Radical Debridement
Radical debridement without bone grafting is sufficient in cases with:
Radical debridement is the
key to successful surgery
predominant epidural abscess
absence of significant vertebral or intradiscal involvement
absence of gross bony destruction, deformity, and instability
Radical Debridement and Bone Grafting
Radical debridement and bone grafting are indicated in patients:
with intraspinal abscesses
without gross bony destruction, deformity, or instability
Primary bone grafting
is preferred
There is still debate on the timingofthebonegrafting. The main concern in pri-
mary bone grafting is the resolution of the graft by the infection. On the other
hand, secondary bone grafting requires reoperation with theoretically increased
morbidity. In the absence of conclusive data in the literature, the present author
prefers primary bone grafting unless radical debridement is not achieved. In this
case, a second-look operation is imperative and, depending on the local situa-
tion, bone grafting is performed during the latter intervention.
Radical Debridement, Bone Grafting, and Instrumentation
Radical debridement and bone stable reconstruction of the spine are favored as
the surgical technique of choice based on the good results obtained with surgical
treatment of spinal tuberculosis [23, 32, 33] (
Table 5):
Table 5. Rationales for radical debridement and stable reconstruction of the spine
improvement of general condition after abscess drainage
prevention of secondary deformity
rapid progress of infection is prevented
in early stages, extirpation of infected focus is easy
late recurrence is less frequent

putative shorter hospitalization and earlier return to work
Instrumentation has
increasingly been used
without recurrent infection
While the use of spinal instrumentation in the presence of spinal infection has
been controversial in the literature, an increasing number of articles indicate that
instrumentation is not contraindicated in cases where radical debridement is
achieved [14]. There are no sufficient data in the literature to allow a conclusive
statement on the role of instrumentation in spinal infection. However, there is no
evidence to suggest that instrumentation prevents the healing of the spinal infec-
tion. The additional stability instead promotes clinical resolution of the infection
and related symptoms (
Table 6).
Anterior Approach. Asingle-stage anterior approach is best suited for cases with:
predominant anterior column involvement
effective radical debridement
absence of gross deformity or instability
Anterior instrumentation appears not to have an adverse effect unless radical
debridement is not achieved [12]. The use of anterior cages in the absence of a
structural auto- or allograft remains controversial. However, early reports in the
literature indicate that this approach can be successful [21].
Posterior Approach. A single posterior approach is only indicated in cases with a
lesion with difficult anterior access, e.g., at the upper thoracic spine T2-4. In
Infections of the Spine Chapter 36 1033
Table 6. Surgical treatment of spinal infections with instrumentation
Author Cases Type of infection Follow-up Technique Complications/outcome Conclusions
Moon et al.
(1995) [33]
44 44 tuberculosis 3.6 (2 –11) years 44 posterior instrumenta-
tion and anterior debride-

ment with fusion
1 loss of correction
0 recurrent infection
Posterior instrumental stabilization and ante-
rior interbody fusion were found helpful in
arresting the disease early, providing early
fusion, preventing progression of kyphosis
and correcting the kyphosis
Carragee
(1997) [8]
17 17 pyogenic
2 years 15 anterior debridement
and posterior debridement
and instrumentation
2 instrumentation failure,
1 wound dehiscence,
2 thrombosis,
1 symptomatic pseudarthrosis,
0 neurological deterioration,
0 recurrent infection
Spinal infection in selected cases allows early
mobilization and does not compromise the
ability to clear infection
Eysel et al.
(1997) [12]
55 32 pyogenic,
12 tuberculosis,
11 unknown
2 years 32 combined anterior
debridement and posterior

instrumentation vs 23
anterior debridement and
instrumentation alone
3 superficial infection,
1 intraoperative aorta rupture,
1gastriculcer,
3 neurological compromise,
0 recurrent infections
No adverse effect of anterior instrumentation
was observed
Kroedel et al.
(1999) [25]
33 19 pyogenic,
4 tuberculosis,
10 unknown
mean 22
(13–53) months
33 radical anterior debride-
ment and extrafocal poste-
rior instrumentation
1 septic brain abscess,
1 peritonitis owing to
bowel laceration,
2 superficial infection,
2 implant failures,
0 recurrent infection
Posterior extrafocal stabilization offers the
advantage of braceless rehabilitation without
life-threatening complications
Faraj and Webb

(2000) [14]
31 31 pyogenic mean 3.8
(1–12) years
Anterior radical debride-
ment and 30 posterior
stabilization or 1 anterior
stabilization
1 graft dislodgement,
1 nosocomial chest
infection (died),
3 wound infection,
1 implant failure,
2 recurrence of spinal infection,
2 recurrent spinal deformities,
0 recurrent infection
Spinal instrumentation is indicated when
after radical debridement of infected verte-
brae, disc material, and bone grafting, the
stability of the spine is still compromised
1034 Section Tumors and Inflammation
those cases, a costotransversectomy approach is necessary to allow for adequate
decompression of the anterior column.
Combined Approach. This is the most widely used approach [8, 12, 19, 25, 42]
consisting of short-segmental posterior pedicle screw fixation, followed by radi-
cal anterior debridement and bone grafting (
Fig. 6). In the cervical spine, a two or
a bc
d ef
Case Study 2
An 81-year-old woman developed progressive, severe back pain. Despite initial analgesics and physiotherapy, the

patient continued to get worse. The patient developed a slight increased fever and felt sick. After severe pain with ambu-
lation, a radiograph (
a) was taken, demonstrating a collapsed L1/2 disc space with partial destruction of the lower end-
plate of L1. The MRI exhibits typical signs of a spinal infection. Note the high signal intensity in a T2W MR sagittal image
(
b) and a paravertebral abscess in the psoas muscles (c, d ). In a first stage the spine was stabilized from T11 to L3 with a
titanium pedicle screw system. In a second stage, during the same operation, the paravertebral abscess and the disc
space and adjacent vertebral bodies L1/2 were debrided. The bone quality was osteoporotic. A tricortical bone graft was
harvested from the iliac crest, but broke during insertion because of poor bone quality. Rather than leaving a large ante-
rior gap, a titanium mesh cage was implanted, supporting the anterior cortex of the severely osteoporotic vertebrae
(
e, f). At 6 months follow-up the patient was ambulating without aid without limiting her daily activities, but she still had
occasional back pain. There was no sign of recurrent infection during a further 1-year follow-up.
Infections of the Spine Chapter 36 1035
more level involvement requires additional posterior stabilization. However, in
cases where the general health status does not allow an additional posterior
approach, external splinting is imperative until the bone graft has healed. In cases
of poor bone quality, e.g., in an osteoporotic spine, longer instrumentation may
become necessary. In those cases, anterior buttress support is necessary to allow for
stable construction. In cases where a tricortical bone graft is too brittle (osteoporo-
sis), a titanium mesh cage can be applied. As a prerequisite, radical debridement
has to be achieved prior to cage implantation and bone grafting (
Case Study 2
).
Recapitulation
Epidemiology.
In an era of very powerful antibiot-
ics, it is sometimes forgotten that spinal infections
are still a potentially life-threatening disease.To-
day, spinal infections predominantly occur in the el-

derly and immunocompromised patient, but the in-
cidence of spinal tuberculosis in younger patients is
again increasing in industrialized countries.
Pathogenesis. Spinal infections in adults appear to
start from the vertebral endplates. The most fre-
quent pathomechanism is a spread of microorgan-
isms via the blood vessels from urogenital, pulmo-
nary, or diabetic foot infections. Spinal infections
are most frequently classified according to the
causative organism (pyogenic, parasitic, fungal in-
fections, tuberculosis) or the location (i.e., discitis,
spondylitis, epidural, and paravertebral abscess).
Clinical presentation. The key feature of spinal in-
fections is the delayed diagnosis. Cardinal symp-
toms are slowly progressive, continuous pain with
pain exacerbation during rest and at night. Fever
and septic states are rare. It is mandatory to search
for predisposing factors such as diabetes, intrave-
nous drug abuse, immunodeficiency, diabetic ul-
cers, and previous septic conditions. The physical
findings are often non-specific unless neurologic
deficits are present.
Diagnostic work-up. The key to diagnosis is to con-
sider spinal infections. CRP and BSR are almost al-
ways elevated while the WBC can remain normal.
The major drawback of standard radiography is the
delay in the appearance of radiographic signs. The
sequence of changes demonstrable on radiographs
is blurred endplates, disc space collapse, develop-
ment of osteolysis and a paravertebral shadow, re-

active sclerosis and kyphotic deformity. MRI is the
imaging modality of choice. Characteristic findings
on MRI suggestive of spinal infections are de-
creased vertebral endplate signal intensity on T1W
images, loss of endplate definition, increased signal
intensity on T2W images, and contrast enhance-
ment of the disc and vertebral endplates. The isola-
tion of the causative organism is very important
andmustbeattemptedineverycase.CT-guided
biopsy is the method of choice because it allows
the sample to be taken from inside the lesion. The
most frequently found organisms are Staphylococ-
cus aureus (30 –55%), E. coli, Salmonella, Enterococ-
cus, Proteus mirabilis, Pseudomonas aeruginosa (in
65%ofdrugabusers),Streptococcus viridans,and
epidermatitis. In the absence of a life-threatening
condition, treatment should not be started without
vigorous attempts to isolate the causative organ-
ism. The likelihood of isolating the organism after
the beginning of antibiotic treatment is minimal.
Non-operative treatment. The general objectives
of treatment are to eradicate the infection, relieve
pain, prevent or reverse a neurologic deficit, re-
store spinal stability, correct spinal deformity, and
prevent recurrence. Antibiotic treatment is the
therapy of choice for uncomplicated cases. Che-
motherapy should not be stopped prior to normal-
ization of the infectious parameters (CRP, BSR,
WBC) and is usually given for 6 –12 weeks. Early
ambulation is attempted and a corset can be used

optionally. In cases of spinal tuberculosis, a triple
(isoniazid, rifampin, and pyrazinamide) or quadru-
ple chemotherapy (plus ethambutol) is recom-
mended for 2 –3 months. After this period, chemo-
therapy should be continued with isoniazid and ri-
fampin in the absence of resistance or side effects.
While there is still debate on the duration of treat-
ment, a total of 12 months is favored by the majori-
ty of experts.
Operative treatment. Surgery is indicated in cases
of disease progression despite adequate antibiotic
treatment, progressive spinal deformity and insta-
bility,andneurological compromise.Thekeyto
1036 Section Tumors and Inflammation
successful surgery is radical debridement. This has
been well demonstrated for the treatment of spinal
tuberculosis, but is applicable to pyogenic infec-
tions as well. Radical debridement and bone graf-
ting are indicated in patients with intravertebral
abscess and without gross bony destruction, defor-
mity, and instability. However, in many cases addi-
tional spinal stabilization is required. Instrumenta-
tion is still controversial in the literature, but an
increasing number of articles have demonstrated
that implants can be used without side effects. Spi-
nal instrumentation promotes rather than prevents
resolution of the infection because of the added
stability. Posterior instrumentation with correction
of the deformity, followed by anterior radical
debridement and bone grafting, is the method of

choice for a spinal infection with predominant
anterior column involvement of the thoracolumbar
spine. Implants can be used atthesiteofinfection
(e.g., in the cervical spine) with the prerequisite that
radical debridement is thoroughly achieved.
Key Articles
Hodgson AR (1964) Report on the findings and results in 30 0 cases of Pott’s disease
treated by anterior fusion of the spine. J West Pacific Orthop Assoc 1:3–7
Landmark paper favoring surgical treatment of spinal tuberculosis in a series of 300
cases.
MoonMS,WooYK,LeeKS,HaKY,KimSS,SunDH(1995) Posterior instrumentation
and anterior interbody fusion for tuberculous kyphosis of dorsal and lumbar spines.
Spine 20:1910 – 6
This paper summarizes present knowledge of spinal tuberculosis and its management.
Antituberculosis agents remain the mainstay of management, with chemotherapy for 12
months preferred to shorter courses. Anterior surgery consisting of radical focal debride-
ment without fusion does not prevent vertebral collapse. Patients who present late with
deformity are candidates for anterior debridement and stabilization with corrective
instrumentation. Posterior stabilization with instrumentation has been found to help
arrest the disease and to bring about early fusion. Posterior instrumented stabilization to
prevent kyphosis in early spinal tuberculosis is indicated, however, only when anterior
and posterior elements of the spine are involved, particularly in children.
Carragee EJ (1997) Instrumentation of the infected and unstable spine: a review of 17
cases from the thoracic and lumbar spine with pyogenic infections. J Spinal Disord
10:317 – 24
In a retrospective review of 17 consecutive cases of spinal instrumentation for pyogenic
vertebral osteomyelitis (PVO) with follow-up of
2 years, the authors demonstrated that
spinal instrumentation in selected cases of PVO allows for early mobilization and did not
seem to compromise the ability to clear infection. In certain recalcitrant cases, stabiliza-

tion seemed to promote clinical resolution of the infection.
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Infections of the Spine Chapter 36 1039
37
Rheumatoid Arthritis
Dieter Grob
Core Messages
✔
Rheumatoid arthritis (RA) most commonly

affects the cervical spine
✔
Tissue destruction causes instability of the
atlantoaxial segment
✔
Compressive myelopathy is the consequence of
instability and repetitive trauma
✔
The “wait and see” policy is rarely advocated
✔
Early surgery prevents extensive and risky inter-
ventions
✔
Marked osteoporosis requires anterior and pos-
terior procedures in advanced stages of the dis-
ease
✔
Consider structural weakness of bone in the
planning of the extent of fusion (adjacent seg-
ment decompensation)
✔
Inclusion of the occiput into the fusion usually
requires fusion of the whole cervical spine
Epidemiology
Rheumatoid arthritis (RA) is a worldwide disease. The original theory, that RA
only occurs in areas with cold and wet weather conditions, turned out to be
wrong; however, its incidence does seem to vary between countries [1].
Anterior atlantoaxial dis-
placement is the most
frequent cervical instability

encountered in RA
In about 40% of all patients with RA, the cervical spine is involved with neck
pain, and of these patients, approximately 50% show instability of the upper cer-
vical spine complex (occiput to C2) [17]. The most common instability is the
anterior translational C1/2 instability, but lateral or posterior subluxation occurs
in a minority of patients. In approximately 20%, vertical migration of the dens
may be observed, and 15–20% suffer from subaxial instability with subluxa-
tions and spinal stenosis.
In spite of the success of modern medical treatment and the decreasing inci-
dence of manifest instability of the spine, surgery will remain one of the treat-
ment options in advanced stages of the disease. While in the second half of the
Despite the success of
modern medical treatment,
surgery will remain a valid
option for non-responders
last century decompressive and stabilizing surgery was the only solution for
severe alterations due to RA and thus represented some kind of last resort for
neglected RA patients, surgery in the future will be the option for non-respond-
ers to modern chemical treatment or untreated “leftovers” [7].
Pathogenesis
Rheumatoid arthritis affects synovial tissue, finally forming an inflammatory
pannus, which represents an aggressive tissue with consecutive destruction of
discoligamentous structures and bony elements around the facets. Due to the
anatomical configuration of the atlantoaxial segment, the manifestation of RA is
most often observed in the upper cervical spine. The three-dimensional motion
in the atlantoaxial segment is controlled exclusively by the joint capsule and the
Tumors and Inflammation Section 1041
a
b
c

d
e
Case Introduction
At the time of first pre-
sentation the patient was
52 years old and had suf-
fered from rheumatoid
arthritis for 4 years. Due
totheaggressivecourse
of the disease she had
had her hips and knees
replaced due to rheuma-
toid destruction of these
joints. Her neck problem
was revealed by the flex-
ion radiograph of her
cervical spine, where a
reducible subluxation of
the atlas was detected
(
a). Due to persisting
pain, atlantoaxial fixation
was performed by trans-
articular screw fixation.
In spite of several other
subsequent interven-
tions, the patient was
without symptoms in her
neck for several years
and a routine check-up

6 years postsurgery
showed solid fusion of
the atlantoaxial segment
in an anatomical posi-
tion. Twelve years after
hernecksurgery,she
started to have painful
sensations in her neck;
however, she refused to
seek medical advice,
being afraid of needing
further intervention (she had sustained a total of 23 interventions due to her rheumatoid disease up to that date!). The
functional views revealed an subaxial instability (
b, c). However, the pain became more intensive and she noted increas-
ing clumsiness of her hands. She finally presented with a stiff and painful neck. A hyperreflexia of upper and lower
extremities was found together with sensory disturbances in her hands. A neurophysiological examination confirmed
the presence of a significant cervical myelopathy. The radiographs showed decompensation of the adjacent levels with
significant retroposition of the vertebral body C3 producing severe spinal stenosis (
d, e).
1042 Section Tumors and Inflammation
fg
Case Introducton (Cont.)
A one-stage surgery was performed with initial anterior resection of the vertebral body of C3. With this step, decompres-
sion of the spinal canal and reduction of the deformity was achieved. In the same sitting, posterior fixation was carried
out to maintain reduction and stability. Laminectomy and flavectomy were performed at the same time to decompress
posteriorly. Since there was no upward migration or pathology in the atlanto-occipital joint, the occiput was not
included in the fixation (
f, g). After surgery, the patient recovered well and noticed an improvement in the dexterity of
her hands and a reduction of the paresthesias.
ligaments – with the exception of extension, in which the dens axis serves as a

bony blocker. With the destruction of the capsuloligamentous elements, a mainly
horizontally orientated instability (
Fig. 1) occurs, which is complicated by subse-
quent bony arrosion of dens and lateral masses of the atlas, leading to an addi-
tional upward migration of the atlantoaxial complex towards the foramen mag-
num.
Pannus formation
is related to instability
The inflammatory pannus seems to be one of the key factors in tissue
destruction. If there is no motion, there is no pannus formation and – as a con-
sequence – no tissue destruction occurs [10]. In this view, surgically induced
fusion, e.g. of the atlantoaxial joint, prevents the destructive process and there-
fore prevents the transformation of a horizontal instability into a vertical insta-
bility [10] (
Fig. 1
).
The subaxial cervical spine may also show instability and spinal stenosis due
to RA changes. Facet joint and disc destruction as well as bony erosion cause
Disc/facet joint destruction
and bony erosion cause
subaxial instability
anterolisthesis and loss of lordosis and – with increasing deformity – spinal ste-
nosis with encroachment of the medulla and nerve roots. Even if the involvement
of the lower cervical spine is mostly primary in the underlying disease, it may
occur secondarily as a consequence of increased lever arms due to stabilizing
procedures of the upper cervical spine (
Case Introduction).
The lumbar spine may also be involved in RA patients; however, here the con-
sequences of long-standing steroid therapy rather than disease specific alter-
ations are predominant. Therefore, degenerative spondylolisthesis and vertebral

fractures may be observed.
Rheumatoid Arthritis Chapter 37 1043