Introduction: The diagnostic yield of and best approaches for imaging-guided percutaneous biopsy for vertebral osteomyelitis is controversial. Early studies suggest yields of up to 90%; however, recent evidence shows lower yields of 30-40%. We aim to determine yield and predictors of yield in percutaneous CT-guided biopsies in vertebral osteomyelitis. Methods: We conducted a retrospective observational single-centre study cohort study of all patients presenting for vertebral biopsy or aspiration between 2014 and 2018. Only patients undergoing biopsy for suspected infection were included. Patients with malignant indications were excluded. Comprehensive review of medical records was performed for clinical presentation, comorbidities, imaging, biomarkers, microbiology and treatment. Results: Overall, 40 out of 88 biopsies were performed for suspected infection, in 36 patients. Mean age was 59 AE 18 years; 29 (81%) were male. Of the 40 samples, an organism was identified in 14 samples (35%). Gram-positive organisms were most commonly identified; Staphylococcus aureus was cultured in 7 (50%) of samples. Mean admission CRP was significantly higher in patients with identified organisms compared to those without (137 AE 106 vs 54 AE 78, P = 0.008). Aspiration was a strong independent predictor of positive microbiological growth on multivariate analysis .02], P = 0.026). Biopsy or aspiration aided clinical decision-making in half of cases. Conclusions: Percutaneous CT-guided biopsy has a modest yield for identifying the culprit organism in suspected cases of vertebral osteomyelitis. Elevated CRP and aspiration of fluid collections are associated with improved microbiological yield and should be considered in deciding when and where to biopsy.
DESCRIPTIONA previously healthy girl aged 15 years presented with a 3-month history of low back pain, lethargy, morning stiffness and nocturnal back discomfort. She had no significant history of weight loss, infective symptoms or neurological symptoms, including bladder or bowel incontinence. There was no recent travel history.Examination revealed normal temperature and mild focal tenderness over the midline lumbar spine, with normal range of motion. There was isolated weakness in left hip flexion, and no other neurological findings. Blood tests showed a normal white cell count (6.6×10 9 /L), elevated erythrocyte sedimentation rate (38 mm/hour) and slightly elevated C reactive protein (11 mg/L, normal<10 mg/ L). X-rays were unremarkable. A limited CT of L3 showed diffuse sclerosis of its spinous process with areas of lytic destruction and mild effacement of the paravertebral fat pads (figure 1). Serial blood cultures were negative for microorganisms. Subsequent empirical antibiotics with intravenous flucloxacillin were initiated for presumed infective osteomyelitis.Further assessment with MRI lumbar spine showed an abnormality at the L3 level, with expansion of the L3 lamina and spinous process, and an area of low T1 signal with corresponding high T2 signal within (figure 2). There was enhancement of this area postcontrast imaging, and adjacent paraspinal oedema without features of malignancy. Whole-body bone scan demonstrated focal abnormal uptake in the L3 spinous process, left sacral ala, left ilium and right proximal tibia (figure 3). Given the multifocality of the metabolically active bone lesions, combined with the relatively benign history and normal biochemistry, the diagnosis of chronic recurrent multifocal osteomyelitis (CRMO) was made. Antibiotics were ceased after 3 days and the patient underwent treatment with non-steroidal anti-inflammatory drugs (NSAIDs), followed by a tapering regimen of prednisolone 10 mg and physical therapy. At 6 months follow-up, she experienced a significant reduction in symptoms and improved quality of life. CRMO is a rare auto-inflammatory disorder which typically affects children (median age
We present the case of a 30-year-old woman admitted at 38 weeks and 3 days gestation with a rare cause of bowel obstruction. Definitive diagnosis was not made until laparotomy. We present the unique management challenges posed and a review of the literature.
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