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Pyogenic Spinal Infection

advanced
6 min
28 marks
6 questions
Clinical Scenario
A 55-year-old male with type 2 diabetes presents with 3 weeks of progressive back pain, fever, and malaise. He has been treated for a urinary tract infection recently. His temperature is 38.5°C, WBC 18,000, CRP 180. On examination, he has severe tenderness over the lumbar spine and has developed leg weakness over the past 48 hours.
Sagittal T2-weighted MRI demonstrating L3-4 disc space infection with high signal in the disc and adjacent vertebral endplates. There is destruction of the L3 and L4 endplates with collapse. A posterior epidural abscess extends from L2 to L5 with cord/cauda compression. Paravertebral collection is visible anteriorly. This represents pyogenic spondylodiscitis with epidural abscess requiring urgent surgical debridement.
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Sagittal T2-weighted MRI demonstrating L3-4 disc space infection with high signal in the disc and adjacent vertebral endplates. There is destruction of the L3 and L4 endplates with collapse. A posterior epidural abscess extends from L2 to L5 with cord/cauda compression. Paravertebral collection is visible anteriorly. This represents pyogenic spondylodiscitis with epidural abscess requiring urgent surgical debridement.

Image source: Open Access medical literature (NIH/PubMed Central) • CC-BY License

Questions

Question 1 (4 marks)

Describe the MRI findings and what is the most likely diagnosis?

Question 2 (5 marks)

What are the risk factors and common causative organisms?

Question 3 (6 marks)

How do you investigate this patient and what are the indications for surgery?

Question 4 (5 marks)

Describe your surgical approach for debridement and stabilization.

Question 5 (4 marks)

What is the antibiotic management strategy?

Question 6 (4 marks)

What are the expected outcomes and prognostic factors?

Exam Day Cheat Sheet

Must Mention

  • •S. aureus most common (50-60%)
  • •Blood cultures x2 BEFORE antibiotics
  • •MRI = investigation of choice
  • •Epidural abscess + neuro deficit = urgent surgery
  • •6 weeks IV minimum, 6-12 weeks total
  • •Titanium instrumentation OK with debridement
  • •CRP to monitor response

Common Pitfalls

  • •Antibiotics before cultures
  • •Missing epidural abscess urgency
  • •Short antibiotic course
  • •Not checking echo for endocarditis
  • •Avoiding needed instrumentation
  • •Missing TB in appropriate populations