Edited by Aditya Karhade and Brian Goh - 7/1/2021
HPI
Details for HPI:
- Duration of symptoms? Time to presentation?
- Exposure?
- Recent invasive procedure [surgery, colonoscopy, dental work]
- Infection (UTI, bacteremia, cellulitis)
- Immunocompromised (steroids, chemo, immunosuppressants, HIV)
- ROS to identify common concomitant infections (UTI, pneumonia, endocarditis, septic arthritis, cellulitis, psoas abscess)
Descriptors
- Spinal level? More urgency for levels with spinal cord
- Ventral? Dorsal? Circumferential to thecal sac?
- Contiguous number of levels? Non-contiguous skip lesions?
- Concomitant area of infection outside spine and paraspinal region?
Workup
Radiographs:
Obtain upright XRs prior to hospital discharge for clinic follow-up to monitor sagittal alignment and stability
Other imaging:
MRI or CT myelogram if unable to obtain MRI
MRI with and without contrast of total spine to look for skip lesions if delay in presentation (defined as symptoms for ≥7 days), a concomitant area of infection outside the spine and paraspinal region, and an erythrocyte sedimentation rate of >95 at presentation
Labs:
CBC w/ diff, LFTs, BMP
ESR, CRP
Blood cultures
UA/Urine culture
Chest XR
Other:
Preoperative workup if operative
Management
Need for acute intervention:
Neurologic deficit:
Decompression +/- fusion if new/progressive neurologic deficit
Weight-bearing and range of motion:
Activity as tolerated
Type of immobilization:
None
Admission or discharge status:
If isolated infection without neurologic deficit and without hemodynamic instability, admit to medicine, IR guided biopsy for culture directed antibiotics, hold empiric IV antibiotics unless hemodynamically unstable
If isolated infection with neurologic deficit, admit to ortho spine for decompression +/- fusion
If isolated infection with hemodynamic instability, admit to SICU under ortho spine attending for decompression +/- fusion
If multisystem infection, admit to medicine for further work-up (TTE, blood cultures)
Anticoagulation:
None
Antibiotics:
If no hemodynamic instability, IR guided biopsy for culture directed antibiotics, hold empiric IV antibiotics unless hemodynamically unstable, ID consult
If hemodynamic instability, admit to ICU with empiric IV antibiotics (vancomycin, cefepime, flagyl) and ID consult
Surgical Indications
Absolute:
- Progressive neurologic deficit
- Isolated infection with hemodynamic instability
- Make sure work-up for other infectious sources has ruled out other possible causes for hemodynamic instability
Relative:
Calculator - Predictors for failure of nonoperative management
Not an indication:
Pain