Spinal Infections Workup
- Author: Federico C Vinas, MD; Chief Editor: Jeffrey A Goldstein, MD more...
Infectious Diseases Society of America guidelines for native vertebral osteomyelitis
In 2015, the Infectious Diseases Society of America (IDSA) published clinical practice guidelines for the diagnosis and treatment of native vertebral osteomyelitis (NVO) in adults. Recommendations pertaining to diagnosis include the following:
NVO is typically diagnosed in the setting of recalcitrant back pain unresponsive to conservative measures and elevated inflammatory markers with or without fever
Plain radiographs of the spine are not sensitive for the early diagnosis of NVO
Magnetic resonance imaging (MRI) of the spine is often required to establish the diagnosis
Except in septic patients or patients with neurologic compromise, empiric antimicrobial therapy should be withheld, when possible, until a microbiologic diagnosis is confirmed
An image-guided or intraoperative aspiration or biopsy of a disc space or vertebral endplate sample submitted for microbiologic and pathologic examination often establishes the microbiologic or pathologic diagnosis of NVO
NVO is commonly monomicrobial and most frequently due to Staphylococcus aureus
Clinicians should suspect the diagnosis of NVO in patients with new or worsening back or neck pain and fever
Clinicians should suspect the diagnosis of NVO in patients with new or worsening back or neck pain and elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP)
Clinicians should suspect the diagnosis of NVO in patients with new or worsening back or neck pain and bloodstream infection or infective endocarditis
Clinicians may consider the diagnosis of NVO in patients who present with fever and new neurologic symptoms with or without back pain
Clinicians may consider the diagnosis of NVO in patients who present with new localized neck or back pain, following a recent episode of S aureus bloodstream infection
A pertinent medical and motor/sensory neurologic examination is recommended in patients with suspected NVO
Obtain bacterial (aerobic and anaerobic) blood cultures (2 sets) and baseline ESR and CRP in all patients with suspected NVO
A spine MRI is recommended in patients with suspected NVO
A combination spine gallium/technetium-99m bone scan is recommended, or a computed tomography (CT) scan or a positron emission tomography (PET) scan, in patients with suspected NVO when MRI cannot be obtained (eg, implantable cardiac devices, cochlear implants, claustrophobia, or unavailability)
Obtain blood cultures and serologic tests for Brucella species in patients with subacute NVO residing in endemic areas for brucellosis
Obtain fungal blood cultures in patients with suspected NVO and at risk for fungal infection (epidemiologic risk or host risk factors)
Perform a purified protein derivative (PPD) test or obtain an interferon gamma release assay in patients with subacute NVO and at risk for Mycobacterium tuberculosis NVO (ie, originating or residing in endemic regions or having risk factors)
In patients with suspected NVO, evaluation by an infectious disease specialist and a spine surgeon may be considered
An image-guided aspiration biopsy is recommended in patients with suspected NVO (on the basis of clinical, laboratory, and imaging studies) when a microbiologic diagnosis for a known associated organism ( S aureus, S lugdunensis, and Brucella species) has not been established by blood cultures or serologic tests
Recommend against performing an image-guided aspiration biopsy in patients with S aureus, S lugdunensis, or Brucella species bloodstream infection suspected of having NVO on the basis of clinical, laboratory, and imaging studies
Advise against performing an image-guided aspiration biopsy in patients with suspected subacute NVO (high endemic setting) and strongly positive Brucella serology
Leukocytosis, the usual indication of infection, is often absent or minimal in patients with chronic pyogenic vertebral osteomyelitis.
Elevation of the ESR, though nonspecific, is the most common laboratory abnormality. Back pain coupled with an increased ESR should lead the clinician to suspect vertebral disease such as infection, neoplasia, or rheumatoid disorder.
Blood cultures should always be obtained before administration of antibiotics.
CRP, synthesized by hepatocytes, is an excellent indicator of inflammation. Patients with bacterial diskitis have higher serum CRP and fibrin. Patients with nonseptic diskitis (ie, chemical diskitis) have only dense fibrotic histologic changes, and serum CRP and fibrin findings are normal.
The process of diagnosing a spinal infection usually begins with a radiograph, though radiographic findings are usually normal in the first 2-4 weeks. If the disk space is involved (diskitis), the disk space may narrow, and destruction of the endplates around the disk may be seen on the radiograph. (See the image below.)
Later, plain radiographs usually reveal rarefaction, loss of bony trabeculation close to the cartilaginous plate, and an irregular narrowing of the vertebral disk space. Vertebral body collapse may also be seen (see the image below). Simultaneously, evidence of rapid bone regeneration may be evident, with the development of bone spurs and dense new bone. A paravertebral soft-tissue mass may also be present.
CT depicts osteomyelitis earlier than plain films do. CT findings include hypodensity at the site of infected disks, lytic fragmentation of the involved bone, gas within an involved vertebra, and decreased density of adjacent vertebrae and nearby soft tissues. Epidural and paraspinal extension of infection may also be seen.
Magnetic resonance imaging
MRI of the spine provides information that CT does not. Characteristic MRI findings include destructive and expansile lesions involving two adjacent vertebrae and their intervening disk. Low-density changes in bone and disk are seen on T1-weighted images, whereas high-density changes are seen in these structures on T2-weighted images, presumably from their increased water content. Intravenous infusion of gadolinium shows enhancement of the involved structures. Paravertebral infection, collections under the posterior longitudinal ligament, and epidural abscesses may also be shown. (See the images below.)
Diffusion-weighted imaging is useful in distinguishing between degenerative and infectious endplate abnormalities. Compared with PET, diffusion-weighted MRI costs less, has faster imaging times, and lacks ionizing radiation.
Radionuclide scans with technetium-99m are very sensitive early indicators of pyogenic vertebral osteomyelitis. Radionuclide scan findings become positive long before plain film changes are evident. Technetium-99m bone scanning is not useful for specifically differentiating infection from metastasis or osteoarthritis. Gallium is more likely to localize an inflammatory lesion, and technetium-99m combined with gallium-167 demonstrates virtually all pyogenic vertebral infections.
In the past, myelography was used in the evaluation of vertebral osteomyelitis to delineate areas of epidural spread and neural compression. MRI has largely supplanted myelography because of its ability to depict not only bony changes but also pus and granulation tissue under the posterior longitudinal ligament and epidural infection.
Urodynamic studies may be helpful. Patients with vertebral osteomyelitis can develop urinary retention. Methods of objectively testing the behavior of the lower urinary tract during filling, storage, and micturition include uroflowmetry, cystometry, sphincteric electromyography, and combined studies. When appropriately used, urodynamic testing provides valuable information for the evaluation and subsequent treatment of neurourologic dysfunction.
CT-guided percutaneous biopsy of the infected vertebra or disk may be done via a needle or trocar. Findings are positive only 60-70% of the time. This is a minimally invasive test used to obtain histologic confirmation of the disease and tissue samples for culture. Trocar biopsies have proved more useful than fine-needle aspiration because they allow a larger amount of material from the infected area to be examined histologically as well as cultured. As with blood cultures, the likelihood of positive tissue culture findings decreases if antibiotic therapy has already been initiated. A 10-year retrospective review suggested that paravertebral soft tissues may also be considered viable biopsy targets.
If blood cultures and percutaneous biopsy fail to identify the infecting organism, open surgical biopsy is indicated. An open surgical biopsy has the highest yield in terms of positive culture findings and diagnostic confirmation.
Histologic findings are similar to those of any bacterial pyogenic infection. Local destruction of the disk and endplates occurs with infiltration of neutrophils in the early stages. Later, a lymphocytic infiltrate predominates.
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