eMedicine Specialties > Radiology > Brain/Spine

Spondylodiskitis

James D LeClair, MD, Neuroradiologist, Cabarrus Radiologists
A Orlando Ortiz, MD, MBA, Chairman of Radiology, Chief of Radiologic Services, Department of Radiology, Winthrop Hospital; Gregg Zoarski, MD, Associate Professor, Director Of Diagnostic And Interventional Neuroradiology, Department Of Radiology, Division Of Neuroradiology, University Of Maryland School Of Medicine

Updated: Jul 25, 2008

Introduction

Background

Spondylodiskitis (spondylodiscitis, infectious spondylitis) is an infection that involves 1 or more of the extradural components of the spine. Although it affects a small proportion (2-7%) of all patients with osteomyelitis, it is important because of its potential morbidity and mortality. Infectious spondylitis most commonly appears as spinal osteomyelitis and/or diskitis. Its complications include paraspinal and epidural abscess formation.

Pyogenic spinal infections most commonly are caused by Staphylococcus aureus (in 60% of patients) and Enterobacter species (in 30% of patients). Osteomyelitis caused by Salmonella is most often seen in patients with sickle cell disease. Pseudomonas aeruginosa, Serratia species, and Candida species most often affect patients with a history of intravenous drug abuse. Mycobacterium tuberculosis causes most nonpyogenic spinal infections; however, fungi (eg, Cryptococcus species, Aspergillus species, coccidioidomycosis) also may cause infections.^1,2,3,4,5

Related eMedicine topics:
Pott Disease (Tuberculous Spondylitis)
Diskitis

Related Medscape topics:
Specialty Site Radiology
Specialty Site Orthopaedics
Resource Center Spinal Disorders Resource Center
Resource Center Back Pain Resource Center
CME/CE The Many Faces of Ankylosing Spondylitis: Evidence-Based Approach to Diagnosis and Management

Pathophysiology

In spondylodiskitis (spondylodiscitis, infectious spondylitis), the 3 main routes of infection are hematogenous spread, direct inoculation, and contiguous spread.

In adults, most cases of spondylodiskitis result from direct inoculation after spinal instrumentation procedures, including surgery, discography, and epidural injections. Infections that spontaneously result from a hematogenous source (eg, bacteremia, intravenous drug abuse) usually begin in a lumbar or thoracic vertebral body subjacent to the vertebral endplate through seeding of septic emboli via small, penetrating end arteries. Hematogenous spread along the Batson venous plexus is no longer considered a major route of infection.

In adults, infection enters the disk space by means of contiguous involvement and by neovascular proliferation.

Loss of disk height may occur as pyogenic organisms release enzymes that dissolve the nucleus pulposus.

Nonpyogenic organisms, such as those that cause tuberculosis (TB), lack proteolytic enzymes; therefore, they tend to spare the disk. These infections are characterized by large paraspinal lesions that are disproportionate with regard to the amount of local bone destruction. Infection may spread to the psoas muscle and result in paravertebral abscesses that tend to calcify (this is especially characteristic of nonpyogenic infections).

In children, most cases of spondylodiskitis are spontaneous and are related to hematogenously borne infection of the intervertebral disk; infection spreads via residual vascular channels that lead directly into the disk. These channels typically regress by the age of 15 years.

Spread from an adjacent source, such as a psoas abscess (see Image 1), is an uncommon mechanism. CSF and lymphatic spread are also uncommon routes of infection.

Risk factors for spondylodiskitis include age older than 50 years, diabetes, immunosuppression, paraplegia, previous spinal fracture, and urinary tract instrumentation.⁶

Frequency

United States

Spondylodiskitis (spondylodiscitis, infectious spondylitis) represents approximately 2-7% of all cases of osteomyelitis; the disease is increasing in frequency.

International

Nonpyogenic (ie, granulomatous) infections of the spine occur more frequently in countries where tuberculosis and brucellosis are endemic than in the United States.

Tuberculosis of the spine (ie, Pott disease) is most prevalent during the fifth decade of life. Paraspinal collection and multivertebral infections are more common than pyogenic infections.

Mortality/Morbidity

Symptoms of spondylodiskitis (spondylodiscitis, infectious spondylitis) may be present for months before the diagnosis is confirmed; this may result in progression of the local disease process. Patients may present with hip contracture or paralysis resulting from abscess formation in the paraspinal or epidural spaces.

In the past, acute deterioration from epidural abscess was a rare complication; however, this complication is increasing in frequency among patients with diabetes, as well as among immunosuppressed patients and persons who abuse intravenous drugs.

• Patients with epidural abscess may present with back pain, fever, or neurologic deficit and/or obtundation.
• Less than 2% of patients with epidural infection are children.
• Acute deterioration from epidural abscess may result from mechanical compression of the spinal cord from a mass effect of the phlegmonous tissues or from spinal instability or ischemic compromise.
• Subarachnoid puncture is not recommended in patients with epidural abscess in the region of the abscess; the procedure may be performed remotely.
• The effects of epidural abscess are seen in the thoracic region in 50% of cases, in the cervical region in 25%, and in the lumbosacral region in 35%.
• Surgical decompression and drainage and prolonged antibiotic use are standard treatment methods, although some patients may be treated conservatively, especially if the disease is extensive and involves many levels of the spine.
• The mortality rate from spondylodiskitis may be as high as 30%.

Race

Spondylodiskitis (spondylodiscitis, infectious spondylitis) has no racial predisposition.

Sex

The male-to-female ratio of spondylodiskitis (spondylodiscitis, infectious spondylitis) is 1.5-3:1.

Age

All age groups are susceptible to spondylodiskitis (spondylodiscitis, infectious spondylitis); however, adults older than 50 years are most often affected.

• Patients with a history of intravenous drug abuse or underlying conditions, such as end-stage renal disease, diabetes, and AIDS, present at a relatively young age.
• Childhood spinal infections are a distinct variety of spondylodiskitis that begins within the disk.

Anatomy

In cases of spondylodiskitis (spondylodiscitis, infectious spondylitis) in children, the mechanism of initiation and spread of hematogenous infection to the spine differs from that in adults.

Compared with adults, children have numerous paravertebral and intraosseous collateral arteries; in addition, in children, there is a direct blood supply to the intervertebral disk. These factors are conducive to direct inoculation. By the age of 15, this supplementary system regresses; it is absent in older patients.

Adult hematogenous infections typically begin through segmental arteries (ie, lumbar, intercostal arteries) that feed small, end-artery metaphyseal branches, causing infarction and bacterial seeding. Infection commonly begins in the anterior subchondral regions of the vertebral body because of the relatively rich supply of metaphyseal branches in these structures.

Spondylodiskitis most commonly involves the lumbar (45%), thoracic (35%), and cervical (10-20%) levels. Secondary epidural abscess formation occurs most frequently in the cervical spine, followed in frequency by the thoracic and lumbar spine. Multilevel or multifocal disease also may occur (most commonly with tuberculosis) and accounts for the remaining patients. In 67% of patients, 2 vertebral bodies and the intervening disk are involved.

Presentation

Although the clinical presentation of patients with spondylodiskitis (spondylodiscitis, infectious spondylitis) varies, it generally commences with the insidious development of localized back pain combined with nonspecific symptoms, such as malaise, fever, or weight loss. Fever and leukocytosis often are absent, but the erythrocyte sedimentation rate is elevated in 95% of patients. The C-reactive protein level is commonly elevated.

Patients are predisposed to spondylodiskitis if they have transient bacteremia; intravenous drug abuse; invasive spinal procedures; infection of the genitourinary tract, skin, and/or soft tissue; or infection of the respiratory tract; the etiology remains unknown in 37% of patients. A culture-specific diagnosis is critical for the optimal treatment of the infections. This diagnosis can be obtained by means of surgery or image-guided biopsy.

The virulence of the organism, the overall health of the patient with respect to chronic illness, and the interval before clinical presentation determine the extent of disease at the initial evaluation. Acute illness is usually defined as illness in which the patient presents within 1 week of symptom onset; in cases of chronic illness, patients may present months after the onset of symptoms.

Medical treatment is the first line of therapy for a patient with no neurologic complications. Usually, a 6-week course of culture-specific intravenous antibiotic, with or without an oral antibiotic, is recommended. External spinal immobilization and/or bracing is also recommended. Operative treatment may be required for patients with a neurologic deficit or spinal instability or in cases in which medical therapy has failed.

Preferred Examination

Although plain images, radiographs, CT, or nuclear medicine studies can help establish the diagnosis of spondylodiskitis (spondylodiscitis, infectious spondylitis), MRI is considered the modality of choice for evaluating the presence and severity of spinal infection. MRI is especially effective for evaluating the neural structures of the spine (ie, spinal cord, nerve roots) and extradural soft tissue.

Along with appropriate history taking, physical examination, and positive blood cultures, findings on MRI or radionuclide studies may confirm the diagnosis.

CT is most useful for characterizing vertebral osteomyelitis in patients with subacute or chronic illness. CT provides radiologic guidance for interventional procedures (ie, biopsy, drainage).

Conventional radiographs are insensitive to the acute changes seen in cases of spondylodiskitis, but they may be used on a limited basis in the follow-up of chronically ill patients.^{7,8,9,10,11,12,13}

Limitations of Techniques

MRI is relatively expensive. In addition, it is contraindicated in patients with certain implanted medical devices (eg, pacemakers), and it is not tolerated by all patients because of claustrophobia or morbid obesity. Good MRIs require the cooperation of the patient; the quality of MRI is degraded by motions of the patient. Use of a gadolinium-based intravenous contrast agent is strongly recommended.

Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). For more information, see the eMedicine topic Nephrogenic Fibrosing Dermopathy. 

NSF/NFD has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness. For more information, see the FDA Public Health Advisory or Medscape.

CT is quick and inexpensive, although it exposes the patient to ionizing radiation. In addition, it is associated with a low risk of an allergic reaction to the intravenous contrast agent, though detection of bone destruction or a paraspinal mass does not require the use of contrast material.

Radionuclide studies may be time consuming, and spatial resolution may be low.

With plain radiographs, results are often normal or nonspecific in patients with acute spinal infection.

Differential Diagnoses

[Reiter Syndrome, Musculoskeletal]
Ankylosing Spondylitis
Gout
Rheumatoid Arthritis, Spine

Other Problems to Be Considered

Degenerative endplate changes (most common mimic)
Neuropathic arthropathy
Postoperative changes (granulation tissue)
Neoplasia (metastasis)
Spondyloarthropathy of hemodialysis
Rheumatoid arthritis
Seronegative spondyloarthropathies (eg, ankylosing spondylitis, Reiter syndrome)

Radiography

Findings

Conventional radiography is insensitive to the early changes of spondylodiskitis (spondylodiscitis, infectious spondylitis). In the acute setting, radiographs are normal. In the subacute period (1-3 wk), reduced disk-space height and/or endplate erosion may be evident. In the chronic period (>10 wk), vertebral body sclerosis or collapse may be observed on either side of a narrowed disk space. Paraspinal soft tissue opacity may develop. Gradual disk obliteration may occur with fusion (ie, osseous, fibrous). Partial restoration of disk height may be observed with successful treatment.

Degree of Confidence

Plain radiographic findings suggestive of subacute or chronic spondylodiskitis (spondylodiscitis, infectious spondylitis), such as disk-space loss, endplate erosion, and vertebral sclerosis, should be correlated with the patient's clinical history.

False Positives/Negatives

In cases of spondylodiskitis (spondylodiscitis, infectious spondylitis), radiographic findings lag behind clinical response to treatment by approximately 1 month.

Computed Tomography

Findings

In spondylodiskitis (spondylodiscitis, infectious spondylitis), CT scans may appear normal early in the course of disease. Disk-space narrowing or decreased attenuation in the disk is often the earliest manifestation of disease. After the administration of iodinated contrast material, the abnormal disk space, vertebral marrow, or paravertebral soft tissues may enhance.

As the disease progresses, destruction of the vertebral body and fragmentation of vertebral endplates are observed. Destruction may be either diffuse or permeative. The presence of paraspinal soft tissue lesions and/or collections aids in the diagnosis of spondylodiskitis. In children, extrusion of the vertebral body may be observed.¹⁴

Degree of Confidence

Overall, CT is more sensitive (68%), more specific (97%), and more accurate (80%) than plain radiography in identifying areas of vertebral osteomyelitis in animal models.

Because of its ease and speed of use, lower cost, and availability, CT is an excellent method for evaluating the bony changes of spondylodiskitis (spondylodiscitis, infectious spondylitis) and for directing radiologic intervention (ie, aspiration or biopsy) in spinal infections. In the diagnosis of active bacterial disk-space infections, the sensitivity and specificity of CT-guided percutaneous aspiration may be as high as 91% and 100%, respectively; however, percutaneous aspiration is less reliable in the diagnosis of nonbacterial infections.

False Positives/Negatives

Gas in the disk space (ie, vacuum phenomenon) may occasionally be observed on CT scans. Although this finding is most often associated with degenerative disk disease, it may also occur with infection.

CT is less sensitive than MRI in depicting soft tissue structures, but its sensitivity may be improved with the use of intravenous contrast material.

Magnetic Resonance Imaging

Findings

MRI is the modality of choice for evaluating spinal infections. In particular, MRI is useful in detecting abnormalities during the acute stage of spinal infection. During the acute stage, MRI may demonstrate increased signal intensity on T2-weighted images in the vertebral body or disk space caused by infarction, abscess, or edema (see Image 2). On T1-weighted images, decreased signal intensity may be observed in the disk and adjacent endplates as a result of edema, and the margin between the disk and the endplate may be diminished.

Paraspinal and epidural abscesses generally appear isointense to muscle on T1-weighted images and hyperintense on fat-saturated T2-weighted or short-tau inversion recovery (STIR) images.

Abscesses of the vertebral body may appear more conspicuous on diffusion-weighted images (DWIs) than on conventional T1- or T2-weighted images.

On contrast-enhanced MRIs, an epidural abscess may appear as an area of peripheral enhancement surrounding an area of fluid signal intensity (see Image 3); it may also appear as an area of abnormal enhancement of disk, vertebral marrow, or paraspinal soft tissue.

The multiplanar capability of MRI allows excellent anatomic localization of the extent of infection, as well as full evaluation of the spinal cord and nerve roots. MRI is also useful for the evaluation of postoperative spinal infections and for the follow-up evaluation of treatment of spondylodiskitis (spondylodiscitis, infectious spondylitis).

Fat-suppression sequences with contrast-enhanced T1-weighted imaging should be routinely performed.^{15,16,17,18,19,20}

Degree of Confidence

MRI is 96% sensitive, 92% specific, and 94% accurate in the evaluation of spondylodiskitis (spondylodiscitis, infectious spondylitis).

False Positives/Negatives

Signal and enhancement changes may persist after clinical resolution of the infection; such findings gradually decrease over weeks to months. This illustrates the fact that contrast enhancement is not always indicative of active infection. These changes do not occur as rapidly as with gallium scanning.

False-negative findings may occur in patients with spondylodiskitis (spondylodiscitis, infectious spondylitis) caused by organisms of low virulence (eg, diphtheroids, coagulase-negative staphylococci).

Ultrasonography

Findings

The usefulness of ultrasound is limited in spondylodiskitis (spondylodiscitis, infectious spondylitis). Occasionally, ultrasonography may be useful for localizing large paraspinal fluid collections for purposes of aspiration and/or drainage. Color Doppler sonography may show areas of hyperemia surrounding abscesses.

Nuclear Imaging

Findings

Radionuclide studies are useful for early detection (3-15 d) of spinal infection. However, establishing this diagnosis may be more difficult in the spine than in other areas of the skeleton because of the presence of active bone marrow.

On 3-phase technetium-99m (^99m Tc) scintigraphy, osteomyelitis is characterized by nonspecific arterial hyperemia and the progressive focal skeletal uptake of tracer.

Bone scan specificity may be increased by combining^99m Tc with an indium-111–labeled WBC or gallium-67 (⁶⁷ Ga) scans.⁶⁷ Ga functions as an acute-phase reactant, accumulating in areas of inflammation.¹¹¹ In-labeled WBCs also accumulate in areas of infection and inflammation. Areas of infection should appear hotter on the⁶⁷ Ga scan than on the accompanying^99m Tc scan. Infective lesions may appear hot or cold on¹¹¹ In WBC scans.⁶⁷ Ga scans may normalize after satisfactory treatment, and they may be used to monitor treatment response.

The use of single-photon emission CT enhances the 3-dimensional localization of infection.^21,22

Degree of Confidence

The degrees of confidence of the aforementioned scans is as follows:

False Positives/Negatives

Nuclear scintigraphy is sensitive for vertebral osteomyelitis; however, increased bone turnover from surgery, fracture, or degenerative changes decreases specificity.

False-negative results may occur when atherosclerosis or primary bone destruction compromises blood flow to a lesion.

Use of¹¹¹ In WBCs may increase the specificity of bone scanning; however, the images may be falsely negative in patients with chronic osteomyelitis or falsely positive in patients with inflammatory or reactive conditions such as rheumatoid arthritis and fractures.

Angiography

Findings

Angiography has no practical role in the diagnosis of spine infection.

Intervention

When a diagnosis of spondylodiskitis (spondylodiscitis, infectious spondylitis) is reached on the basis of patient history, physical examination, and corroborative imaging findings, a blood culture may identify the causative organism and direct antibiotic therapy; however, blood cultures are negative in 50% of patients with spinal infection.

Invasive methods may be required to establish the diagnosis. Spinal biopsy may be performed as an open surgical procedure or as an image-guided percutaneous procedure. The morbidity rate associated with percutaneous image-guided biopsy (eg, with CT [see Image 4] or fluoroscopy [see Image 5]) is lower than the morbidty rate associated with open biopsy. Percutaneous biopsy may be highly sensitive and specific. Multiple samples should be obtained and submitted in appropriate containers for Gram staining, acid-fast bacillus smears, fungal staining, and culturing.^23,24

See Medical/Legal Pitfalls below for a discussion of the effect of concurrent antibiotic therapy.

Medicolegal Pitfalls

• Failure to make the diagnosis after percutaneous spinal biopsy is a pitfall. The culture is most likely to be negative if the patient was recently treated or is currently being treated with antibiotics. Therefore, if biopsy is considered for diagnosis, it should be performed as early in the clinical course as possible.
• Failure to detect infection at the site of recent spinal operations is problematic because normal granulation tissue or recurrent disk herniation may be difficult to differentiate from superimposed infection.
• Failure to differentiate nonpyogenic organisms from neoplasia is another pitfall. The tendency of subligamentous spread to skip, the indolent course, and a lack of disk destruction may mimic findings of cancer.
• Failure to differentiate spondylodiskitis (spondylodiscitis, infectious spondylitis) from seronegative spondyloarthropathies (eg, ankylosing spondylitis, psoriatic arthritis, Reiter disease) is a pitfall. Patients with these conditions may present with some or all of the imaging abnormalities of spondylodiskitis.
• Failure to distinguish the radiologic characteristics of spondylodiskitis from those seen in patients receiving long-term dialysis who may present with a noninfectious, rapidly progressive spondyloarthropathy is a pitfall.²⁵
• Failure to differentiate spondylodiskitis from degenerative disk disease, which may mimic spondylodiskitis in rare cases, is a pitfall. The 2 conditions may usually be differentiated using MRI.

Multimedia

Media file 1: T2-weighted MRI shows a large, right psoas abscess with epidural extension. Despite the large fluid collection, results of percutaneous biopsy were culture negative. The patient was treated with intravenous antibiotics before the procedure.

Media file 2: Diskitis/osteomyelitis is seen on this T2-weighted MRI of the lumbar spine, which demonstrates destruction of the L3-4 disk space with the adjacent endplate and/or vertebral body. L3 and L4 vertebral bodies show increased T2 signal, indicating edema and/or infarction. Also shown is a retropulsion of debris, which compresses the thecal sac.

Media file 3: The epidural abscess on this contrast-enhanced T1-weighted MRI demonstrates the loss of disk-space height, which is most prominent at C4-5 and C5-6. A large, peripherally enhancing epidural abscess extends from C5-6 to the C2 level. The thecal sac and cord are compressed.

Media file 4: This image of a CT-guided biopsy of diskitis/osteomyelitis demonstrates extensive destruction and fragmentation of the vertebral body resulting from spondylodiskitis. CT-guided percutaneous needle aspiration and biopsy were performed to obtain material for cultures to direct appropriate antibiotic therapy.

Media file 5: Fluoroscopy-guided radiograph shows how disk aspiration may be used to direct an image-guided procedure. This image also demonstrates the relatively subtle changes of spondylodiskitis on radiography. Although early loss of the disk space may be present, no definite endplate erosion is seen. MRI findings were supportive of infection; the biopsy was culture positive for Staphylococcus aureus.

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Keywords

spondylodiskitis, spondylodiscitis, infectious spondylitis, infective spondylitis, osteomyelitis, vertebral osteomyelitis with discitis, IS, intravenous drug abuse, IVDA

Contributor Information and Disclosures

Author

James D LeClair, MD, Neuroradiologist, Cabarrus Radiologists
Disclosure: Nothing to disclose.

Coauthor(s)

A Orlando Ortiz, MD, MBA, Chairman of Radiology, Chief of Radiologic Services, Department of Radiology, Winthrop Hospital
Disclosure: Nothing to disclose.

Gregg Zoarski, MD, Associate Professor, Director Of Diagnostic And Interventional Neuroradiology, Department Of Radiology, Division Of Neuroradiology, University Of Maryland School Of Medicine
Disclosure: Nothing to disclose.

Medical Editor

Jeffrey L Creasy, MD, Associate Professor, Associate Section Head, Division of Neuroradiology, Director, Neuroradiology Fellowship, Department of Radiology, Vanderbilt University
Jeffrey L Creasy, MD is a member of the following medical societies: American College of Radiology, American Society of Neuroradiology, and Radiological Society of North America
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

James G Smirniotopoulos, MD, Professor of Radiology, Neurology, and Biomedical Informatics, Chairman, Department of Radiology and Radiological Sciences, Uniformed Services University of the Health Sciences
James G Smirniotopoulos, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, American Society of Head and Neck Radiology, American Society of Neuroradiology, American Society of Pediatric Neuroradiology, Association of University Radiologists, and Radiological Society of North America
Disclosure: Nothing to disclose.

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