• HPI

    • 45 yo male presents with a few weeks of low grade fever, neck pain and progressive difficulty with walking.
    • Blood cultures reveal methicillin sensitive Staphylococcus aureus and treatment with nafcillin was initiated.
    • Patient transferred with imaging revealed C7 collapse with infectious changes.
    • PMH: significant for IV drug abuse.

    Physical Exam

    • Patient in hard collar with limited neck mobility.
    • Slight decrease in muscle strength in both upper extremities.
    • Myelopathic exam with increased deep tendon reflexes in bilateral lower extremeties and bilateral triceps tendons.

    Figure 2. (Below) MRI reveals enhancement of dura (horizontal arrow) and epidural space with obliteration (vertical arrow) of sub-arachnoid space. Sagittal images reveal epidural contrast enhancement and kyphosis. MR T2W sagittal images show severe kyphosis and spinal cord compression. 

     

    Figure 1. CT of Cervical Spine - Shows a gibbus at C7 with angulation and vertebral body collapse.

    Figure 2: MRI with gadolinium contrast

    1. What is the concordance between blood culture and abscess culture in spinal abscess?

    2. In light of neurologic findings in the setting of an infectious spinal etiology, what is the role of corticosteroid administration?

    3. What surgical procedure would you recommend for this patient?

     4. If the abscess culture grows methicillin sensitive S. aureus, what antibiotic regimen would you recommend?

    5. Which of the following describes you?

    6. I practice in one of the following locations.

    7. Please add any suggestions or comments regarding this case: 

    • antibiotics - intravenous for 6 weeks, followed by oral for 12 months.
    • Needs nafcillin IV 2g every four hours for 6 weeks then 6 weeks of oral antibiotic.
    • I´d try a 360, initially with anterior approach, thorough debridement and cleaning, C7 corpectomy, rotate the patient, and perform laminectomy C6, C7 and T1, with transpedicular instrumentation from C5-T2, Close, rotate again, and apply iliac crest graft, or box and anterior cervical plate.
    • May use autograph (ant iliac crest) in this case.
    • In case of spinal abscess best option is cage fixsation because due to infection alograft may give again compression and poor result.diet control and full A/B course of 6 week is best. avoid to use steriod but do surgery as early as posible to save from spinal cord demage. Use of hard cooler Must. dr tulat
    • Would use peri-operative steroids for about 3 days. Due to limited films, unsure if stable posteriorly regarding facet joints, as related to need for supplementary posterior instrumented fusion.
    • This case needs AP decamp, stabilize, fuse w 6 weeks IV abx following the definitive surgery
    • the oppinion of a recognized expert would be of great value as well as the presentation of the answers.
    • I think any allograft strut has high chance of being infected. There is the possibility for return later. I would add auto graft
    • The principal aim in this cases is to clean the area and start with an antibiotic regiment further more, 6 weeks.
    • Anterior C7 carpectomy with c6D1 fusion.
    • Stabilize in halo prior to surgery
    • I would use morsellized iliac crest autograft to put in the titanium cage and posterolaterally. I would add Rifampin to the antibiotic regimen.
    • The patient had a spondylodicitis. Our treatment will be 1. a combination auf 3 antibiotics (Vancomycin + Cetriaxon + Metronidazol) until we obtain a antibiogramm. 2. Operation with ventral and dorsal instrumentation with intra-OP biopsy for the pathology and microbiology. 3. Looking the patient for the source of the infection and treat it. 4. After antibiogramm we will switch to the “sensible antibiotic”, iv for 4 weeks and then to po for 8 weeks. 5. MRI, CT and XR-Control after 6 to 8 weeks 6. To continue the antibiotic if the leuco and CRP don’t become normal.
    • I would asl Infectious Disease to manage the antibiotics
    • thank you
    • none
    • He needs anterior decompression, re-alignment and stabilisation. Fusion will occur eventually even without instrumentation although it may be in less than perfect position. There is no indication that combined anterior and posterior surgery has any advantage, nor that complex fixation is better than simple decompression with allograft apart from the potential to remove an external brace earlier. Bacteriological study will answer regarding course of medication but radiological evidence of graft union will indicate effect.
    • I think any allograft strut has high chance of being infected. There is the possibility for return later. I would add auto graft
    • Cervical traction first. If good deformity correction anterior approach+/-posterior. If deformity persists posterior approach first for lami and correction of deformity followed by anterior column reconstruction
    • I would not necessarily use the interbody replacement choices given. There is edema in T1 and fibula tends to telescope. I would consider a Peek device or metatarsal or tricortical iliac crest allografts.
    • Great case and complex resolution. The combination (ant and post.)approach at the level is the key for long term stabilization.
    • Expert review of case for maximal educational benefit
    • The use of the term "infectious changes" is incorrect unless you mean that the infected vertebrae and disc are communicating the infection. You should be more precise in your use of the English language particularly in scientific settings. Is this pathological situation the result of infection(namely infected) or is it communicating the infection elsewhere( infectious)? Those are the questions you should ask yourself. Now if you mean that the infected bone or disc is communicating the infection to the epidural space then you might have a case or if the disc was initially infected and communicated that infection to the adjacent bone and epidural spaces. However you would have to determine which occurred first. If you can't then safest to avoid the term infectious.
    • Retired

We use cookies to improve the performance of our site, to analyze the traffic to our site, and to personalize your experience of the site. You can control cookies through your browser settings. Please find more information on the cookies used on our site here. Privacy Policy