Preparation for Surgery for Spine Infections in Children

Indications for Surgery

• New neurological dysfunction: The onset of weakness, numbness, and bowel or bladder incontinence is an indication for intervention, with surgery affording the most rapid means of treatment.
• Progressing infection: An infection that progresses (or persists without change in size) despite a course of IV antibiotics is an indication that surgery is needed.
• Progressive pain: Progressive pain is an indication that the IV antibiotics are inadequately managing the infection.

Spine infections in children

• Refractory disease or abscess: Cases refractory to medical management, evolution of the disease clinically or radiographically, and abscess formation are indications for surgical intervention and debridement. Those patients who develop sepsis or a progressive deformity are also candidates for surgical intervention.

Spinal epidural, subdural, and intramedullary spinal cord abscesses in children

• Presence of an abscess: As stated on the Medical Management page, in most cases the identification of an abscess on radiographic evaluation is an indication for surgery.
• Identify pathogen: Isolation of the pathogen is essential in treatment and management of vertebral osteomyelitis. Percutaneous or open biopsies are recommended in all cases. Antibiotic therapy is recommended after isolation of the pathogen.
• Debridement +/- instrumentations for progression: Cases refractory to medical management and that evolve clinically or radiographically in spite of medical management are candidates for surgical intervention and debridement. Following debridement, spinal instrumentation may be necessary for stabilization.

Preoperative Orders

Spine infections in children

• Evaluate for spinal stability: Diagnostic testing (x-rays and/or CT scan) should be done to assess the patient’s spinal stability. Patients with spinal instability should be maintained on strict spinal precautions during movement and log rolled when transfer to operating table is necessary.

Spinal epidural, subdural, and intramedullary spinal cord abscesses in children

• Timing of antibiotic introduction: If the patient is being taken to the operating room immediately, one may consider delaying the use of antibiotics until cultures have been obtained.

Anesthetic Considerations

Spine infections in children

• Consider need for fiberoptic or nasal intubation: When cervical spine instability is present, endotracheal intubation should be performed without spinal extension. This may necessitate nasal or fiberoptic endotracheal intubation.
• Consider need for gastric decompression: Those patients for whom emergent surgical consideration is needed should have gastric decompression via nasogastric tube and suction.

Spinal epidural, subdural, and intramedullary spinal cord abscesses in children

• Discuss possible need for IOM: The anesthesia team should be notified in advance in cases where intraoperative neurophysiological monitoring is to be used in surgery for planning on total intravenous anesthesia.

Devices to Be Implanted

Spine infections in children

• Spine instrumentation: Spinal instrumentation may be necessary for stabilization.

Spinal epidural, subdural, and intramedullary spinal cord abscesses in children

• Spine instrumentation: If necessary, the surgeon may use instrumentation for stabilization because an unstable infected spine is worse than a stable infected spine.

Ancillary/Specialized Equipment

Spine infections in children

• IOM: If there is to be implantation of spinal instrumentation and/or manipulation of the spine’s configuration, then intraoperative neurophysiological monitoring might be indicated.

Spinal epidural, subdural and intramedullary spinal cord abscesses in children

• Navigational systems: A navigation system and intraoperative ultrasound can be used to localize small abscesses and minimize exposure.
• IOM: If there is to be implantation of spinal instrumentation and/or manipulation of the spine’s configuration, then intraoperative neurophysiological monitoring might be indicated.