General Principles in the Medical and Surgical Management of Spinal Infections: A Multidisciplinary Approach

Alfredo Quiñones-Hinojosa, MD; Peter Jun, MD; Richard Jacobs, MD; William S. Rosenberg, MD; Philip R. Weinstein, MD

Disclosures

Neurosurg Focus. 2004;17(6) 

In This Article

Abstract and Introduction

Abstract

Object: Infections along the spinal axis are characterized by an insidious onset, and the resulting delays in diagnosis are associated with serious neurological consequences and even death. Infections of the spine can affect the vertebral bodies, intervertebral discs, spinal canal, and surrounding soft tissues. Neurological dysfunction occurs when the spinal cord becomes compressed, edematous, or ischemic due to compression by abscess or vascular compromise. The aim of this paper was to detail general diagnostic and management principles for this disease.
Methods: Recent progress in medical technologies, including the development of potent antimicrobial drugs, advanced imaging, and improved surgical methods, have dramatically reduced morbidity and mortality rates for spinal infections; however, debate still exists on the proper management of this disease. In this paper, the authors review the current management protocols for spinal infections at their institution, focusing on medical and surgical treatments for vertebral osteomyelitis, intervertebral disc space infections, and spinal canal and soft-tissue abscesses.
Conclusions: Technological advances in imaging modalities, pharmaceutics, and surgery have resulted in excellent outcomes and have greatly reduced the morbidity and mortality rates associated with spinal infections. Currently, treatment of spinal infections requires a multidisciplinary team that includes infectious diseases experts, neuroradiologists, and spine surgeons. The key to successful management of spinal infections is early detection.

Introduction

There is a long history of illness and death caused by infections of the spine, and evidence of this entity has been discovered in mummified corpses.[117] Infections develop when the host's local immune responses are overwhelmed by microbial agents. This process can occur in various anatomical locations along the spinal axis, including vertebral bone, intervertebral disc space, epidural or intradural space within the spinal canal, and adjacent soft tissues.

Early treatments were primarily symptomatic, emphasizing bed rest and immobilization. Laminectomy was the first attempt at surgical management; however, because of its failure to address the anterior component of the disease process and the frequent complication of postoperative spinal instability, it is now used less often.[113,116] In 1911, Albee[3] described a posterior fusion technique that reduced kyphotic deformity, but extensive preoperative infection and pronounced kyphosis often resulted in fusion failure. Hodgson and Stock[50] later used an anterior approach to treat spinal infections, with great success. This has now become the surgical approach of choice in many cases.

Management of infections of the spine has evolved greatly during the past century. Advances in imaging, pharmaceutical treatment, and surgical technologies have changed the way these infections are approached. The advent of MR imaging has allowed for earlier detection and more detailed lesion localization. Effective antimicrobial agents have allowed for more aggressive surgical procedures, and have even promoted a shift toward nonsurgical management modalities. Surgical techniques and tools, such as structural grafting and instrumentation, have decreased the morbidity associated with treatment of this disease.

Although still significant, the death rate from spinal infection has declined to 20%.[58] The nature of the disease has evolved as well, with the rise in organisms resistant to multiple drugs adding a new dimension to care. Immunocompromised patients and intravenous drug abusers complicate matters with their distinct presentations. Today, effective treatment requires an interdisciplinary approach that includes specialists in infectious diseases and interventional radiology, coordinated by the spine surgeon. In this paper we will concentrate in the current diagnosis and management of spinal infections, and we hope to provide the reader with the most current management strategies for this clinical entity, which is a disease that has devastating consequences for some patients.

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