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Current Treatment Options for Spinal Osteomyelitis & Discitis

Often described as “insidious,” spinal osteomyelitis and discitis — infections of the vertebral bone and disc space — are generally characterized by a slow, progressive clinical course and subtle presentation. Typically taking an average of one-to six months — and sometimes as long as a year — before detection, they pose diagnostic and treatment challenges, requiring expert attention from specialists in facilities equipped with state-ofthe-art technology.

“Spinal infections are relatively rare. They’re found in 1 in 200,000 patients,” said Winthrop-University Hospital neurosurgeon Benjamin Cohen, MD, a spine surgery specialist. “But, infections anywhere in the body can migrate and…

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 An ominous cause of back pain: Vertebral Osteomyelitis

The classic presentation of VO is back pain with focal weakness and fever. This is traditional and is rarely missed, but not very common. However, the patient can present with back pain without focal defect and be afebrile. Other symptoms may include dysesthesias, painful or difficult urination, muscle spasms, weight loss, or bowel or bladder incontinence. In a busy ED where the patients are primarily passive in a stretcher, it is easy to gloss over the history or physical exam clues. Some clues to this diagnosis include pain that becomes decentralized, pain that has worsened, and the presence of new neurologic deficits. Sometimes patients with a fever and new neurologic symptoms, regardless of back pain, may also have VO. Initial treatment for VO is empiric antibiotic therapy, most often vancomycin and ceftriaxone, administered via IV every 12 hours for six weeks.

 Do Not Miss This Diagnosis: Discitis/Osteomyelitis

General features: Affects one vertebral segment, defined as one disc and its two adjacent vertebral bodies. Most commonly affects the lumbar spine.

 Vertebral Discitis-osteomyelitis (VDO)

Vertebral discitis-osteomyelitis (VDO) is a continuum of disease, with both entities occurring at different times based on the age of the patient; disc infection happens first in young children, while osteomyelitis of the end plates occurs first in adults. Most cases are caused by arterial hematogenous spread of infection; other causes include penetrating trauma, direct extension of infection, or interventional procedures. In developed countries, Staphylococcus aureus is the most common infectious agent; worldwide, the most common agent is tuberculosis (Pott disease). VDO is more common in older patients and those with a history of intravenous drug abuse, compromised immune system, chronic alcoholism or steroid use, and diabetes.

Articles of Interest

Antibiotic Treatment of Vertebral Osteomyelitis, Discitis and Epidural Abscess of the Spine

Vertebral OM, discitis, and epidural abscess often occur as a result of haematogenous seeding. S. aureus is the most common cause of vertebral OM, discitis and epidural abscess but there are multiple other causative organisms which need to be considered. Empirical approaches are becoming less effective due to increasing resistance.

CORE EM: Vertebral Osteomyelitis

Spondylodiscitis: a term encompassing osteomyelitis, spondylitis and discitis. Often used interchangeably with osteomyelitis. Clinical presentation is very nonspecific; evaluate all patients presenting with back pain for infectious risk factors.

Diagnostic Quandary: Salmonella Agbeni Vertebral Osteomyelitis and Epidural Abscess

The patient’s pain continued to increase in severity over the next several weeks, and he was evaluated by multiple healthcare professionals with no discovered pathology. Approximately 5 weeks following the fall, repeat CT scan and MRI were conducted which then revealed extensive findings of discitis/osteomyelitis at L5–S1 as well as an epidural abscess resulting in severe narrowing of the central spinal canal.

Discitis

Discitis, infection of the disc and vertebral endplates, has significant morbidity and mortality. Although early diagnosis and treatment leads to a better outcome, a delay in diagnosis is common due to nonspecific and inconsistent clinical signs and symptoms. A variety of imaging modalities may be used to evaluate suspected discitis with varying degrees of effectiveness.

Spinal Infection

Although osteomyelitis, discitis and spinal epidural abscesses refer to discrete infection patterns, these conditions can overlap when there is a progression of a single infectious focus. For example, osteomyelitis can extend posteriorly to form an epidural abscess or it might spread to the adjacent intervertebral disc and vertebral body, causing spondylodiscitis. The etiology of most spinal infections is usually seeding of the spine from a distant source of infection via the bloodstream, (so-called hematogenous spread).

Spondylodiscitis

Spondylodiscitis, (rare plural: spondylodiscitides) also referred to as discitis-osteomyelitis, is characterized by infection involving the intervertebral disc and adjacent vertebrae.

Thoracic Osteomyelitis and Discitis

Vertebral osteomyelitis can result in severe spinal cord compression and spinal deformity. It may present nonspecifically with back pain or with paraparesis in advanced cases. Clinicians should be familiar with the epidemiology, signs, symptoms, and radiographic evidence of thoracic osteomyelitis and discitis to diagnose and treat these conditions expeditiously prior to the appearance of neurological deficits. Treatment consists of antibiotics and potentially surgery, both of which must be tailored to the individual patient and pathogen to optimize outcomes.

Vertebral (spinal osteomyelitis, spondylodiscitis, septic discitis, disc space infection)

May result in concomitant paravertebral, epidural, or psoas abscess; increased risk of neurologic sequelae. Urgent neurosurgical consult required.

Vertebral Osteomyelitis

Despite technological advances in diagnostics and treatment, vertebral osteomyelitis (VO) and discitis place heavy burdens on today’s health care system. Due to the insidious nature of vertebral body infection, definitive diagnosis may be delayed for weeks or months after initial patient presentation. Symptoms are often nonspecific and may mimic common strains or sprains of the back or neck. Complaints of fever and chills, night sweats, or nocturnal pain not relieved by changing positions may indicate an infectious condition.

Vertebral Osteomyelitis, Discitis, and Spinal Epidural Abscess in Adults

To improve the timely diagnosis and initial treatment of vertebral osteomyelitis, discitis or paravertebral abscess with or without spinal epidural abscess in adult patients...

Resources

Musculoskeletal Key

Vertebral osteomyelitis and discitis constitute almost 97% of all spine infections. Untreated, these infections carry a mortality rate as high as 25% and predispose individuals to significant pain, deformity, and neurologic deterioration.

StatPearls

Vertebral osteomyelitis (additionally referred to as spinal osteomyelitis or spondylodiskitis) accounts for approximately 3% to 5% of all cases of osteomyelitis annually. Vertebral osteomyelitis often has a nonspecific clinical presentation and thus delayed diagnosis up to several months is not uncommon.