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Diskitis Treatment & Management

  • Author: Alvin Marcovici, MD; Chief Editor: Jeffrey A Goldstein, MD  more...
 
Updated: Jan 29, 2016
 

Medical Therapy

Antibiotics

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 antibiotics are a requirement, even for outpatients. They are usually administered for 6-8 weeks. Before parenteral therapy is discontinued, the erythrocyte sedimentation rate (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 (see Complications and Long-Term Monitoring).[1, 3]

The use of oral antibiotics after intravenous (IV) 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

Immobilization is necessary, especially in the initial stages of the disease. The goal of immobilization is to provide the opportunity for the affected vertebrae to fuse in an anatomically aligned position.

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. 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

Pain medications can be a useful adjunct to antibiotic therapy, in that they allow increased mobilization.[2]

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Surgical Therapy

Indications for surgery beyond open biopsy include the following:

  • Neurologic deficit
  • Spinal deformity
  • Disease progression
  • Noncompliance
  • Antibiotic toxicity

The goal of surgery are as follows:

  • To remove diseased tissue
  • To decompress neural structures
  • To ensure spinal stability

Although in most cases the vertebrae fuse spontaneously after 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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Complications

Neurologic deficits develop in 13-40% of patients, especially those with diabetes or other systemic illnesses. Transfer to an institution with neurosurgical or orthopedic spinal care is warranted for any patient demonstrating neurologic decline for decompression and possible stabilization.

Long-term antibiotic therapy may lead to ototoxicity or renal toxicity.

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Diet and Activity

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

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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Prevention

No specific deterrence is available for diskitis except treatment of the underlying disease (eg, diabetes, sepsis).

Sharma et al reported on the severe complication of diskitis following diskography.[10] They found that the available clinical evidence did not conclusively demonstrate that IV or intradiskal antibiotics during diskography decreased the rate of diskitis in comparison with sterile technique alone. Animal model research supports prophylactic antibiotic use when used before iatrogenic inoculation of intervertebral disks. Both single- and double-needle techniques when used with stylettes are superior to nonstyletted techniques, according to the authors.

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Consultations

Consultations to be considered include the following:

  • Infectious disease
  • Neurosurgery
  • Orthopedic spine surgery
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Long-Term Monitoring

Once the correct treatment is implemented, monitor patients to rule out progressive neurologic deficit.

A falling ESR is consistent with successful treatment. Although ESR values should fall by at least one third to one half, rarely do they return to preinfection levels. Reduction of C-reactive protein (CRP) levels has been shown to be more sensitive than ESR in some studies.

Serial radiographic examination is a necessity to detect bony collapse or deformity. Successful treatment is accompanied by appropriate changes, including sclerosis of the endplates, on plain radiography and computed tomography (CT). Nevertheless, radiographic findings are significantly slower than clinical response and cannot be used to assess eradication of infection.

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Contributor Information and Disclosures
Author

Alvin Marcovici, MD Consulting Staff, Southcoast Neurosurgery

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

Disclosure: Nothing to disclose.

Coauthor(s)

George I Jallo, MD 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, American Society of Pediatric Neurosurgeons

Disclosure: Received grant/research funds from Codman (Johnson & Johnson) for consulting; Received grant/research funds from Medtronic for consulting.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

William O Shaffer, MD Orthopedic Spine Surgeon, Northwest Iowa Bone, Joint, and Sports Surgeons

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

Disclosure: Received royalty from DePuySpine 1997-2007 (not presently) for consulting; Received grant/research funds from DePuySpine 2002-2007 (closed) for sacropelvic instrumentation biomechanical study; Received grant/research funds from DePuyBiologics 2005-2008 (closed) for healos study just closed; Received consulting fee from DePuySpine 2009 for design of offset modification of expedium.

Chief Editor

Jeffrey A Goldstein, MD Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Director of Spine Service, Director of Spine Fellowship, Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, NYU Langone Medical Center

Jeffrey A Goldstein, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, North American Spine Society, Scoliosis Research Society, Cervical Spine Research Society, International Society for the Study of the Lumbar Spine, AOSpine, Society of Lateral Access Surgery, International Society for the Advancement of Spine Surgery, Lumbar Spine Research Society

Disclosure: Received consulting fee from Medtronic for consulting; Received consulting fee from NuVasive for consulting; Received royalty from Nuvasive for consulting; Received consulting fee from K2M for consulting; Received ownership interest from NuVasive for none.

References
  1. Conaughty JM, Chen J, Martinez OV, et al. Efficacy of linezolid versus vancomycin in the treatment of methicillin-resistant Staphylococcus aureus discitis: a controlled animal model. Spine. 2006 Oct 15. 31(22):E830-2. [Medline].

  2. Hooten WM, Mizerak A, Carns PE, Huntoon MA. Discitis after lumbar epidural corticosteroid injection: a case report and analysis of the case report literature. Pain Med. 2006 Jan-Feb. 7(1):46-51. [Medline].

  3. Walters R, Rahmat R, Fraser R, Moore R. Preventing and treating discitis: cephazolin penetration in ovine lumbar intervertebral disc. Eur Spine J. 2006 Sep. 15(9):1397-403. [Medline].

  4. Martínez Hernández PL, Amer López M, Zamora Vargas F, García de Paso P, Navarro San Francisco C, Pérez Fernández E, et al. [Spontaneous infectious spondylodiscitis in an internal medicine department: epidemiological and clinical study in 41 cases]. Rev Clin Esp. 2008 Jul-Aug. 208(7):347-52. [Medline].

  5. Cottle L, Riordan T. Infectious spondylodiscitis. J Infect. 2008 Jun. 56(6):401-12. [Medline].

  6. Karadimas EJ, Bunger C, Lindblad BE, Hansen ES, Høy K, Helmig P, et al. Spondylodiscitis. A retrospective study of 163 patients. Acta Orthop. 2008 Oct. 79(5):650-9. [Medline].

  7. Maus U, Andereya S, Gravius S, Ohnsorge JA, Miltner O, Niedhart C. [Procalcitonin (PCT) as diagnostic tool for the monitoring of spondylodiscitis]. Z Orthop Unfall. 2009 Jan-Feb. 147(1):59-64. [Medline].

  8. Jeong DK, Lee HW, Kwon YM. Clinical Value of Procalcitonin in Patients with Spinal Infection. J Korean Neurosurg Soc. 2015 Sep. 58 (3):271-5. [Medline].

  9. Eguchi Y, Ohtori S, Yamashita M, Yamauchi K, Suzuki M, Orita S, et al. Diffusion magnetic resonance imaging to differentiate degenerative from infectious endplate abnormalities in the lumbar spine. Spine (Phila Pa 1976). 2011 Feb 1. 36(3):E198-202. [Medline].

  10. Sharma SK, Jones JO, Zeballos PP, Irwin SA, Martin TW. The prevention of discitis during discography. Spine J. 2009 Jul 28. [Medline].

 
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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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