Diskitis Clinical Presentation

  • Author: George I Jallo, MD; Chief Editor: Mary Ann E Keenan, MD   more...
 
Updated: Feb 9, 2011
 

History

  • Unfortunately, adult diskitis has a slow, insidious onset, which can cause diagnosis to be delayed for months. Neck or back pain with localized tenderness is the initial presenting complaint. Movement exacerbates these symptoms, which are not alleviated with conservative treatment (eg, analgesics, bed rest).
    • In patients who are chronically ill, a high incidence of epidural extension of the infection exists, causing lower extremity weakness or plegia. Fever, chills, weight loss, and symptoms of systemic disease may be present but are not common.
    • In postoperative patients, symptoms usually begin days to weeks after surgery. Symptoms are similar to those experienced by patients with spontaneous diskitis, which consists of pain without neurologic abnormality. Limited movement and localized tenderness also occur; however, superficial signs of infection are rare (only 10% of cases). Diagnosis is rarely delayed in postoperative patients, which is the main reason that neurologic deficit is uncommon in these cases.
  • The disease has a more acute course in children. A sudden onset of back pain, refusal to walk, and irritability are the most common symptoms. Fever is often present, accompanied by local tenderness and limited back motion.
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Physical

Localized tenderness over the involved area with concomitant paraspinal muscle spasm is the most common physical sign. If the cervical or lumbar segments are involved, restricted mobility secondary to pain occurs. Reported rates of neurologic deficit (eg, radiculopathy, myelopathy) vary widely from 2% to 70%. Cervical disease is associated with a much higher rate of neurologic deficit.

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Causes

  • Diskitis is thought to spread to the involved intervertebral disk via hematogenous spread of a systemic infection (eg, urinary tract infection [UTI]). Many sites of origin have been implicated, but UTI, pneumonia, and soft-tissue infection seem to be the most common. Direct trauma has not been conclusively shown to be related to diskitis. Intravenous drug use with contaminated syringes offers direct access to the bloodstream for a variety of organisms. Often, no other site of infection is discovered.
  • Staphylococcus aureus is the organism most commonly found; however, Escherichia coli and Proteus species are more common in patients with UTIs. Pseudomonas aeruginosa and Klebsiella species are other gram-negative organisms observed in intravenous drug abusers, although they are not seen as commonly as S aureus. Not surprisingly, medical conditions that predispose patients to infections elsewhere in the body are associated with diskitis. Diabetes, AIDS, steroid use, cancer, and chronic renal insufficiency are common comorbidities.[1]
  • Although rare, infection of the disk space can also occur following surgical intervention at the site. The rate of infection following anterior cervical diskectomy has been quoted at 0.5% of cases. The rate of infection for lumbar diskectomy is half of that. In such cases, infection is transmitted through direct inoculation of the operative site. As in spontaneous diskitis, the most common organism is S aureus, but Staphylococcus epidermidis and Streptococcus species also should be considered.
  • Childhood diskitis has not been consistently associated with an initial causative infection elsewhere in the body. S aureus is the most common organism found.
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Contributor Information and Disclosures
Author

George I Jallo, MD  Associate Professor of Neurosurgery, Pediatrics and Oncology, Director, Clinical Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine

George I Jallo, MD is a member of the following medical societies: American Association of Neurological Surgeons, American Medical Association, and American Society of Pediatric Neurosurgeons

Disclosure: Codman (Johnson & Johnson) Grant/research funds Consulting; Medtronic Grant/research funds Consulting

Coauthor(s)

Alvin Marcovici, MD  Consulting Staff, Southcoast Neurosurgery

Alvin Marcovici, MD is a member of the following medical societies: American Association of Neurological Surgeons, Congress of Neurological Surgeons, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

K Daniel Riew, MD  Mildred B Simon Distinguished Professor of Orthopedic Surgery, Professor of Neurologic Surgery, Washington University School of Medicine; Chief, Cervical Spine Surgery, Department of Orthopedic Surgery, Barnes-Jewish Hospital

K Daniel Riew, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, AO Foundation, Cervical Spine Research Society, North American Spine Society, and Scoliosis Research Society

Disclosure: Medtronic Royalty Medtronic Vertex; Biomet Royalty Maxan anterior cervical plate; Osprey Royalty Interbody Graft; Osprey Stock Options None; SpineMedica None None; Synthes Consulting fee Other

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

William O Shaffer, MD  Professor, Vice-Chairman and Residency Program Director, Department of Orthopedic Surgery, University of Kentucky at Lexington

William O Shaffer, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, International Society for the Study of the Lumbar Spine, Kentucky Medical Association, Kentucky Orthopaedic Society, North American Spine Society, Southern Medical Association, and Southern Orthopaedic Association

Disclosure: DePuySpine 1997-2007 (not presently) Royalty Consulting; DePuySpine 2002-2007 (closed) Grant/research funds SacroPelvic Instrumentation Biomechanical Study; DePuyBiologics 2005-2008 (closed) Grant/research funds Healos study just closed; DePuySpine 2009 Consulting fee Design of Offset Modification of Expedium

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Mary Ann E Keenan, MD  Professor, Vice Chair for Graduate Medical Education, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine; Chief of Neuro-Orthopedics Program, Department of Orthopedic Surgery, Hospital of the University of Pennsylvania

Mary Ann E Keenan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, American Society for Surgery of the Hand, and Orthopaedic Rehabilitation Association

Disclosure: Nothing to disclose.

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Axial CT scan in a patient with diskitis demonstrates extensive destruction of the vertebral endplate. Note the preservation of the posterior elements, including facet joints, lamina, and spinous process. This is characteristic for pyogenic diskitis and less common in tuberculosis (Pott disease).
Sagittal T1-weighted MRI of the lumbar spine in a 74-year-old man, revealing diskitis of the L4-L5 disk space. Note extensive destruction of the endplates of the adjacent vertebral bodies. No compression of the thecal sac is present, which is an important consideration when contemplating surgical intervention.
Contrast-enhanced sagittal T1-weighted MRI image in a 55-year-old woman shows thoracic diskitis with an associated epidural abscess and spinal cord compression. Because of the significant cord compression, this patient underwent surgical decompression.
Trajectory of a needle in a biopsy of the infected disk space guided by CT scan. Care is taken to avoid the thecal sac and nerve roots.
 
 
 
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