Madhavan Karthik, Chieng Lee Onn, Armstrong Valerie L, Wang Michael Y
1Department of Neurological Surgery, University of Miami, Miami, Florida; and.
2Department of Neurosurgery, Beaumont Health System, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan.
J Neurosurg Spine. 2019 Feb 15;30(5):674-682. doi: 10.3171/2018.9.SPINE18824. Print 2019 May 1.
Discitis and osteomyelitis are seen in end-stage renal disease (ESRD) patients due to repeated vascular access for hemodialysis and urinary tract infections leading to recurrent bacteremia. Discitis and osteomyelitis are underdiagnosed due to the nonspecific initial presentation of back pain. In this article, we review the literature for better understanding of the problem and the importance of early diagnosis by primary care physicians and nephrologists. In addition, we discuss the decision-making, follow-up, management, and neurological outcomes.
A detailed PubMed search was performed using the following terms: "end stage renal disease (ESRD)" and "chronic renal failure (CRF)," combined with "spine infections," "spondylodiscitis," "discitis," and "osteomyelitis." Search results were limited to articles written in English, case reports, and case series from 1973 to 2012. Editorials, reviews, and commentaries were excluded. Only studies involving human patients were included. The authors also included 4 patients from their own patient population.
A total of 30 articles met the inclusion criteria. Including the 4 patients from the authors' patient population, 212 patients with spine infections and maintenance dialysis were identified. The patients' ages ranged from 38 to 78 years. The duration of dialysis ranged from a few days to 16 years. The time from onset of back pain to diagnosis ranged from 3 days to 6 months. The most common causative organism was Staphylococcus aureus, followed by Staphylococcus epidermidis and gram-negative bacteria. Most of the patients were treated with antibiotics alone (76.8%), although surgery was indicated when patients presented with neurological deficits (p < 0.011). Approximately one-quarter of the patients developed neurological deficits, with devastating consequences. Fever and neurological deficits at presentation, culture positive for methicillin-resistant S. aureus, and age > 65 years were highly correlated with mortality in our analysis.
Several risk factors lead to failure of antibiotics and progression of disease in patients with ESRD. Challenges to diagnosis include vague presenting symptoms, co-existing destructive spondyloarthropathy, poor immune response, chronic elevations of inflammatory markers, and recurrent bacteremia. Infectious processes are more likely to cause permanent neurological deficits than transient deficits. The authors recommend close observation and serial imaging of these patients for early signs of neurological deficits. Any signs of disease progression will require aggressive surgical debridement.
由于终末期肾病（ESRD）患者因反复进行血液透析的血管通路及尿路感染导致复发性菌血症，故而会出现椎间盘炎和骨髓炎。由于背痛的初始表现不具特异性，椎间盘炎和骨髓炎常被漏诊。在本文中，我们回顾文献以更好地理解这一问题以及初级保健医生和肾病学家早期诊断的重要性。此外，我们还讨论了决策制定、随访、管理及神经学转归。
使用以下检索词在PubMed上进行详细检索：“终末期肾病（ESRD）”和“慢性肾衰竭（CRF）”，并与“脊柱感染”“脊椎间盘炎”“椎间盘炎”及“骨髓炎”相结合。检索结果仅限于1973年至2012年期间用英文撰写的文章、病例报告及病例系列。排除社论、综述及评论。仅纳入涉及人类患者的研究。作者还纳入了来自其自身患者群体的4例患者。
共有30篇文章符合纳入标准。包括作者患者群体中的4例患者，共识别出212例患有脊柱感染且维持透析的患者。患者年龄在38岁至78岁之间。透析时间从几天到16年不等。从背痛发作到诊断的时间从3天到6个月不等。最常见的致病菌是金黄色葡萄球菌，其次是表皮葡萄球菌和革兰氏阴性菌。大多数患者仅接受抗生素治疗（76.8%），尽管当患者出现神经功能缺损时需进行手术（p < 0.011）。约四分之一的患者出现神经功能缺损，后果严重。在我们的分析中，就诊时发热和神经功能缺损、耐甲氧西林金黄色葡萄球菌培养阳性及年龄>65岁与死亡率高度相关。
多种危险因素导致ESRD患者抗生素治疗失败及疾病进展。诊断面临的挑战包括症状表现模糊、并存破坏性脊柱关节病、免疫反应差、炎症标志物长期升高及复发性菌血症。感染过程更易导致永久性神经功能缺损而非短暂性缺损。作者建议对这些患者进行密切观察及系列影像学检查以发现神经功能缺损的早期迹象。疾病进展的任何迹象都需要积极的手术清创。
