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Spinal Infections Workup

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

Approach Considerations

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.[35] 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
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Laboratory Studies

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.

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Imaging Studies

Plain radiography

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.)

Spinal infections. Lateral plain radiographs of Pa 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.

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.

Spinal infections. A 47-year-old woman (Patient B) 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.

Computed tomography

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.[36] 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.)

An MRI of Patient B reveals an enhancing mass affe 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. T2-weighted MRI of Patient A. E 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.

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.[37]

Radionuclide scanning

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.[38]

Myelography

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.

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Other Tests

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.

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Biopsy

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.[39]

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.[40]

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Histologic Findings

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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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.

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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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