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Pediatric vertebral infections different from adult infection
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By Joseph Pagkalos, MRCS(Ed), Royal Lancaster Infirmary, United Kingdom; and Fatih Kucukdurmaz, MD, Mus Governmental Hospital, Turkey
In the symposium Spondylodiscitis: Treatment Options, Muharrem Yazici, MD, from Hacettepe University, Turkey, discussed whether pediatric vertebral infections differ from adult infections.
These infections are uncommon both in children and adults. The etiology, progress of disease and treatment are different in children than in the adult population. The differences start from the pathogenesis of the disease. Children’s intervertebral discs, namely annulus pulposus, are vascular tissue, in contrast to the adults. This condition allows the bacteria to reach discs by vascular route in children, whereas in adults, discitis is nearly always secondary to osteomyelitis. In children, osteomyelitis in vertebrae is nearly always secondary to discitis.
Trauma history
He explained that even though there is no clear explanation, there is usually a trauma history in children prior to discitis and they show multiple symptoms. Children may refuse to walk even though there is no back pain. They have a characteristic movement in taking something from the floor: they bend first, but after a certain point they put their hands to their knee to give support.
Gastrointestinal symptoms are also common in these children. They have leukocytosis and elevated erythrocyte sedimentation rate and C-reactive protein, as in usual infections. X-ray, computerized tomography (CT), technetium scan and MRI are helpful, but mostly MRI.
Treatment of discitis also differs in children and adults. Discitis is usually a mild disease in children although it is a challenging disease in adults. Bed rest and antibiotics are usually adequate in children; however, adults require surgical debridement and stabilization.
Vertebral osteomyelitis
Yazici said there are also differences in vertebral osteomyelitis between children and adults. The growth potential of a child’s spine is the most important difference. This potential provides more opportunity to heal without deformity in children.
In tuberculous spondylitis, surgical intervention is less necessary in children than in adults. Conservative treatment is still an important choice of treatment in children.
He concluded his presentation by stressing that children are not miniature adults.
Nonspecific infections
Ulf Liljenqvist, MD, offered additional information on nonspecific infections of the spine. After naming the indications for using implants in such cases, he gave the “gold standard” approach according to the Münster Group.
This standard consists of posterior instrumentation that will offer the stability of the spine, anterior debridement and reconstruction of the anterior column. Liljenqvist stressed the need for adequate posterior fixation with two levels above and below the lesion being common practice.
When reconstructing the anterior column, the speaker suggested the use of an expandable titanium cage filled with autologous bone graft and gentamycin sponges. He stressed the benefits of approaching the spine posteriorly first, especially when using expandable cages. Finally, the keys to success were summarized, namely radical debridement; a minimum of 8 weeks of antibiotic coverage; good blood supply; and the use of titanium to achieve sound fixation.