IDSA 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.^[59]

Recommendations pertaining to diagnosis included 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

Treatment recommendations included the following:

In patients with neurologic compromise with or without impending sepsis or hemodynamic instability, immediate surgical intervention and initiation of empiric antimicrobial therapy are recommended
In patients with normal and stable neurologic examination and stable hemodynamics, hold empiric antimicrobial therapy until a microbiologic diagnosis is established
In patients with hemodynamic instability, sepsis, septic shock, or progressive or severe neurologic symptoms, initiate empiric antimicrobial therapy in conjunction with an attempt to establish a microbiologic diagnosis
A total duration of 6 weeks of parenteral or highly bioavailable oral antimicrobial therapy is recommended for most patients with bacterial NVO
A total duration of 3 months of antimicrobial therapy is recommended for most patients with NVO due to Brucella species
Surgical intervention is recommended in patients with progressive neurologic deficits, progressive deformity, and spinal instability with or without pain despite adequate antimicrobial therapy
Surgical debridement with or without stabilization is recommended in patients with persistent or recurrent bloodstream infection (without alternative source) or worsening pain despite appropriate medical therapy (weak, low)
Recommend against surgical debridement and/or stabilization in patients who have worsening bony imaging findings at 4-6 weeks in the setting of improvement in clinical symptoms, physical examination, and inflammatory markers

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Media Gallery

Spinal infections. Lateral plain radiographs of Patient A with diskitis at C4-5. Note 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 small epidural abscess, is present. The patient underwent C4-5 anterior cervical diskectomy and arthrodesis using autologous iliac crest bone graft and instrumental fixation with titanium plate and screws.
Spinal infections. Patient B (47-year-old woman) presented with intractable back pain. Radiographs reveal significant collapse and destruction of the L4 vertebral body. MRI of lumbar spine was ordered.
MRI of Patient B reveals enhancing mass affecting L4 vertebral body with compromise of spinal canal. Patient underwent several blood cultures and CT-guided trocar biopsy; culture results were negative. Surgical procedure was necessary.
Spinal infections. Patient B developed lower-extremity weakness, and follow-up studies reveal further compression of L4 and compromise of canal. Anterolateral approach was performed with corpectomy, decompression of spinal canal, restoration of anterior column support, and arthrodesis with titanium cage and autologous iliac crest bone graft. Pathology and Gram stain revealed some hyphae. Culture findings were positive for Aspergillus species. Patient underwent full course of amphotericin B and completely recovered.
MRI with gadolinium contrast in 41-year-old patient with history of IV drug use and extensive osteomyelitis, diskitis, and anterior spinal epidural abscess causing compression of spinal cord.
Intraoperative fluoroscopy in 41-year-old patient with history of IV drug use and extensive osteomyelitis, diskitis, and anterior spinal epidural abscess treated with corpectomy and anterior stabilization.
AP intraoperative fluoroscopy. Given abnormal softening of bones by osteomyelitis, same patient underwent posterior stabilization of spine with lateral mass and pedicle screws.
3D CT of 41-year-old man with severe osteomyelitis and diskitis at L3 and L4. Note bony destruction. This was later demonstrated with gadolinium-enhanced MRI.
Gadolinium-enhanced MRI in 37-year-old male with history of IV methamphetamine use who developed severe diskitis at L3-4. Epidural abscess is also present. Treatment of his condition required extensive surgical decompression and stabilization. Cultures showed polymicrobial infection, including gram-positive and gram-negative bacteria. Antibiotic beads soaked in vancomycin and tobramycin were applied to surgical site.
Gadolinium-enhanced MRI in 67-year-old male with L3-4 and L4-5 diskitis. Initial cultures were negative. He was treated medically with 8 weeks of IV antibiotics and clinical follow-up with ESR and CRP.
Same patient presented several months later with intractable pain. His CT and MRI showed extensive destruction of disks and vertebral bodies. His condition required extensive debridement with stabilization of spine using transpedicular screws and rods. Antibiotic beads were placed at surgical site.

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Author

Federico C Vinas, MD Medical Director of Neurosurgery, AdventHealth Daytona Beach; Assistant Professor, University of Central Florida College of Medicine, Daytona Beach Campus

Federico C Vinas, MD is a member of the following medical societies: American Association of Neurological Surgeons, American College of Surgeons, Congress of Neurological Surgeons, North American Spine Society

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 Former 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, International Society for the Study of the Lumbar Spine, Kentucky Medical Association, Kentucky Orthopaedic Society, North American Spine Society, Southern Medical Association, Southern Orthopaedic Association

Disclosure: Nothing to disclose.

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, AOSpine, Cervical Spine Research Society, International Society for the Advancement of Spine Surgery, International Society for the Study of the Lumbar Spine, Lumbar Spine Research Society, North American Spine Society, Scoliosis Research Society, Society of Lateral Access Surgery

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Globus, 3Spine<br/>Received income in an amount equal to or greater than $250 from: Globus, Nuvasive, Surgalign, 3Spine.

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.

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.

Spinal Infections Guidelines

IDSA Guidelines for Native Vertebral Osteomyelitis

References

Tables

Contributor Information and Disclosures

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