Spinal Infections Clinical Presentation

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

History

The onset is usually insidious. Back pain is the most common symptom. Most patients have a history of several weeks or months of gradually progressing neck or back pain that increases with movement. The pain is initially localized at the level of the involved area and gradually increases in intensity. Thereafter, the pain eventually becomes so severe that it is not relieved by analgesics or even complete bedrest. Usually, neurologic signs are not present until late in the disease course and may be associated with destruction and collapse of the vertebral body. [33]

Children with vertebral osteomyelitis and associated diskitis usually present with an abrupt onset of malaise, fever, and back pain. They commonly demonstrate back stiffness, restricted motion, guarded walking, and spine tenderness. Some patients can also present acutely with fever, night sweats, elevated leukocyte counts, and signs and symptoms of shock.

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Physical Examination

In the typical case with mild symptoms, physical examination reveals only mild tenderness over the spinous process of the involved vertebra, and minimal spasm may be present in nearby paravertebral muscles. A decreased range of motion is also common. Only about half of patients are febrile.

Later, neurologic compromise is caused by bony collapse, spread of the infection underneath the posterior longitudinal ligament, or frank epidural abscess with compression of the spinal cord or nerve roots. A progression to radicular signs followed by weakness and paralysis suggests the formation of an epidural abscess. [34] Spinal epidural abscess occurs in 5-18% of cases and is most commonly located anteriorly in the epidural space. Cervical vertebral osteomyelitis is associated with paralysis more commonly than either thoracic or lumbar infection. [1]

In patients with neurologic compromise, a detailed motor and sensory examination should be performed. Muscle strength and weakness are graded on a scale of 0 to 5, with a strength of 0/5 representing paralysis and a strength of 5/5 considered normal, as follows:

  • 0 - No contraction
  • 1 - Flicker of movement
  • 2 - Can move when gravity is eliminated
  • 3 - Can elevate against gravity
  • 4 - Can move against resistance (–4, slight resistance; 4, moderate resistance; +4, strong resistance)
  • 5 - Normal strength

The sensory examination should include detection of a sensory level, posterior column function, normal and abnormal reflexes, and examination of rectal tone and perianal sensation. The presence of a Babinski sign should also be noted and documented. The neurologic examination should be repeated and documented at regular intervals to serve as a reference for improvement or deterioration of the patient's neurologic status over time.

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Complications

Patients dying from vertebral osteomyelitis typically succumb to the spinal-neural infection or to other attendant problems, such as secondary sepsis, inanition, or the original infection. The mortality for osteomyelitis ranges from 2% to 12%. Neurologic deficits develop in 13-40% of patients, especially those with diabetes or other systemic illnesses.

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