Spondylodiscitis, a term encompassing vertebral osteomyelitis, spondylitis and discitis, is the main manifestation of haematogenous osteomyelitis in patients aged over 50 years. Staphylococcus aureus is the predominant pathogen, accounting for about half of non-tuberculous cases. Diagnosis is difficult and often delayed or missed due to the rarity of the disease and the high frequency of low back pain in the general population. In this review of the published literature, we found no randomized trials on treatment and studies were too heterogeneous to allow comparison. Improvements in surgical and radiological techniques and the discovery of antimicrobial therapy have transformed the outlook for patients with this condition, but morbidity remains significant. Randomized trials are needed to assess optimal treatment duration, route of administration, and the role of combination therapy and newer agents.

Spondylodiscitis: update on diagnosis and management

Copyright © 2010 Massachusetts Medical Society. A 57-year-old man presents with fever, chills, and new lumbar back pain 2 weeks after undergoing a prostate biopsy because of an increased prostate-specific antigen level. His temperature is 39.7°C; he has an enlarged, tender prostate and lumbar spine tenderness. His white-cell count is 9100 per cubic millimeter, and the C-reactive protein level is 343 mg per liter. Urine and blood cultures reveal multidrug-resistant, extendedspectrum β-lactamase–producing Escherichia coli susceptible to imipenem. How should he be evaluated and treated?

Clinical practice. Vertebral osteomyelitis.

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(14)61233-2.pdf

Antibiotic treatment for 6 weeks versus 12 weeks in patients with pyogenic vertebral osteomyelitis: an open-label, non-inferiority, randomised, controlled trial.

SUMMARY Vertebral osteomyelitis (VO) is a rare event. To estimate the incidence of VO in France for 2002–2003, national hospital-discharge data were used. Hospital stays were categorized as definite, probable or possible VO. Unique patient identification numbers allowed the investigators to link patients with multiple hospital stays and to analyse data for individual patients. A sample of medical records was reviewed to assess the specificity of the VO case definition. In 2002–2003, 1977 and 2036 hospital stays corresponding to 1422 and 1425 patients (median age 59 years, male :female ratio 1 . 5) were classified as definite (64 %), probable (24 %) and possible (12 %) VO. The overall incidence of VO was 2 . 4/100 000. Incidence increased with age : 0 . 3/100 000 ( 70 years). The main infectious agents reported were Staphylococcus spp. (38 %) and Mycobacterium tuberculosis (31 %). The most frequent comorbidities were septicaemia (27 %) and endocarditis (9 %). Three percent of patients died. A review of 90 medical records confirmed the diagnosis of VO in 94 % of cases. Using a hospital database and a specific case definition, nationwide surveillance of VO is possible.

Epidemiology of vertebral osteomyelitis (VO) in France: analysis of hospital-discharge data 2002–2003

STUDY DESIGN We performed a retrospective review of 48 cases of pyogenic spinal infection presenting over a 12-year period to the National Spinal Injuries Unit (NSIU) of the Republic of Ireland. The NSIU is the tertiary referral center for all adult spinal injuries and diseases of the spine warranting surgical intervention in the Republic of Ireland. OBJECTIVES The objective of this study was to analyze the presentation, etiology, management, and outcome of nontuberculous pyogenic spinal infection in adults. SUMMARY OF BACKGROUND DATA Pyogenic spinal infection encompasses a broad range of clinical entities, including spondylodiscitis, septic discitis, vertebral osteomyelitis, and epidural abscess. Management of pyogenic spinal infection can involve conservative methods and surgical intervention. METHODS The medical records, radiologic imaging, and bacteriology results of 48 patients with pyogenic vertebral osteomyelitis from 1992 through 2004 were reviewed. The Hospital Inpatient Enquiry (HIPE) System and the NSIU Database were used to identify our study cohort. RESULTS The average age of presentation was 59 years with an even distribution between males and females. Most patients (21 of 48) were symptomatic for between 2 and 6 weeks before presenting to hospital. The most frequently isolated pathogen was Staphylococcus aureus, in 23 of 48 cases (48%); 35 of 48 cases (73%) were managed by conservative measures alone, including antibiotic therapy and spinal bracing. However, in 13 of 48 cases (27%), surgical intervention was required because of neurologic compromise or mechanical instability. CONCLUSIONS In the majority of cases, conservative management of pyogenic spinal infection with antibiotic therapy and spinal bracing is very successful. However, in a minority of cases, surgical intervention is warranted and referral to a specialist center is appropriate.

Nontuberculous pyogenic spinal infection in adults: a 12-year experience from a tertiary referral center.

We studied the spectrum of septic discitis presenting to two busy district general hospitals over 2.5 years (November 1996 to April 1999), surveying the case notes of all patients attending Royal Bournemouth and Poole Hospitals with probable septic discitis on magnetic resonance imaging (MRI). Twenty-two cases of septic discitis were identified, suggesting an annual incidence of 2/100 000/year. Seventy-three percent of patients were aged > or =65 years. In 91% of patients, back pain was the presenting symptom, with neurological signs evident in 45% of patients. Fever >37.5 degrees C was present in 68% of patients, and a marked elevation of erythrocyte sedimentation rate (ESR) in 91%. Diagnosis was originally by MRI in 86% of patients, with plain radiographs not diagnostic of discitis in the early stages of the infection. Staphylococcus aureus was the commonest pathogen (41%), but in 18% of patients, no organism was identified. The major predisposing factors to septic discitis were invasive procedures (41%), underlying cancer (25%) and diabetes (18%). Pre-existing degenerative spinal disease was found in 50% of patients. Four patients whose causative organism was not isolated had a poorer outcome: one death and three with increased morbidity. Our estimated incidence rate (2/100 000/year) is higher than that in previous studies and may be due to a higher detection rate with MRI and/or a genuine increase in the number of cases. Septic discitis should be considered in any patient who has severe localized pain at any spinal level, especially if accompanied by fever and elevated ESR, or in the immunosuppressed.

N Hopkinson

Papers

A case ascertainment study of septic discitis: clinical, microbiological and radiological features.