Osteomyelitis of the spinal column

Osteomyelitis of the spinal column is considered a relatively rare, severe, life-threatening, difficult to diagnose and difficult disease to treat.
We observed 92 patients aged 6 to 73 years (the average age was 38.4 years). Men – 64 patients (69.6%) suffer 2.3 times more often than women – 28 patients (30.4%). The distribution by age was as follows: under 20 years old – 9; 20 – 40 years old – 44; 41 – 60 years old – 32; over 60 years – 7 patients.

The demographic picture of this disease can vary. Patients, according to foreign authors, represent an older age group with poor health. This may be due to an increase in life expectancy, as well as an increase in the intensity of treatment for serious diseases, the use of chemotherapy, etc.

Purulent inflammation of the vertebrae can occur in three ways: the bacterial pathogen enters the bone either from the outside (for example, through a wound), or from the neighboring joint, soft tissues (phlegmon, abscess), or, metastatically from a distant focus of purulent infection, which causes the development of hematogenous osteomyelitis of the spinal column (GOPS). A number of predisposing factors can be distinguished: septic conditions, massive surgical interventions, the presence of unresolved foci of infection, prolonged intravenous administration of drugs, hormonal therapy, renal or hepatic failure, various immunosuppressive conditions, incl. HIV, drug addiction.

The proportion of staphylococcal flora can reach 83% (Staphylococcus aureus occurs 2-4 times more often). With an increase in the patient’s age and the severity of immunodeficiency, the proportion of saprophytic flora increases significantly. The manifestation of HOPS is associated with the appearance of febrile fever, signs of general intoxication against the background of severe pain in the affected spine. From local manifestations, it is possible to note severe pain on palpation of the processes of the affected vertebrae, hyperemia and pasty tissues of the back. The patient tries to avoid even the slightest movement in the spine.

The clinical picture of GOPS has changed significantly since the beginning of the widespread use of antibiotics in clinical practice. Septic forms are much less common. The disease proceeds under a huge number of “masks”: osteochondrosis, abscesses and phlegmons of the back, neck, retroperitoneal space, paranephritis, etc. Most often, subacute begins against the background of subfebrile fever.

With spondylography, osteo-destructive processes generally appear no earlier than 4-6 weeks, although the earliest signs: a decrease in the height of the intervertebral disc, edema of the pre- and paravertebral tissues are insufficiently evaluated. Along with destructive processes, there are osteoplastic ones, the severity of which can give a wide variety of X-ray manifestations. Initial growths are determined after 6-8 weeks along the border with the destruction zone. Although they can spread to several adjacent vertebrae, the bone block as an outcome of the process is formed only in chronic osteomyelitis in 20% of cases.

The use of modern diagnostic methods – CT, MRI, with the proper clinical alertness of doctors to this disease, can reduce the time for making a diagnosis from 2-6 months. up to 1-4 weeks.

Treatment of GOPS should be comprehensive. We assign a leading role in this treatment to surgical intervention: on the cervical spine – by the anterior approach, on the thoracic spine – extrapleural posterolateral, on the lumbar – extraperitoneal.

Conservative treatment does not lose its importance with early diagnosis (up to 1 month), while intravenous or intra-arterial antibiotic therapy is prescribed for 4-6 weeks, taking into account the sensitivity of the flora. No clinical effect within 1 month. leaves the only adequate method of treatment – surgical intervention, which must combine surgical and orthopedic principles. In addition to sanitizing the focus of infection, it is necessary to restore the supporting function of the spine. With the phenomena of tissue sclerosis in the focus of infection, it is advisable to produce ultrasonic cavitation of broad-spectrum antibiotics.

The removed tissues are subjected to histological examination and determination of flora, its sensitivity to antibiotics.

The focus of inflammation is drained in the shortest possible way.

The immune qualities of the body are studied, if necessary, the immune status is corrected.

Our clinic has accumulated extensive experience in the treatment of GOPS. The views on surgical treatment have changed. We have moved from the only previously possible sequestrnecretomy operations to the most progressive neuro-orthopedic interventions, such as replacing defects formed during the resection of vertebral bodies with porous titanium nickelide implants impregnated with antibiotic solutions.

Unlike bone grafts, which themselves can be involved in the inflammatory process, porous titanium nickelide implants provide good stabilization from the moment of their application, and then fusion.

The effectiveness of this technique increases significantly when supplemented with transpedicular fixation. This makes it possible to significantly reduce the duration of inpatient treatment of patients and the overall period of rehabilitation.

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