Zusammenfassung
Infektionen der Wirbelsäule kommen selten und eher bei älteren Patienten mit Harnwegsinfekten und Diabetes mellitus vor. Mit der Zunahme von immunsupprimierten Patienten , v. a. bei Drogenabusus oder HIV-Infektion, und von Immigranten aus Ländern der 2. und 3. Welt steigt die Inzidenz von Infektionen an der Wirbelsäule gerade auch bei jüngeren Patienten. Typisch ist nur ein Erreger als Verursacher, mit Staphylococcus aureus als häufigstem bakteriellem Keim. Die Keimbesiedelung erfolgt vornehmlich hämatogen und betrifft initial die endplattennahenAreale des Wirbelkörpers. Bei unspezifischer Klinik sind insbesondere die Kernspintomographie und der mikrobiologische Keimnachweis im Punktat diagnostisch wesentlich. Im Vordergrund der Therapie steht die gezielte Antibiose über mindestens 6–8 Wochen. Eine Indikation zur Op. mit osteosynthetischer Stabilisierung und Spondylodese besteht in der Regel bei neurologischen Ausfällen, knöcherner Instabilität sowie Abszessen.
Abstract
Spinal infections are rare, occurring most often in elderly patients with urinary tract infections or diabetes. With the increasing number of patients with immune suppression, and also the increasing number of immigrants in the population, spinal infections are seen more frequently, especially in young adults. Typically spinal infections are monomicrobial, Staphylococcus aureus being the most common organism. Hematogenous spread of bacteria through the arterial paravertebral collateral vessels into the subchondral bone marrow of the vertebral bodies is the most common source of infection. Clinical presentation is often nonspecific. Important diagnostic measurements are laboratory studies, radiological evaluation including MR image scans, and CT-guided percutaneous biopsy of the lesion for microbiological studies. The management of spinal infections consists of antimicrobial therapy over 6–8 weeks. Surgical intervention is indicated in neurologically compromised patients for spinal instability and abscesses.
Literatur
Abbey DM, Turner DM, Wasron JS, Wirt TC, Scalley RD (1995) Treatment of postoperative wound infections following fusion with instrumentation. J Spinal Disord 8: 278–283
Abe E, Yan K, Okada K (2000) Pyogenic vertebral osteomyelitis presenting as a single spinal compression fracture: a case report and review of the literature. Spinal Cord 38: 639–644
Abramovitz JN, Batson RA, Yablon JS (1986) Vertebral osteomyelitis. The surgical management of neurologic complications. Spine 11: 418–420
Aguila LA, Piraino DW, Modic MT, Dudley AW, Duchesneau PM, Weinstein MA (1985) The intranuclear cleft of the intervertebral disc: Magnetic resonance imaging. Radiology 155: 155–158
Allain TJ, Stevens PE, Bridges LR, Phillips ME (1988) Dialysis myelopathy: Quadriparesis due to extradural amyloidosis of β2 microglobulin origin. BMJ 296: 752–753
Al-Muhim FA, Ibrahim EM, el-Hassan AY (1995) Magnetic resonance imaging of tuberculous spondylitis. Spine 20: 2287–2292
Batson OV (1940) The function of the vertebral veins and their role in the spread of metastases. Ann Surg 112: 138–149
Becker W, Goldenberg DM, Wolf F (1994) The use of monoclonal antibodies and antibody fragments in the imaging of infectious lesions. Semin Nucl Med 24: 142–153
Boachie-Adjei O, Squillante RG (1996) Tuberculosis of the spine. Orthop Clin North Am 27: 95–103
Bohlman HH, Freehafer A, Dejak J (1985) The results of treatment of acute injuries of the upper thoracic spine with paralysis. J Bone Joint Surg 67-A: 360–369
Bonfiglio M, Lange TA, Kim YM (1973) Pyogenic vertebral osteomyelitis. Disc space infections. Clin Orthop 96: 234–247
Broner FA, Garland DE, Zigler JE (1996) Spinal infections in the immunocompromised host. Orthop Clin North Am 27: 37–46
Bullogh PG, Boachie-Adjei O (1988) Atlas of spinal diseases. Lippincott, Philadelphia
Chahal AS, Jyoti SP (1990) The radical treatment of tuberculosis of the spine. Int Orthop 4: 93–99
Chazan B, Strahilevitz J, Millgram MA, Kaufmann S, Raz R (2001) Bacteroides fragilis vertebral infection secondary to anal dilatation. Spine 26: E377–378
Choong K, Monaghan P, McGuigan L, McLean R (1990) Role of bone scintigraphy in the early diagnosis of discitis. Ann Rheum Dis 49: 932–934
Christensen D (1994) Pre-Columbian mummy lays TB debate to rest. Sci News 145: 181
Coapes CM, Roysam GS (2001) Vertebral osteomyelitis secondary to epidural catheter use: a case report. Spine 26: 1492–1494
Colson P, La Scola B, Champsaur P (2001) Vertebral infections caused by Haemophilus aphrophilus: case report and review. Clin Microbiol Infect 7: 107–113
Coopan R, Schoenbaum S, Younger MD, Friedberg S, D’Elia J (1976) Vertebral osteomyelitis in insulin-dependent diabetics. S Afr Med J 50: 1993–1996
Cortet B, Richard R, Deprez X et al. (1994) Aspergillus spondylodiscitis: Successful conservative treatment in 9 cases. J Rheumatol 21: 1287–1291
Coventry MB, Ghormley RK, Kernohan JW (1945) The intervertebral disc, its microscopic anatomy and pathology. Part I: Anatomy, development and physiology. J Bone Joint Surg 27-A: 105.112
Crock HV (1986) Internal disc disruption. A challenge to disc prolapse fifty years on. Spine 11: 650–653
Darouiche RO, Hamill RJ, Greenberg SB, Weathers SW, Musher D (1992) Bacterial spinal epidural abscess: Review of 43 cases and literature survey. Medicine 71: 369–385
Dietze DD, Fessler RG, Jacob RP (1997) Primary reconstruction for spinal infections. J Neurosurg 86: 981–989
Digby JM, Kersley JB (1979) Pyogenic nontuberculous spinal infection: an analysis of thirty cases. J Bone Joint Surg 61-B: 47–55
Dina TS (1992) Infection of the spine. Semin Spine Surg 4: 98–110
Eismont FJ, Bohlman HH, Soni PL, Goldberg VM, Freehafer AA (1983) Pyogenic and fungal vertebral osteomyelitis with paralysis. J Bone Joint Surg 65-A: 19–29
Elghazawi AK (1991) Clinical syndromes and differential diagnosis of spinal disorders. Radiol Clin North Am 29: 651–663
Engh CA, Hughes JL, Abrams RC, Bowerman JW (1971) Osteomyelitis in the patient with sickle-cell-disease. J Bone Joint Surg 53-A: 1–15
Faraj AA, Webb JK (2000) Spinal instrumentation for primary pyogenic infection: report of 31 patients. Acta Orthop Belg 66: 242–247
Forsythe M, Rothman RH (1978) New concepts in the diagnosis and treatment of infections of the cervical spine. Orthop Clin North Am 9: 1039–1051
Franks ME, Lavelle JP, Yokoyama T, Chuang YC, Chancellor MB (2000) Metastatic osteomyelitis after pubovaginal sling using bone anchors. Urology 56: 330–331
Frazier DD, Campbell DR, Garvey TA, Wiesel S, Bohlman HH, Eismont FJ (2001) Fungal infections of the spine. Report of eleven patients with long term follow-up. J Bone Joint Surg 83-A: 560–565
Friedmand DP, Hills JR (1994) Cervical epidural spinal infection: MR imaging characteristics. Am J Roentgenol 163: 699–704
Frederickson B, Yuan H, Olans R (1978) Management and outcome of pyogenic vertebral osteomyelitis. Clin Orthop 131: 160–167
Fountain SS (1979) A single stage combined surgical approach for vertebral resections. J Bone Joint Surg 61-A: 1011–1017
Garcia A Jr, Grantham SA (1960) Haematogenous pyogenic vertebral osteomyelitis. J Bone Joint Surg 42-A: 429–436
Garst RJ (1992) Tuberculosis of the spine: a review of 236 cases in an underdeveloped region from 1954 to 1964. J Spinal Disord 5: 286–300
Gerszten PC, Gerszten E, Allison MJ (2001) Diseases of the spine in south american mummies. Neurosurgery 48: 208–213
Gillams AR, Chadda B, Carter AP (1996) MR appearance of the temporal evolution and resolution of infectious spondylitis. Am J Roentgenol 166: 903–907
Govender S, Charles RW, Ballaram RS, Achary DM (1988) Vertebral osteomyelitis after a closed fracture of the spine. S Afr Med J 73: 124–126
Govender S, Kumar KP (2001) Aspergillus spondylitis in immunocompetent patients. Int Orthop 25: 74–76
Govender S, Mutasa E, Parbhoo AH (1999) Cryptococcal osteomyelitis of the spine. J Bone Joint Surg 81-B: 459–461
Graziano GP, Sidhu KS (1993) Salvage reconstruction in acute and late sequalae from pyogenic thoracolumbar infection. J Spinal Disord 6: 199–207
Griffiths HE, Jones DM (1971) Pyogenic infection of the spine. A review of twenty-eight cases. J Bone Joint Surg 53-B: 383–391
Guhlmann A, Brecht-Krauss D, Suger G, Glatting G, Kotzerke J, Kinzl L, Reske SN(1998) Fluorine-18-FDG PET and technetium-99m antigranulocyte antibody scintigraphy in chronic osteomyelitis. J Nucl Med 39: 2145–2152
Hadjipavlou AG, Mader JT, Necessary JT, Muffoletto AJ (2000) Haematogenous pyogenic spinal infections and their surgical management. Spine 25: 1668–1679
Harris TJ, Lichtman DM, Swafford AR (1981) Pyogenic vertebral osteomyelitis complicating abdominal stab wounds. J Trauma 21: 75–79
Heary RF, Vaccaro AR, Mesa JJ, Balderston RA (1996) Thoracolumbar infections in penetrating injuries to the spine. Orthop Clin North Am 27: 69–81
Heller JG (1992) Postoperative infections of the spine. In: Rothman RH, Simeone FA (eds) The Spine, 3rd edn. WB Saunders, Philadelphia
Hodgson AR, Stock FE (1960) Anterior spine fusion for the treatment of tuberculosis of the spine. J Bone Joint Surg 42-A: 295–310
Hodgson AR, Yau A, Kwon JS, Kim D (1964) A clinical study of 100 consecutive cases of Pott’s paraplegia. Clin Orthop 36: 128–150
Holzmann RS, Bishko F (1971) Osteomyelitis in heroin addicts. Ann Intern Med 75: 693–696
Horowitz MD, Dove DB, Eismont FJ, Green BA (1985) Impalement injuries. J Trauma 25: 914–916
Hotze AL, Briele B, Overbeck B et al. (1992) Technetium-99-labeled antigranulocyte antibodies in suspected bone infections. J Nucl Med 33: 526–531
Ido K, Shimizu K, Nakayama Y, Shikata J, Matsushita M, Nakamura T (1996) Suction/irrigation for deep wound infection after spinal instrumentation: a case study. Eur Spine J 5: 345–349
Kaim A, Maurer T, Ochsner P, Jundt G, Kirsch E, Mueller-Brandt J (1997) Chronic complicated osteomyelitis of the appendicular skeleton: diagnosis with technetium-99m labeled monoclonal antibody-immunoscintigraphy. Eur J Nucl Med 24: 732–738
Kälicke T, Schmitz A, Risse JH et al. (2000) Fluorine-18 fluorodeoxyglucose PET in infectious bone disease: results of histologically confirmed cases. Eur J Nucl Med 27: 524–528
Kemp HBS, Jackson JW, Jeremiah JD, Cook J (1973) Anterior fusion of the spine for infective lesions in adults. J Bone Joint Surg 55-B: 715–734
Kulowski J (1936) Pyogenic osteomyelitis of the spine: An analysis and discussion of 102 cases. J Bone Joint Surg 18: 343–364
Küker W, Mull M, Mayfrank L, Töpper R, Thron A (1997) Epidural spinal infection: Variability of clinical and magnetic resonance imaging findings. Spine 22: 544–550
Kuntz D, Naveau B, Bardin T, Drueke T, Treves R, Dryll A (1984) Destructive spondyloarthropathy in haemodialyzed patients: A new syndrome. Arthritis Rheum 27: 369–375
Kushawa VP, Shaw BA, Gerardi JA, Oppenheim WL (1996) Musculoskeletal coccidoidomycosis. A review of 25 cases. Clin Orthop 332: 190–199
Lang EW, Pitts LH (1996) Intervertebral disc space infection caused by a Aspergillus fumigatus. Eur Spine J 5: 207–209
Lehmann CR, Deckey JE, Hu SS (2000) Eikanella corrodens vertebral osteomyelitis secondary to direct inoculation: a case report. Spine 25: 1185–1187
Lifeso RM, Weaver P, Harder EH ( 1985) Tuberculous spondylitis in adults. J Bone Joint Surg 67-A: 1405–1413
Lonser RR, Brodke DS, Dailey AT (2001) Vertebral osteomyelitis secondary to Pseudallescheria boydii. J Spinal Disord 14: 361–364
Love C, Patel M, Lonner BS, Thomas MB, Palestro CJ (2000) Diagnosing spinal osteomyelitis: a comparison of bone and Ga-67 scintigraphy and magnetic resonance imaging. Clin Nucl Med 25: 963–977
Lowe J, Kaplan L, Liebergall M, Floman Y (1989) Serratia osteomyelitis causing neurological deterioration after spine fracture. J Bone Joint Surg 71-B: 256–258
Lucio E, Adesokan A, Hadjipavlou AG, Crowe WN, Adegboyega PA (2000) Pyogenic spondylodiskitis: a radiologic/pathologic and culture correlation study. Arch Pathol Lab Med 124: 712–716
Makins GH, Abbott FC (1896) On acute primary osteomyelitis of the vertebra. Ann Surg 23: 510–539
Malawski SK, Lukawski S (1991) Pyogenic infection of the spine. Clin Orthop 272: 58–66
Marcelli C, Pérennou D, Cyteval C, Leray H, Lamarque IL, Mion C, Simon L (1996) Amyloidosis-related cauda equina compression in long-term haemodialysis patients. Spine 21: 381–385
Martin NS (1970) Tuberculosis of the spine: A study of the results of treatment during the last 25 years. J Bone Joint Surg 52-B: 613–628
Massie JB, Heller JG, Abitbol JJ, McPherson D, Garfin SR (1992) Postoperative posterior spinal wound infections. Clin Orthop 284: 99–108
McAfee PC, Bohlmann HH (1985) Complications following Harrington instrumentation for fractures of the thoracolumbar spine. J Bone Joint Surg 67-A: 672–686
McGuire RA, Eismont FJ (1994) The fate of autogenous bone graft in surgically treated pyogenic osteomyelitis. J Spinal Disord 7: 206–215
McLean DR, Rusell N, Khan MY (1992) Neurobrucellosis: Clinical and therapeutic features. Clin Infect Dis 15: 582–590
Merkel KD, Brown ML, Dewanjee MK, Fitzgerald RH Jr (1985) Comparison of Indium-labeled-leucocyte imaging with sequential Technetium-Gallium scanning in the diagnosis of low-grade musculo-skeletal sepsis. J Bone Joint Surg 67-A: 465–476
Milgram JW, Romine JS (1982) Spontaneous osteomyelitis complicating a compression fracture of the lumbar spine. Spine 7: 179–182
Miller BR, Schiller WR (1989) Pyogenic vertebral osteomyelitis after transcolic gunshot wound. Military Med 154: 64–66
Miller DJ, Mejicano GC (2001) Vertebral osteomyelitis due to Candida Species: case report and literature review. Clin Infect Dis 33: 523–530
Moula T, Fowles JV, Kassab MT, Sliman N (1981) Pott’s paraplegia: a clinical review of operative treatment in 63 adults and children. Int Orthop 5: 23–29
Niu CC, Chen WJ, Chen LH, Shih CH (2000) Destructive spondyloarthropathy mimicking spondylitis in long-term haemodialysis patients. Arch Orthop Trauma Surg 120: 594–597
Nussbaum ES, Rigamonti D, Standiford H, Numaguchi Y, Wolf AL, Robinson WL (1992) Spinal epidural abscess: A report of 40 cases and review. Surg Neurol 38: 225–231
Oga M, Arizono T, Takasita M, Sugioka Y (1993) Evaluation of the risk of instrumentation as a foreign body in spinal tuberculosis. Clinical and biologic study. Spine 18: 1890–1894
Osenbach RK, Hitchon PW, Menezes AH (1990) Diagnosis and management of pyogenic vertebral osteomyelitis. Surg Neurol 33: 266–275
Özerbil OM, Ural O, Topatan HI, Erongun U (1998) Lumbar spinal root compression caused by brucellar granuloma. Spine 23: 491–493
Parry M, Grant B, Yukna M, Adler-Klein D, McLeod G, Taddonio R, Rosenstein C (2001) Candida osteomyelitis and diskitis after spinal surgery: an outbreak that implicates artificial nail use. Clin Infect Dis 32: 352–357
Patzakis MJ, Rao S, Wilkins J (1991) An analysis of 61 cases of vertebral osteomyelitis. Clin Orthop 264: 178–183
Perronne C, Saba J, Behlouhl D, Salmon-Ceron D, Leprot C, Wilde JL, Kahn MF (1994) Pyogenic and tuberculous spondylodiskitis (vertebral osteomyelitis) in 80 adult patients. Clin Infect Dis 19: 746–750
Pina MA, Modrego PJ, Uroz, JJ, Cobeta JC, Lerin FJ (2001) Brucellar spinal epidural abscess of cervical location: report of four cases. Eur Neurol 45: 249–253
Post MJ, Sze G, Quencer RM, Eismont FJ, Green BA, Gahbauer U (1990) Gadolinium-enhanced MR in spinal infection. J Comput Assist Tomogr 14: 721–729
Pott P (1936) Remarks on that kind of palsy of the lower limbs which is frequently found to accompany a curvature of the spine, and is supposed to be caused by it: Together with its method of cure, to which are added observations on the necessity and property of amputations in certain circumstances. Medical Classics, vol 1. William & Wilkins, Baltimore
Przybylski GJ, Sharan AD (2001) Single-stage autogenous bone grafting and internal fixation in the surgical management of pyogenic discitis and vertebral osteomyelitis. J Neurosurg 94: 1–7
Quiles I, Blazquez JC, De Teresa L, Plaza J, Medrano C (2000) Vertebral osteomyelitis due to Pasteurella aerogenes. Scand J Infect Dis 32: 566–567
Resnick D, Niwayama G (1995) Osteomyelitis, septic arthritis, and soft tissue infection. Axial skeleton. In: Resnick D (ed) Diagnosis of bone and joint disorders, 3rd edn. WB Saunders, Philadelphia, pp 2419–2447
Richards BS (1995) Delayed infections following posterior spinal instrumentation for the treatment of idiopathic scoliosis. J Bone Joint Surg 77-A: 524–529
Ridley N, Shaikh MI, Remedios D (1998) Radiology of skeletal tuberculosis. Orthopedics 21: 1213–1220
Romanick PC, Smith TK, Kopaniky DR, Oldfield D (1985) Infection about the spine associated with low-velocity-missile injury to the abdomen. J Bone Joint Surg 67-A: 1195–1201
Ross PM, Fleming JL (1976) Vertebral body osteomyelitis: spectrum and natural history. Clin Orthop 118: 190–198
Rothman SLG (1996) The diagnosis of infections of the spine by modern imaging techniques. Orthop Clin North Am 27: 15–31
Rousselin B, Helenon O, Zingraff J,Delon S, Drueke T, Bardin T, Moreau JF (1990) Pseudotumor of the craniocervical junction during long-term hemodialysis. Arthritis Rheum 33: 1567–1573
Ruffer MA (1918) Arthritis deformans and spondylitis in ancient Egypt. J Pathol Bacteriol 22: 212–226
Safran O, Rand N, Kaplan L, Sagiv S, Floman Y (1998) Sequential or simultaneous, same-day anterior decompression and posterior stabilization in the management of vertebral osteomyelitis of the lumbar spine. Spine 23: 1885–1890
Sandoe JA, Witherden IR, Settle C (2001) Vertebral osteomyelitis caused by Enterococcus raffinosus. J Clin Microbiol 39: 1678–1679
Sapico FL, Montgomerie JZ (1980) Vertebral osteomyelitis in intravenous drug abusers: report of three cases and review of the literature. Rev Infect Dis 2: 196–206
Sapico FL, Montgomerie JZ (1990) Vertebral osteomyelitis. Infect Dis Clin North Am 4: 539–550
Sharif HS, Aidejan OA, Clark DC et al. (1989) Brucellar and tuberculous spondylitis: Comparative imaging features. Radiology 171: 419–425
Shiota E, Masatoshi N, Kuniyoshi T (2001) Surgical therapy for dialysis-related spondyloarthopathy: review of 30 cases. J Spinal Disord 14: 165–171
Smith NR (1931) The intervertebral discs. Br J Surg 18: 358–375
Solis-Garcia del Pozo J, Martinez-Alfaro E, Abdad L, Solera J (2000) Vertebral osteomyelitis caused by Streptococcus agalactiae. J Infect 41: 84–90
Spiegel P, Kengla KW, Isaacson AS (1972) Intervertebral disc inflammation in children. J Bone Joint Surg 54-A: 284–296
Stauffer RN (1975) Pyogenic vertebral osteomyelitis. Orthop Clin North Am 6: 1015–1027
Stäbler A, Baur A, Kruger A, Weiss M, Helmberger T, Reiser M (1998) Differenzialdiagnose der erosiven Osteochondrose und bakteriellen Spondylitis in der Magnetresonanztomographie. Fortschr Röntgenstr. 168: 421–428
Stäbler A, Reiser MF (2001) Imaging of spinal infection. Radiol Clin North Am 39: 115–135
Stone JL, Cybulski GR, Rodriguez J, Gryfinski ME, Kant R (1989) Anterior cervical debridement and strut-grafting for osteomyelitis of the cervical spine. J Neurosurg 70: 879–883
Takahashi J, Ebara S, Kamimura M et al. (2001) Early-phase enhanced inflammatory reaction after spinal instrumentation surgery. Spine 26: 1698–1704
Theiss SM, Lonstein JE, Winter RB (1996) Wound infections in reconstructive spine surgery. Orthop Clin North Am 27: 105–110
Turpin S, Lambert R (2001) Role of scintigraphy in musculoskeletal and spinal infections. Radiol Clin North Am 39: 169–189
Tyrrell PN, Cassar-Pullicino VN, McCall IW (1999) Spinal infection. Eur Radiol 9: 1066–1077
Verdu A, Garcia-Granero E, Garcia-Fuster MJ, Martin A, Millan M, Lledo S (2000) Lumbar osteomyelitis and epidural abscess complicationg recurrent pilonidal cyst. Dis Colon Rectum 43: 1015–1017
Vincent KA, Benson DR, Voegeli TL (1988) Factors in the diagnosis of adult pyogenic vertebral osteomyelitis. Orthop Trans 12: 523–524
Whalen RL, Brown ML, McLeod R, Fitzgerald RH Jr (1991) Limitations of indium leukocyte imaging for the diagnosis of spine infections. Spine 16: 193–197
Wiley AM, Trueta J (1959) The vascular anatomy of the spine and its relationship to pyogenic vertebral osteomyelitis. J Bone Joint Surg 41-B: 796–809
William RL, Fukui MB, Meltzer CC, Swarnkar A, Johnson DW, Welch W (1999) Fungal spinal osteomyelitis in the immunocompromised patient: MR findings in three cases. Am J Neuroradiol 20: 381–385
Willis TA (1949) Nutrient arteries of the vertebral bodies. J Bone Joint Surg 31-A: 538–540
Wisneski RJ (1991) Infectious disease of the spine. Diagnostic and treatment considerations. Orthop Clin North Am 22: 491–501
Wolansky LJ, Heary RF, Patterson T et al. (1999) Pseudosparing of the endplate: A potential pitfall in using MR to diagnose infectious spondylitis. Am J Roentgenol172: 777–780
Yau AC, Hodgson AR (1968) Penetration of the lung by the paravertebral abscess in tuberculosis of the spine. J Bone Joint Surg 50-A: 243–254
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Müller, E.J., Russe, O.J. & Muhr, G. Osteomyelitis der Wirbelsäule. Orthopäde 33, 305–315 (2004). https://doi.org/10.1007/s00132-003-0603-2
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DOI: https://doi.org/10.1007/s00132-003-0603-2