Remodeling of the spine in spondylodiscitis of children at the age of 3 years or younger

Abstract

Spondylitis/spondylodiscitis is still an uncommon diagnosis often with a delay in diagnosis and treatment due to the uncharacteristic symptoms. The aim of this study is to increase the awareness and outline a pattern of investigation and treatment. We present six children with an average age of 23 months (19-33 months) at time of diagnosis, conservative treated and with a mean follow-up of 31 months (12-65 months). The evaluation included past medical history, clinical symptoms, X-rays, MRI-investigations and laboratory studies [CRP, erythrocytes sedimentation rate (ESR), white blood count (WBC) and blood cultures] during the course of treatment and follow-up. The predominate clinical findings were: limp, refusal to walk and/or back pain. The mean duration of symptoms until presentation at our clinic was 24 days (4-42 days), the final diagnosis was set after an average of 12 days (7-14 days). Laboratory findings were unspecific but ESR best correlated with the clinical symptoms during the therapy. Five patients were treated by parenteral antibiotics for a minimum of 3 weeks, followed by oral antibiotics adapted to the clinical and laboratory findings. One child received a combined antituberculous chemotherapy after positive skin test for tbc. All six children were immobilized with a body-plaster-cast for an average time of 15 weeks (5-26 weeks). Four patients additionally were treated by further corset therapy for an average of 10 months (3-18 months). Radiological findings on plane X-rays (a.p. and lateral views) at time of diagnosis were decreased height of the disk space and erosions of adjacent vertebral endplates and residues of these radiological changes with signs of bony healing (sclerotic vertebral endplates or partial fusion) were seen at the latest follow-up. There was no case of instability or deformity like scoliosis or kyphosis. The MRI showed the earliest detectable typical vertebral bone involvements and confirmed the diagnosis in combination with laboratory findings and clinical symptoms. Spondylitis/spondylodiscitis should be considered as diagnosis in children with refusal to walk or gait disturbances especially in combination with elevated ESR. MRI is the tool of choice to set the diagnosis early. With an adequate and early therapy of bracing (body-plaster-cast), antibiotics and clinical monitoring good long-term result without spine instability or deformity can be achieved.

Kingella kingae spondylodiscitis in young children: toward a new approach for bacteriological investigations? A preliminary report

“…The disease seems to be self-limiting in most cases [6] and, therefore, the indication for more invasive procedures, such as biopsy or needle aspiration, is currently not established. In spondylodiscitis, the inoculation usually occurs by haematogenous spread to the disc and then to the vertebral body [2]. Studies of vertebral body and disc vascular anatomy have demonstrated that there is, in the young child, an important network of vessels that go through the cartilaginous vertebral endplates and enters the annulus [24].…”

“…Laboratory findings, such white blood cell count (WBC), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), often provide non-specific information [1]. Blood cultures are often the only means available to select the antimicrobial therapy, but, surprisingly, show a high percentage of negative results (88-100%) [1][2][3]. The indication for more invasive procedures such as biopsy or needle aspiration is currently not established.…”

Spinal infections in children: a review

“…Vascularisation in children is made up of vessels across the cartilaginous vertebral plate and into the ring; after eight years of age, these vessels disappear, but a rich anastomotic network of vessels remains in the periphery of the disc. In adults, however, the disc is avascular, and intraosseous anastomoses occur at around 30 years of age [4,13,14,16]. In children, the metaphysis of the vertebral body has a rich blood network, with an incomplete vascular ring that ends at the base of the pedicle.…”

“…From a clinical viewpoint, it is a disease with unspecific signs and symptoms, such as abdominal pain, fever and difficulty walking [11,12]. Children's inability to express themselves is also a relevant factor [13], often resulting in difficult and delayed diagnosis [9]. The onset of spondylodiscitis in children is basically different from that in adults, in terms of its course and severity.…”

A Case of Spondylolysis and Spondylodiscitis in a Child

“…Of all infectious bone diseases, the prevalence of spondylodiscitis is 2-4% in children less than 3 years of age [2] and the incidence of all spinal infections in people aged less than 20 years is 0,3 per 100,000 cases per year [3]. The symptoms in children usually are refuse to sit or walk, but in most cases are unspecific and delay the diagnosis.…”