Treatments

Treatment for osteomyelitis is usually conservative and based primarily on use of intravenous antibiotic treatment. Occasionally, surgery may be necessary to alleviate pressure on the nerves, clean out infected material, and/or stabilize the spine.

Conservative treatments
Treatment for spinal infections usually includes a combination of intravenous antibiotic therapy, bracing and rest.

Most cases of vertebral osteomyelitis are caused by Staphyloccocus Aureus, which is generally very sensitive to antibiotics. The intravenous antibiotic treatment usually takes about four weeks, and then is usually followed by about two weeks of oral antibiotics. For infection caused by tuberculosis, a year of oral antibiotic treatment is often necessary.

Bracing is recommended to provide stability for the spine while the infection is healing. It is usually continued for 6 to 12 weeks, until either a bony fusion is seen on x-ray, or until the patient’s pain subsides. A rigid brace works best and need only be worn when the patient is active.

Surgical treatments
Surgical decompression is necessary if an epidural abscess places pressure on the neural elements. Because surgical decompression often destabilizes the spine further, instrumentation and fusion are also frequently included to prevent worsening deformity and pain.

If the infection does not respond to antibiotic therapy, surgical debridement and removal of infected material may be necessary. Most infections are predominantly in the anterior structures (such as the vertebral body) and the debridement is best done through an anterior (front) approach. Stabilization and fusion are also done after removing the infected bone.

Surgery may also be necessary if there is a great deal of bony destruction with resultant deformity and pain. Reconstructing the bony elements and stabilizing the spine can help reduce pain and prevent further collapse of the spine. The surgery usually needs to be done from a combined anterior (front) and posterior (back) approach.

Most surgeons prefer not to place instrumentation in the front of the spine, where most of the infection is located. If the bacteria set up around inserted hardware, it can then form a covering over itself that protects it from antibiotics. If this happens, the hardware needs to be removed to eradicate the infection.

Bone grafting for anterior column support is usually followed by posterior instrumentation, which places the hardware in a relatively clean environment and decreases the chance of a bacterial infection around the hardware.

By: Alex R. Vaccaro, MD
April 15, 2000