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Spinal Infections Treatment & Management

  • Author: Federico C Vinas, MD; Chief Editor: Jeffrey A Goldstein, MD  more...
 
Updated: Dec 22, 2015
 

Approach Considerations

Treatment indications

The combination of mechanical compression of the spinal cord by pus or granulation tissue can result in ischemia with spinal cord infarction, which accounts for the rapid neurologic progression of this disease. Patients with a spinal epidural abscess may progress to complete paralysis within minutes to hours, even while receiving optimal antibiotic therapy. In addition, patients with vertebral osteomyelitis can develop pathological fractures, caused by the softening of the bone, and present with acute spinal cord compression.

Most patients with pyogenic vertebral osteomyelitis respond to medical management. However, surgery may be required if medical management is unsuccessful. Indications for surgery include the following:

  • Significant osseous involvement
  • Neurologic deficits - Neurologic deterioration can be caused by significant kyphosis, by infection behind the vertebral body under the posterior longitudinal ligament, or by infection in the epidural space
  • Septic course with clinical toxicity from an abscess not responding to antibiotics
  • Failure of needle biopsy to obtain necessary cultures
  • Failure of intravenous (IV) antibiotics alone to eradicate the infection

Infectious Diseases Society of America guidelines for native vertebral osteomyelitis

The Infectious Diseases Society of America (IDSA) has published clinical practice guidelines for the diagnosis and treatment of native vertebral osteomyelitis (NVO) in adults.[35] Treatment recommendations include the following:

  • In patients with neurologic compromise with or without impending sepsis or hemodynamic instability, immediate surgical intervention and initiation of empiric antimicrobial therapy are recommended
  • In patients with normal and stable neurologic examination and stable hemodynamics, hold empiric antimicrobial therapy until a microbiologic diagnosis is established
  • In patients with hemodynamic instability, sepsis, septic shock, or progressive or severe neurologic symptoms, initiate empiric antimicrobial therapy in conjunction with an attempt to establish a microbiologic diagnosis
  • A total duration of 6 weeks of parenteral or highly bioavailable oral antimicrobial therapy is recommended for most patients with bacterial NVO
  • A total duration of 3 months of antimicrobial therapy is recommended for most patients with NVO due to Brucella species
  • Surgical intervention is recommended in patients with progressive neurologic deficits, progressive deformity, and spinal instability with or without pain despite adequate antimicrobial therapy
  • Surgical debridement with or without stabilization is recommended in patients with persistent or recurrent bloodstream infection (without alternative source) or worsening pain despite appropriate medical therapy (weak, low)
  • Recommend against surgical debridement and/or stabilization in patients who have worsening bony imaging findings at 4-6 weeks in the setting of improvement in clinical symptoms, physical examination, and inflammatory markers
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Medical Therapy

The overall treatment plan for a patient with vertebral osteomyelitis must be individualized according to the patient's general medical condition, neurologic status, presence of large associated abscesses, and biomechanical factors. Underlying infections (eg, retropharyngeal, pelvic, decubital) require simultaneous treatment if the vertebral infection is to be cured.

Antibiotic treatment must be tailored to the isolated organism and any other sites of infection. Broad-spectrum antibiotics covering both gram-positive and gram-negative organisms, aerobes and anaerobes, including methicillin-resistant S aureus, are instituted initially until the organism is isolated. Most cases of vertebral osteomyelitis are caused by S aureus, which generally is sensitive to antibiotics. Although rare, spinal tuberculosis or fungal infection must be considered in the face of persistently negative culture findings and lack of response to antibiotics.[2, 41, 42]

Antibiotics are given for variable lengths of time. It appears that 6-8 weeks of parenteral antibiotic therapy is effective in most cases. Before parenteral antibiotics are discontinued, the erythrocyte sedimentation rate (ESR) should have fallen to at least two thirds of the pretherapy level. In addition, the patient should be afebrile, without pain on mobilization, and without any disease-related complications such as neurologic deficits. A persistently high ESR implies continuing infection, and additional IV antibiotics are indicated. In such an instance, an additional biopsy can be taken of the infected vertebra to see if organisms not susceptible to the chosen antibiotics are present.[43, 44]

Bracing is recommended to provide stability for the spine while the infection is healing. The goal of immobilization is to provide opportunity for the affected level to fuse in an anatomically aligned position. Bracing is usually continued for 6-12 weeks, until either bony fusion is seen on radiographs or the patient's pain subsides. A rigid brace works best and need be worn only when the patient is active.

After successful conservative treatment of pyogenic vertebral osteomyelitis and eventual union, some degree of vertebral body collapse may still occur. The greater the amount of bone destruction present before treatment, the greater the likelihood of eventual kyphosis. After antibiotic treatment, therefore, the spine must be monitored using sequential radiographs. Kyphosis formation may lead to eventual neural impingement, and the kyphosis itself may require late surgical correction.

Medications

Vancomycin is a potent antibiotic directed against gram-positive organisms and that is active against Enterococcus species. It is useful in the treatment of bloodstream infection and skin-structure infection and is indicated in patients who cannot receive or have failed to respond to penicillins and cephalosporins or have infections with resistant staphylococci.

To avoid toxicity, the current recommendation is to assay vancomycin trough levels after the third dose is drawn one half hour prior to the next dose. Use creatinine clearance (CrCl) to adjust the dose in patients diagnosed with renal impairment. Vancomycin is used in conjunction with gentamicin for prophylaxis in patients who are allergic to penicillin and are undergoing gastrointestinal (GI) or genitourinary (GU) procedures. The adult dosage is 0.5-2 g/day IV; the pediatric dosage is 40 mg/kg/day IV. Vancomycin is a pregnancy category C drug.

Nafcillin is the initial therapy for suspected penicillin G–resistant streptococcal or staphylococcal infections. Use parenteral therapy initially in severe infections, and change to oral therapy as the patient’s condition warrants. Because of the risk of thrombophlebitis, particularly in elderly patients, parenteral administration should continue for only a short period (1-2 days) before being changed to the oral route as clinically indicated.

Adult dosing of nafcillin is 1 g IV or intramuscularly (IM) every 4-6 hours. Neonatal dosing (0-4 kg) is 10 mg/kg IM every 12 hours. Dosing in children who weigh 4-40 kg is 25 mg/kg IM every 12 hours or 50 mg/kd/day orally in four divided doses or, alternatively, 100-200 mg/kg/day IV/IM in four or six divided doses. Nafcillin is a pregnancy category B drug.

Gentamicin is an aminoglycoside antibiotic that has gram-negative coverage. It is used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Consider gentamicin if penicillins or other less toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms. Dosing regimens are numerous; the dosage should be adjusted on the basis of CrCl and changes in volume of distribution. Gentamicin may be given IV or IM.

In adults, dosing of gentamicin for serious infections and normal renal function is 3 mg/kg IV every 8 hours. The loading dose and the maintenance dose are 1-2.5 mg/kg IV and 1-1.5 mg/kg IV, respectively, every 8 hours. The extended dosing regimen for life-threatening infections is 5 mg/kg/day IV/IM every 6 or 8 hours. Follow each regimen by at least a trough level drawn on the third or fourth dose (30 minutes before dosing); a peak level may be drawn 30 minutes after a 30-minute infusion.

In children younger than 5 years, gentamicin dosing is 2.5 mg/kg IV/IM every 8 hours. In those older than 5 years, dosing is 1.5-2.5 mg/kg IV/IM every 8 hours or 6-7.5 mg/kg/day in three divided doses, not to exceed 300 mg/day; monitor as in adults.

Ceftazidime is a third-generation cephalosporin with broad-spectrum, gram-negative activity. It has lower efficacy against gram-positive organisms and higher efficacy against resistant organisms. Ceftazidime arrests bacterial growth by binding penicillin-binding proteins. Adult dosing is 1-2 g IV/IM every 8 or 12 hours. Neonatal dosing is 30 mg/kg IV every 12 hours. In infants and children, dosing is 30-50 mg/kg IV every 8 hours, not to exceed 6 g/day. Ceftazidime is a pregnancy category B drug.

Complications

Long-term antibiotic treatment may, in itself, lead to complications such as cranial nerve (CN) VIII and renal toxicity, skin rashes, and other sequelae associated with specific antimicrobials.

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Surgical Therapy

Although most patients with pyogenic vertebral osteomyelitis respond to medical management, surgery may be required (see Approach Considerations, Treatment Indications).[2, 45, 46, 27, 28, 29, 30, 31, 47, 48, 49] Goals of surgery include preservation of neural function and achievement of stable bony fusion without severe kyphosis, which itself could lead to neural compromise or disabling radicular pain.

Preparation for surgery

Most patients who need to undergo a surgical procedure for the treatment of a vertebral infection are chronically debilitated and require a careful preoperative evaluation, including a hematologic and coagulation profile, chest radiography, and electrocardiography (ECG). Blood is typically typed and cross-matched.

An accurate preoperative documentation of the patient's neurologic condition is of primary importance. In patients with spinal instability or spinal cord compression, particular care should be taken to avoid unnecessary movement of the spine during transport, induction of anesthesia, endotracheal intubation, and positioning. Patients with a full stomach undergoing emergency surgery should have gastric decompression via a nasogastric tube and suction. Patients with cervical spinal instability or cervical spinal cord compression may benefit from fiberoptic endotracheal intubation while awake.

If antibiotic therapy has not been initiated preoperatively, prophylactic antibiotics are generally administrated after the cultures have been obtained.

Procedure

Infections located in the vertebral body or spinal cord compression produced by collapse of the vertebral body are best corrected by an anterior or anterolateral surgical approach (see the image below), which allows one to decompress the neural elements and to remove the infected disk and involved vertebral bodies. Patients with extensive vertebral destruction usually require instrumentation and fusion.

Spinal infections. Patient B developed lower extre Spinal infections. Patient B developed lower extremity weakness, and follow-up studies reveal further compression of L4 and compromise of the canal. An anterolateral approach was performed with a corpectomy, decompression of the spinal canal, restoration of the anterior column support, and arthrodesis with a titanium cage and autologous iliac crest bone graft. The pathology and Gram stain revealed some hyphae. Culture findings were positive for Aspergillus species. The patient underwent a full course of amphotericin B and completely recovered.

In cases of posterior osteomyelitis, especially if a posteriorly placed epidural abscess is present, laminectomy may be indicated. Whether subsequent fusion should be performed depends on the extent of bone removal, the condition of the anterior spinal column, and the likelihood of postoperative spinal instability or deformity.

After the patient is under general anesthesia and the endotracheal tube is secured, the patient's eyes should be well lubricated and taped shut. A Foley catheter is placed, and bilateral thromboembolism-deterrent (TED) hose and sequential compression boots are used. The extremities should be padded carefully to prevent compression-related neural injury.

Patient positioning depends on the particular surgical approach; the preferred position is usually prone for a posterior approach, supine for anterior approaches, and oblique for an anterolateral approach. It is important to avoid applying pressure to the thorax and abdomen so that epidural bleeding can be minimized.

Decompression of the spinal cord and nerve roots with drainage of purulent material and debridement of compressive granulation tissue is central to this procedure. A full set of aerobic, anaerobic, fungal, and acid-fast bacteria cultures should be obtained early in the procedure. Appropriate antibiotics should be administrated at this time. Debridement and drainage should be followed by extensive irrigation with antibiotic solution. In most cases, closure can be done primarily, with a surgical drain left in place.

In some patients, an arthrodesis with internal instrumental fixation may be necessary at the time of decompression. There is strong support in the literature for a staged anterior decompression and strut fusion followed by a second-stage posterior spinal fixation. However, there is growing support in the literature for the view that in selected patients, anterior fixation can be combined with a strut fusion.[45, 46, 50]

Postoperative care

Significant postoperative discomfort limits activity for several days in most patients. A morphine patient-controlled analgesia (PCA) pump usually is employed during the first 36-48 hours.

To allow early patient mobilization postoperatively, patients are braced with an appropriate molded orthosis for a variable period, and a physical therapist is consulted.

The antibiotics should be adjusted according to the culture results.

Nursing care should include frequent repositioning, vigorous pulmonary toilet, and deep venous thrombosis (DVT) prophylaxis.

Complications

During the postoperative period, patients with neurologic deficits are prone to multiple complications, including skin decubitus, pulmonary problems, DVT, and urinary sepsis.

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Long-Term Monitoring

Once correct treatment is implemented, patients require neurologic monitoring to exclude progressive neurologic deterioration. Home health care may help provide parenteral antibiotics, which typically are given until the infection resolves. Rehabilitation for any residual neurologic deficit may be necessary. This would include restrengthening programs and ambulation retraining.

In addition, follow-up laboratory and radiologic studies are necessary. A falling ESR is consistent with successful treatment. Decreases in serum C-reactive protein (CRP) have been shown to be more sensitive than ESR. Serial radiographic studies are needed to detect bony collapse or deformity.

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Contributor Information and Disclosures
Author

Federico C Vinas, MD Consulting Neurosurgeon, Department of Neurological Surgery, Halifax Medical Center

Federico C Vinas, MD is a member of the following medical societies: American Association of Neurological Surgeons, American College of Surgeons, American Medical Association, Florida Medical Association, North American Spine Society, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

J Richard Rhodes, MD Orthopedic Surgeon, Atlantic Orthopaedics, PA, and Coastal Medical Research

J Richard Rhodes, MD is a member of the following medical societies: Florida Medical Association, Florida Orthopaedic Society

Disclosure: Nothing to disclose.

Amy L Stumpf, PA-C, MPH Clinical Director, Assistant Professor, Physician Assistant Program, Nova Southeastern University

Disclosure: Nothing to disclose.

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.

Additional Contributors

James F Kellam, MD, FRCSC, FACS, FRCS(Ire) Professor, Department of Orthopedic Surgery, University of Texas Medical School at Houston

James F Kellam, MD, FRCSC, FACS, FRCS(Ire) is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Orthopaedic Trauma Association, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

References
  1. Schimmer RC, Jeanneret C, Nunley PD. Osteomyelitis of the cervical spine: a potentially dramatic disease. J Spinal Disord Tech. 2002 Apr. 15(2):110-7. [Medline].

  2. Ziai WC, Lewin JJ 3rd. Update in the diagnosis and management of central nervous system infections. Neurol Clin. 2008 May. 26(2):427-68. [Medline].

  3. Kourbeti IS, Tsiodras S, Boumpas DT. Spinal infections: evolving concepts. Curr Opin Rheumatol. 2008 Jul. 20(4):471-9. [Medline].

  4. An HS, Seldomridge JA. Spinal infections: diagnostic tests and imaging studies. Clin Orthop Relat Res. 2006 Mar. 444:27-33. [Medline].

  5. Mylona E, Samarkos M, Kakalou E, Fanourgiakis P, Skoutelis A. Pyogenic Vertebral Osteomyelitis: A Systematic Review of Clinical Characteristics. Semin Arthritis Rheum. 2008 Jun 10. [Medline].

  6. Jaramillo-de la Torre JJ, Bohinski RJ, Kuntz C 4th. Vertebral osteomyelitis. Neurosurg Clin N Am. 2006 Jul. 17(3):339-51, vii. [Medline].

  7. Hegde V, Meredith DS, Kepler CK, Huang RC. Management of postoperative spinal infections. World J Orthop. 2012 Nov 18. 3(11):182-9. [Medline]. [Full Text].

  8. Fujiyoshi T, Goto K, Shiomori T. [A case of spinal epidural abscess associated with retropharyngeal abscess]. Nippon Jibiinkoka Gakkai Kaiho. 2002 Nov. 105(11):1143-6. [Medline].

  9. Lee KC, Tsai YT, Lin CY. Vertebral osteomyelitis combined streptococcal viridans endocarditis. Eur J Cardiothorac Surg. 2003 Jan. 23(1):125-7. [Medline].

  10. 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. 208(7):347-52. [Medline].

  11. Urrutia J, Bono CM, Mery P, Rojas C, Gana N, Campos M. Chronic liver failure and concomitant distant infections are associated with high rates of neurological involvement in pyogenic spinal infections. Spine (Phila Pa 1976). 2009 Apr 1. 34(7):E240-4. [Medline].

  12. Murillo O, Roset A, Sobrino B, Lora-Tamayo J, Verdaguer R, Jiménez-Mejias E, et al. Streptococcal vertebral osteomyelitis: multiple faces of the same disease. Clin Microbiol Infect. 2013 Jun 22. [Medline].

  13. Cahill DW, Love LC, Rechtine GR. Pyogenic osteomyelitis of the spine in the elderly. J Neurosurg. 1991 Jun. 74(6):878-86. [Medline].

  14. Gotway MB, Marder SR, Hanks DK. Thoracic complications of illicit drug use: an organ system approach. Radiographics. 2002 Oct. 22 Spec No:S119-35. [Medline].

  15. Toyota T. Vertebral osteomyelitis in diabetes mellitus. Intern Med. 1997 Jun. 36(6):382-3. [Medline].

  16. Hadjipavlou AG, Mader JT, Necessary JT. Hematogenous pyogenic spinal infections and their surgical management. Spine. 2000 Jul 1. 25(13):1668-79. [Medline].

  17. Colmenero JD, Jimenez-Mejias ME, Sanchez-Lora FJ. Pyogenic, tuberculous, and brucellar vertebral osteomyelitis: a descriptive and comparative study of 219 cases. Ann Rheum Dis. 1997 Dec. 56(12):709-15. [Medline].

  18. Miller DJ, Mejicano GC. Vertebral osteomyelitis due to Candida species: case report and literature review. Clin Infect Dis. 2001 Aug 15. 33(4):523-30. [Medline].

  19. Nussbaum ES, Rockswold GL, Bergman TA. Spinal tuberculosis: a diagnostic and management challenge. J Neurosurg. 1995 Aug. 83(2):243-7. [Medline].

  20. Vinas FC, King PK, Diaz FG. Spinal aspergillus osteomyelitis. Clin Infect Dis. 1999 Jun. 28(6):1223-9. [Medline].

  21. Wang YC, Lee ST. Candida vertebral osteomyelitis: a case report and review of the literature. Chang Gung Med J. 2001 Dec. 24(12):810-5. [Medline].

  22. Milstone AM, Maragakis LL, Townsend T, Speck K, Sponseller P, Song X, et al. Timing of Preoperative Antibiotic Prophylaxis: A Modifiable Risk Factor for Deep Surgical Site Infections After Pediatric Spinal Fusion. Pediatr Infect Dis J. 2008 Jun 19. [Medline].

  23. Sasso RC, Garrido BJ. Postoperative spinal wound infections. J Am Acad Orthop Surg. 2008 Jun. 16(6):330-7. [Medline].

  24. Gerometta A, Rodriguez Olaverri JC, Bitan F. Infections in spinal instrumentation. Int Orthop. 2012 Feb. 36(2):457-64. [Medline]. [Full Text].

  25. Fernandez M, Carrol CL, Baker CJ. Discitis and vertebral osteomyelitis in children: an 18-year review. Pediatrics. 2000 Jun. 105(6):1299-304. [Medline].

  26. Yoon SH, Chung SK, Kim KJ, Kim HJ, Jin YJ, Kim HB. Pyogenic vertebral osteomyelitis: identification of microorganism and laboratory markers used to predict clinical outcome. Eur Spine J. 2010 Apr. 19(4):575-82. [Medline].

  27. Matsui H, Hirano N, Sakaguchi Y. Vertebral osteomyelitis: an analysis of 38 surgically treated cases. Eur Spine J. 1998. 7(1):50-4. [Medline].

  28. McHenry MC, Easley KA, Locker GA. Vertebral osteomyelitis: long-term outcome for 253 patients from 7 Cleveland-area hospitals. Clin Infect Dis. 2002 May 15. 34(10):1342-50. [Medline].

  29. Arnold PM, Baek PN, Bernardi RJ. Surgical management of nontuberculous thoracic and lumbar vertebral osteomyelitis: report of 33 cases. Surg Neurol. 1997 Jun. 47(6):551-61. [Medline].

  30. Gepstein R, Folman Y, Lidor C. Management of pyogenic vertebral osteomyelitis with spinal cord compression in the elderly. Paraplegia. 1992 Nov. 30(11):795-8. [Medline].

  31. Rath SA, Neff U, Schneider O. Neurosurgical management of thoracic and lumbar vertebral osteomyelitis and discitis in adults: a review of 43 consecutive surgically treated patients. Neurosurgery. 1996 May. 38(5):926-33. [Medline].

  32. Gupta A, Kowalski TJ, Osmon DR, Enzler M, Steckelberg JM, Huddleston PM, et al. Long-term outcome of pyogenic vertebral osteomyelitis: a cohort study of 260 patients. Open Forum Infect Dis. 2014 Dec. 1 (3):ofu107. [Medline].

  33. Buranapanitkit B, Lim A, Kiriratnikom T. Clinical manifestation of tuberculous and pyogenic spine infection. J Med Assoc Thai. 2001 Nov. 84(11):1522-6. [Medline].

  34. Boody BS, Jenkins TJ, Maslak J, Hsu WK, Patel AA. Vertebral Osteomyelitis and Spinal Epidural Abscess: An Evidence-based Review. J Spinal Disord Tech. 2015 Jul. 28 (6):E316-27. [Medline].

  35. Berbari EF, Kanj SS, Kowalski TJ, Darouiche RO, Widmer AF, Schmitt SK, et al. 2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adultsa. Clin Infect Dis. 2015 Sep 15. 61 (6):e26-46. [Medline].

  36. Carragee EJ. The clinical use of magnetic resonance imaging in pyogenic vertebral osteomyelitis. Spine. 1997 Apr 1. 22(7):780-5. [Medline].

  37. 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].

  38. Nolla JM, Ariza J, Gomez-Vaquero C. Spontaneous pyogenic vertebral osteomyelitis in nondrug users. Semin Arthritis Rheum. 2002 Feb. 31(4):271-8. [Medline].

  39. Chang CY, Simeone FJ, Nelson SB, Taneja AK, Huang AJ. Is Biopsying the Paravertebral Soft Tissue as Effective as Biopsying the Disk or Vertebral Endplate? 10-Year Retrospective Review of CT-Guided Biopsy of Diskitis-Osteomyelitis. AJR Am J Roentgenol. 2015 Jul. 205 (1):123-9. [Medline].

  40. Gras G, Buzele R, Parienti JJ, Debiais F, Dinh A, Dupon M, et al. Microbiological diagnosis of vertebral osteomyelitis: relevance of second percutaneous biopsy following initial negative biopsy and limited yield of post-biopsy blood cultures. Eur J Clin Microbiol Infect Dis. 2013 Sep 21. [Medline].

  41. Jordan MC, Kirby WM. Pyogenic vertebral osteomyelitis. Treatment with antimicrobial agents and bed rest. Arch Intern Med. 1971 Sep. 128(3):405-10. [Medline].

  42. Park KH, Chong YP, Kim SH, Lee SO, Choi SH, Lee MS, et al. Clinical characteristics and therapeutic outcomes of hematogenous vertebral osteomyelitis caused by methicillin-resistant Staphylococcus aureus. J Infect. 2013 Jul 31. [Medline].

  43. Carragee EJ, Kim D, van der Vlugt T. The clinical use of erythrocyte sedimentation rate in pyogenic vertebral osteomyelitis. Spine. 1997 Sep 15. 22(18):2089-93. [Medline].

  44. Ueda Y, Kawahara N, Murakami H, Matsui T, Tomita K. Pyogenic osteomyelitis of the atlas: a case report. Spine (Phila Pa 1976). 2009 Apr 20. 34(9):E342-5. [Medline].

  45. Safran O, Rand N, Kaplan L. Sequential or simultaneous, same-day anterior decompression and posterior stabilization in the management of vertebral osteomyelitis of the lumbar spine. Spine. 1998 Sep 1. 23(17):1885-90. [Medline].

  46. Dai LY, Chen WH, Jiang LS. Anterior instrumentation for the treatment of pyogenic vertebral osteomyelitis of thoracic and lumbar spine. Eur Spine J. 2008 Jun 25. [Medline].

  47. Hee HT, Majd ME, Holt RT. Better treatment of vertebral osteomyelitis using posterior stabilization and titanium mesh cages. J Spinal Disord Tech. 2002 Apr. 15(2):149-56; discussion 156. [Medline].

  48. Ploumis A, Mehbod AA, Dressel TD, Dykes DC, Transfeldt EE, Lonstein JE. Therapy of Spinal Wound Infections Using Vacuum-assisted Wound Closure: Risk Factors Leading to Resistance to Treatment. J Spinal Disord Tech. 2008 Jul. 21(5):320-3. [Medline].

  49. Zausinger S, Schoeller K, Arzberger T, Muacevic A. Combined surgical and radiosurgical treatment of symptomatic aggressive vertebral osteomyelitis. Minim Invasive Neurosurg. 2010 Apr. 53(2):80-2. [Medline].

  50. Graziano GP, Sidhu KS. Salvage reconstruction in acute and late sequelae from pyogenic thoracolumbar infection. J Spinal Disord. 1993 Jun. 6(3):199-207. [Medline].

  51. Ambrose GB, Alpert M, Neer CS. Vertebral osteomyelitis. A diagnostic problem. JAMA. 1966 Aug 22. 197(8):619-22. [Medline].

  52. Boussel L, Marchand B, Blineau N. [Imaging of osteoarticular tuberculosis]. J Radiol. 2002 Sep. 83(9 Pt 1):1025-34. [Medline].

  53. Buranapanitkit B, Lim A, Geater A. Misdiagnosis in vertebral osteomyelitis: problems and factors. J Med Assoc Thai. 2001 Dec. 84(12):1743-50. [Medline].

  54. Del Santo M, Malorgio C, Not T. Vertebral osteomyelitis in 2 children. Clin Pediatr (Phila). 2002 Nov-Dec. 41(9):711-3. [Medline].

  55. Djurasovic M, Glassman SD, Dimar JR 2nd. Vertebral osteonecrosis associated with the use of intradiscal electrothermal therapy: a case report. Spine. 2002 Jul 1. 27(13):E325-8. [Medline].

  56. Ehara S, Khurana JS, Kattapuram SV. Pyogenic vertebral osteomyelitis of the posterior elements. Skeletal Radiol. 1989. 18(3):175-8. [Medline].

  57. Heary RF, Hunt CD, Wolansky LJ. Rapid bony destruction with pyogenic vertebral osteomyelitis. Surg Neurol. 1994 Jan. 41(1):34-9. [Medline].

  58. Hidalgo-Ovejero AM, Otermin I, Garcia-Mata S. Pyogenic vertebral osteomyelitis. J Bone Joint Surg Am. 1998 May. 80(5):764. [Medline].

  59. Isobe Z, Utsugi T, Ohyama Y. Recurrent pyogenic vertebral osteomyelitis associated with type 2 diabetes mellitus. J Int Med Res. 2001 Sep-Oct. 29(5):445-50. [Medline].

  60. Jain R, Sawhney S, Berry M. Computed tomography of vertebral tuberculosis: patterns of bone destruction. Clin Radiol. 1993 Mar. 47(3):196-9. [Medline].

  61. Kao PF, Tsui KH, Leu HS. Diagnosis and treatment of pyogenic psoas abscess in diabetic patients: usefulness of computed tomography and gallium-67 scanning. Urology. 2001 Feb. 57(2):246-51. [Medline].

  62. Khan IA, Vaccaro AR, Zlotolow DA. Management of vertebral diskitis and osteomyelitis. Orthopedics. 1999 Aug. 22(8):758-65. [Medline].

  63. King DM, Mayo KM. Infective lesions of the vertebral column. Clin Orthop. 1973 Oct. 96:248-53. [Medline].

  64. Klein JD, Hey LA, Yu CS. Perioperative nutrition and postoperative complications in patients undergoing spinal surgery. Spine. 1996 Nov 15. 21(22):2676-82. [Medline].

  65. Phadke DM, Lucas DR, Madan S. Fine-needle aspiration biopsy of vertebral and intervertebral disc lesions: specimen adequacy, diagnostic utility, and pitfalls. Arch Pathol Lab Med. 2001 Nov. 125(11):1463-8. [Medline].

  66. Przybylski GJ, Sharan AD. Single-stage autogenous bone grafting and internal fixation in the surgical management of pyogenic discitis and vertebral osteomyelitis. J Neurosurg. 2001 Jan. 94(1 Suppl):1-7. [Medline].

  67. Rasool MN. Primary subacute haematogenous osteomyelitis in children. J Bone Joint Surg Br. 2001 Jan. 83(1):93-8. [Medline].

  68. Schilling F, Fedlmeier M, Eckardt A. [Vertebral manifestation of chronic recurrent multifocal osteomyelitis (CRMO)]. Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr. 2002 Oct. 174(10):1236-42. [Medline].

  69. Sexton DJ, Spelman D. Current best practices and guidelines. Assessment and management of complications in infective endocarditis. Infect Dis Clin North Am. 2002 Jun. 16(2):507-21, xii. [Medline].

  70. Shih TT, Huang KM, Hou SM. Early diagnosis of single segment vertebral osteomyelitis--MR pattern and its characteristics. Clin Imaging. 1999 May-Jun. 23(3):159-67. [Medline].

  71. Stauffer RN. Pyogenic vertebral osteomyelitis. Orthop Clin North Am. 1975 Oct. 6(4):1015-27. [Medline].

  72. Stephens JC, Artz SW, Ames BN. Guanosine 5'-diphosphate 3'-diphosphate (ppGpp): positive effector for histidine operon transcription and general signal for amino-acid deficiency. Proc Natl Acad Sci U S A. 1975 Nov. 72(11):4389-93. [Medline].

  73. Turpin S, Lambert R. Role of scintigraphy in musculoskeletal and spinal infections. Radiol Clin North Am. 2001 Mar. 39(2):169-89. [Medline].

 
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Spinal infections. Lateral plain radiographs of Patient A with diskitis at C4-5. Note the severe disk space narrowing and subluxation seen at C4-5.
Spinal infections. T2-weighted MRI of Patient A. Evidence of osteomyelitis and diskitis, as well as a small epidural abscess, is present. The patient underwent a C4-5 anterior cervical diskectomy and arthrodesis using autologous iliac crest bone graft and instrumental fixation with a titanium plate and screws.
Spinal infections. A 47-year-old woman (Patient B) who presented with intractable back pain. Radiographs reveal significant collapse and destruction of the L4 vertebral body. An MRI of the lumbar spine was ordered.
An MRI of Patient B reveals an enhancing mass affecting the L4 vertebral body with compromise of the spinal canal. The patient underwent several blood cultures and a CT-guided trocar biopsy; culture results were negative. A surgical procedure was necessary.
Spinal infections. Patient B developed lower extremity weakness, and follow-up studies reveal further compression of L4 and compromise of the canal. An anterolateral approach was performed with a corpectomy, decompression of the spinal canal, restoration of the anterior column support, and arthrodesis with a titanium cage and autologous iliac crest bone graft. The pathology and Gram stain revealed some hyphae. Culture findings were positive for Aspergillus species. The patient underwent a full course of amphotericin B and completely recovered.
 
 
 
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