Espondilodiscites sépticas: diagnóstico e tratamento

Abstract

RESUMO -Estudamos retrospectivamente 24 pacientes com espondilodiscite séptica de diferentes etiologias (hematogênica, primária e infantil) e os diferentes aspectos envolvidos em seu diagnóstico e tratamento. Constatamos que a velocidade de hemossedimentação é um bom parâmetro laboratorial para acompanhar a evolução da doença, mas deve ser sempre interpretada conjuntamente com o quadro clínico e os achados de neuroimagem. Biópsias devem ser reservadas para os casos de diagnóstico duvidoso e o tratamento clínico realizado sempre que afastadas as seguintes condições: sepse, déficit neurológico, deformidade severa, abscesso epidural e corpo estranho (discite primária). A abordagem cirúrgica deve ser planejada levando em conta o estágio da doença, sendo preferencialmente por via posterior nas fases supurativas e anterior nas demais. Baseados em nossa experiência e em revisão da literatura, propomos um algoritmo para orientar o diagnóstico e o tratamento das espondilodiscites sépticas.PALAVRAS-CHAVE: discite séptica, espondilodiscite séptica, osteomielite vertebral.Septic spondylodiscitis: diagnosis and treatment Septic spondylodiscitis: diagnosis and treatment Septic spondylodiscitis: diagnosis and treatment Septic spondylodiscitis: diagnosis and treatment Septic spondylodiscitis: diagnosis and treatment ABSTRACT -We studied retrospectively 24 patients with septic discitis of different etiologies (hematogenic, primary and infantile) and the different aspects involved in its diagnosis and treatment. Erythrocyte sedimentation rate proved to be a valuable parameter and should always be interpreted carefully along with the clinical and neuroimaging findings. Biopsies should be reserved for doubtful cases with atypical course. Clinical treatment should be initiated after the following situations have been ruled out: sepsis, neurological deficit, severe deformity, epidural abscess and foreign body (primary disease). The surgical approach may be chosen based on the stage of disease, being preferably posterior in suppurative forms and anterior in the nonsuppurative stage. Based on our experience and on information gathered by literature review, we propose an algorithm to guide diagnosis and treatment in patients with septic discitis. KEY WORDS: septic discitis, septic spondilodiscitis, vertebral osteomyelitis. A espondilodiscite séptica ainda representa um desafio ao médico, quanto ao seu diagnóstico e tratamento. A literatura neurocirúrgica é muito escassa sobre o assunto e a maioria das publicações está distribuída entre especialidades como ortopedia, clí-nica geral, reumatologia, pediatria e radiologia. Embora sua fisiopatologia não seja completamente esclarecida, a maioria dos trabalhos é retrospectiva, formas diferentes da doença sendo agrupadas das mais diversas maneiras. Termos como espondilodiscite, discite infantil e osteomielite vertebral são empregados como doenças diferentes, não se fazendo distinção entre adultos e crianças de diferentes idades e a inexistência de uma classificação universalmente aceita torna d...

Spondylodiscitis with Extensive Spine Involvement—Case Report

“…1,2,4,6 They can be classified as pyogenic (bacterial cause), granulomatous (tuberculosis, brucellosis and fungi) and parasitic, which is rarely observed. [1][2][3] Most infections are bacterial, [1][2][3][4] and the main etiological agent involved is S. aureus, 1,2,[7][8][9] with an incidence in between 30 and 80% of the cases. 1,2…”

“…It works as a method of excluding other causes of low back pain. [1][2][3][4]8,11 The method of choice for the diagnosis of spondylodiscitis is the MRI, providing an image of the entire spinal cord, as well as visualizing the propagation of the inflammatory process to the neighboring vertebral bodies, as well as to the paravertebral and spinal spaces. 1,2,14,15 Computed tomography (CT) has a lower accuracy than MRI regarding the specific diagnosis of spondylodiscitis; however, it has a good capacity to identify bone destruction and paravertebral abscesses after contrast injection.…”

“…1,2 Blood culture is the simplest procedure available to detect the pathogen, with sensitivity of up to 70%, in patients who were not previously treated. [1][2][3][4]6,8 Some authors recommend the collection of at least three pairs of cultures for diagnostic purposes. 1 Percutaneous needle biopsies and tomography guided needle aspiration can also be used, the latter being less sensitive (50%) due to the small amount of material collected.…”

“…The indications for emergency surgery in spondylodiscitis are: loss of neurological function and sepsis, instability of the patient, possibility of sequelae such as deformities, lesions that affect the intraspinal space, inability to establish a specific diagnosis, with possible presence of an active malignant process and failure in the conservative treatment. [1][2][3]8,16 The objectives of the surgery are: to remove the septic focus, to collect material for culture of the possible infectious agent, and to stabilize the affected section of the spine by means of fixation of the vertebral column. 1,2,8,16 The standard procedure used consists of debridement, decompression of the affected site and fixation of the spine by anterior fusion.…”

“…[1][2][3]8,16 The objectives of the surgery are: to remove the septic focus, to collect material for culture of the possible infectious agent, and to stabilize the affected section of the spine by means of fixation of the vertebral column. 1,2,8,16 The standard procedure used consists of debridement, decompression of the affected site and fixation of the spine by anterior fusion. 1,2,[17][18][19][20][21]…”