Spinal osteomyelitis

Spinal myeloma is not quite the correct term. There is a disease called myeloma. It develops as a result of malignant degeneration of lymphocyte precursors. As a result, a clone of malignant cells is formed, which gradually spreads throughout the body, affecting the bone marrow and internal organs.

• Causes of the disease
• Mechanism of disease progression
• Early signs of spinal myeloma
• Diagnostics
• Treatment
• Does spinal myeloma metastasize?
• Survival prognosis
• Complications
• Remission

Damage to the spine in myeloma can be represented by two options:

• Single focus of osteodestruction. In this case we are talking about solitary plasmacytoma.
• Multiple foci of osteodestruction. The picture is consistent with multiple myeloma.

A number of authors consider solitary plasmacytoma to be an early stage of the development of multiple myeloma, since in most patients it disseminates throughout the body over time, even against the background of a seemingly radical cure.

Bone damage in myeloma is an inevitable process that accompanies every patient in the later stages of the disease. The following signs are noted:

• Osteolysis is the melting of bone tissue.
• Osteoporosis is a decrease in bone density.
• Against the background of osteolysis and osteoporosis, pathological fractures inevitably occur - a violation of the integrity of the bone without the influence of a pronounced traumatic factor.
• Hypercalcemia is an increase in the content of calcium ions in the blood due to its release from bone tissue.

Causes of the disease

Myeloma develops due to malignant degeneration of B lymphocytes, or rather their precursors. What causes these mutations is not clear, but there are some patterns that increase the likelihood of developing the disease compared to the general population. These patterns are called risk factors. For myeloma it is:

• Age over 40 years.
• Male gender.
• Negroid race.
• The presence of immunodeficiency conditions, both congenital and acquired: HIV, treatment with cytostatics, the need to take immunosuppressive therapy for organ transplantation, etc.
• The presence of myeloma in close relatives.
• Exposure to radiation, including radiation therapy in the treatment of oncology.
• Monoclonal gammopathy.

TREATMENT OF OSTEOMYELITIS OF THE EXTREMITIES

When treating osteomyelitis, mandatory hospitalization is indicated. Along with surgical treatment of the affected area, it is necessary to prescribe massive antibiotic therapy (intravenous and intramuscular administration of antibacterial drugs), powerful detoxification therapy (plasma transfusions and blood substitutes), immunostimulants, vitamin therapy, hemosorption, hyperbaric oxygenation.

ACUTE HEMATOGENIC OSTEOMYELITIS

When treating acute hematogenous osteomyelitis in children under six years of age, the following is indicated:

1. Cefuroxime and Amoxicillin/Clavulanate (first-line drugs);
2. Ampicillin/Sulbactam;
3. Ceftriaxone and Oxacillin (alternative drugs);

For children over six years of age and adults, the following are used for the treatment of acute hematogenous osteomyelitis:

1. Oxacillin and Gentamicin;
2. Amoxicillin/Clavulanate (first-line drugs);
3. Cefuroxime;
4. Cephalozolin and Netilmicin;
5. Lincomycin and Gentamicin;
6. Clindamycin and Gentamicin;
7. Fluoroquinolone and Rifampicin (alternative drugs);

POST-TRAUMATIC AND POST-OPERATIVE OSTEOMYELITIS

For post-traumatic and postoperative osteomyelitis, the following are prescribed:

1. Ofloxacin;
2. Ciprofloxacin and Lincomycin (first-line drugs);
3. Cefepime;
4. Vancomycin and third-fourth generation cephalosporins;
5. Imipenem;
6. Linezolid and Ceftriaxone;

OSTEOMYELITIS OF JOINTS AND SPINE

For osteomyelitis of the joints and spine the following are prescribed:

1. Oxacillin;
2. Ceftriaxone and Aminoglycosides (first-line drugs);
3. Ciprofloxacin and Rifampicin (alternatives);

HEMODIALYSIS AND DRUG ADDICTION

For patients on hemodialysis and drug addicts, the following are used:

1. Oxacillin and Ciprofloxacin;
2. Vancomycin and Ciprofloxacin;

SICKLE CELL ANEMIA

For patients with sickle cell anemia:

1. Ciprofloxacin or third generation cephalosporins (Ceftriaxone, Cefotaxime, Cefoperazone).

Mechanism of disease progression

The mechanisms of progression of solitary plasmacytoma to multiple myeloma are not fully understood due to the rarity of this pathology. However, there is reason to believe that the transformation is caused by genome instability, when random genetic damage leads to the disruption of the differentiation process of plasma cells, the apoptosis mechanism is blocked, and they begin to divide and multiply uncontrollably.

Early signs of spinal myeloma

In the early stages of spinal lesions, there may be no symptoms, and the disease is discovered by chance during an examination for another reason. The first sign is pain. At first they are not intense and not constant. Most often, they are localized in the lumbar and thoracic region. Symptoms are nonspecific, so patients are often misdiagnosed, such as osteochondrosis, radiculitis or neuralgia.

As the disease progresses, the destruction of bone tissue increases, which leads to an increase in symptoms. The pain in the spine becomes constant and intensifies with the slightest movement. In some cases, myeloma manifests with sudden sharp pain that occurs due to pathological fractures. In some cases, the latter are complicated by compression of the spinal cord and its roots.

In general, the intensity of pain is directly dependent on the tumor mass. The more malignant cells, the stronger the destruction of bone tissue, and the symptoms are correspondingly more pronounced.

Neurological symptoms

In focal myeloma, neurological symptoms mainly develop against the background of compression of the nerve roots and spinal cord by the tumor mass. In this case, paresis and paralysis will be observed, depending on the level of damage. The second cause of the development of neurological symptoms is pathological fractures of the vertebrae.

When transformed into multiple myeloma, neurological complications are found in 10-40% of patients. They are associated both with the neoplastic effect of the tumor on nerve tissue and with the side effects of chemotherapy used for specific treatment. In this case, both the central and peripheral nervous systems can be affected:

• Autonomic dysfunction - dizziness, fatigue, nausea, tachycardia, sleep disturbances, etc.
• Pyramidal insufficiency - muscle activity is disrupted, their motor activity and tone decrease, which gradually leads to atrophic changes. There may be clonic seizures.
• Cerebellar insufficiency is a violation of movement coordination, expressed in the form of involuntary muscle contractions (chorea, myoclonus), impaired facial expressions, speech and intelligence, tremor of the head and limbs.

Myelomalacia

Under the influence of tumor cells, foci of destruction appear in bone tissue. Firstly, this is due to the direct replacement of bone tissue by a tumor. Secondly, malignant cells secrete substances that suppress the activity of osteoblasts (cells responsible for the repair of bone matter) and activate the actions of osteoclasts, which, on the contrary, lead to bone destruction due to the dissolution of its mineral component.

Book a consultation 24 hours a day

+7+7+78

Features of symptoms

The main noticeable symptom is called pain, but in fact it is far from the first, it’s just that the symptoms of the disease are not obvious at the initial stage. In addition, pain also occurs with all other diseases of the spine, so even with the onset of pain, the infection goes unnoticed for a long time, for months. Patients begin to worry when general intoxication, a feeling of chills, a rise in temperature, increased sweating and weight loss are added to the pain, and the pain begins to manifest itself especially strongly at night.

The most obvious symptom of osteomyelitis is pain against the background of general intoxication and poor health

In accordance with the infecting ability of pathogens, three types of osteomyelitis developing in vertebral structures are distinguished.

1. Spicy.
2. Primary chronicle.
3. Chronic.

Table. Symptoms of osteomyelitis by type.

By the way. Almost always, patients mistake the primary chronic and stable chronic form for manifestations of osteochondrosis or other vertebral and joint pathologies, or diseases of internal organs such as the lungs and heart.

During its development, osteomyelitis inflames not only the bone tissue, but also spreads to the entire blood supply system in the spine. This can lead to sepsis, disability and death.

Occasionally, the infection involves nerve structures in the inflammatory process by moving into the spinal canal, causing the formation of an epidural abscess. It puts pressure on the nerves, and if the source of infection is located in the neck or chest area, it can result in paraplegia (paralysis of either lower or upper limbs in pairs) and quadriplegia (simultaneous paralysis of all limbs).

By the way. Victims of osteomyelitis most often become older men, especially those who experience frequent stress and excessive tension and have a large number of different diseases. This reduces immunity and makes it impossible to cope with bacteria that cause inflammation.

Victims of osteomyelitis are most often older men

When the disease takes a protracted chronic form, the number of purulent foci in the bone increases and their size also increases. New inflamed tissue may begin to grow, which comes into conflict with healthy tissue and infects it, expanding the area of ​​infection. The bone marrow does not remain aloof from the inflammatory process, since the accumulating pus interferes with the normal functioning of the blood cells that provide it with nutrition.

Diagnostics

To make a diagnosis, it is necessary to conduct a comprehensive examination, including a number of instrumental studies.

Blood and urine analysis

A general blood test often reveals normochromic, less often macrocytic anemia. A characteristic sign is an increase in ESR, in some patients it can exceed 100 mm/hour. With extensive damage to the bone marrow, neutropenia and thrombocytopenia are detected.

A general urine test reveals increasing proteinuria, which is associated with the progression of nephropathy. Special studies reveal a specific protein - M-protein, M-gradient, Bence-Jones protein.

Myelogram

A myelogram (examination of a bone marrow sample under a microscope) shows an increase in plasma cells. The diagnosis of myeloma is made if the number of plasma cells exceeds 10%.

X-ray and MRI

X-ray diagnostic methods are not specific, but they can determine the stage and extent of myeloma. With solitary plasmacytoma, a single focus of osteolysis will be detected. In multiple myeloma, imaging will show osteopenia and multiple areas of osteolysis. A characteristic picture is the detection in the images of a large number of “stamped” foci of destruction, which look like zones of radiological clearing. For diagnosis, an X-ray of the spine in 2 projections is used; if there is little information content, a computed tomography is prescribed. PET-CT will detect microfoci of tumor lesions that are not visualized by other research methods. MRI may be prescribed to assess damage to the spinal cord and spinal roots in pathological vertebral fractures.

Treatment

Radiation therapy

Most patients with spinal myeloma are treated with radiation therapy with a total dose of 40 Gy, since myeloma cells are very sensitive to ionizing radiation. If the tumor size is more than 5 cm, the dose may be increased to 50 Gy. The irradiation field should include at least one unaffected vertebra above and below the tumor site. Signs of treatment effectiveness are sclerosis and remineralization of the lesion.

In the treatment of multiple myeloma with spinal involvement, radiation is used as part of palliative therapy to relieve pain and slow down osteolysis.

Surgery

Surgical treatment is indicated for patients with functional instability of the spine and in the presence of neurological symptoms. In some cases, if indicated, the patient is offered to undergo preventive surgery, without waiting for pathological fractures. Various types of vertebroplasty are used as part of the treatment.

Chemotherapy

The use of chemotherapy for patients with solitary plasmacytoma remains controversial. But for patients with multiple myeloma with spinal lesions, this is a key treatment method. Great progress has been made with the inclusion of thalidomide, lenalidomide and bortezomib in protocols:

• Bortezomib is an inhibitor of proteasomes, enzymes that play an important role in maintaining cell homeostasis, growth and reproduction. Inhibition of proteasome action blocks selective proteolysis, which affects many intracellular processes, including signal transduction. All together this leads to cell death. In addition, it was experimentally confirmed that bortezomib enhances the activity of osteoblasts and suppresses the functions of osteoclasts in patients with myeloma.
• Thalidomide is a drug that has immunomodulatory, antiangiogenic and cytotoxic effects. The prerequisite for the use of this drug was the data that in patients with myeloma, increased angiogenesis is detected in the bone marrow, which promotes the proliferation and dissemination of malignant cells. Further testing revealed that, in addition to the antiangiogenic effect, the drug causes cell apoptosis. Currently, thalidomide is used in patients who have not yet been prescribed treatment, with relapses after previous courses of chemotherapy, as well as in patients resistant to other types of drugs. It can be used both as monotherapy and in polychemotherapy regimens.
• Lenalidomide. From a structural point of view, it is similar to thalidomide, but has a more pronounced biological effect. It has shown the greatest effectiveness in the treatment of hematopoietic tumors, especially in the presence of mutations of chromosome 5.

Patients with bone myeloma, including spinal myeloma, are a complex category of patients that are difficult to treat. Therefore, whenever possible, they are prescribed 4-5 component chemotherapy regimens, for example, VDCR or VD-PACE, which contain bortezomib.

Treatment of spinal infection

As a rule, in the main cases osteomyelitis is treated conservatively. Therapy is carried out with intravenous antibiotics.

Since the disease is primarily caused by the Staphyloccocus bacterium, which is highly sensitive to antibiotics, the intravenous treatment process takes about a month, and then a control two-week course begins, which is administered orally. During the entire period, the patient is prescribed bed rest.

Antibiotics for osteomyelitis

Important! If the infection is of tuberculosis etiology, the patient may take antibiotics for up to a year.

In addition to therapy, the spine is fixed for six to twelve weeks using a rigid corset, until x-rays show positive dynamics of therapy.

Does spinal myeloma metastasize?

Unfortunately, all currently available treatment methods for solitary plasmacytoma do not guarantee complete cure. Relapses may develop, which are localized both outside the primary tumor and at the site of the former lesion. Regional lymph nodes are less commonly affected.

Also, focal myeloma (plasmocytoma) can transform into multiple myeloma. In half of the patients, transformation is detected within 5 years after treatment of plasmacytoma, and in 72% - within 10 years. The median time to progression is 2 years, but there can be significant differences. The key point is the age of the patient - the older he is, the higher the risk of transformation.

Diagnostic procedures

Due to hidden symptoms, it can be difficult to diagnose vertebral osteomyelitis, especially in its early stages. Therefore, in case of any back pain, especially those of unclear etiology, you must immediately consult a doctor for instrumental examinations and laboratory diagnostics. In some cases, in order to carry out a bacteriological analysis and identify the type of bacterial culture - the causative agent, a puncture is required.

Spine biopsy

The beginning of the diagnostic process usually begins with the appointment of x-rays, which, by the way, may not show anything for up to four weeks after the onset of the inflammatory process.

Spinal osteomyelitis on x-ray

By the way. In order for a change in bone tissue to be visualized, it must be destroyed to at least 30%. However, X-rays show long before this a decrease in the intervertebral distance and destruction of the end plates if intervertebral structures are involved in the process.

MRI with contrast is more informative than x-rays. Since infection destabilizes blood flow, making it unstable and increasing in certain areas, contrast can show these areas by accumulating there.

Magnetic resonance imaging

Laboratory tests are blood cultures, which can be used to identify the causative agent of infection in order to select the necessary antibiotic therapy. But culture, unfortunately, reveals the pathogen in only 50% of episodes.

There are also inflammatory markers that make it possible to predict an existing infection with some accuracy. In particular, this is an indicator of the erythrocyte sedimentation rate, which is exceeded in 90% of cases of osteomyelitis. Decoding the leukocyte blood count is considered the most valuable and informative laboratory diagnostic method.

Leukocyte blood formula. Decoding

If the infectious process is confirmed, but the pathogen cannot be detected, a tissue biopsy is performed to prescribe the correct treatment. It is carried out with a needle under the control of a computed tomograph. If indicated, an open biopsy can be performed.

Remission

The achievement of remission is indicated by sclerosis and remineralization of the tumor focus. All patients treated for focal plasmacytoma should be under lifelong medical supervision, since there is always a possibility of the disease progressing to multiple myeloma.

Book a consultation 24 hours a day
+7+7+78

OSTEOMYELITIS OF THE EXTREMITIES

Content

1. CLASSIFICATION
2. NON-SPECIFIC OSTEOMYELITIS
3. SPECIFIC OSTEOMYELITIS
4. CAUSES
5. PHOTO OF OSTEOMYELITIS
6. TREATMENT OF OSTEOMYELITIS OF THE EXTREMITIES
7. ACUTE HEMATOGENIC OSTEOMYELITIS
8. POST-TRAUMATIC AND POST-OPERATIVE OSTEOMYELITIS
9. OSTEOMYELITIS OF JOINTS AND SPINE
10. HEMODIALYSIS AND DRUG ADDICTION
11. SICKLE CELL ANEMIA

Osteomyelitis is an inflammatory process of a purulent-necrotic nature that affects the bone tissue surrounding the periosteum and bone marrow. The causative agents of osteomyelitis, in the vast majority of cases, are staphylococci and streptococci.

Osteomyelitis that occurs for the first time is called acute. If the patient has a protracted course of the disease with exacerbations and remissions, then we are talking about a chronic course of the inflammatory process of osteomyelitis. Often, with osteomyelitis, the entire bone tissue, including the bone marrow area, is involved in the inflammation process. In the chronic process of osteomyelitis, bone sclerosis and deformation occur.