Diagnosis Of Vertebral Osteomyelitis Research Articles

1299. Clinical Characteristics of Native Vertebral Osteomyelitis in Patients with a History of Acupuncture

Abstract Background Considering that vertebral osteomyelitis (VO) can occur via various routes. It can be predicted that clinical characteristics may vary depending on the way of infection or risk factors of the disease. In this study, the clinical characteristics, causative pathogens, clinical features, and prognosis of the native VO in patients with a history of acupuncture were compared with those without a history of acupuncture. Methods This retrospective study was conducted at a university-affiliated hospital in Seoul, from May 2006 to February 2021. The patients of age 18 or older with native VO were enrolled. Data on demography, clinical presentation, treatment, causative organisms, and clinical outcomes were collected via electronic medical records. Results A total of 100 patients with VO were reviewed, among which 34 patients had a history of acupuncture before the diagnosis of VO. The frequency of Gram-positive cocci (GPC) was significantly higher in the acupuncture group than in the non-acupuncture group (p=0.016). Abscess was observed more frequently in the acupuncture group than in the non-acupuncture group (p=0.01). Patients with abscesses underwent surgical treatment more often than those without (p=0.021). There was no difference in clinical outcomes between the two groups, including mortality, neurologic sequelae, and recurrent after one year. Conclusion This study suggests that confirming a history of acupuncture may help predict the pathogen or clinical characteristics of the disease. If the patient has a history of acupuncture, GPC can be considered the causative organism. The presence of abscesses may lead to surgical treatment more frequently. Disclosures All Authors: No reported disclosures

109. The impact of patient characteristics on outcomes of surgically managed vertebral osteomyelitis in the United States: insights from a national database study

<h3>BACKGROUND CONTEXT</h3> Vertebral osteomyelitis (VO) is a potentially devastating spinal infection associated with a significant morbidity burden and a mortality rate. The incidence of VO is increasing and its diagnosis is often delayed due to its characteristic non-specific, insidious onset of symptoms (recalcitrant back pain). Nonsurgical management consisting of a 6-week course of antibiotics with optional bracing remains first line treatment for VO; however, surgical intervention is often required. At present, data are limited on the epidemiology of surgical management in VO in the United States as previous reports are based on older studies with small sample sizes, mostly from Europe or Asia Pacific. Furthermore, no study to date has evaluated the impact of patient characteristics on surgical outcomes and complications on a large scale. <h3>PURPOSE</h3> To analyze the characteristics of patients who have VO requiring surgical intervention. <h3>STUDY DESIGN/SETTING</h3> National database study. <h3>PATIENT SAMPLE</h3> This study included 228,044 patients with vertebral osteomyelitis from 1998 to 2013 (44,401 surgically managed). <h3>OUTCOME MEASURES</h3> (1) Patient demographics: age, sex, race, Deyo Index (DI - a measure of comorbidity), type of comorbid pathology; (2) hospitalization data: length of stay (LOS), hospitalization charges, insurance provider; (3) surgical procedure type and utilization; (4) complication and mortality rate. <h3>METHODS</h3> A review of the National Inpatient Sample (NIS) database was performed for all patients admitted in the United States between 1998 to 2013 with a diagnosis of VO. Patients were then sub-stratified into those who underwent surgical intervention vs those treated with nonsurgical management. Patient demographics, hospitalization data, surgical procedure type and utilization, and complication and mortality rate were compared between groups. Differences between patient demographics for the surgical and nonsurgical groups were assessed using independent sample t-tests, linear regressions, and ANOVA. <h3>RESULTS</h3> A total of 228,044 patients were estimated to be admitted in the United States for VO from 1998 to 2013, of which 44,401 patients underwent surgical intervention. The incidence of surgical intervention for patients who had VO significantly increased from 0.6 per 100,000 U.S. persons in 1998 to 1.1 per 100,000 US persons in 2013. Compared to the nonsurgically managed cohort, surgically managed VO patients were significantly p <0.001) younger (56 surgical vs 60 non-surgical), had a lower mean DI (0.88 vs 1.33) and lower hospital mortality rate, but experienced a significantly (p <0.001) longer length of hospitalization (9.01 vs 9.98 days) and higher total hospitalization charges. Regardless of surgical approach, surgery of the thoracic spine carried the highest complication and mortality rate (49% and 3.4%, respectively). Anterior approach to the cervical spine was associated with the lowest rate of any complication (10.2%). Surgical management of VO of the lumbar spine had the lowest mortality rate for all approaches: anterior (0.3%), posterior (0.2%), or combined (0.1%). Congestive heart failure and liver disease most significantly predicted mortality (OR: 6.1 for CHF and OR: 2.9 liver disease) and renal disease most significantly predicted increased total hospital costs (OR: 7.4). The mean inflation adjusted total hospital costs increased from $20,355 per patient in 2001 to $39,991 in 2013. <h3>CONCLUSIONS</h3> VO is an understudied condition with a steady increase in its incidence in the US. It appears that the rate and the need for invasive procedures to salvage this condition is also increasing. This study identified certain patient demographics, comorbidities, and surgical approaches associated with higher complications, mortality rate and overall costs. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

A case report of native vertebral osteomyelitis caused by Cutibacterium modestum

BackgroundCutibacterium modestum was named in 2020. C. modestum was previously called Propionibacterium humerusii. Several implant-associated infections caused by Cutibacterium species have been previously reported, but native vertebral osteomyelitis due to these bacteria has rarely been reported.Case presentationA 72-year-old man, who had previously received several nerve block injections for low back pain, was referred to our hospital for deterioration in back pain in the last 1 month. MRI findings were suggestive of L5-S1 vertebral osteomyelitis. Blood cultures and bone biopsy culture revealed the presence of Gram-positive bacilli. The isolate was identified as C. modestum by 16SrRNA gene sequencing. A diagnosis of vertebral osteomyelitis caused by C. modestum was made. Minocycline followed by oral amoxicillin was administered for 3 months. His symptom improved and did not recur after treatment completion.ConclusionA case of vertebral osteomyelitis caused by C. modestum was encountered. Although C. modestum is very similar to C. acnes, it could be accurately identified by 16SrRNA gene sequencing. This case represents the first documented C. modestum infection in humans.

Diagnosis of vertebral osteomyelitis.

Native vertebral osteomyelitis (NVO) is a potentially fatal infection which has seen a gradual increase in its incidence over the past decades. The infection is insidious, presenting with symptoms of back pain. Fever is present in about 60 % of patients. Prompt diagnosis of NVO is important to prevent the development of complications. Numerous laboratory and imaging tools can be deployed to accurately establish the diagnosis. Imaging techniques such as magnetic resonance, nuclear imaging, and computed tomography are essential in diagnosing NVO but can also be useful in image-guided biopsies. Laboratory tools include routine blood tests, inflammatory markers, and routine culture techniques of aspirated specimens. Recent advances in molecular techniques can assist in identifying offending pathogen(s). In this review, we detail the arsenal of techniques that can be utilized to reach a diagnosis of NVO.

Comparison of serum procalcitonin and interleukin-6 levels with CRP levels in the follow-up of antimicrobial treatment of patients with pyogenic and granulomatous vertebral osteomyelitis

Background/Aim: Infection of the intervertebral disc and adjacent vertebrae is called vertebral osteomyelitis (VO). This study aims to determine whether procalcitonin (PCT) and interleukin (IL)-6 markers are more valuable than white blood cells (WBC), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) in the follow-up in patients with VO who were administered antibiotherapy. Methods: All adult patients with a diagnosis of VO were included in this prospective cohort study. The patients were divided into two groups as those with pyogenic and granulomatous VO. Serum WBC, CRP, ESH, PCT and IL-6 levels were measured at baseline, and the 2nd, 4th, 8th and 12th weeks of antibiotherapy. The changes in the laboratory parameters of the patients during follow-up were evaluated. Results: Of the 30 patients included in the study, there were 22 and 8 patients in the PVO and GVO groups, respectively. Baseline IL-6 measurement was above the reference in all patients, CRP was elevated in 96.6%, and PCT was increased in only one patient. Although there was a paradoxical increase in PCT values in the PVO group in the 2nd week compared to the pre-treatment values, a rapid decrease was observed in the 4th and 8th weeks. In the GVO group, the gradual decrease in PCT in parallel with the treatment response was considered to predict clinical improvement. IL-6 values decreased by 43.2% and 50% compared to baseline at the 4th and 8th weeks of treatment, respectively, in the PVO group. In the GVO group, a 50% reduction was detected in the 4th week of treatment compared to baseline. Conclusion: PCT and IL-6 biomarkers are valuable indicators in treatment follow-up. Although not statistically significant, the most stable decrease was observed in IL-6. Using IL-6 for the follow-up of the patients with VO may prevent long-term antibiotherapy.

P43. Validity of routine diagnostic tests for vertebral osteomyelitis/discitis and its influence by the infecting organism

BACKGROUND CONTEXT Spine surgeons rely on multiple tests to correctly diagnose adult vertebral osteomyelitis. Patient temperature, serum C- reactive protein (CRP), erythrocyte sedimentation rate (ESR) and serum polymorphonuclear leukocyte percentage (PMN%) are traditionally used as first-line tests because of their perceived high sensitivity for vertebral osteomyelitis. However, the influence of the infecting organism on the degree of marker elevation remains relatively unaddressed in the spine literature. It is possible each of these markers have a distinct sensitivity based on the infecting organism. PURPOSE The purpose of this study was to determine whether mean serum laboratory marker levels differed based on infecting organism and whether certain organisms are associated with greater elevated values. STUDY DESIGN/SETTING This was a retrospective institutional database review at the University of Missouri-Columbia from 2015-2019. PATIENT SAMPLE A total of 133 patients diagnosed with vertebral osteomyelitis who underwent blood culture, and/or biopsy prior to treatment. OUTCOME MEASURES ESR, CRP, WBC, PMN%, maximum temperature, culture organism. METHODS The mean peak inflammatory marker levels were compared among organisms with student's T test. Demographics, comorbidities and Charleston Comorbidity Index (CCI) were collected and multivariable logistic regression models were utilized. Receiver operating characteristic curve analysis was performed to delineate separate, optimal cut offs for CRP, ESR, WBC, and PMN% for patients with culture positive osteomyelitis. RESULTS Patients diagnosed with osteomyelitis had a max mean temperature of 37.2 C, CRP of 10.8 mg/L, ESR of 72 mm/hr, WBC of 12.1 cells/L, and PMN% of 74.1. A total of 105 patients (79%) had positive cultures. For CRP, Staphylococcus aureus (13.9 mg/L) and antibiotic resistant organisms (methicillin resistant Staphylococcus aureus and vancomycin-resistant Enterococci) (14.3 mg/L) had a higher mean value than culture negative cases (5.65 mg/L). For ESR, antibiotic resistant organisms (72.1 mm/hr) had a higher mean value than culture negative cases (57.9 mm/hr). For WBC, Staphylococcus aureus (14.4 cells/L), antibiotic resistant organisms (13.6 cells/L), and coagulase negative Staphylococcus (11.8 cells/L) had a higher mean value than culture negative cases (8.22 cells/L). For PMN%, Staphylococcus aureus (75.9%), antibiotic resistant organisms (77.2%), coagulase negative Staphylococcus (77.7%), and Streptococcus species (79.7%) had a higher mean peak value than culture negative cases (67.7%). Both Staphylococcus aureus (13.9 mg/L, 72.1 mm/hr, 14.4 cells/L, 75.9%) and antibiotic resistant organisms (14.3 mg/L, 94.0 mm/hr, 13.6 cells/L, 77.2%) had elevated CRP, ESR, WBC, and PMN% compared to fungal organisms (2.56 mg/L, 43.7 mm/hr, 8.17 cells/L, 64.0%). Temperature showed no significant differences in mean values among all organisms. Gram negative, Enterococcus, and fungal organisms did not show significant differences in mean values versus culture negative cases. CONCLUSIONS Serum laboratory markers in the diagnosis of vertebral osteomyelitis appear to be influenced by the infecting organism type. Laboratory values in patients diagnosed with vertebral osteomyelitis with culture negative or low-virulence organisms are lower compared to antibiotic resistant and Staphylococcus aureus organisms. Temperature did not correlate with a diagnosis of osteomyelitis. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Role of Image-Guided Biopsy in the Diagnosis and Antimicrobial Management of Vertebral Osteomyelitis

Purpose The aim of this study was to evaluate the role of fluoroscopy-guided vertebral biopsy in vertebral osteomyelitis and determine if it results in a change in antimicrobial management based on bone culture yield. Materials and Methods This study is a retrospective chart review of 83 patients (49 men, 34 women; age range, 28–92 years; mean age, 56.9 years) with a diagnosis of vertebral osteomyelitis on imaging (computed tomography or magnetic resonance imaging) who underwent a fluoroscopy-guided biopsy from January 2010 to May 2015. Data collection included patient demographic information; etiology/risk factors for vertebral osteomyelitis; antibiotic exposure within 30 days before biopsy; blood, urine, and bone culture results; and any postprocedural change in antibiotic therapy. The primary outcome is culture yield from biopsy, whereas the secondary outcome is to determine if a change in antimicrobial therapy occurred based on biopsy results. A change in antimicrobial management is defined as transitioning from empiric antibiotic coverage to narrow-spectrum antibiotics based on positive bone culture yield or discontinuation of empiric antibiotic coverage based on negative culture yield. Biopsy culture yield was tested against a change in antimicrobial management with statistical analysis including the Fisher exact test. Results Positive bone culture yields were obtained in 22 (27%) of the 83 cases. Of the 22 that were positive, only 11 resulted in a change in antimicrobial management where broad empiric coverage was switched to narrow-spectrum organism-specific coverage. Of the remaining 61 negative cultures, only 2 (3%) had a change in management where the empiric antibiotic treatment was discontinued. Whether the culture results were positive or negative, 70 patients (84%) did not have any change in antimicrobial management after biopsy with the results being statistically significant (odds ratio, 27.3; 95% confidence interval, 5.25–141.82; P &lt; 0.0001). Conclusions Vertebral biopsies do not cause a significant change in antimicrobial management in the majority of cases.

Vertebral Osteomyelitis: A Mortality Analysis Comparing Surgical and Conservative Management.

Study Design:Retrospective cohort study.Objectives:To compare the mortality between patients treated for vertebral osteomyelitis (VO) with either surgical or conservative management and to construct a predictive model for mortality after VO.Methods:All patients with a diagnosis of VO in Region North Denmark from 2004 to 2014 were followed for at least 2 years or until death. They were all treated according to a standardized guideline for the choice of treatment modality. Nineteen dichotomized variables with possible influence on the mortality were registered for all patients in the study. LASSO (least absolute shrinkage and selection operator) penalized Cox regression analysis was used to build a predictive model for 2-year survival after VO.Results:A total of 125 patients were eligible for inclusion, mean age 67 years, 36 women. 75 were treated surgically. Twenty-one patients were dead 2 years after the diagnosis. Kaplan-Meier estimate of 2-year survival was 0.82 [0.75, 0.88]. Any difference in mortality between surgically and conservatively treated patients was nonsignificant at 1 and 2 years (univariate Cox regression analysis). Significant factors included in the predictive model after LASSO penalized Cox regression analysis was Charlson Comorbidity Index (CCI), cardiovascular disease, C-reactive protein (CRP) normalization, thoracic infection, and Karnofsky score. The area under the curve (AUC) for the predictive model ranged from 0.74 to 0.77.Conclusion:Patients undergoing surgical management for vertebral osteomyelitis according to standardized and agreed-upon guidelines had no higher mortality than those allocated to conservative treatment. The predictive model included 5 variables associated with an increased mortality: CCI, CRP normalization, cardiovascular disease, thoracic infection, and Karnofsky score.

1983. Oral Therapy with Rifampin Associated with Minocycline or Moxifloxacin in Vertebral Osteomyelitis due to Gram-Positive Micro-organisms: A Retrospective Study of 64 Cases

BackgroundIDSA guidelines about vertebral osteomyelitis (VO) recommend parenteral antimicrobial therapy (PAT) as the standard treatment for Gram-positive pathogens (GPP). In this setting, a switch to oral antimicrobial therapy (OAT) with excellent bioavailability could be considered. However, among fluoroquinolones, moxifloxacine is not recommended in staphylococcal VO, and among tetracycline, only doxycycline should be considered with rifampin, for brucelar VO. The aim of our study was to review the efficacy and safety of OAT with rifampin associated with moxifloxacin (Rif-Mox) or minocycline (Rif-Mino) in the treatment of VO due to GPP.MethodsObservational, retrospective study in a Belgian teaching hospital, over 10 years. All charts with a diagnosis of VO were reviewed. Patients with VO who received definite OAT with Rif-Mox or Rif-Mino were included. An episode of VO caused by the same species within 24 months after the initial episode represented a relapse; other situations were considered as recurrences.ResultsOf 655 charts, 75 matched our inclusion criteria. Eleven were rejected: missing data six cases; death before the end of treatment five cases, including one death related to VO. Key data are shown in the figure. Fifty-five and 9 patients received Rif-Mox and Rif-Mino OAT, respectively. The median duration of PAT and OAT were 14 days and 64.5 days, respectively and the global treatment median duration was 89 days. The duration of PAT was essentially driven by the presence of an associated bacteremia or endocarditis, particularly in cases due to Staphylococci. Interestingly, OAT without initial PAT was performed in six cases without failure. The follow-up after end of therapy was ≥2 years. There was no recurrence or relapse in Rif-Mino group. In Rif-Mox group, there was one recurrence occuring 6 months after the end of therapy. Two others recurrences were observed >24 months after the end of therapy and were not notified. No treatment was stopped because of intolerance or significant adverse events.ConclusionOAT with Rif-Mox or Rif-Mino was safe, well tolerated and achieved a high level of cure in VO due to GPPs, including cases with spinal hardware infection. Disclosures All authors: No reported disclosures.

Vertebral Osteomyelitis: Unexpected Cause of Back Pain

Osteomyelitis is an inflammation of bone caused by a pyogenic organism. Osteomyelitis is one of the most important musculoskeletal infections, commonly occurring in long bones. Vertebral osteomyelitis is fairly rare and is often overlooked. It is usually acquired hematogenously, although there are other ways of infection. Only about half of patients develop fever > 38 °C and symptoms are unspecific. The most common organism is Staphylococcus aureus , with Pseudomonas aeruginosa being an unexpected pathogen accounting for about 6%. We present a case of a 56-year-old Hispanic male that visited emergency room presenting with back pain of 3 weeks of evolution being discharged home. Patient returned 2 days after with no improvement. Blood test returned under normal range. Physical exam showed a focal tenderness at thoracic level. Blood culture recovered Pseudomonas aeruginosa sensitive to levofloxacin. CT/MRI was performed and showed vertebral osteomyelitis. Antibiotic was started for 6 weeks. Therapy was guided with erythrocyte sedimentation rate (ESR)/C-reactive protein (CRP). Patient was evaluated monthly for 6 months and improved. Vertebral osteomyelitis is a challenging diagnosis. The consequences of the disease are dire if not diagnosed on time. Historically, the diagnosis of vertebral osteomyelitis remains in a positive culture of bone biopsy. Nowadays, when handling a suspected hematogenous vertebral osteomyelitis, blood culture has gained importance. Whether a blood culture recovered a pathogen, therapy should be based on sensitivity and can be guided following ESR/CRP levels. This type of management can preclude invasive and expensive methods, such as bone biopsy. J Med Cases. 2017;8(8):246-248 doi: https://doi.org/10.14740/jmc2870w

Investigations of Hospitalized Cases of Pyogenic Vertebral Osteomyelitis

Pyogenic vertebral osteomyelitis is d f 昀cult to diagnose and treat. The duration of antibiotic therapy, the administration of treatment, and several other factors regarding pyogenic vertebral osteomyelitis remain contro‐ versial. The aim of this investigation was to examine its diagnosis and treatment and consider possible solutions. This was a retrospective study of 11 cases of hospitalized patients with pyogenic vertebral osteomyelitis, includ‐ ing their diagnosis, treatment, and other factors. The diagnosis of vertebral osteomyelitis was con 昀rmed with the combination of imaging and biological evidence. The Erythrocyte Sedimentation Rate (ESR) level served as an index to determine the duration of therapy. The duration from symptom onset to diagnosis was 3–63 (median 10) days. Rate of positive blood cultures were obtained in 8 cases (72.7%). The most frequent comorbidity was infective endocarditis in 4 cases (36.6%). Affected vertebrae were lumber spine in 9 cases (81.8%) and multiple level involvement in 8 cases (72.7%). The mean duration of antibiotic therapy was 69.6 ± 17.9 days, with no recurrence. Patients diagnosed with pyogenic vertebral osteomyelitis require careful examination for infective endocarditis. Lumber level and multiple level involvement were more frequent than had previously been repor‐ ted. Based on our experience, C-reactive Protein (CRP) is more useful than ESR as an index to evaluate the clinical response to therapy and may help determine the duration of treatment. It is important for general physi‐ cians to monitor vertebral osteomyelitis properly and provide an appropriate diagnosis and treatment.

A Case of Vertebral Osteomyelitis and Spinal Epidural Abscess Caused byHaemophilus aphrophilus

Haemophilus aphrophilus is an aerobic, gram-negative oropharyngeal bacterium, commonly isolated from cases of HACEK endocarditis. In addition, H. aphrophilus has also been shown to cause invasive bone and joint infections. Although multiple cases of H. aphrophilus endocarditis have been described, no cases of invasive bone and joint infections caused by H. aphrophilus have been reported in Korea. Here we report the case of a 69-year old woman with a diagnosis of vertebral osteomyelitis and spinal epidural abscess with compressive myelopathy caused by H. aphrophilus, in which there was no objective evidence of infective endocarditis. She was successfully treated with intravenous administration of cefotaxime and drainage of the epidural abscess by laminectomy of the T3-7 vertebrae. (Korean J Med 2014;86:515-518)

Risk Factors for a Delay in Diagnosis of Vertebral Osteomyelitis

Risk Factors for a Delay in Diagnosis of Vertebral Osteomyelitis

Unusual Case of Osteomyelitis and Discitis in a Drug User with a Background of Chronic Back Pain: Do Not Miss the Serious Etiologies

Chronic back pain is a common presenting complaint that is frequently encountered by clinicians. The challenge for clinicians is identifying the relatively few patients with a significant probability of a more serious problem that requires further evaluation. Such individuals require further evaluation for possible occult malignancy, infection, or fracture. We present a case of a 50-year-old male with a past medical history of chronic back pain and IV drug abuse who presented with acute back pain and in whom a diagnosis of vertebral osteomyelitis was missed during multiple visits to the emergency room.

Vertebral osteomyelitis after cardiac surgery

Background Mediastinitis after open-heart surgery is a serious complication that has a decreasing incidence but still a significantly high mortality rate. Back pain may develop during the course of treatment for mediastinitis, and this should suggest vertebral osteomyelitis in the differential diagnosis. Diagnosis of vertebral osteomyelitis may be difficult because of the insidious onset and delayed diagnosis, and treatment may result in serious neurologic compromise and even death of the patient. Methods This retrospective study involves 5 patients who had open-heart surgery and mediastinitis that was further complicated by vertebral osteomyelitis. Average delay in diagnosis was 18 days after the onset of symptoms. Magnetic resonance imaging was the most helpful tool for diagnosis. Methicilline-resistant Staphylococcus aureus was identified as the responsible microorganism in all patients. Neurologic compromise occured (one paraplegia and one paraparesia) in 2 patients during medical treatment. Results Along with the medical treatment, all patients were surgically treated due to either one or more of the following reasons: unresolving symptoms, sudden neurologic compromise, or impaired spinal column stability despite appropriate conservative treatment. One patient died 10 days postoperatively. The mean follow-up period for the remaining 4 patients was 47 (12 to 95) months. Complete recovery was achieved, and they were able to return to their routine daily activities. Conclusions Vertebral osteomyelitis should be borne in mind when a patient develops back pain during the course of mediastinitis. Suspicion, early diagnosis with appropriate imaging, and proper treatment are crucial to prevent catastrophic complications.

An important differential diagnosis for persistent back pain

Between 1/1994 and 12/1998 40 patients with a vertebral osteomyelitis were treated at the Orthopedic University Hospital of Witten/Herdecke. All data of 15 female and 25 male patients with an mean age of 61 years (25-87 years) were analyzed in a retrospective study. Diagnosis of vertebral osteomyelitis was made between 1 and 84 weeks after onset of symptoms. Before admissions in our hospital up to 4 hospitalizations without proper diagnosis were reported. The treatment consisted bed-rest in an individual orthesis and percutaneous discovertebral biopsy before systemic administration of antibiotics. In 11 from a total of 21 biopsies we could prove bacteria as follows: 6 times Staphylococcus aureus, 2 times E. coli and 3 times Mycobacterium tuberculosis. Radiological diagnosis was made by conventional x-ray in 2 dimensions and nuclear magnetic resonance. Together with radiological, histological, microbiological and laboratory investigation we found 11 patients with a specific tuberculosis of the spine, 25 patients with a pyogenic vertebral osteomyelitis and 4 patients with a post-nucleotomy osteomyelitis. 14 patients underwent operative treatment. All patients were mobilized in an individual brace after CRP and ESR indicated remission of inflammation. DURATION OF HOSPITAL TREATMENT: Duration of the hospital treatment lasted between 33 and 137 days. At follow-up 12 months after demission 35 patients were free of symptoms, two patients had still signs of osteomyelitis, two patients, one of them with recurrence of spondylitis, were reoperated because of dislocation of the implants, and one patient died after surgery suffering from severe peritonitis and multi-organ-failure. We report pathogenesis and the current diagnostic and therapeutic concept of treatment of the vertebral osteomyelitis. Despite modern diagnostic possibilities, diagnosis of vertebral osteomyelitis is often made very late. Vertebral osteomyelitis is an important differential diagnosis for persistent back pain and needs to be considered more often.

Discitis and Vertebral Osteomyelitis in Children: An 18-Year Review

Discitis and vertebral osteomyelitis are uncommon entities, and diagnosis often is confounded by their similar clinical presentation, because characteristic radiographic findings are not evident until late in the course of illness. To compare the age distribution, clinical manifestations, and radiographic findings, especially magnetic resonance imaging (MRI), in children with discitis or vertebral osteomyelitis. A retrospective review of 57 children with a discharge diagnosis of discitis or vertebral osteomyelitis hospitalized from January 1980 through December 1998. Fifty patients met inclusion criteria: 36 with discitis and 14 with vertebral osteomyelitis. The mean age at presentation was younger for children with discitis than for those with vertebral osteomyelitis (2.8 vs 7.5 years of age) and the duration of symptoms longer for children with vertebral osteomyelitis than for those with discitis (33 vs 22 days). The initial symptom for both groups of children was refusal to walk, limp, or back pain, but children with osteomyelitis more often were febrile (79% vs 28%) and ill-appearing than those with discitis. Thirty-three patients with discitis had radiographs of the spine; 25 (76%) had abnormalities that were diagnostic. Ten discitis patients had MRI; 9 (90%) had abnormalities consistent with this diagnosis. Thirteen children with vertebral osteomyelitis had radiographs of the spine, but in only 7 (54%) were these abnormal. However, 11 had MRIs, and in each the diagnosis of vertebral osteomyelitis was established. This comparative study suggests that age and clinical presentation distinguish most patients with discitis from those with vertebral osteomyelitis. Although radiographs of the spine usually are sufficient to establish the diagnosis of discitis, MRI is the diagnostic study of choice for pediatric patients with suspected vertebral osteomyelitis.

Vertebral osteomyelitis at a Norwegian university hospital 1987-97: clinical features, laboratory findings and outcome.

Altogether 40 patients aged 13-91 y (average 58 y) with vertebral osteomyelitis were treated at the Bergen University Hospital between July 1987 and June 1997. All patients presented with back pain, 33 (83%) had vertebral tenderness, and 26 (65%) patients were febrile. The duration of symptoms before diagnosis was < 3 weeks in 13 patients, and from 3 to 16 weeks in the remaining 27 patients. C-reactive protein (CRP) level and erythrocyte sedimentation rate (ESR) were elevated in 39 and 38 patients, respectively. Staphylococcus aureus was the most frequent cause of osteomyelitis followed by Streptococcus spp., Escherichia coli and Mycobacterium tuberculosis. Magnetic resonance imaging was superior to other radiological methods and demonstrated changes consistent with osteomyelitis in all 23 patients examined with this method. 35 patients survived. 18/35 surviving patients had pareses and 17 underwent surgery with drainage of abscesses or laminectomy. All 35 patients made a good recovery and only 3 patients experienced permanent pareses. The diagnosis of vertebral osteomyelitis is easily missed, and treatment is often delayed, particularly in the elderly in whom signs of sepsis may not manifest. However, persisting localized pain and tenderness over the spine together with elevated CRP and ESR should prompt the physician to consider vertebral osteomyelitis. Fever and leukocytosis may support the diagnosis, but may not always be present.

Pyogenic Vertebral Osteomyelitis: Analysis of 20 Cases and Review

The diagnosis of vertebral osteomyelitis is easily missed, particularly for the elderly in whom signs of sepsis may not manifest. The case records of 20 patients with vertebral osteomyelitis who were treated at our hospital between January 1989 and April 1993 were reviewed. The average age of the patients was 72 years. Infection was most commonly due to intravenous cannula-related sepsis. Eighty-five percent of patients presented with back pain, and only 30% had a fever. Computerized tomography and magnetic resonance imaging were the most useful radiological investigations; nuclear scanning was sensitive but insufficiently specific. Staphylococcus aureus was the infecting organism in 13 of 16 patients whose microbiological diagnosis was made by blood or bone cultures. Six (45%) of these 13 patients were infected with methicillin-resistant S. aureus (MRSA). Nosocomial infection occurred in 12 (60%) of the patients studied, including all patients with MRSA infections. Vertebral osteomyelitis may be largely preventable if infection-control aspects of intravenous cannulation are improved, attempts at reducing and preventing MRSA colonization are made, and therapy for bacteremias is optimized.

The role of indium-III labelled white cell scanning in the diagnosis of vertebral osteomyelitis

The role of indium-III labelled white cell scanning in the diagnosis of vertebral osteomyelitis