Spinal Infections Workup

  • Author: Federico C Vinas, MD; Chief Editor: Mary Ann E Keenan, MD   more...
 
Updated: Mar 16, 2011
 

Laboratory Studies

  • Leukocytosis, the usual indication of infection, is often absent or minimal in patients with chronic pyogenic vertebral osteomyelitis.
  • Elevation of the erythrocyte sedimentation rate (ESR), although 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 prior to administration of antibiotics.
  • C-reactive protein (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 histological changes, and serum CRP and fibrin findings are normal.
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Imaging Studies

  • Plain radiographsSpinal 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.
    • The process of diagnosing a spinal infection usually begins with a radiograph, although radiograph 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.
    • 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. 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.
  • Computed tomography (CT): This modality depicts osteomyelitis earlier than plain films. 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. An MRI of Patient B reveals an enhancing mass affeAn 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.
  • Magnetic resonance imaging (MRI): MRI of the spine provides information that is not available with CT scans.[24] Characteristic magnetic resonance findings include destructive and expansile lesions involving 2 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. Diffusion-weighted imaging is useful in distinguishing between degenerative and infectious endplate abnormalities. Compared with positron emission tomography, diffusion-weighted MRI costs less, has faster imaging times, and lacks ionizing radiation.[25] Spinal infections. T2-weighted MRI of Patient A. ESpinal 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.
  • Radionuclide scans with technetium Tc 99m are very sensitive early indicators of pyogenic vertebral osteomyelitis. Radionuclide scan findings become positive long before plain film changes are evident. Technetium Tc 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 combined with gallium citrate Ga 167 demonstrates virtually all pyogenic vertebral infections.[26]
  • 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: 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 neurourological dysfunction.
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Diagnostic Procedures

  • CT guided percutaneous biopsy of the infected vertebra or disk may be done by 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 a larger amount of material from the infected area may be examined histologically in addition to being cultured. As with blood cultures, the likelihood of positive tissue culture findings decreases if antibiotic therapy has already been initiated.
  • If blood cultures and percutaneous biopsy techniques 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.
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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, Congress of Neurological Surgeons, Florida Medical Association, and North American Spine Society

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 and 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

James F Kellam, MD  Vice-Chair, Department of Orthopedic Surgery, Director of Orthopedic Trauma and Education, Carolinas Medical Center

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

Disclosure: Nothing to disclose.

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

Disclosure: Medscape 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.

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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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