A.V. Gorozhanin1, K.V. Sorokin1, O.N. Dreval2, V.A. Lazarev2, G.K. Shepeleva4, I.A. Aleksandrova3, A.N. Borzunov1
( 1 Botkin Municipal Clinical Hospital;
2 Faculty of Neurosurgery of the Russian Medical Academy of Postgraduate Education;
3 Burdenko Research Institute of Neurosurgery;
4 Faculty of Infectious Diseases of the Moscow State Medical-Stomatologic University, Moscow)
The research goal has been determining an algorithm of rational diagnosis and tactics of surgical treatment of cases with purulent external meningitis and nonspecific spondylitis; estimating significance of both bacteriologic studies, carried out during antibacterial therapy, and data of immunologic examinations in control of treatment efficacy.
Material and Methods. There were 42 cases, treated at the Botkin Municipal Hospital (Moscow) for pyo-inflammatory diseases of the spine with compression of the spinal cord and cerebrospinal roots. There were 23 males (54.8%) and 19 females (45.2%). Their age varied from 18 up to 75 years (mean age – 50.1 years). An inflammatory focus was localized in the cervical spine (5 cases, 11.9%), thoracic spine (22 cases, 53.4%) and lumbosacral spine (15 cases, 53.7%). One patient (2.4%) had two foci, localized in the cervical and lumbar spine. Spread of a pyo-inflammatory focus was as follows: 1-3 levels – 24 patients (57.1%), 4-5 levels – 11 patients (26.1%), 6-12 levels – 7 patients (16.7%). The cases were divided into 4 groups. The first group included 4 patients (9.4%) with chronic spondylitis or productive external meningitis and duration of the spinal cord compression of more than 40 days (47-112 days). The second group consisted of 10 cases (23.8%) with spondylitis and adjacent purulent external meningitis, conditioning ventral and ventrolateral compression of the dural sac and spinal cord. The third group was represented by 2 cases (4.8%) with intradural intramedullary abscesses. The forth group comprised 26 patients (61.9%) with epidural abscesses of the vertebral canal. Bacteriologic study of pus or exudate from an inflammatory focus, drain discharge and blood was carried out in all the cases before and during antibacterial therapy. The immune status was estimated in 11 cases (26.2%) before and after intervention and during antibacterial therapy. One of the goals of this estimation was revealing immunosuppression. A clinical picture and social adaptation were evaluated, using Karnofski scale.
A Clinical Picture and Diagnosis. Diagnosis was verified in all the cases during MRI examination. The patients with spondylitis underwent CT examination with reformation. Severity of a state and organic insufficiency was evaluated on admission and during the first postoperative day, using APACHE 11 and SOFA respectively. The ACC/SCCM classification (1992) was indicative of sepsis in 27 cases (64.1%). Etiologic causes were as follows: At. Aureus – 24 cases (57.1%), St. Epiclermidis – 4 cases (9.5%), Entembacter Likvefascies – 1 case (2.4%).
Treatment of Purulent External Meningitis and Nonspecific Spondylitis. Interventions were performed in 38 cases (90.5%). Laminectomy with drainage of a vertebral canal was made in 35 patients (92.1%). Passive drainage and active aspiration were used in 23 (60.5%) and 15 (39.5%) cases respectively. Proteolytic enzymes (trypsin, chymotrypsin) were administered to all the cases intraoperatively and during the whole period of drains stay in a vertebral canal. Oblique corporotomy and drainage of a vertebral canal with active aspiration were performed at the cervical level in 3 cases (7.9%) with spondylitis and adjacent external meningitis. Drainage duration was 7 days on the average and depended on a character of wound discharge. Operations were performed either during the first hours (29 cases, 76.3%) or within 3 days (9 cases, 23.7%) after admission. Operations were made at the following clinical stages (according to Heusner): I – 4 cases (10.5%), II – 6 (15.8%), III – 23 (60.5%), IV – 5 (13.2%).
Antibacterial therapy with broad-spectrum antibiotics, effecting staphylococcus, was carried out before obtaining results of bacteriologic tests. Then it was corrected in compliance with data of bacteriologic monitoring.
Outcomes. A total mortality rate was 23.8% (10 cases). Fatal outcomes were caused by thromboembolism of the pulmonary artery (4 patients, 40%), severe sepsis (5 cases, 50%), chronic sepsis (1 case, 10%). As for cases, treated therapeutically, dynamics of social adaptation, estimated on the basis of Karnofski scale, was insignificant. All of them remained disabled even in a year (a maximum score of 70).
As for operated patients with spondylitis and adjacent external meningitis, 6 of them (60%) had severe sepsis. It conditioned a high rate of mortality (40%). However, a state of survivors improved considerably. A mean score on admission and discharge (Karnofski scale) was 37 and 73.3 respectively. The greatest number of cases with verified sepsis (20; 76.9%) was watched in the group with epidural abscesses of a vertebral canal. The mortality rate was 19.2% (5 cases). A score on admission and discharge (Karnofski scale) was 38.1 and 69.1 respectively.
Conclusions. It is necessary to use MRI and sometimes Ct with reformation in diagnosis of the above pathology. After diagnosis verification operations should be performed as soon as possible. An approach should ensure adequate treatment of a purulent focus. Active drainage of a vertebral canal with constant irrigation of a purulent focus by antiseptic solutions should be carried out via microirrigators. It is necessary to use proteolytic enzymes, as it allows to clean a purulent focus and to get a local immunomodulating effect. Bacteriologic monitoring helps to choose rational antibacterial therapy. Estimation of an immunologic status makes it possible to exercise additional control over adequacy of a purulent focus treatment and to reveal immunodeficiency.