Osteomyelitis of the spine and pelvis (both uncommon)

The spine can be affected by tuberculosis, or by suppurative osteomyelitis due to a variety of pyogenic organisms, especially Staphylococcus aureus, streptococci, Brucella, and occasionally S. typhi. Tuberculosis is always chronic, but pyogenic osteomyelitis can be acute, subacute, or chronic.

A patient with acute osteomyelitis of his spine is usually a very ill child with fever and severe back pain, usually in his lumbar region. There may be some inflammatory oedema over his spine, which is very tender, and may be arched backwards by muscle spasm, as if he had tetanus or meningitis. X-rays may show a paravertebral abscess, usually with normal bones. He may be paraplegic as the result of inflammatory oedema involving his cord. If he is to have any chance of survival the pus must be drained, by removing the transverse processes of some of his vertebrae and part of some of his ribs.

If his osteomyelitis is chronic, he is usually an older child or adult. He is in pain, but has little or no fever, and no arching of his back.

Tuberculosis of the spine is described in Section 29.4, which also gives a detailed description of costotransversectomy for the drainage of a cold abscess. Here we give a short description of the same operation for acute osteomyelitis.

Paraplegia associated with osteitis of the spine, is usually due to inflammatory oedema pressing on the cord. If you can see an abscess on the X-ray, operate; but if there is no X- ray evidence of an abscess, you may still find pus. If he has no spasms, he will probably recover in 3 to 6 months. But if he has extensor, or worse, flexor spasms, his paraplegia is likely to be permanent.

OSTEOMYELITIS [s8]OF THE SPINE AND PELVIS THE SPINE DIFFERENTIAL DIAGNOSIS. See also Section 29.4a and Fig. 29-3a.

If the bodies of a patient's vertebrae are abnormal, but not his intervertebral discs, suspect malignancy.

If the disc and the adjoining bone are diseased, especially if this is maximal anteriorly, suspect infection. The diseased bone softens, and the vertebral bodies become wedge-shaped.

If there is other evidence of tuberculosis (a positive sputum or suggestive chest X-rays etc), treat him for it.

If there is marked osteoporosis but no osteosclerosis, and tuberculosis is common in your district, treat him for it.

If there is porosis and sclerosis, he may have osteomyelitis or tuberculosis, so:

(1) Refer him for costotransversectomy, or if this is impossible, do it yourself, especially if tuberculosis is uncommon in your district and the condition is acute or subacute.

Or, (2) treat him for both diseases for 3 to 6 weeks. During this time a non-tuberculous lesion should have improved greatly (no pain and little or no tenderness), whereas a tuberculous one will have changed very little.

If you are in doubt as to the diagnosis, treat him for tuberculosis. In most developing countries 90% of cases of osteitis of the spine are tuberculous.

If he is paraplegic, or has a paravertebral abscess (pyogenic or tuberculous) he needs a costotransversectomy. If he has acute osteomyelitis, this is particularly urgent, so refer him or proceed as follows. Aim to drain the pus; there is no need to drill.

METHOD. Give him a general anaesthetic, intubate him, and control his ventilation (A 18.1). Lie him prone with a pillow under his chest to keep his abdomen free. Make a straight longitudinal 10 to 15 cm incision over his spinous processes, or, better, an incision curved towards his left side with its ends over his spinous processes. Use a scalpel and a periosteal elevator to approach the bodies of his vertebrae, by separating his spine from his sacrospinalis muscle on the left. Control bleeding by packing the wound with a large swab and waiting.

In the thoracic area, remove the proximal 3 cm of a rib opposite the middle of the abscess with its transverse process. Cut the rib distally with rib shears or bone cutters, push away the soft tissue deep to the bone, and dissect its proximal end. You will find that it has a small joint with its corresponding vertebral body and another with the transverse process. Cut this transverse process at its base and remove it with the piece of rib. Do the same for one or two neighbouring vertebrae.

Push your finger between the side of the vertebral body and the tissues covering his pleura[md]recognize this by its movement. If you feel close in front of his spine, you should find pus.

In the lumbar region, when you reach his transverse processes, remove two or three of them with bone nibblers. You will now reach the plane between his quadratus lumborum and the bodies of his vertebrae, where you should find pus.

Clean this out and remove any obviously dead bone. His muscles will fit back snugly next to his spine. Suture his deep fascia. If much pus was present insert a drain. Close his skin. Send pus for culture. For more details see Section 29.4a.

If you don't find pus, nibble away a little bone next to a vertebral disc and send this for histology; it may be tuberculous.

THE PELVIS Osteomyelitis of the pubis occasionally follows symphysiotomy (18.4). If it involves his innominate bone, try antibiotics for up to 6 weeks. Sequestra are unusual. If pain and or sinuses persist treatment is difficult, so refer him.

Fig. 7-14 DISASTER WITH AN INFECTED HIP. This is patient Hasina whose story is given in the text. Infection has displaced the epiphysis of her femur, and moved its shaft upwards. The infection in her thigh is producing gas shadows.