Diagnosis and management of primary pyogenic spinal infections in intravenous recreational drug users

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Primary spine infection secondary to intravenous drug abuse (IVDA) is a difficult clinical entity encountered by spine surgeons and infectious disease specialists. Patients tend to be noncompliant with the treatment and follow-up, and some continue to use IV recreational drugs even after the diagnosis of spine infection. The authors undertook this study to analyze the presentation, etiology, demographic characteristics, treatment, and outcome of primary pyogenic spinal infection in patients with IVDA as the major risk factor.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>The medical records, radiology imaging, and laboratory results (white blood cell count, inflammatory markers, bacteriology cultures) of all patients with pyogenic spine infection and history of IVDA presenting to a tertiary care center from August 2005 through December 2013 were retrospectively reviewed. The department of neurosurgery database and the hospital electronic medical records of University Hospital in San Antonio were used to identify the cohort for our study.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>A total of 164 patients with spinal infection were evaluated during the study period; 102 of these patients had a history of IVDA. Their average age was 45.4 years, and only 14 (13.7%) were women. The mean laboratory values at presentation included a white blood cell count of 11.1 × 10<jats:sup>3</jats:sup> cells/μl (range 0.5–32 × 10<jats:sup>3</jats:sup> cells/μl), erythrocyte sedimentation rate (ESR) of 74 mm/hr (range 9.9–140 mm/hr), and C-reactive protein (CRP) level of 67 mg/L (range 0.1–327 mg/L). Twenty-six patients (25.4%) had an associated epidural abscess. The most common organism isolated from cultures of the bone and/or blood was methicillin-sensitive <jats:italic>Staphylococcus aureus</jats:italic> (MSSA), which was found in 37 cases. A close second was methicillin-resistant <jats:italic>S. aureus</jats:italic> (MRSA), found in 23 cases. The most commonly involved region was the lumbar spine (24 cases [57.8%]), and most patients (69.6%) had involvement of only a single level. Eighty patients were initially treated with long-term IV antibiotic therapy, and only 22 underwent surgical intervention (24 procedures). Of the latter group, 8 patients underwent laminectomy alone while 16 required some type of instrumented stabilization. Of the patients requiring stabilization procedures, 2 (12.5%) required reoperation with extension of their surgical constructs to other levels. The average follow-up was 29.7 weeks (range 6 weeks to 3 years).</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Diagnosis and management of spinal infection in patients with a history of IVDA is challenging. The data from this study show that initial laboratory values are difficult to interpret given that only a minority of these patients present with leukocytosis. Back pain was the only reliable predictor of spine infection. The authors' experience indicates that the majority of patients with spine infection and a history of IVDA can be successfully treated with IV antibiotic therapy alone.</jats:p></jats:sec>

Staphylococcus aureus Infections: Epidemiology, Pathophysiology, Clinical Manifestations, and Management

“…In a nationwide Japanese study, the incidence increased from 5.3 per 100,000 person-years in 2007 to 7.4 per 100,000 person-years in 2010 (411). The major risk factors for vertebral OM are advancing age (389,409,411), diabetes mellitus (384,386,411,412), injection drug use (412,413), and immunosuppression (389,412), and the growing incidence of these risk factors, together with increased access to advanced radiological modalities, may explain the increasing incidence of vertebral OM. The majority of patients with vertebral OM and concomitant SAB are Ͼ60 years of age (414).…”

Unusual cervical spine epidural abscess

“…It can be divided into discitis, spondylitis, and spondylodiscitis with/without epidural abscess. Some comorbidities such as old age, diabetes mellitus, immunocompromised status (steroid use, human immunodeficiency infection, chronic renal failure), alcoholism, malignancy, and intravenous drug abuse are vulnerable to spinal infection [1][2][3][4]. Drug abusers have a higher occurrence rate of spinal infection owing to risk of local or systemic infection.…”

“…However, drug abusers with spinal infection are younger than ordinary cases of spinal infection. The average age is about the fourth decade of age [1,2]. Backache is a reliable presentation of spinal infection in drug abusers.…”

“…In recent years, the increasing rate of intravenous drug abuse makes more spinal infection cases [1]. The most common symptoms include fever, backache, and neurological deficit [2].…”

“…Drug abusers have a higher occurrence rate of spinal infection owing to risk of local or systemic infection. The incidence rate is about 0.5 to 2.2 per 100,000 cases [1]. In the past, spinal infection is more prevalent in fifth and sixth decades of age.…”