History of the Management of Spine Infections in Children

Understanding of Disease

• 17th century B.C. – first description of spine infection: The earliest record of spinal infections dates back to the 17th century B.C. The Edwin Smith Papyrus, as it is known today, was initially found in a tomb in Thebes, Egypt.

Edwin Smith Papyrus, 17th Century B.C.:

• 3rd century B.C. – tuberculosis of spine described: Hippocrates in the 3rd century B.C. commented on spinal tuberculosis, stating that “when gibbosity occurs in youth before the body is fully grown, spinal growth stops, but the arms and legs are fully developed.” To date, pediatric spinal infections, although not as common as adult spinal infections, are still very prevalent worldwide.
• 1820 – Bergamaschi describes spinal osteomyelitis: A pathological description of bacterial vertebral osteomyelitis was first provided in 1820 by Bergamaschi (13).
• 1830 – Hart publishes first description of intramedullary abscess: The first recorded case of spinal intramedullary spinal cord abscess was published by J. Hart in the Dublin Hospital Reports in 1830 (99). Since then, fewer than 100 cases of primary intramedullary abscesses in adults have been described in the extant literature. Fewer than 40 cases of pediatric intramedullary abscesses have been reported since 1875.
• 1854 – “Idiopathic inflammation of the theca vertebrae” described: Bristowe, in 1854, reported “idiopathic inflammation of the theca vertebrae, with accumulation of pus following the course of the spinal nerves” (15). Langdon noted a second case of “pachimeningitis spinalis externa” in 1899 (146).
• 1901 – Barth describes first surgical drainage of epidural abscess: The first successful drainage of a spinal epidural abscess with functional recovery of the patient was performed in 1901 by Barth (14).

Technological Development

• Intraoperative ultrasound: DiPietro et al. described the use of ultrasound in children in 1993 (129). Since then, Coley, Unsinn, and others have reported the use of portable ultrasounds as an affordable and easy technology for initial screening of spinal lesions in small and older but thin children (130, 131). They can be adapted to portable devices and images can be assessed via internet.

Surgical Technique

• Increasing number of applicable spine techniques: For epidural and subdural abscesses, several types of surgical procedures have been described, including needle aspiration, corpectomy, laminotomy, and laminectomy. Vertebral distraction, flavotomy, and the use of a cannula for aspiration of empyemas and irrigation of the epidural or subdural space have been described (19).
• Myelotomy and drainage of abscesses sufficient: In intramedullary abscesses, needle aspiration followed by myelotomy and pus drainage, without radical wall excision, minimizes the neurological deficits. With the abscess cavity open, draining out pus seems adequate, and vigorous abscess wall scraping is not required. Nonabsorbable thin prolene sutures may be applied for dural closure (25).