Spontaneous Spondylodiscitis Research Articles

Spondylodiscitis 10 Years Experience of 40 Cases in a Third Level Hospital in Bogotá, Colombia

Introduction Spondylodiscitis is an infrequent pathology and may be overlooked in clinical practice. Diagnosis requires a high level of suspicion by physicians; a multidisciplinary approach is essential. The objective was to describe the incidence, risk factors, clinical characteristics, management and outcomes of patients with spontaneous spondylodiscitis. Material and Methods Medical records of patients treated for infectious discitis at a third level hospital in Bogotá, Colombia, between January 2003 and August 2014 were reviewed. Postoperative infections and vertebral osteomyelitis were excluded. Results Spontaneous spondylodiscitis was diagnosed and treated in 40 patients (mean age 60,8 years, 60% male, 40% female). Most patients presented with subacute pain, 25% with fever, one patient with hypoesthesia in both legs, normal physical exam was observed in 24% of patients and no patient had paresis/paralysis. Among comorbid diseases, type 2 diabetes mellitus was the most relevant (20%). Concomitant infection at diagnosis was present in 7.5% of patients. WBC count and PCR were the most frequent laboratory test and MRI the most performed radiological test being positive in all cases. Procalcitonine was assessed in 10% of patients. Lumbar segments were involved in 62,5% of patients. S. Aureus and S. Epidermidis were the most common isolated microorganism (10% of patients) 55% of patients received I.V. inhospital antibiotic for less than 1 month, followed by 2–6 weeks of oral antibiotics in 75% of patients. Linezolid, Rifampicin and Vancomycine were the most frequently used antibiotics (alone or in combination). 20% of patients underwent surgical treatment. Abscess was observed in 7 patients (17,5%) all of whom went to surgical treatment. 2 patients developed infectious endocarditis and 1 patient died. 8 patients presented recurrence of the disease. Mean inhospital length was 30 days. Conclusion Spondylodiscitis diagnose must be suspected in patients presented with persistent back pain and specific risk factors (i.e., Diabetes Mellitus, Immunosuppression). Appropriate images and laboratory tests (MRI, WBC count, PCR and procalcitonine) must be assessed to reach an early diagnosis and antibiotic treatment guided by causative organism. Surgical treatment must be considered in specific cases. Recurrence is not common and must be prevented.

Author Response: Management of Postoperative discitis.

Dear Editor, We appreciate the readers for having assessed our manuscript and provided their valuable comments, and we are pleased to respond to the points they have raised. Below are the responses to the two points they have brought out. First, we thank them for acknowledging our interpretation that postoperative discitis is an often misdiagnosed or underdiagnosed cause of persistent pain after lumbar discectomy. The risk factors for developing neurological deficits in cases of spondylodiscitis like age, diabetes, rheumatoid arthritis, steroid use, etc. are more relevant in cases of spontaneous spondylodiscitis [1]. On the other hand, patients with postoperative discitis following lumbar discectomy more often present with pain and instability without much neurological deficits. We agree with the readers that nutrition panel, blood urea nitrogen/creatinine levels, and liver function tests are other helpful investigations. However, as erythrocyte sedimentation rate and C-reactive protein are considered major inflammatory markers, we have highlighted those investigations for being helpful in assessing response to treatment in patients. In addition, the readers have indicated their preference for adding interbody fusion to improve anterior support and stability. We would like to emphasize that in cases with postoperative discitis, posterior approach, debridement and immobilization is considered to be sufficient and is known to promote accelerated fusions [2]. We hope to have adequately addressed the points raised by our readers and thank them for their precious input and comments.

Management of adult spontaneous spondylodiscitis and its rising incidence.

Spondylodiscitis refers to the infection of the intervertebral disc and osteomyelitis of the adjacent endplates, and it is uncommon in the developed world. Broad consensus indicates its incidence is on the rise. The aim of this retrospective study was twofold. First, we sought to give an up-to-date incidence estimate by comparing case presentation over two time periods (1995-1999 and 2008-2011). Data from the England and Wales census in 2001 and 2011 were used for incidence estimation. The second part of this study aimed to generate management guidance from data from medical and radiographic records of the 2008-2011 patient cohort. The incidence of adult spontaneous spondylodiscitis in the local region between 2008 and 2011 was 3.67/100,000 per year, representing a 150% increase from the incidence in 1995-1999. Our data demonstrate that methicillin sensitive Staphylococcus aureus remains the most common offending pathogen of spontaneous spondylodiscitis. The mean C-reactive protein (CRP) level remained at >30mg/l after a month of starting antibiotic treatment in both medically and surgically managed groups. Evidence suggests that the incidence of spondylodiscitis is on the rise. A review of our case series has demonstrated the effectiveness of intravenous antibiotic therapy. While no official guidance exists for when to switch from intravenous to oral antibiotics, our study shows that CRP at 1 month is >30mg/l and we recommend 6 weeks of intravenous therapy, followed by 6 further weeks of oral therapy.

Differential diagnosis between tuberculous spondylodiscitis and pyogenic spontaneous spondylodiscitis: a multicenter descriptive and comparative study

Background contextAlthough tuberculous and pyogenic spondylodiscitis are common causes of spinal infections, their protean manifestation complicates differential diagnosis. PurposeThe clinical, laboratory, and radiologic characteristics of tuberculous and pyogenic spontaneous spondylodiscitis were compared in this study. Study designThis multicenter retrospective study was conducted in 11 teaching hospitals in the Republic of Korea from January 2011 to December 2013. Patient sampleStudy subjects included adult patients (≥18 years) diagnosed with tuberculous (n=60) or pyogenic (n=117) spontaneous spondylodiscitis. Outcome measuresRisk factors for tuberculous spondylodiscitis were determined, and their predictive performance was evaluated. MethodsMultivariate logistic regression analysis was performed to determine predictors independently associated with tuberculous spondylodiscitis. Receiver-operating characteristic curve analysis using the presence or absence of risk factors was used to generate a risk index to identify patients with increased probability of tuberculous spondylodiscitis. ResultsOf 177 patients, multivariate logistic regression analysis showed that patients with tuberculous spondylodiscitis (n=60) were more frequently women, with increased nonlumbar spinal involvement and associated non-spinal lesions, delayed diagnosis, higher serum albumin levels, reduced white blood cell counts, and lower C-reactive protein and procalcitonin levels. Among 117 patients with pyogenic spondylodiscitis, the most frequent causative microorganism was Staphylococcus aureus (64.1%). The mean diagnostic delay was significantly shorter, which may reflect higher clinical expression leading to earlier diagnosis. A combination of clinical data and biomarkers had better predictive value for differential diagnosis compared with biomarkers alone, with an area under the curve of 0.93, and sensitivity, specificity, and positive and negative predictive values of 95.0%, 79.5%, 70.4%, and 96.9%, respectively. ConclusionsThis study provides guidance for clinicians to predict the causative organisms of spondylodiscitis in uncertain situations and before culture or pathologic examinations. Clinical data and single biomarkers combined can be useful for differential diagnoses between tuberculous and pyogenic spondylodiscitis.

Anaerobic Spondylodiscitis due to Fusobacterium Species: A Case Report Review of the Literature.

Spondylodiscitis caused by Fusobacterium species is rare. Most cases of spontaneous spondylodiscitis are caused by Staphylococcus aureus and most postoperative cases are caused by Staphylococcus aureus or coagulase-negative staphylococci. Escherichia coli is the most common Gram-negative organism causing spondylodiscitis. Fusobacterium species are unusual causes for anaerobic spondylodiscitis. We report the case of a patient with spontaneous L2-L3 spondylodiscitis, vertebral osteomyelitis, and epidural abscess caused by Fusobacterium species and review the literature for patients with Fusobacterium spondylodiscitis.

A new in vivo method to investigate antibiotic penetration and concentration in spontaneous infectious spondylodiscitis

Spontaneous discitis is unusual and typically affects children. Hematogenous delivery of an infectious organism is the likely main cause. Common treatment method including conservative and surgical treatments, which also needs prolonged antimicrobial therapy based on an effective inhibitory concentration, can be achieved on the local disc space. Intradiscal antibiotic concentration was measured after the disc was harvested after preventive administration of antibiotics in previous studies. On the one hand the disc cannot simulate the infection situation when the inflammation leads to end plate destruction, vascular invasion and increase of permeability. On the other hand antibiotic concentrations were measured in vitro which cannot tell the actual situation in vivo. It is necessary to find a reliable evaluation method to decide whether the antibiotic can penetrate and make an effective inhibitory concentration in the local disc at the beginning of the treatment in vivo. Systemic antibiotics like nutrients enter and leave the disc by the only way of passive diffusion. The postcontrast MRI has been widely used as a noninvasive method of studying transport into the disc. The enhancement following contrast administration can be measured in T1 sagittal MR images by placing suitable cursors and evaluating the signal intensity (SI) of the region. Therefore we hypothesise that serial postcontrast MRI can be used to measure antibiotic concentration in the infected intervertebral disc in vivo. If the hypothesis is verified, we can better determine the choice of antibiotics and antibiotic treatment regime at the beginning of the treatment to improve the treatment success rate.

Comparative analysis of tuberculous and brucellar spondylodiscitis

Our aim was to compare the clinical, radiological and prognostic features of spontaneous spondylodiscitis secondary to tuberculosis (TS) and brucellosis (BS). This prospective study involved 41 patients diagnosed with spondylodiscitis. Of these, 18 (43.1%) had BS and 23 (56.1%) had TS. The mean age of TS patients was 52 ± 13.43 years and older than BS patients (P < 0.001). A prolonged clinical course of the disease, constitutional symptoms, lymphocytosis, increased erythrocyte sedimentation rate (ESR), presence of posterior vertebrae lesions and psoas abscesses were significantly more frequent in the TS group. There are significant clinical, biological and radiological differences between TS and BS. These differences permit a presumptive aetiological diagnosis and orient the initial empirical medical treatment while awaiting a final microbiological diagnosis.

Spontaneous spondylodiscitis: presentation, risk factors, diagnosis, management, and outcome

Spontaneous spondylodiscitis is an uncommon disease, which may result in serious complications with potentially high morbidity and mortality. We conducted a prospective case study over a 2-year period in order to analyze the clinical features, approaches to management, and outcome of spondylodiscitis. Eight consecutive patients (four men, four women; age range 53-82 years) suffering from spondylodiscitis were identified during the study period. Parameters recorded included: demographics, past medical history, predisposing factors, presenting signs and symptoms, spinal level and extension of the infection, laboratory indices of inflammation, microbiological testing, radiological assessment, kind and duration of treatment, follow-up magnetic resonance imaging (MRI) studies, and outcome. Duration of symptoms varied from 14 to 90 days. All patients had back pain; fever>or=38 degrees C was present in 5/8 (62.5%) and neurological findings in 6/8 (75%). Diabetes mellitus was identified in six (75%). Most of the patients had elevated laboratory markers of inflammation. At the initial MRI, 12 anatomical levels were found. The microorganism was identified in 7/8 by blood or bone marrow cultures (50% Staphylococcus aureus). None of the patients underwent surgical intervention. Seven patients (87.5%) recovered to full activity; follow-up MRI study results were not always in parallel with the clinical improvement of patients. Spontaneous spondylodiscitis should be considered in every patient with back pain accompanied by fever and laboratory markers of inflammation. The major predisposing risk factor seems to be uncontrolled diabetes. MRI appears to be the method of choice for confirming diagnosis. Timely and accurate diagnosis along with prompt administration of antibiotics appears mandatory for a favorable outcome and avoidance of surgical intervention.

A comparative analysis of tuberculous, brucellar and pyogenic spontaneous spondylodiscitis patients

This study aimed to compare clinical, laboratory, and radiological features of spontaneous spondylodiscitis secondary to tuberculosis and brucellosis, both of which are endemic in Turkey, and spondylodiscitis due to other bacterial causes (pyogenic spondylodiscitis) and to provide guidance for clinicians in determining causative agents of spondylodiscitis. This prospective study involved 75 patients diagnosed as spondylodiscitis. All the patients were divided into three groups: tuberculous spondylodiscitis (Group TS), brucellar spondylodiscitis (Group BS), and pyogenic spondylodiscitis (Group PS). Forty patients (53.3%) were male and 35 (46.7%), female. The mean age of the patients was 57.8+/-14.8 years (17-82 years). Group TS included 13 patients (17.3%), Group BS 32 patients (42.7%), and Group PS 30 patients (40%). A significantly higher rate of microorganisms was isolated and a significantly higher rate of high fever was determined in Group BS. Group TS had a significantly higher rate of accompanying chronic renal failure, constitutional symptoms, psoas abscess, history of tuberculosis, high sedimentation rate, involvement of posterior elements, and/or surgical treatment. The presence of back pain, fever, elevated inflammatory markers and a documented history of tuberculosis in association with radiological involvement of the posterior spinous elements is pathognomonic of tuberculous spinal infection, even in the absence of positive culture.

Comparative study of postoperative and spontaneous pyogenic spondylodiscitis

Postoperative spondylodiscitis (POS) is poorly characterized, partly owing to its rarity. The aim of this prospective study was to compare the clinical, biological, bacteriological, and imaging features of postoperative and spontaneous spondylodiscitis (SS). A multidisciplinary spondylodiscitis cohort follow-up study was conducted between February 1999 and June 2003 in a 500-bed teaching hospital. All patients hospitalized in internal medicine, orthopedic, and neurosurgery wards with a culture-proven diagnosis of pyogenic spondylodiscitis were included. Clinical and bacteriological data were collected. All patients underwent computed tomography and/or magnetic resonance imaging of the spine. Sixteen patients had SS and 7 patients had POS. Patients with POS tended to be younger (52 versus 69 years), with less frequent underlying diseases (29 versus 75%) and a more prolonged interval between symptom onset and diagnosis (16 versus 3.4 weeks) than patients with SS. Blood cultures were positive in 14 and 81% of cases in the POS and SS groups, respectively, and invasive diagnostic procedures were necessary in 86% of patients with POS and 19% of patients with SS ( P = 0.005). Staphylococci were the more frequent isolates in both groups but were more frequently coagulase-negative in POS patients than in patients with SS ( P = 0.01). Vertebral edema tended to be more frequent in POS and was located more posteriorly than in SS ( P = 0.023). POS is associated with specific clinical, microbiological, and imaging features possibly related to pathophysiologic characteristics. Knowledge of these characteristics should help reduce the current delay in the diagnosis of POS.

Medical and Surgical Management of Pyogenic and Nonpyogenic Spondylodiscitis

Learning Objectives: After reading this article, the participant should be able to: Define the principles of conservative and surgical treatment of pyogenic spontaneous spondylodiscitis. Describe the indications for conservative and surgical treatment of pyogenic spontaneous spondylodiscitis. Describe the incidence, clinical presentation, laboratory findings, and the most appropriate treatment of postoperative spondylodiscitis. This article is the second in a four-part series.

Medical and Surgical Management of Pyogenic and Nonpyogenic Spondylodiscitis

Learning Objectives: After reading this article, the participant should be able to: 1. Describe the pathogenesis of pyogenic spontaneous spondylodiscitis in children and adults. 2. Describe the clinical presentation, laboratory findings, and most common bacterial etiology of pyogenic spontaneous spondylodiscitis. 3. Describe the various radiographic evaluation modalities and their respective accuracy rates. This article is the first in a four-part series.

Spontaneous Spondylodiscitis Caused by Klebsiella pneumoniae

A rare case of spontaneous spondylodiscitis caused by Klebsiella pneumoniae in a 55-year-old man who presented with thoracolumbar pain is described. Increased erythrocyte sedimentation rate and C-reactive protein level were pertinent laboratory findings. Computed tomography revealed a paravertebral mass and destruction of the 10th and 11th vertebrae. Magnetic resonance imaging (MRI) showed spondylodiscitis in the same area. Culture of a biopsy sample from the mass grew Klebsiella pneumoniae, while histological examination confirmed the inflammation. A combination of ceftazidime, amikacin and ciprofloxacin resulted in disappearance of the pain. Two months later, MRI showed substantial improvement of the lesions.