M M

80 70 61 58 67

Orthopedics Internal medicine Neurosurgery Internal medicine Internal medicine

Neurosurgery Orthopedics

18 19

F F

81 78

20

F

21 22 23 24 25 26 27

M F F M M M M

Location

Therapy

Origin

C T T, L C, T, L T

Emergency operation Planning operation Emergency operation Conservative Planning operation

Pyogenic Pyogenic Pyogenic Pyogenic TB

T L L L C T L

Planning operation Planning operation Conservative Conservative Planning operation Planning operation Conservative (ventricular drainage)

TB Pyogenic Pyogenic Pyogenic Pyogenic TB Pyogenic

Neurosurgery Neurosurgery

L T C L L

Conservative Conservative Emergency operation Planning operation Conservative

Pyogenic TB Pyogenic TB Pyogenic

Internal medicine Surgery

Neurosurgery Neurosurgery

T L

Pyogenic Pyogenic

73

Internal medicine

Neurosurgery

T

35 80 53 70 68 69 63

Internal medicine Internal medicine Orthopedics Internal medicine Internal medicine Internal medicine Internal medicine

Neurosurgery Neurosurgery

L C L T T T T

Planning operation conservative Z planning operation Emergency operation Zplanning operation Conservative Conservative Planning operation Conservative Emergency operation Planning operation Emergency operation

Orthopedics Orthopedics Neurosurgery Neurosurgery

Third department

Fourth department

Orthopedics

Neurosurgery

Neurosurgery Neurosurgery

Neurosurgery Neurosurgery Neurosurgery

Neurosurgery

Neurosurgery

Neurosurgery

S agalactiae Unknown S aureus S agalactiae

unknown unknown unknown unknown Penicillinresistant Staphylococcus pneumoniae Unknown Unknown S aureus, S agalactiae, P aeruginosa Unknown Unknown

TB

Pyogenic Pyogenic Pyogenic Pyogenic Pyogenic Pyogenic Pyogenic

Unknown Unknown Unknown Unknown S aureus Unknown Unknown

TB indicates tuberculosis; WBC, white blood cell; CRP, C-reactive protein; C, cervical; T, thoracic; L, lumbar.

(Table 1, case no. 15). Based on the established diagnosis, 25 patients were finally hospitalized in the department of neurosurgery and 2 patients in the department of orthopedics of our hospital (Table 1, case nos. 23 and 24). Among the 27 patients in our study, there were 4 cervical lesions, 11 thoracic lesions, 10 lumbar lesions, and 2 multiple combined lesions. Neurological findings at admission to the last department were evaluated, and we were able to evaluate neurological findings in 26 cases. The 1 patient whose neurological findings could not be evaluated had meningitis because of infection by penicillin-resistant Staphylococcus pneumoniae while staying in the department of internal medicine. He was being treated for fever and lumbago and subsequently developed hydrocephalus and loss of consciousness (Table 1, no. 12). Two patients presented with tetraparesis, 13 patients presented with paraparesis, and 1 patient presented with hemiparesis. Abscess or granuloma strongly pressing on the epidural

spinal cord was observed in all the patients who presented with paralysis. Ten patients had no neurological findings. In all 27 cases, there were 21 cases with pyogenic spondylodiscitis. In those patients diagnosed with pyogenic spondylodiscitis, the causal microorganism was identified in 6 patients, including 2 patients with simple infection, by Staphylococcus aureus, 2 patients with simple infection by Streptococcus agalactiae, 1 patient with simple infection by penicillin-resistant Streptococcus pneumoniae, and 1 patient with complex infection by S aureus, S agalactiae, and Pseudomonas aeruginosa. There were 6 patients with tuberculosis spondylodiscitis. In all 27 patients, 17 patients underwent surgical treatment (Table 1). For cervical lesions (3 patients), the anterior approach with fusion was performed. For thoracic lesions, the transthoracic anterolateral approach was performed in 6 patients, and laminectomy was performed in 2 patients. The transthoracic anterolateral approach and posterior approach were performed in only

S. Asamoto et al. / Surgical Neurology 64 (2005) 103 – 108

Initial laboratory data

Interval

Initial symptom

Neurology on admission

Outcome

Meningitis

Pain Pain Pain Pain

Tetraparesis Paraparesis Paraparesis Paraparesis

Excellent Excellent Excellent Excellent

+

Pain

Paraparesis

Excellent

y d mo mo

Pain Pain Pain Pain Pain Pain

Free Paraparesis Free Free Hemiparesis Paraparesis Consciousness disturbance

Excellent Good Excellent Excellent Good Excellent Dead

Excellent No change Excellent Good Excellent

fever (8C)

WBC

CRP

40 39 39.1 36.1

10200

2.1

13000 14200

4.5 2.4

8d 2 mo 4 wk 10 d

36.2

5700

0.5

3 mo

36.5 36.1 36.5 36.3

5700 18530 4300 5400

0.1 30.35 0.1 0.5

36.3 38.7

4100 6700

0.3 0.2

6 mo 1d

38.5 36.1 39.0 38.0 36.0

8300 6200 8500 9100 10700

17 0.3 4.2 3.7 5.6

1d 3 mo

36.5

8100

0.7

1 mo

36.2

5000

0.1

36.0 38.9 38.6 37.7 38.0 36.3 40 39

7400

3.4 7.5 22.3 20.6

8700 11500 6500 10800

6.6

2 5 2 1

1.7 y 2 mo

2 mo 2 wk 4d 1 mo 5 mo 1 mo 3 mo 1.5 mo

Subclinical

105

DM DM Steroid -induced DM

DM

Pain

DM

Pain

DM

Pain

Free Paraparesis Tetraparesis Paraparesis Free

Pain

Free

Excellent

Pain

Paraparesis

Good

Pain Pain Pain Pain Pain Pain Pain Pain

Paraparesis Free Free Free Paraparesis Paraparesis Paraparesis Paraparesis

Good Excellent Good Good No change No change Good No change

DM DM

1 patient (Table 1, case no. 20). For lumbar lesions, posterior fixation was performed in 3 patients, and laminectomy was performed in 1 patient. For multiple combined lesions (1 patient), laminectomy was performed. For the fusion we used iliac bone in all patients. Among the 17 patients, 5 patients (3 patients with tuberculosis spondylodiscitis and 2 patients with pyogenic spondylodiscitis) underwent surgical intervention with instrumentation. Of these 5 patients, 2 patients with pyogenic spondylodiscitis were treated with a preventive therapy over 1 month followed by instrumentation under a chronic state; the remaining 3 patients with tuberculosis spondylodiscitis were treated with instrumentation despite being in a drainage state. Six patients underwent emergency operation. Of these 6 patients, 5 had pyogenic spondylodiscitis, and 1 had tuberculosis spondylodiscitis. Among the 27 patients, 8 patients had DM complication (including steroid-induced DM), 7 patients had pyogenic spondylodiscitis, and 1 patient

Spondylodiscitis after sepsis

+

+ +

+

+ +

+

had tuberculosis spondylodiscitis. In addition, 6 patients showed complication by meningitis caused by spondylodiscitis: 5 patients were pyogenic and 1 was tuberculous. The latter 2 patients had a repeated episode of meningitis complication (Table 1, case nos. 18 and 26). Furthermore, spondylodiscitis developed after severe infection in 2 patients, after severe meningitis in 1, and after sepsis following colonic cancer in another (Table 1, case nos. 10 and 19) [14,16,20,22,27,39]. In patients who received therapy to protect against distinctly established causal microorganisms, an antibiotic with defined sensitivity was selected and continuously administered by intravenous drip infusion until white cell count, C-reactive protein value, and sedimentation time had normalized successfully. Even after normalization of these hematological data, however, the antibiotic continued to be administered orally for a further 2 months. Patients with tuberculosis spondylodiscitis were orally administered the combination of pyrazinamid

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(1.5 g/d), ethambutol hydrochloride (0.75 g/d), rifampicin (450 mg/d), and isoniazid (0.3-0.4 g/d) for 2 months. Then, the combination of ethambutol hydrochloride, rifampicin, and isoniazid was administered for a further 4 months. 3. Outcome Except for those who died, follow-up was completed for all patients, the duration of which ranged from 4 to 116 (average 44.6) months. After the therapy, patient outcome was graded as bexcellent,Q bgood,Q bno change,Q or bbad.Q The result was assessed as excellent when return to full activity was confirmed; good when the symptoms improved but the patient failed to return to social activities, no change when no noticeable change was observed in the symptoms before and after treatment, and bad when the symptoms were worse after treatment. Fourteen patients were graded as bexcellent,Q 8 as bgood,Q 4 as bno change,Q and no patient as bbad.Q One patient died because of infection by penicillin-resistant Staphylococcus pneumoniae. 4. Discussion 4.1. Diagnosis It is very difficult to diagnose spondylodiscitis at the first medical examination [5,13,17,18,20,28,31-33]. Because a primary symptom of spondylodiscitis is usually pain or fever, almost all affected persons have no sense of risk and thus tend to neglect it for several days [3,8,23,27,29,36]. Such patients then visit a hospital when the symptoms do not ease or become worse, and most of them often visit a department of internal medicine first [7,9,10,37]. In our study as well, the department of internal medicine was the most frequently visited first choice by these patients (18 of 27 cases, 66.7%) [27,33]. Note that no patient was diagnosed as spondylodiscitis at the first examination except for 2 patients who first visited the departments of orthopedics and neurosurgery in our hospital. Even for the patient who visited our department of neurosurgery first, spondylodiscitis was diagnosed by chance while staying in our hospital because of cerebral infarction. However, the diagnosis was made earlier because the patient visited the department of neurosurgery first, although the disease was found by chance [37]. Experienced neurosurgeons always consider spondylodiscitis in the differential diagnosis; so although the patient visited our department first by chance, the successful early diagnosis was not accidental. In the case of pyogenic spondylodiscitis in particular, many patients have DM as a basic disease [10]. In our series as well, 8 of 27 patients had DM. Although it is very difficult to diagnose spondylodiscitis first according to nonspecific symptoms such as pain or fever, this disease complicated with DM should be ranked high in the differential diagnosis. Actually, 1 of the 8 spondylodiscitis patients with DM revealed severe diabetic retinopathy. In this case, the ophthalmologic diagnosis

preceded the neurological symptoms such as back pain, suggesting that other doctors specializing in DM might see a spondylodiscitis patient soon after such neurological symptoms arise. Even doctors examining DM patients consistently may easily fail to diagnose spondylodiscitis unless it is considered. Although most patients with spondylodiscitis have no DM complication, it should always be listed in the differential diagnosis because such cases are not rare. Based on our experience, we believe it is vital to educate doctors in other departments to be aware of this disease, especially those doctors treating patients with DM. 4.2. Therapeutic strategy Concerning the therapeutic strategy for spondylodiscitis, there is no clear consensus [5,12,15,18,19,34,38]. Antibiotics without surgery seem to be the best treatment for spondylodiscitis. A preventive treatment may be the priority, and surgical intervention a final measure [2]. Carrega et al reported a large number of cases without surgery [5], but surgical treatment must be chosen in some cases. Although there are no distinct criteria for selecting surgical intervention, such intervention is appropriate when a neurological defect or symptom (for example, motor weakness, sensory disturbance, or onset of neurogenic bladder) herald cauda equina syndrome, causing remarkable disturbance in daily living, pain, or increasing numbness is observed, or when resistance to a preventive treatment is confirmed [6,24,30]. Surgery is reserved for decompression of neural structures, especially with associated spinal epidural abscess or compression by reactive granulation tissue. When a repeated complication of meningitis is evident, however, surgical intervention is desirable irrespective of the neurological findings observed. Although an emergency operation is of course necessary when the symptoms are progressing rapidly, it is desirable to evaluate the nature, that is, pyogenic or tuberculosis, as accurately as possible [30,32,35]. On the other hand, immobilization for at least 6 weeks during antibiotic therapy is recommended, so surgical intervention has the advantage of early mobilization over being bedridden. In our institution, spirial puncture is routinely performed to identify promptly the possible causal microorganism under guidance by CT [1,11,26]. Instrumentation is practical in cases that are tuberculous spondylodiscitis in nature [21,25,35,40]. In fact, we have used instrumentation in cases of tuberculosis spondylodiscitis that presented with pus discharge. However, we have never used instrumentation for acute pyogenic spondylodiscitis. Although instrumentation seems impractical in pyogenic interventions in general, a case who became infected with other diseases after instrumentation was encountered in our department [4]. In this patient, however, fortunately the instrumentation did not need to be removed, and the prognosis was good. Although we have no experience, based on this case, we suppose that instrumentation can be used for acute pyogenic spondylodiscitis. Case no. 15 (Table 1) significantly

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recovered from tetraparesis immediately after the surgery. However, although a cervical brace was used postoperatively, instability was observed 1 week after surgery, and a Halo vest had to be used for 3 months thereafter. If strong internal fixation by instrumentation had been secured at the first surgery, there might have been no need to use the Halo vest. Pyogenic cases remain to be examined in future studies [19,30].

[16]

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[18]

5. Conclusion To enhance the rate of diagnosis at the first examination, it is important to increase the awareness of doctors in particular in the field of internal medicine. If the diagnosis can be made earlier, the need to perform surgical intervention is reduced. In view of the high incidence of DM complication, this disease should be taken into account when a patient with DM is followed up.

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[21]

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Commentary

such a diagnosis, perhaps more noteworthy in this article is the successful outcome of instrumented fusion after spinal infection, even in diabetic patients. Clearly, careful antibiotic treatment ahead of surgery and prolonged antibiotic use after surgery, particularly where instrumentation is used, are requisites to the prevention of further infection problems, but internal fixation is not contraindicated where previous infection exists. Ronald P. Pawl, MD Lake Forest, Illinois 60045, USA

Although the authors stress early recognition of spinal infection and caution general medical physicians to consider

Everything has its beauty but not everyone sees it. — Confucius