Osteomyelitis in the spinal cord injured: a review and a preliminary report on the use of hyperbaric oxygen therapy

Paraplegia zz (1984) 17-24 © 1984 International Medical Society of Paraplegia OSTEOMYELITIS IN THE SPINAL CORD INJURED: A REVIEW AND A PRELIMINARY REPORT ON THE USE OF HYPERBARIC OXYGEN THERAPY By I. ELTORAI, M.D. , G. B. HART, M.D. , MICHAEL B. STRAUSS, M.D. The Spinal Cord Injury Service, Veterans Administration Medical Center, 5901 East Seventh Street, Longbeach, 90822 California, USA. Summary. Spinal Cord Injury patients are liable to develop osteomyelitis mostly by extension from pressure ulcers. In 2055 records reviewed in the Long Beach Spinal Cord Injury Service of the Veterans Administration Medical Center, the incidence was found to be 4"3 per cent. Of these osteomyelitis developed secondary to pressure ulcers in 88 per cent, the rest developed as a result of trauma and/or surgery. Forty-four patients manifesting chronic osteomyelitis were treated in a monoplace hyperbaric oxygen (HBO) chamber, in addition to receiving antibiotic and surgical treatment. HBO was found useful as an adjunct to help to resolve the bone infection and encourage wound healing. Two-thirds of the patients were cured, and the follow-up was from 6 months to 9 years. We believe that HBO is a useful adjunctive therapeutic measure in the management of chronic osteo myelitis in the spinal cord injured and in the prevention of its complications. Key words: Spinal cord injured patients; Osteomyelitis; Hyperbaric oxygen therapy; Antibiotic therapy; Surgical treatment. Introduction SPINAL CORD INJURY (SCI) was recorded from the earliest records of civilisa tion. The Edwin Smith Papyrus (Breasted et al. , 1930), written about 5000 years ago, contains a clear description of the cardinal symptoms of a com plete lesion of the spinal cord following a neck injury. In the same papyrus, considered as the first textbook of surgery, the oldest known records of bone diseases are found. Open fractures and the draining of bones were treated as inflammatory diseases using a pharmacopoea of plant and animal extracts, as well as by splinting. In spite of the antiquity of both spinal cord injury and osteomyelitis, the incidence of osteomyelitis in SCI patients has not been well documented, but according to Eltorai (1981) it occurs in about 5 per cent of such (SCI) patients. It most commonly affects the hips, the ischia, the sacrum and the calcaneous, in descending order of frequency. Less common sites are the ankle, the knee, the elbow, and lumbar vertebrae. It is rarely seen in the toes, metatarsals, tibia, fibula and the ulna. Staphay lococcus au reus had been the predominant organism. The radiological signs have been observed in the majority of cases in the form of osteoperiostitis, bone destruction, sequestration, pathological dislocation of joints and occasionally pathological fractures of a long bone. This paper discusses the aetiology and pathophysiology of chronic osteomyelitis in SCI patients, and reviews the treatment of this condition in 44 cases treated by the conventional methods of surgery and antibiotics; but in addition by hyperbaric oxygen therapy. This is the first report of 17 18 PARAPLEGIA our experience using hyperbaric oxygen for the treatment of chronic osteomylitis in SCI patients. Aetiology Osteomyelitis in SCI patients is called 'transferred osteomyelitis' (Burri, 1975). The most common predisposing factor is a pressure ulcer. In 88 per cent of our series, the infection spread from the infected pressure ulcer to the underlying bone (Eltorai, 1981). Pressure sores are the end result of tissue ischaemia due to pressure and/or shearing forces with consequent necrosis and bacterial invasion. The fourth, or deepest degree of ulceration, may involve the underlying periosteum (periostitis) or the cortex (osteitis) or the whole thickness of the bone, causing osteomyelitis. Bone infection occurs after there is bacterial invasion of the skin, subcutaneous fat, muscles, tendons, ligaments and bursae. In 12 per cent of the cases studied (10 patients) other causes of osteo myelitis include trauma to the paralysed extremities with or without open fractures (6 cases). It is known that open reduction with or without internal metallic fixation is liable to be complicated by osteomyelitis in SCI. There is a 65 per cent incidence of osteomyelitis in open fractures in general (Wald vogel, 1970). Other infrequently encountered causes (of which we had none), include puncture wounds, and animal and human bites. Failed amputations constituted another cause of osteomyelitis in our series (4 cases). All patients in this group had peripheral obliterative arterial disease; three with Leriche's Syndrome. Haematogenous osteomyelitis, which is the common cause in non-Spinal Cord Injured, (Resnick and Niwayama 1981), was not observed in this group of patients. The course of the disease is usually chronic, but subacute cases and acute septicaemic cases have been encountered. Septicaemia in these patients is secondary to bone and/or joint infection from a pressure ulcer, especially in the diabetic and the malnourished. Material Of 2055 patients reviewed at the Spinal Cord Injury Service of the Veterans Administration Medical Centre at Long Beach, California, 90 patients had osteomyelitis; that is, an incidence of 4'3 per cent (Eltorai, 1981). The majority had the chronic variety. Forty-four (49 per cent) of the 90 patients received adjunctive hyperbaric oxygen therapy; they were all spinal cord injury patients. One patient, in addition, had multiple sclerosis. Ages ranged from 24-83 years. All patients were males. Thirty of the patients had paraplegia and 14 had tetraplegia. The onset of the osteomyelitis was 1-30 years following injury. In the majority of the patients with osteo myelitis the infection involved the pelvis or the lower extremities. Table I lists the sites of involvement. Seven patients had more than one focus of osteomyelitis (16 per cent). The bacteriological findings from the sinuses, wounds and bone cultures usually showed mixed flora. Staphylococcus au reus was cultured in almost 100 per cent of the cases. It was either the predominant organism or was associated with a mixed flora. Other organisms cultured included the strepto coccus group in 33 per cent Pseudomonas aerogenosa in 66 per cent, Proteus HYPERBARIC OXYGEN THERAPY FOR OSTEOMY ELITIS 19 TABLE I Sites of chronic osteomyelitis in 44 patients (7 (16%) had more than one focus) Site Hip regions; i.e. hip joints, upper femora, trochanters Pelvis (I ilium, 4 ischium & lOS. pubis) Lumbar spine Sacrum Knee joint Tibia Elbow Number Percentage °1 ,0 28 64 6 14 3 5 2 2 4 7 II 4 4 8 group in 33 per cent, Enterococcus in 42 per cent, E-Coli in 21 per cent, and other organisms in 8 per cent (e.g. Klebsiella, Providencia, and Serratia). Diptheroids were detected in almost half of the cultures. Radiological signs of osteomyelitis were evident in 86 per cent of the patients. These were mostly areas of destruction, radiolucent are (...truncated)