Why

She fell?
Dr KC Cheng
Chairman: Dr Winnie Mok

Background
F/81y
Lives with husband. Walks with stick
PMH:
Hypertension on amlodipine 5mg daily, lisinopril 5mg daily
Allergic rhinitis
Eczema on Synalar Cr 0.0125% BD
Impaired glucose tolerance
1 year ago: OGTT Fasting 6.1mmol/L, 2hr pp 9mmol/L; HbA1c 6.7
FU GOPC

HPI
Non syncopal fall at home
Lower back pain afterwards
Malaise for 2 days
No dysuria but daughter said patient has not
passed urine for some time

Physical Examination
BP 170/62mmHg P106/min T 40.1C SpO2 95% RA
Chest clear
HS normal. No murmur
Abdomen soft, non-tender
Powers
5 5
5- 5-

Visual acuity normal

No joint tenderness or swelling
Mild tenderness over lumbro-sacral spine
Generalized eczematous skin with lichenification

CBC on admission

LRFT on admission

Further Investigations

CXR

XR Pelvis

XR L-S
Spine

Differential diagnosis
? Postural hypotension
? Urinary tract infection
? URTI
? Deconditioning

Progress
No postural BP drop
Started IV augmentin
Pelvis X ray: No fracture
L-S spine X ray: degenerative changes
Per rectal exam: no melena. Early OGD for
anaemia
Dietitian consulted for hypoalbuminemia

Progress
Random bladder scan: >999ml. Foley to BSB
Blood culture smear- Gram +ve cocci in clusters
Metformin and diamicron started, H'stix
13-16mmol/L, Hba1c 8.2%
Became afebrile, transfer to FYKH on D3

At FYKH
Premorbid:
Walked unaided till few months ago, walks with stick before admission
P/E:
Oriented to time/place/person
Chest clear
HS normal. PSM at apex, radiates to axilla.
Normal pulse volume. No radiation to carotids
Abd soft, non-tender
Stage II sacral pressure ulcer
Generalized eczematous skin

At FYKH
MOTOR POWER

RIGHT

LEFT

Hip Flexion

Hip Extension

4-

4-

Knee Flexion

Knee Extension

Dorsiflexion

4+

4+

Plantar flexion

4+

4+

REFLEXES

RIGHT

LEFT

Knee

Absent

Absent

Ankle

Absent

Absent

Plantar response

Equivocal

Equivocal

Unable to cooperate for sensory and

coordination testing

At FYKH
Remained afebrile in FYKH

D1 Augmentin

D4 Augmentin

Bld C/ST on admission

Bld C/ST on D2 admission

Anaemia of chronic inflammation

Normal B12, folate

At FYKH
Failed to wean Foley catheter after
24hr urine saved. RU 522ml

What shall we do next?

What shall we do next?

A. Try some laxatives, then wean Foley
B. Try wean Foley after completed 2 weeks of
augmentin
C. Consult urology
D. Per rectal examination
E. Transfer back to acute hospital

At FYKH
Repeated PR exam after failed to wean Foley:
Lax anal tone
Repeated 1 more set of blood culture

Transferred back to
Queen Mary Hospital

Current active problems

Lower limb weakness
Acute retention of urine
Lax anal tone
MSSA bacteremia
Systolic murmur over apex
Leukocytosis, anaemia, hypoalbuminemia
Hyperglycemia

Further investigations?

URGENT MRI LS Spine

MRI T2W saggital

PATIENT

NORMAL

MRI T2W saggital

MRI T1W saggital

T2 hyperintense
disc at L1/2, L2/3,
L4/5

L1

L1

L5

L5

Septic discitis
NORMAL

MRI T2W saggital

Signal increase in T2-
weighted sequence
due to marrow
oedema

MRI T1W saggital

Decrease T1 signal
due to marrow
oedema

L1

L1

L5

L5

L2/3 spondylodisciitis

PATIENT

NORMAL
PATIENT

NORMAL

PATIENT

L1

L5

T2W saggital

Pus collection:
high signal in T2
weighted and low
in T1 weighted

NORMAL

L1

L1

L5

L5

Extensive epidural phlegmon

T2W saggital

T1W saggital

MRI T1W Saggital + Contrast

OUR
PATIENT

A PATIENT with
epidural abscess

T1W saggital
(CON)

No definite epidural abscess

Not the end

MRI T2W axial

Is this normal?

MRI T2W axial

What are these?

MRI T2W axial

MRI T2W axial

Bilateral psoas abscess

Urgent MRI L-S spine:

L2/3 spondylodisciitis.
Extensive epidural phlegmon or early abscess
from L2-S2 levels.
Significant spinal canal narrowing especially at
L3-4 with AP diameter limited to 4mm.
Para-vertebral extension with multiple abscesses
within psoas muscles R 1.4cm L 4cm

MOTOR POWER

RIGHT

LEFT

Hip Flexion

Hip Extension

4-

4-

Knee Flexion

Knee Extension

Dorsiflexion

4+

4+

Plantar flexion

4+

4+

REFLEXES

RIGHT

LEFT

Knee

Absent

Absent

Ankle

Absent

Absent

Plantar response

Equivocal

Equivocal

LL lower motor neuron type weakness + AROU +

lax anal tone = cauda equina syndrome

Transthoracic echocardiogram:
Concentric LVH. Normal LV cavity. EF 60%.
Mild LAE. Restrictive posterior mitral valve leaflet
with MS. Mild MR
Trivial PR, TR. RVSP ~28mmHG
No definitive vegetation seen.

Progress
Seen by microbiologist:
Stop Augmentin
Start IV Cefazolin 2g Q8H IV +
Moxifloxacin 400mg daily po

Progress at QMH
After 12 days of antibiotics
MOTOR POWER

RIGHT

LEFT

Hip Flexion

Hip Extension

4+

Knee Flexion

4+

Knee Extension

4+

Dorsiflexion

4+

Plantar flexion

Still on Foley catheter

Progress
CT guided aspiration of bilateral psoas abscesses

Progress
Weaned Foley catheter
Lower limbs power further improve
Transferred to convalescence hospital for
rehabilitation and continuation of antibiotics

Progress
Walks with stick
Discharged home after 2 months of IV
antibiotics
Bladder control satisfactory
Oral antibiotics was continued
Completed a total of 3 months antibiotics
Started Calcium and Vit D supplement
Pain control satisfactory with paracetamol prn

Antibiotics Regime
Augmentin 10/8-15/8/2014
IV Cefazolin 16/8-8/10/2014
Cephalexin 9/10- 27/11/2014
Moxifloxacin 18/8-10/9/2014

Anaemia improving

Albumin normalised

CRP normalised

ESR slowly downtrend

Good glycemic control

On Admission
10/8/2014

23/1/2015

16/8/2014

8/3/2015

T2 Axial MRI

16/8/2014

8/3/2015

Summary
MSSA spondylodiscitis presented as fall and
lower back pain and features of cauda equina
syndrome
Precipitated by generalized eczema and
undiagnosed diabetes mellitus
Anemia, hypoalbuminemia improved with
treatment of underlying inflammatory process
Back to premorbid status with a prolonged
duration of antibiotics

Pyogenic spondylitis

Pyogenic spondylitis
Broad range of clinical entities:
Pyogenic spondylodiscitis
Septic discitis
Vertebral osteomyelitis
Epidural abscess

WY Cheung, KDK Luk, Pyogenic spondylitis,

International Orthopaedics (SICOT) (2012)
36:397-404

Epidemiology
0.2-2 cases per 100,000 per year
95% pyogenic spine infections involve the
vertebral body +/- disc
5% involve posterior elements of the spine

WY Cheung, KDK Luk, Pyogenic spondylitis,

International Orthopaedics (SICOT) (2012)
36:397-404

Risk Factors

Diabetes mellitus
Malnutrition
Substance abuse
HIV
Malignancy
Long term steroid use
Renal failure
Liver cirrhosis
Septicemia
WY Cheung, KDK Luk, Pyogenic spondylitis,
International Orthopaedics (SICOT) (2012)
36:397-404

Pyogenic spondylitis-Pathophysiology
Commonly hematogeous spread
Cellular bone marrow and the sluggish but
voluminous blood supply to the spine makes it
vulnerable to bacterial inoculation and
infection

Pathophysiology

Pathophysiology

Usually involve multiple

segments of contiguous
vetebrae

Anatomy

Pathophysiology

Pathophysiology

Pathophysiology
Untreated may spread to adjacent structures
Spread into the spinal canal and form epidural abscess
Destruction of the intervertebral disc and vertebral bodies
spinal instability, vertebral collapse with kyphosis, and
neural compression
Ischaemic damage to the spinal cord as a result of septic
thrombosis

Clinical features
Delay in diagnosis is not uncommon, range from 2-12
weeks
Back or neck pain > 90%
Fever < 20%
Nausea, vomiting
Anorexia
Weight loss
Lethargy
Confusion
Limb weakness, numbness
W. Y. Cheung & Keith D. K. Luk. Pyogenic spondylitis.
International Orthopaedics (SICOT) (2012) 36:397404

Laboratory tests
ESR sensitive for pyogenic infection, elevated
in >90% patients
CRP elevated in >90% of patients with spinal
infection, more specific than ESR
CRP normalises faster than ESR with
appropriate treatment
WBC may not be elevated
W. Y. Cheung & Keith D. K. Luk. Pyogenic spondylitis.
International Orthopaedics (SICOT) (2012) 36:397404

Microbiology in the PAST

1955-1960 on 2000 cases, spinal tuberculosis
accounted for 59% of cases

Leong JC, Fraser RD (1996) Spinal infection. In: Diesel SW (ed)

The lumbar spine, 2nd ed. WB Saunders Co

Microbiology NOW
Staphlococcus aureus and streptococcus sp.
>50%
E. Coli, proteus UTI
Gram negative bacilli IVDU
Coagulase negative staphlococcus, streptococcus
viridans immunocompromised

W. Y. Cheung & Keith D. K. Luk. Pyogenic spondylitis.

International Orthopaedics (SICOT) (2012) 36:397404

Diagnosis
MRI - Gold standard
Sensitivity: 96%; Specificity: 92%; Accuracy: 94%

An HS, Seldomridge A (2006) Spinal infections. Diagnostic tests

and imaging studies. Clin Orthop Relat Res 444:2733

Management

Bed rest till acute pain improves

External immobilisation
Antibiotics
10-20% require open surgery

W. Y. Cheung & Keith D. K. Luk. Pyogenic spondylitis.

International Orthopaedics (SICOT) (2012) 36:397404

Management
Absolute indications for surgical treatment:
Spinal cord or cauda equina compression with
progressive neurological deficits
Relatives indications:
Uncertain diagnosis for which open surgery can obtain
tissues for bacteriological and histological confirmation
Failed conservative Mx after 2-3wks of antibiotics
Significant progressive spinal deformity with instability
W. Y. Cheung & Keith D. K. Luk. Pyogenic spondylitis.
International Orthopaedics (SICOT) (2012) 36:397404

Management
Emperical therapy:
3rd G cephalosporin + vancomycin +
metronidazole
Directed to the pathogen if culture +ve

Management
Optimal duration of antibiotic therapy is not
well defined, with several studies
recommending six to eight weeks of
intravenous therapy and others recommending
only four weeks.
Antibiotic therapy for less than four weeks may
result in an unacceptably high recurrence rate
OR until resolution of the SEA on MRI
W. Y. Cheung & Keith D. K. Luk. Pyogenic spondylitis.
International Orthopaedics (SICOT) (2012) 36:397404

Management
In our centre, we treat with intravenous
antibiotics until the CRP is normal which usually
takes about two to four weeks, then change to
oral antibiotics for a total of three months

W. Y. Cheung & Keith D. K. Luk. Pyogenic spondylitis.

International Orthopaedics (SICOT) (2012) 36:397404

Geriatrics Practice and Care

Premorbid status must be clarified in detail
Full neurological examination in patients with
fall
Reason of fall must be identified
Acute onset of lower limb weakness with
AROU suspects cauda equina syndrome and
warrants MRI L-S spine

Geriatrics Practice and Care

Adequate pain control and early mobilization

Rehabilitation
Optimize nutrition
Adequate Ca supplement and Vit D
Aim back to premorbid status

Learning Points
Pyogenic spondylitis is a neurological and life
threatening condition
Lower back pain with degenerative changes
in XR L-S spine is not enough

Learning Points
Failure to diagnose spondylodiscitis is likely to
result in under-treatment, with potential
irreversible neurological damage
Patients with MSSA bacteremia must undergo
echocardiography (25 to 32 percent have
infective endocarditis)
Duration of antibiotics for pyogenic
spondylitis despite usually adequate for IE,
but essential to look for any valvular damage

Thank You