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

Lener S, Hartmann S, Barbagallo GMV, Certo F, Thomé C, Tschugg A. Management of spinal infection: a review of the literature. Acta Neurochir (Wien). 2018 Mar. 160 (3):487-496. [QxMD MEDLINE Link].
Chenoweth CE, Bassin BS, Mack MR, Oppenlander ME, Patel RD, Quint DJ, et al. Vertebral Osteomyelitis, Discitis, and Spinal Epidural Abscess in Adults [Internet]. Ann Arbor, MI: Michigan Medicine University of Michigan; 2018 Dec. [Full Text].
Schimmer RC, Jeanneret C, Nunley PD, Jeanneret B. Osteomyelitis of the cervical spine: a potentially dramatic disease. J Spinal Disord Tech. 2002 Apr. 15 (2):110-7. [QxMD MEDLINE Link].
Ziai WC, Lewin JJ 3rd. Update in the diagnosis and management of central nervous system infections. Neurol Clin. 2008 May. 26 (2):427-68, viii. [QxMD MEDLINE Link].
Kourbeti IS, Tsiodras S, Boumpas DT. Spinal infections: evolving concepts. Curr Opin Rheumatol. 2008 Jul. 20 (4):471-9. [QxMD MEDLINE Link].
An HS, Seldomridge JA. Spinal infections: diagnostic tests and imaging studies. Clin Orthop Relat Res. 2006 Mar. 444:27-33. [QxMD MEDLINE Link].
Mylona E, Samarkos M, Kakalou E, Fanourgiakis P, Skoutelis A. Pyogenic vertebral osteomyelitis: a systematic review of clinical characteristics. Semin Arthritis Rheum. 2009 Aug. 39 (1):10-7. [QxMD MEDLINE Link].
Jaramillo-de la Torre JJ, Bohinski RJ, Kuntz C 4th. Vertebral osteomyelitis. Neurosurg Clin N Am. 2006 Jul. 17 (3):339-51, vii. [QxMD MEDLINE Link].
Hegde V, Meredith DS, Kepler CK, Huang RC. Management of postoperative spinal infections. World J Orthop. 2012 Nov 18. 3 (11):182-9. [QxMD MEDLINE Link]. [Full Text].
Cohen LL, Shore BJ, Williams KA, Hedequist DJ, Hresko MT, Emans JB, et al. Diagnosing and treating native spinal and pelvic osteomyelitis in adolescents. Spine Deform. 2020 Oct. 8 (5):1001-1008. [QxMD MEDLINE Link].
Fujiyoshi T, Goto K, Shiomori T, Udaka T, Sakabe A, Tanabe T, et al. [A case of spinal epidural abscess associated with retropharyngeal abscess]. Nihon Jibiinkoka Gakkai Kaiho. 2002 Nov. 105 (11):1143-6. [QxMD MEDLINE Link].
Lee KC, Tsai YT, Lin CY, Tsai CS. Vertebral osteomyelitis combined streptococcal viridans endocarditis. Eur J Cardiothorac Surg. 2003 Jan. 23 (1):125-7. [QxMD MEDLINE Link].
Martínez Hernández PL, Amer López M, Zamora Vargas F, García de Paso P, Navarro San Francisco C, Pérez Fernández E, et al. [Spontaneous infectious spondylodiscitis in an internal medicine department: epidemiological and clinical study in 41 cases]. Rev Clin Esp. 2008 Jul-Aug. 208 (7):347-52. [QxMD MEDLINE Link].
Urrutia J, Bono CM, Mery P, Rojas C, Gana N, Campos M. Chronic liver failure and concomitant distant infections are associated with high rates of neurological involvement in pyogenic spinal infections. Spine (Phila Pa 1976). 2009 Apr 1. 34 (7):E240-4. [QxMD MEDLINE Link].
Murillo O, Roset A, Sobrino B, Lora-Tamayo J, Verdaguer R, Jiménez-Mejias E, et al. Streptococcal vertebral osteomyelitis: multiple faces of the same disease. Clin Microbiol Infect. 2014 Jan. 20 (1):O33-8. [QxMD MEDLINE Link].
Cahill DW, Love LC, Rechtine GR. Pyogenic osteomyelitis of the spine in the elderly. J Neurosurg. 1991 Jun. 74 (6):878-86. [QxMD MEDLINE Link].
Gotway MB, Marder SR, Hanks DK, Leung JW, Dawn SK, Gean AD, et al. Thoracic complications of illicit drug use: an organ system approach. Radiographics. 2002 Oct. 22 Spec No:S119-35. [QxMD MEDLINE Link].
Toyota T. Vertebral osteomyelitis in diabetes mellitus. Intern Med. 1997 Jun. 36 (6):382-3. [QxMD MEDLINE Link].
Sørensen LT. Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review. Ann Surg. 2012 Jun. 255 (6):1069-79. [QxMD MEDLINE Link].
Sørensen LT. Wound healing and infection in surgery. The clinical impact of smoking and smoking cessation: a systematic review and meta-analysis. Arch Surg. 2012 Apr. 147 (4):373-83. [QxMD MEDLINE Link].
Khurana VG. Adverse impact of smoking on the spine and spinal surgery. Surg Neurol Int. 2021. 12:118. [QxMD MEDLINE Link].
Kong L, Liu Z, Meng F, Shen Y. Smoking and Risk of Surgical Site Infection after Spinal Surgery: A Systematic Review and Meta-Analysis. Surg Infect (Larchmt). 2017 Feb/Mar. 18 (2):206-214. [QxMD MEDLINE Link].
Pirogowicz I, Gwiazda E, Hoffmann K, Drobnik J, Steclwko A. [Cigarette smoking and immunity disorder]. Przegl Lek. 2007. 64 (10):886-8. [QxMD MEDLINE Link].
Hadjipavlou AG, Mader JT, Necessary JT, Muffoletto AJ. Hematogenous pyogenic spinal infections and their surgical management. Spine (Phila Pa 1976). 2000 Jul 1. 25 (13):1668-79. [QxMD MEDLINE Link].
Colmenero JD, Jiménez-Mejías ME, Sánchez-Lora FJ, Reguera JM, Palomino-Nicás J, Martos F, et al. Pyogenic, tuberculous, and brucellar vertebral osteomyelitis: a descriptive and comparative study of 219 cases. Ann Rheum Dis. 1997 Dec. 56 (12):709-15. [QxMD MEDLINE Link].
Miller DJ, Mejicano GC. Vertebral osteomyelitis due to Candida species: case report and literature review. Clin Infect Dis. 2001 Aug 15. 33 (4):523-30. [QxMD MEDLINE Link].
Nussbaum ES, Rockswold GL, Bergman TA, Erickson DL, Seljeskog EL. Spinal tuberculosis: a diagnostic and management challenge. J Neurosurg. 1995 Aug. 83 (2):243-7. [QxMD MEDLINE Link].
Vinas FC, King PK, Diaz FG. Spinal aspergillus osteomyelitis. Clin Infect Dis. 1999 Jun. 28 (6):1223-9. [QxMD MEDLINE Link].
Wang YC, Lee ST. Candida vertebral osteomyelitis: a case report and review of the literature. Chang Gung Med J. 2001 Dec. 24 (12):810-5. [QxMD MEDLINE Link].
Pereira-Duarte M, Camino G, Estefan M, Kido G, Solá C, Gruenberg M. [Vertebral cryptococosis. Case report and literature review]. Rev Chilena Infectol. 2019 Oct. 36 (5):656-662. [QxMD MEDLINE Link].
Wang J, Barke RA, Ma J, Charboneau R, Roy S. Opiate abuse, innate immunity, and bacterial infectious diseases. Arch Immunol Ther Exp (Warsz). 2008 Sep-Oct. 56 (5):299-309. [QxMD MEDLINE Link].
Khademi H, Kamangar F, Brennan P, Malekzadeh R. Opioid Therapy and its Side Effects: A Review. Arch Iran Med. 2016 Dec. 19 (12):870-876. [QxMD MEDLINE Link].
Shanmugam VK, Couch KS, McNish S, Amdur RL. Relationship between opioid treatment and rate of healing in chronic wounds. Wound Repair Regen. 2017 Jan. 25 (1):120-130. [QxMD MEDLINE Link]. [Full Text].
Milstone AM, Maragakis LL, Townsend T, Speck K, Sponseller P, Song X, et al. Timing of preoperative antibiotic prophylaxis: a modifiable risk factor for deep surgical site infections after pediatric spinal fusion. Pediatr Infect Dis J. 2008 Aug. 27 (8):704-8. [QxMD MEDLINE Link].
Tan T, Lee H, Huang MS, Rutges J, Marion TE, Mathew J, et al. Prophylactic postoperative measures to minimize surgical site infections in spine surgery: systematic review and evidence summary. Spine J. 2020 Mar. 20 (3):435-447. [QxMD MEDLINE Link].
Snopko P, Kolarovszki B, Opšenák R, Hanko M, Richterová R. Surgical site infections after degenerative lumbar spine surgery. Rozhl Chir. Winter 2018. 97 (12):539-545. [QxMD MEDLINE Link].
Koyama K, Ohba T, Ebata S, Haro H. Postoperative Surgical Infection After Spinal Surgery in Rheumatoid Arthritis. Orthopedics. 2016 May 1. 39 (3):e430-3. [QxMD MEDLINE Link].
Tomov M, Wanderman N, Berbari E, Currier B, Yaszemski M, Nassr A, et al. An empiric analysis of 5 counter measures against surgical site infections following spine surgery-a pragmatic approach and review of the literature. Spine J. 2019 Feb. 19 (2):267-275. [QxMD MEDLINE Link].
Zhou J, Wang R, Huo X, Xiong W, Kang L, Xue Y. Incidence of Surgical Site Infection After Spine Surgery: A Systematic Review and Meta-analysis. Spine (Phila Pa 1976). 2020 Feb 1. 45 (3):208-216. [QxMD MEDLINE Link].
Larcher R, Maury C, Charbit J, Jean-Pierre H, Le Moing V, Klouche K, et al. Cervical anaerobic vertebral osteomyelitis following surgical tracheotomy: a case report. BMC Infect Dis. 2019 Jul 22. 19 (1):648. [QxMD MEDLINE Link].
Ntalos D, Schoof B, Thiesen DM, Viezens L, Kleinertz H, Rohde H, et al. Implementation of a multidisciplinary infections conference improves the treatment of spondylodiscitis. Sci Rep. 2021 May 4. 11 (1):9515. [QxMD MEDLINE Link].
Giannini D, Antonucci M, Petrelli F, Bilia S, Alunno A, Puxeddu I. One year in review 2020: pathogenesis of rheumatoid arthritis. Clin Exp Rheumatol. 2020 May-Jun. 38 (3):387-397. [QxMD MEDLINE Link].
Favalli EG, Ingegnoli F, De Lucia O, Cincinelli G, Cimaz R, Caporali R. COVID-19 infection and rheumatoid arthritis: Faraway, so close!. Autoimmun Rev. 2020 May. 19 (5):102523. [QxMD MEDLINE Link].
Zhang S, Wang L, Bao L, Sun H, Feng F, Shan J, et al. Does Rheumatoid Arthritis Affect the Infection and Complications Rates of Spinal Surgery? A Systematic Review and Meta-Analysis. World Neurosurg. 2021 Jan. 145:260-266. [QxMD MEDLINE Link].
Gerometta A, Rodriguez Olaverri JC, Bitan F. Infections in spinal instrumentation. Int Orthop. 2012 Feb. 36 (2):457-64. [QxMD MEDLINE Link]. [Full Text].
Issa K, Diebo BG, Faloon M, Naziri Q, Pourtaheri S, Paulino CB, et al. The Epidemiology of Vertebral Osteomyelitis in the United States From 1998 to 2013. Clin Spine Surg. 2018 Mar. 31 (2):E102-E108. [QxMD MEDLINE Link].
Fernandez M, Carrol CL, Baker CJ. Discitis and vertebral osteomyelitis in children: an 18-year review. Pediatrics. 2000 Jun. 105 (6):1299-304. [QxMD MEDLINE Link].
Yoon SH, Chung SK, Kim KJ, Kim HJ, Jin YJ, Kim HB. Pyogenic vertebral osteomyelitis: identification of microorganism and laboratory markers used to predict clinical outcome. Eur Spine J. 2010 Apr. 19 (4):575-82. [QxMD MEDLINE Link].
Matsui H, Hirano N, Sakaguchi Y. Vertebral osteomyelitis: an analysis of 38 surgically treated cases. Eur Spine J. 1998. 7 (1):50-4. [QxMD MEDLINE Link].
McHenry MC, Easley KA, Locker GA. Vertebral osteomyelitis: long-term outcome for 253 patients from 7 Cleveland-area hospitals. Clin Infect Dis. 2002 May 15. 34 (10):1342-50. [QxMD MEDLINE Link].
Arnold PM, Baek PN, Bernardi RJ, Luck EA, Larson SJ. Surgical management of nontuberculous thoracic and lumbar vertebral osteomyelitis: report of 33 cases. Surg Neurol. 1997 Jun. 47 (6):551-61. [QxMD MEDLINE Link].
Gepstein R, Folman Y, Lidor C, Barchilon V, Catz A, Hallel T. Management of pyogenic vertebral osteomyelitis with spinal cord compression in the elderly. Paraplegia. 1992 Nov. 30 (11):795-8. [QxMD MEDLINE Link].
Rath SA, Neff U, Schneider O, Richter HP. Neurosurgical management of thoracic and lumbar vertebral osteomyelitis and discitis in adults: a review of 43 consecutive surgically treated patients. Neurosurgery. 1996 May. 38 (5):926-33. [QxMD MEDLINE Link].
Gupta A, Kowalski TJ, Osmon DR, Enzler M, Steckelberg JM, Huddleston PM, et al. Long-term outcome of pyogenic vertebral osteomyelitis: a cohort study of 260 patients. Open Forum Infect Dis. 2014 Dec. 1 (3):ofu107. [QxMD MEDLINE Link].
Courjon J, Lemaignen A, Ghout I, Therby A, Belmatoug N, Dinh A, et al. Pyogenic vertebral osteomyelitis of the elderly: Characteristics and outcomes. PLoS One. 2017. 12 (12):e0188470. [QxMD MEDLINE Link]. [Full Text].
Roth A, Chuard C. [Vertebral osteomyelitis in adults]. Rev Med Suisse. 2019 Oct 9. 15 (666):1818-1822. [QxMD MEDLINE Link].
Buranapanitkit B, Lim A, Kiriratnikom T. Clinical manifestation of tuberculous and pyogenic spine infection. J Med Assoc Thai. 2001 Nov. 84 (11):1522-6. [QxMD MEDLINE Link].
Boody BS, Jenkins TJ, Maslak J, Hsu WK, Patel AA. Vertebral Osteomyelitis and Spinal Epidural Abscess: An Evidence-based Review. J Spinal Disord Tech. 2015 Jul. 28 (6):E316-27. [QxMD MEDLINE Link].
[Guideline] Berbari EF, Kanj SS, Kowalski TJ, Darouiche RO, Widmer AF, Schmitt SK, et al. 2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults. Clin Infect Dis. 2015 Sep 15. 61 (6):e26-46. [QxMD MEDLINE Link].
Carragee EJ, Kim D, van der Vlugt T, Vittum D. The clinical use of erythrocyte sedimentation rate in pyogenic vertebral osteomyelitis. Spine (Phila Pa 1976). 1997 Sep 15. 22 (18):2089-93. [QxMD MEDLINE Link].
Hirschfeld CB, Kapadia SN, Bryan J, Jannat-Khah DP, May B, Vielemeyer O, et al. Impact of diagnostic bone biopsies on the management of non-vertebral osteomyelitis: A retrospective cohort study. Medicine (Baltimore). 2019 Aug. 98 (34):e16954. [QxMD MEDLINE Link].
Ueda Y, Kawahara N, Murakami H, Matsui T, Tomita K. Pyogenic osteomyelitis of the atlas: a case report. Spine (Phila Pa 1976). 2009 Apr 20. 34 (9):E342-5. [QxMD MEDLINE Link].
Scharrenberg JS, Yagdiran A, Brinkmann J, Brune M, Siewe J, Jung N, et al. The diagnostic value of soluble urokinase-type plasminogen activator receptor (suPAR) for the discrimination of vertebral osteomyelitis and degenerative diseases of the spine. J Orthop Surg Res. 2019 Nov 14. 14 (1):367. [QxMD MEDLINE Link]. [Full Text].
Kouijzer IJE, Scheper H, de Rooy JWJ, Bloem JL, Janssen MJR, van den Hoven L, et al. The diagnostic value of ¹⁸F-FDG-PET/CT and MRI in suspected vertebral osteomyelitis - a prospective study. Eur J Nucl Med Mol Imaging. 2018 May. 45 (5):798-805. [QxMD MEDLINE Link].
Russo A, Graziano E, Carnelutti A, Sponza M, Cadeo B, Sartor A, et al. Management of vertebral osteomyelitis over an eight-year period: The UDIPROVE (UDIne PROtocol on VErtebral osteomyelitis). Int J Infect Dis. 2019 Dec. 89:116-121. [QxMD MEDLINE Link]. [Full Text].
Carragee EJ. The clinical use of magnetic resonance imaging in pyogenic vertebral osteomyelitis. Spine (Phila Pa 1976). 1997 Apr 1. 22 (7):780-5. [QxMD MEDLINE Link].
d'Angelo P, de Horatio LT, Toma P, Ording Müller LS, Avenarius D, von Brandis E, et al. Chronic nonbacterial osteomyelitis - clinical and magnetic resonance imaging features. Pediatr Radiol. 2021 Feb. 51 (2):282-288. [QxMD MEDLINE Link].
Almansour H, Pepke W, Akbar M. Pyogenic spondylodiscitis : The quest towards a clinical-radiological classification. Orthopade. 2020 Jun. 49 (6):482-493. [QxMD MEDLINE Link].
Eguchi Y, Ohtori S, Yamashita M, Yamauchi K, Suzuki M, Orita S, et al. Diffusion magnetic resonance imaging to differentiate degenerative from infectious endplate abnormalities in the lumbar spine. Spine (Phila Pa 1976). 2011 Feb 1. 36 (3):E198-202. [QxMD MEDLINE Link].
Nolla JM, Ariza J, Gómez-Vaquero C, Fiter J, Bermejo J, Valverde J, et al. Spontaneous pyogenic vertebral osteomyelitis in nondrug users. Semin Arthritis Rheum. 2002 Feb. 31 (4):271-8. [QxMD MEDLINE Link].
Zakaria Mohamad Z, A Rahim A, Kow RY, Karupiah RK, Zainal Abidin NA, Mohamad F. Diagnostic Accuracy and Adequacy of Computed Tomography Versus Fluoroscopy-Guided Percutaneous Transpedicular Biopsy of Spinal Lesions. Cureus. 2022 Jan. 14 (1):e20889. [QxMD MEDLINE Link]. [Full Text].
Chang CY, Simeone FJ, Nelson SB, Taneja AK, Huang AJ. Is Biopsying the Paravertebral Soft Tissue as Effective as Biopsying the Disk or Vertebral Endplate? 10-Year Retrospective Review of CT-Guided Biopsy of Diskitis-Osteomyelitis. AJR Am J Roentgenol. 2015 Jul. 205 (1):123-9. [QxMD MEDLINE Link].
Gras G, Buzele R, Parienti JJ, Debiais F, Dinh A, Dupon M, et al. Microbiological diagnosis of vertebral osteomyelitis: relevance of second percutaneous biopsy following initial negative biopsy and limited yield of post-biopsy blood cultures. Eur J Clin Microbiol Infect Dis. 2014 Mar. 33 (3):371-5. [QxMD MEDLINE Link].
Marathe NA, Tedesco G, Chiesa AM, Mallepally AR, Di Carlo M, Ghermandi R, et al. Pyogenic and Non-pyogenic Spinal Infections: Diagnosis and Treatment. Curr Med Imaging. 2022. 18 (2):231-241. [QxMD MEDLINE Link].
Atesok K, Vaccaro A, Stippler M, Striano BM, Carr M, Heffernan M, et al. Fate of Hardware in Spinal Infections. Surg Infect (Larchmt). 2020 Jun. 21 (5):404-410. [QxMD MEDLINE Link].
Verla T, North R, Simpson V, Ropper AE. Osteomyelitis-Discitis at the Thoracolumbar Junction and the Development of Postinfectious Spinal Deformity: A Surgical Case Series. Int J Spine Surg. 2020 Aug. 14 (4):552-558. [QxMD MEDLINE Link].
Novak I, Košak R, Travnik L, Gorenšek M, Bošnjak K, Vengust R, et al. Polyetheretherketone (PEEK) cages for anterior column reconstruction in pyogenic vertebral osteomyelitis. J Orthop Surg (Hong Kong). 2019 May-Aug. 27 (2):2309499019842490. [QxMD MEDLINE Link].
Christiansen PA, Huang S, Smith JS, Shaffrey ME, Uribe JS, Yen CP. Mini-open lateral retropleural/retroperitoneal approaches for thoracic and thoracolumbar junction anterior column pathologies. Neurosurg Focus. 2020 Sep. 49 (3):E13. [QxMD MEDLINE Link].
Verdú-López F, Vanaclocha-Vanaclocha V, Mayorga-Villa JD. Minimally invasive spine surgery in spinal infections. J Neurosurg Sci. 2017 Jun. 61 (3):303-315. [QxMD MEDLINE Link].
Mehkri Y, Felisma P, Panther E, Lucke-Wold B. Osteomyelitis of the spine: treatments and future directions. Infect Dis Res. 2022. 3 (1):[QxMD MEDLINE Link].
Watkins RR, Yendewa G, Burdette SD, Horattas S, Haller NA, Mangira C, et al. DISC: Describing Infections of the Spine treated with Ceftaroline. J Glob Antimicrob Resist. 2018 Jun. 13:146-151. [QxMD MEDLINE Link].
Rutges JP, Kempen DH, van Dijk M, Oner FC. Outcome of conservative and surgical treatment of pyogenic spondylodiscitis: a systematic literature review. Eur Spine J. 2016 Apr. 25 (4):983-99. [QxMD MEDLINE Link].
Bell J, Sequeira S, Kamalapathy P, Puvanesarajah V, Hassanzadeh H. Rheumatoid Arthritis Increases Risk of Medical Complications Following Posterior Lumbar Fusion. World Neurosurg. 2021 May. 149:e729-e736. [QxMD MEDLINE Link].
Bhattacharyya S, Bradshaw MJ. Infections of the Spine and Spinal Cord. Continuum (Minneap Minn). 2021 Aug 1. 27 (4):887-920. [QxMD MEDLINE Link].
Jordan MC, Kirby WM. Pyogenic vertebral osteomyelitis. Treatment with antimicrobial agents and bed rest. Arch Intern Med. 1971 Sep. 128 (3):405-10. [QxMD MEDLINE Link].
Park KH, Chong YP, Kim SH, Lee SO, Choi SH, Lee MS, et al. Clinical characteristics and therapeutic outcomes of hematogenous vertebral osteomyelitis caused by methicillin-resistant Staphylococcus aureus. J Infect. 2013 Dec. 67 (6):556-64. [QxMD MEDLINE Link].
Safran O, Rand N, Kaplan L, Sagiv S, Floman Y. Sequential or simultaneous, same-day anterior decompression and posterior stabilization in the management of vertebral osteomyelitis of the lumbar spine. Spine (Phila Pa 1976). 1998 Sep 1. 23 (17):1885-90. [QxMD MEDLINE Link].
Dai LY, Chen WH, Jiang LS. Anterior instrumentation for the treatment of pyogenic vertebral osteomyelitis of thoracic and lumbar spine. Eur Spine J. 2008 Aug. 17 (8):1027-34. [QxMD MEDLINE Link].
Hee HT, Majd ME, Holt RT, Pienkowski D. Better treatment of vertebral osteomyelitis using posterior stabilization and titanium mesh cages. J Spinal Disord Tech. 2002 Apr. 15 (2):149-56; discussion 156. [QxMD MEDLINE Link].
Ploumis A, Mehbod AA, Dressel TD, Dykes DC, Transfeldt EE, Lonstein JE. Therapy of spinal wound infections using vacuum-assisted wound closure: risk factors leading to resistance to treatment. J Spinal Disord Tech. 2008 Jul. 21 (5):320-3. [QxMD MEDLINE Link].
Zausinger S, Schoeller K, Arzberger T, Muacevic A. Combined surgical and radiosurgical treatment of symptomatic aggressive vertebral osteomyelitis. Minim Invasive Neurosurg. 2010 Apr. 53 (2):80-2. [QxMD MEDLINE Link].
Jin Y, Liu A, Overbey JR, Medikonda R, Feghali J, Krishnan S, et al. Risk factors for surgical intervention in patients with primary spinal infection on initial presentation. J Neurosurg Spine. 2022 Feb 4. 1-9. [QxMD MEDLINE Link].
Graziano GP, Sidhu KS. Salvage reconstruction in acute and late sequelae from pyogenic thoracolumbar infection. J Spinal Disord. 1993 Jun. 6 (3):199-207. [QxMD MEDLINE Link].
Elmajee M, Munasinghe C, Aljawadi A, Elawady K, Shuweihde F, Pillai A. Posterior stabilisation without formal debridement for the treatment of non-tuberculous pyogenic spinal infection in frail and debilitated population - A systematic review and meta-analysis. J Clin Orthop Trauma. 2021 Apr. 15:9-15. [QxMD MEDLINE Link]. [Full Text].
Sasso RC, Garrido BJ. Postoperative spinal wound infections. J Am Acad Orthop Surg. 2008 Jun. 16 (6):330-7. [QxMD MEDLINE Link].

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: Medtronic, Nuvasive, NLT Spine, RTI, Magellan Health<br/>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.

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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