Recovery From Surgery for Spine Infections in Children

Postoperative Orders 

Spine infections in children

• Infectious disease and physical therapy consultations: Infectious disease consultation is usually obtained to help follow the patient during treatment. Physical therapy is progressively introduced.
• Intravenous antibiotics: A 6–8 week course of IV antibiotics is suggested following speciation of organisms grown in cultures.
• PCA for pain management: Patients experience significant postoperative pain after a surgical procedure, and PCA pumps are recommended in the initial 36–48 hours postoperatively.
• Mobilization: Mobilization is recommended postoperatively. Nursing care should involve attempts to prevent deep venous thrombosis with frequent repositioning. The patient should be evaluated for the need for orthotics prior to the reintroduction of weight-bearing. Aggressive pulmonary toilet should be implemented as well.

Spinal epidural abscesses in children

• Intravenous antibiotics, at least initially: For spinal epidural abscess, 3–4 weeks of IV antibiotics followed by 4 weeks of oral antibiotics usually suffices. A 6–8 week course of IV antibiotics is suggested if there is documented concomitant vertebral osteomyelitis (52).
• Broad-spectrum antibiotics until organism known: Broad-spectrum IV antibiotics are started as soon as diagnosis is established (55). If the organism and source are unknown, S. aureus is considered to be the most likely; and the empiric antibiotics such as third-generation cephalosporin (e.g., cefotaxime) in addition to vancomycin (until MRSA can be ruled out) and rifampicin orally are used (52). If MRSA is ruled out, vancomycin should be switched to synthetic penicillin (e.g., nafcillin or oxacillin). The prevalence of methicillin-resistant strains of S. aureus has led many to suggest treatment with vancomycin in combination with either an aminoglycoside or third-generation cephalosporin until culture results are obtained (21).
• Clinical improvement and ESR, CRP: The duration of antibiotic therapy is usually determined by a combination of clinical (i.e., reduced pain, improved function, or both), laboratory (i.e., normalized ESR level, CRP level, or both) and radiographic improvement (i.e., resolved epidural fluid collection, osteomyelitis, or both). Failure to reduce ESR levels suggests residual infection (22, 52).
• Infectious disease and physical therapy consultations: Infectious disease consultation is obtained to help follow the patient during treatment. Physical therapy is progressively introduced.

Spinal subdural and intramedullary spinal cord abscesses in children

• Flat in bed: After a dural opening, it is recommended that a patient remain flat in bed for 24–48 hours to avoid CSF leakage and resulting hypotensive headaches.
• Antibiotics continued: Antibiotics are continued for 4–8 weeks; results of cultures and sensitivities are followed (55).
• Clinical improvement and ESR and CRP levels: The duration of antibiotic therapy is usually determined by a combination of clinical (i.e., reduced pain, improved function, or both), laboratory (i.e., normalized ESR level, CRP level, or both), and radiographic (i.e., resolved subdural fluid collection) improvement. Failure to reduce ESR level suggests residual infection.
• Infectious disease and physical therapy consultations: Infectious disease consultation is obtained to help follow the patient during treatment. Physical therapy is progressively introduced.

Postoperative Morbidity

Spine infections in children

• Antibiotic complications: Long-term antibiotic therapy may lead to cranial nerve palsies (CN VIII), renal toxicity, hearing impairment, skin rashes, and antibiotic-specific complications.
• Complications of spinal instability and lack of mobility: Patients may experience more profound neurological deficits, skin decubiti, deep venous thrombosis, pulmonary emboli, urinary sepsis, dysautonomia, and spasticity.

Spinal epidural abscesses in children

• Pain at surgical site: Intravenous morphine or fentanyl for pain management and diazepam for muscle relaxation are currently used for children during the first 24–48 hours after spinal surgery. Intravenous ketorolac, a NSAID, has proven to be effective as well (133). Other NSAIDs and paracetamol-like analgesics cannot provide adequate and effective analgesia (133). These drugs can reduce opioid requirements and pain scores only when they are used together with opioids. The postoperative use of opioids causes severe side effects such as nausea, vomiting, urinary retention, itching, sedation, and respiratory depression. Thus, opioid use is avoided for children, and, consequently, adequate analgesia cannot be provided. Central and peripheral nerve blocks have been used to provide optimal pain control in the postoperative period. An experienced pediatric anesthesiologist must administer all of these treatments (134-138). Local anesthesia administered into the incision area reduces the opioid requirement and can usually be administered as a single dose or as a continuous infusion via a wound catheter (139).

Spinal subdural abscesses in children

• Pain at surgical site: See Discussion under heading Spinal Epidural Abscesses in Children above.
• Headaches

Intramedullary spinal cord abscesses in children

• Syringomyelia and intraspinal cyst: Residual intramedullary fluid collections have been reported (140).
• Spinal tethering: Although the incidence of this complication is unknown, the scarring and possible arachnoiditis could be considered as a causative factor for neurological deterioration months to years after surgery.
• Scoliosis: Scoliosis has been known to develop from laminectomies in younger children.
• Neuropathic pain: Paresthesias and dysesthesias have been noted to occur both before and after surgery in patients with intramedullary spinal cord abscesses (141).