家庭醫業 陳昱彰 1 徐嘉吟 2 陳宏明 3 曾俊雄 4 前言 (human immunodeficiency virus, HIV) (strain) (osteoarthritis, OA) (pyogenic spondylitis and discitis) (nonpyogenic spondylitis) (granulomatous spondylitis) (spine compression fracture) ( p r i m a r y o r m e t a s t a s i s cancer) 10%-30% 1 台北市立聯合醫院仁愛院區骨科總醫師 2 汐止國泰綜合醫院家庭醫學科主治醫師 3 台北市立聯合醫院仁愛院區骨科科主任 4 台北市立聯合醫院仁愛院區外科醫療部部主任 spine, discitis, pyogenic spondylitis, back pain. 病例摘要 病例一 : 3 4 (Heroin) C (hepatitis C) 3~4 (NSAID) (URI) (UTI) (WBC) 6,490/ul X MRI (pyogenic discitis with psoas muscle abscess (pathogen) 416 家庭醫學與基層醫療第二十四卷第十二期
(Staphylococcus aureus) Oxacillin 2g q6h IVD a n t e r i o r d i s c e c t o m y, p a r t i a l corpectomy, and anterior fusion M R S A ( m e t h i c i l l i n - r e s i s t a n t S t a p h y l o c o c c u s a u r e u s Vancomycin 1g q12h IVD (posterior instrumented fusion) Vancomycin 1g q12h IVD 病例二 : 51 HIV HIV CD4 術後 H A A R T ( H i g h l y a c t i v e antiretroviral treatment) 9,260/ul X MRI (infectious spondylitis) ( s p i n a l stenosis) Oxacillin 2g q6h IVD Case1 術前 病例三 : 75 37.4~37.8 家庭醫學與基層醫療第二十四卷第十二期 417
(E.coli) q u i n o l o n e Ciproxin(ciprofloxacin) 200mg q12h IVD C- (C-reactive protein, CRP) (erythrocyte sedimentation rate, ESR) Case2 術前 Case3 術前 術後 6,390/ul X 術後 418 家庭醫學與基層醫療第二十四卷第十二期
感染性脊椎炎及椎間盤炎 (infectious spondylitis and discitis) ( p y o g e n i c ) (nonpyogenic) (granulomatous) (hematogenous) ( d i r e c t ) ( p o s t - operative) (hematogenous pyogenic infection) (seeding) (disc) (avascular) (vertebral body) (vertebral endplate ) ESR CRP (immunocompromised state) L-spine(50~60%) T-spine(30~40%) C-spine(10%) 60~80% 60 MRSA G(-) 20 H I V ( + ) HIV(+) HIV ESR CRP (debridement) (decompression) (instrumented fusion) 家庭醫學與基層醫療第二十四卷第十二期 419
( i n f e c t i o u s discitis (disectomy)) (osteomyelitis of vertebral bodies (partial c o r p e c t o m y ) ) (paravertebral abscess) (approach) (b o n e g r a f t) bone graft (artificial bone graft) (autogenous bone graft) (bone graft source) (i l i a c b o n e) (r i b s) (anterior fusions) (anterior fusion) (anterior instrumented fixation) (pedicle) (pedicle screws) (rod) (link) ( p o s t e r i o r i n s t r u m e n t e d fixation) 結論 (OA) 參考資料 1. G e r o g e W. Wo o d I I: I n f e c t i o n o f S p i n e; Campbell s Operative orthopaedics; 10th edition; 2029-60. 2. Grauer JM, Whang P: Infections of Spine, Editor: Fischgrund JS: Orthopaedic Knowledge Update 9, United States of America, American Academy of orthopaedic Surgeons,2008: 593-601. 3. Govender S: Spinal Infections, J Bone Joint Surg; 2005; 87,11:1454-8. 420 家庭醫學與基層醫療第二十四卷第十二期
4. LeClair JD : Spondylodiskitis ; emedicine; radiology; spine; 2008:405-12. 5. Carragee EJ: Pyogenic vertebral osteomyelitis; J Bone Joint Surg, 1997:874. 6. Metta H, Corti M, Redini L, Yampolsky C, Schtirbu R: Spinal epidural abscess due to Mycobacterium tuberculosis in a patient with AIDS: case report and review of the literature; Braz J Infect Dis 2006;10:146-8. 7. Jaramillo-de la Torre JJ, Bohinski RJ, Kuntz C: Vertebral Osteomyelitis, Neurosurgery Clinics of North America; 2006, 339-51. 8. Reihsaus E, Waldbaur H, Seeling W: Spinal epidural abscess: a meta-analysis of 915 patients, Neurosurg Rev 2000,23:175-204. 9. Dagirmanjian A, Schils J, McHenry M: MR Imaging of spinal infections, Magn Reson imaging Clin N Am 1999,7:525-38. 10. Patel P, Olive KE, Krishnan K: Septic Discitis: An Important Cause of Back Pain, South Med J, 2003;96:692-5,. (99) 24 24 家庭醫學與基層醫療第二十四卷第十二期 421