Diskitis Treatment & Management

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

Medical Care

  • Antibiotic treatment must be tailored to the isolated organism and any other sites of infection.
    • Broad-spectrum antibiotics must be used if no organism is isolated; however, this is very rare, and other disease processes (eg, spinal tuberculosis) must be considered in the face of persistently negative cultures.
    • Parenteral treatment is usually administered for 6-8 weeks. Before parenteral therapy is discontinued, the ESR should have dropped by one half to one third, the patient should have no pain on ambulation, and there should be no neurologic deficits.[1, 3]
    • The use of oral antibiotics following intravenous treatment has not been shown to be of added benefit.
    • Any laboratory or clinical sign of persistent infection should prompt another biopsy and continued antibiotic therapy.
  • Immobilization is necessary, especially in the initial stages of the disease.
    • Two weeks of bed rest should be followed by external immobilization with a brace when the patient gets out of bed.
    • Any pain on ambulation is an indication for continued bed rest.
    • The goal of immobilization is to provide the opportunity for the affected vertebrae to fuse in an anatomically aligned position.
    • Generally, bracing is used for 3-6 months following initiation of treatment; however, even with the use of appropriate antibiotics and bracing, collapse of the vertebral segments and kyphos formation may occur.
  • Pain control is an important adjunct to antibiotics and immobilization.[2]
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Surgical Care

Indications for surgery beyond open biopsy include neurologic deficit, spinal deformity, disease progression, noncompliance, and antibiotic toxicity. The goal of surgery is to remove diseased tissue, decompress neural structures, and ensure spinal stability. Although in most cases the vertebrae fuse spontaneously following diskitis and osteomyelitis, operative fusion can be a useful adjunct by allowing earlier mobilization of the patient. Despite early concerns, use of a fusion plug and metallic instrumentation in an infected field has not been shown to impede successful treatment.

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Consultations

  • Infectious disease
  • Neurosurgery
  • Orthopedic spine surgery
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Diet

No particular diet has been shown to have a clinical benefit in patients with diskitis.

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Activity

Many authors believe that 2 weeks of bed rest with initial treatment helps prevent the development of a kyphotic deformity. Use of an orthotic brace to help stabilize the spine while spontaneous fusion takes place is recommended for 3-6 months. Ambulation is recommended only if the patient has neither pain nor radiographic signs of instability.

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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.

References

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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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