Osteomyelitis is the medical term for infection of bone tissue. Infections can enter bone tissue through the bloodstream or spread from nearby tissues. Osteomyelitis can begin in the bone itself if an infection occurs during an injury.
In children, osteomyelitis most often affects the long bones of the legs and upper arms, while in adults, osteomyelitis of the spinal bones (vertebrae) is more common. People with diabetes may develop osteomyelitis in the lower extremities if there are trophic ulcers on the legs. If previously osteomyelitis was considered an incurable disease, now this disease can be successfully treated. Most patients with osteomyelitis require surgery to remove dead bone tissue along with intensive antibiotic therapy (strong antibiotics given parenterally for at least 6 weeks). With osteomyelitis of the spine, infection of the vertebrae occurs. It is a fairly rare cause of back pain, especially in young, healthy adults.
As a rule, the infection enters the vertebral body hematogenously (through the bloodstream). The veins in the lower part of the spine also drain the pelvis (Watson's venous plexus) and thus infections easily enter the spine. Therefore, in most cases, the cause of vertebral osteomyelitis is infections that occur after urological procedures (for example, cystoscopy).
Risk factors
Bone tissue is generally resistant to infection. For osteomyelitis to occur, conditions must be present that increase the bones' vulnerability to infection.
Recent injuries or surgeries. In case of severe bone fractures or deep punctures, infection penetrates into the bone or nearby tissue. Surgical repositioning of bone fragments or endoprosthetic surgery may also inadvertently introduce infection into the bone.
Poor circulation. When blood vessels are damaged or the blood flow through them is disrupted, conditions arise for a deficiency of immune cells responsible for counteracting microbes and preventing the small number of microbes that accidentally enter the tissue from multiplying. What begins as a small cut can progress to a deep ulcer that can involve deeper tissue and even bone. Diseases that impair blood circulation include:
- Diabetes
- Peripheral artery disease often associated with smoking
- Sickle cell anemia
Medical catheters
A medical catheter connects the outside world with the internal organs. And although these catheters are necessary for some conditions, they can serve as conduits for infections into the body. Therefore, catheters increase the risk of infection, including osteomyelitis. Examples include:
- Catheters for dialysis
- Bladder catheters
- Intravenous catheters, which are necessary for long-term administration of medications (months or even years)
Intravenous drug administration
People who inject drugs are at greater risk of developing osteomyelitis because they typically use unsterile needles and do not clean the skin before injections.
Common causes of osteomyelitis.
The following groups of people are most susceptible to developing osteomyelitis:
- Elderly patients
- Intravenous drug addicts
- Patients with a weakened immune system
The immune system may be weakened as a result of the following conditions:
- Long-term use of corticosteroids to treat systemic diseases such as rheumatoid arthritis.
- Insulin-dependent diabetes mellitus
- Patients with transplanted organs
- Acquired immunodeficiency syndrome (AIDS)
- Malnutrition
- Cancer
Intravenous drug use is causing an increase in the number of patients with spinal infections. As a rule, the microorganism most often affecting the spine is Staphylococcus aureus, and among drug addicts who use intravenous drugs, Pseudomonas aeruginosa is often the causative agent of a spinal infection. Treatment of these two pathogens requires different antibiotic treatments.
In the recent past, Mycobacterium tuberculosis has been a common cause of spinal infections. At present, spinal tuberculosis practically does not occur in developed countries and is common only in poor, backward countries with a low standard of living. But drug addicts may have a tuberculous infection.
Most vertebral body infections occur in the lumbar spine due to the nature of the venous blood flow. With tuberculous lesions of the vertebrae, the cervical and thoracic spine are most often affected.
Osteomyelitis
Manifestations of acute osteomyelitis depend on the route of infection, the general condition of the body, the extent of traumatic damage to the bone and surrounding soft tissues. On radiographs, changes are visible 2-3 weeks after the onset of the disease.
Hematogenous osteomyelitis
As a rule, it develops in childhood, with a third of patients becoming ill before the age of 1 year. Quite rare cases of the development of hematogenous osteomyelitis in adults are actually relapses of the disease suffered in childhood. Most often it affects the tibia and femur. Multiple bone lesions are possible.
From a remote source of inflammation (soft tissue abscess, phlegmon, infected wound), microbes are carried through the blood throughout the body. In long tubular bones, especially in their middle part, a wide network of vessels is well developed, in which the speed of blood flow slows down. Infectious agents settle in the cancellous bone. Under unfavorable conditions (hypothermia, decreased immunity), microbes begin to multiply rapidly, and hematogenous osteomyelitis develops. There are three forms of the disease:
Septic-pyemic form
. Characterized by an acute onset and severe intoxication. Body temperature rises to 39-40°, accompanied by chills, headache and repeated vomiting. Possible loss of consciousness, delirium, convulsions, hemolytic jaundice. The patient's face is pale, lips and mucous membranes are bluish, and the skin is dry. The pulse is increased, the pressure is reduced. The spleen and liver enlarge, and sometimes bronchopneumonia develops.
On the 1st-2nd day of the disease, precisely localized, sharp, drilling, bursting or tearing pain appears in the affected area, intensifying with the slightest movements. The soft tissues of the limb are swollen, the skin is hot, red, and tense. When it spreads to nearby joints, purulent arthritis develops.
After 1-2 weeks, a focus of fluctuation (fluid in the soft tissues) forms in the center of the lesion. Pus penetrates the muscles, intermuscular phlegmon is formed. If the phlegmon is not opened, it can open on its own with the formation of a fistula or progress, leading to the development of periarticular phlegmon, secondary purulent arthritis or sepsis.
Local form
. The general condition suffers less and sometimes remains satisfactory. Signs of local inflammation of bone and soft tissue predominate.
Adynamic (toxic) form
. Rarely seen. Characterized by lightning-fast onset. The symptoms of acute sepsis predominate: a sharp increase in temperature, severe toxicosis, convulsions, loss of consciousness, a pronounced decrease in blood pressure, acute cardiovascular failure. Signs of bone inflammation are weak and appear late, which makes diagnosis and treatment difficult.
Post-traumatic osteomyelitis
Occurs with open bone fractures. The development of the disease is facilitated by contamination of the wound at the time of injury. The risk of developing osteomyelitis increases with comminuted fractures, extensive soft tissue damage, severe concomitant injuries, vascular insufficiency, and decreased immunity.
Post-traumatic osteomyelitis affects all parts of the bone. In linear fractures, the area of inflammation is usually limited to the fracture site; in comminuted fractures, the purulent process tends to spread. Accompanied by hectic fever, severe intoxication (weakness, weakness, headache, etc.), anemia, leukocytosis, increased ESR. The tissues in the area of the fracture are swollen, hyperemic, and sharply painful. A large amount of pus is released from the wound.
MRI of the foot. Osteomyelitis of the talus and tibia with the presence of an extensive area of bone tissue destruction.
Gunshot osteomyelitis
More often occurs with extensive lesions of bones and soft tissues. The development of osteomyelitis is promoted by psychological stress, decreased body resistance and insufficient wound treatment.
General symptoms are similar to post-traumatic osteomyelitis. Local symptoms in acute gunshot osteomyelitis are often mild. The swelling of the limb is moderate, there is no profuse purulent discharge. The development of osteomyelitis is indicated by a change in the wound surface, which becomes dull and covered with a gray coating. Subsequently, inflammation spreads to all layers of the bone.
Despite the presence of a focus of infection, with gunshot osteomyelitis, bone fusion usually occurs (the exception is significant bone fragmentation, large displacement of fragments). In this case, purulent foci end up in the callus.
Postoperative osteomyelitis
It is a type of post-traumatic osteomyelitis. Occurs after osteosynthesis operations of closed fractures, orthopedic operations, insertion of wires when applying compression-distraction devices or applying skeletal traction (wire osteomyelitis). As a rule, the development of osteomyelitis is caused by non-compliance with asepsis rules or a highly traumatic operation.
Contact osteomyelitis
Occurs due to purulent processes in the soft tissue surrounding the bone. Especially often, the infection spreads from soft tissue to the bone with panaritium, abscesses and phlegmon of the hand, and extensive wounds of the scalp. Accompanied by increased swelling, increased pain in the area of injury and the formation of fistulas.
Treatment
Only in hospital in the traumatology department. The limb is immobilized. Massive antibiotic therapy is carried out taking into account the sensitivity of microorganisms. To reduce intoxication, replenish blood volume and improve local blood circulation, plasma, hemodez, and 10% albumin solution are transfused. For sepsis, methods of extracorporeal hemocorrection are used: hemosorption and lymphosorption.
A prerequisite for successful treatment of acute osteomyelitis is drainage of the purulent focus. In the early stages, burr holes are made in the bone, followed by washing with solutions of antibiotics and proteolytic enzymes. For purulent arthritis, repeated punctures of the joint are performed to remove pus and administer antibiotics; in some cases, arthrotomy is indicated. When the process spreads to soft tissues, the resulting ulcers are opened, followed by open rinsing.
Symptoms
The first symptom of a spinal infection is pain, but this symptom also occurs with other spinal diseases, and therefore a spinal infection develops almost unnoticeably and over a long period of time. In addition to back pain, there may be symptoms of general intoxication and inflammation of the body, such as fever, chills, sweating, weight loss, and increased pain at night. Spinal infection rarely involves nerve structures. However, the infection can move into the spinal canal and cause the development of an epidural abscess, which in turn can put pressure on the nerve elements. If it occurs in the cervical or thoracic spine, it can result in paraplegia or quadriplegia.
General information
Osteomyelitis of the mandible is more common, more severe and has more complications. With chronic osteomyelitis of the lower jaw, the bone is affected deeper, which can lead to jaw fractures. Inflammation affects a dangerous area - the jaw processes. Acute osteomyelitis of the lower jaw easily turns into subacute and then chronic.
Osteomyelitis of the upper jaw develops more rapidly and can lead to inflammation of the maxillary sinuses. However, since the bone tissue here is less dense, abscesses and phlegmons develop less often with osteomyelitis of the upper jaw, and the disease itself is easier.
The entry point for infection is a diseased tooth, and the causative agents of inflammation are Staphylococcus aureus and Staphylococcus alba, pneumococci, Escherichia coli and typhoid bacilli. This microflora is usually located in areas of chronic infection of the tissues surrounding the tooth.
Inflammation in osteomyelitis does not occur suddenly; initially, a chronic infection develops in the gum for a long time - for example, in periodontitis or periodontitis. Then, if the outflow of waste products from the infection is disrupted, the microflora from the lesion spreads to the surrounding tissue.
Osteomyelitis of other parts of the skeletal system is caused by only one type of pathogen - staphylococcus (streptococcus), which penetrates the tissue through the bloodstream. Since osteomyelitis of the jaw can be caused by different pathogens, the course of the disease has much more distinctive features than with ordinary osteomyelitis.
Diagnostics
It is sometimes quite difficult to diagnose spinal osteomyelitis in the early stages. If spinal osteomyelitis is suspected, diagnostic instrumental and laboratory tests must be performed. Sometimes a puncture may be required to collect material for bacteriological analysis and identify bacterial cultures.
Diagnostic tests
The process of diagnosing a spinal infection usually begins with an x-ray.
X-rays may be normal for 2 to 4 weeks after the infection begins. Visualization of bone tissue damage requires destruction of 50-60% of the vertebral bone tissue. When intervertebral structures are involved (discitis), there is a decrease in the distance between the vertebrae and destruction of the end plates.
The most informative method for diagnosing osteomyelitis is an MRI study with contrast. Infection leads to an increase in blood flow in the vertebral body, and accordingly, the contrast will accumulate more in the vertebrae damaged by the infection.
Scintigraphy is sometimes used, but, unfortunately, this method does not differentiate a tumor or other diseases from an infection.
Laboratory research
Blood culture allows you to determine the causative agent of the infection and select the necessary antibiotic accordingly. But blood culture allows the microorganism to be cultured in no more than half of the cases. Some tests (inflammatory markers) suggest the presence of infection. This is especially true for such an analysis as ESR (erythrocyte sedimentation rate), which will be elevated in osteomyelitis in 80-90% of cases. An analysis of the leukocyte blood count also has diagnostic value.
If these markers are normal, then it is very unlikely that the patient has an infection.
If these markers are elevated, they play a diagnostic role and are also criteria for the effectiveness of treatment. A decrease in inflammatory markers is a good indicator of the adequacy of treatment of the infection.
A tissue biopsy may be ordered if necessary to determine the causative agent of the infection, and the biopsy is performed using a puncture needle and under control. In selected cases, an open biopsy may also be required for diagnosis.
CLASSIFICATION
There are nonspecific and specific osteomyelitis. Depending on the path by which microbes penetrate the bone, endogenous (hematogenous) and exogenous osteomyelitis are distinguished.
NON-SPECIFIC OSTEOMYELITIS
Nonspecific osteomyelitis is caused by bacterial pathogens such as:
- Staphylococcus aureus.
- Staphylococcus epidermidis (70% of cases).
- Streptococcus.
- Enterobacteriaceae.
- Pseudomonas aeruginosa.
SPECIFIC OSTEOMYELITIS
Specific osteomyelitis occurs when:
- Tuberculosis of bones and joints.
- Brucellosis.
- Syphilis.
- Enterobacteriaceae.
- Pseudomonas aeruginosa.
In rare cases, the cause of osteomyelitis may be the microbacterium tuberculosis.
As a rule, osteomyelitis is initially acute. In favorable cases it ends with recovery, in unfavorable cases it becomes chronic. In atypical forms of osteomyelitis (Brodie's abscess, Ollier's albuminous osteomyelitis, Garre's sclerosing osteomyelitis) and some infectious diseases (syphilis, tuberculosis, etc.) there is no acute phase of inflammation, the process is primarily chronic.
Treatment
Treatment of osteomyelitis is usually conservative and is based mainly on the use of intravenous antibiotic treatment. Surgery may sometimes be used to decompress nerve structures, debride damaged bone tissue, remove necrotic tissue, or stabilize the spine.
Conservative treatment includes antibiotic therapy, restorative drugs and rest. Most cases of spinal osteomyelitis are caused by Staphyloccocus Aureus, which is usually very sensitive to antibiotics. Intravenous antibiotic treatment usually takes about four weeks, followed by a two-week course of oral antibiotics. Tuberculosis infections require antibiotics for a year. Fixation of the spine (using a corset) is necessary for a period of 6-12 weeks, until positive dynamics are noted on x-rays. Preference is given to rigid corsets.
Surgery
Surgical decompression is necessary if the epidural abscess puts pressure on nerve structures. Because surgical decompression often further destabilizes the spine, vertebral fixation is usually performed along with it. Surgical debridement of foci of infection is necessary in case of resistance to antibiotic therapy. Surgery may also be necessary if there is a lot of bone destruction with subsequent deformity and pain. Reconstruction of the bony elements and stabilization of the spine can help reduce pain and prevent further destruction of the spine.
Why you should entrust treatment to the ENT department of dentistry
Treatment of osteomyelitis of the jaw should be carried out comprehensively - surgery to eliminate the source of infection, treatment of the affected bone, drug treatment and restorative therapy.
The usual tactics for treating osteomyelitis with inflammation penetrating the maxillary sinuses is to redirect the patient from one specialist to another. First, specialized specialists eliminate the source of infection - a dental surgeon removes the causative tooth, an otolaryngologist treats inflammation in the sinuses. Then, in the inpatient departments of otolaryngology or maxillofacial surgery, a surgical operation is performed to excise the infected soft and bone tissues of the maxillary sinus and remove sequesters.
ENT dentistry combines several areas of medical services and allows you to combine otolaryngological, surgical and dental treatment options. This is an optimized approach to the rehabilitation of patients with combined pathologies of the maxillary sinuses of a “dental” and external nature. Allows a comprehensive surgical and treatment program to be carried out in one place.
We have been treating combined ENT and dental pathologies for more than 20 years
When the maxillary sinuses are involved in the process, treatment is carried out by experienced maxillofacial surgeons with ENT training, candidates of medical sciences. A full-fledged ENT department is equipped with modern equipment to perform complex operations.
Levin Dmitry Valerievich Chief physician and founder of the Doctor Levin center
Complications
Osteomyelitis can cause the following complications:
- necrosis of bone tissue. Infection in the bone tissue can lead to disruption of blood circulation in the bone, which leads to necrosis of the bone tissue. If the areas of necrosis are small, then their surgical removal can lead to tissue restoration. With large necrosis, removal of all necrotic tissue or limb is required if we are talking about osteomyelitis of the extremities.
- septic arthritis. In some cases, an infection in the bone tissue can spread to nearby joints.
- Impaired bone growth. In children, the most common localization of osteomyelitis foci is the growth zones of tubular bones, which can further lead to impaired bone growth.
- skin cancer. If osteomyelitis leads to an open wound with pus discharge, then the risk of developing squamous cell carcinoma sharply increases.