Spondylodiscitis: update on diagnosis and management

Abstract

Spondylodiscitis, a term encompassing vertebral osteomyelitis, spondylitis and discitis, is the main manifestation of haematogenous osteomyelitis in patients aged over 50 years. Staphylococcus aureus is the predominant pathogen, accounting for about half of non-tuberculous cases. Diagnosis is difficult and often delayed or missed due to the rarity of the disease and the high frequency of low back pain in the general population. In this review of the published literature, we found no randomized trials on treatment and studies were too heterogeneous to allow comparison. Improvements in surgical and radiological techniques and the discovery of antimicrobial therapy have transformed the outlook for patients with this condition, but morbidity remains significant. Randomized trials are needed to assess optimal treatment duration, route of administration, and the role of combination therapy and newer agents.

Failure modes in conservative and surgical management of infectious spondylodiscitis

“…Twelve patients needed surgery, and thus conservative treatment failed in 13.1 % of patients. Karadimas et al [12] noted 17.1 % failures among patients managed non-surgically; other authors have reported failure rates from 12 to 16 % [1,4,7]. We had three in-hospital deaths in this group.…”

“…Consensus regarding the diagnosis exists. A combination of history, clinical, laboratory and microbiological findings are crucial, and MRI has become the imaging modality of choice [7]. Contrary to diagnostics, treatment measures are still widely discussed.…”

“…If spondylodiscitis is diagnosed early and there are no complications, it can be successfully treated conservatively [2,18]. It is also obvious that the failure of conservative measures, compression of neural elements, mechanical derangement (instability, malalignment, severe bone destruction), and intractable pain demands surgery that can guarantee thorough debridement, decompression, restoration of spinal alignment and correction of instability [7,8,18]. However, surgeons still discuss staging, surgical access, and usage of instrumentation or cages [3,14,15,20].…”

Surgical treatment of spondylodiscitis. An update

“…Aetiologically, spinal infection can be classified as pyogenic, granulomatous (tuberculosis, brucellosis, or fungal infection) or parasitic. Although improvements in surgical and radiological techniques together with modern antimicrobial therapy have dramatically diminished the morbidity and mortality of the disease, no well-designed randomised trial for its treatment has been published, although spinal surgical infections have been covered [23]. Furthermore, its incidence, although rare, is increasing up to four to 24 cases per million per year due to better diagnosis [33], intravenous drug use, a rise in health care-associated infection, e.g.…”

“…Spinal spondylitic tuberculosis diagnosis can be confirmed by the polymerase chain reaction (PCR) [29], and molecular diagnostic methods using broad-range 16S rDNA PCR are also especially useful in the context of prior antibiotic use or the presence of fastidious micro-organisms. Species-specific PCR, particularly targeting Staphylococcus aureus, can increase the sensitivity further with the additional benefit of providing methicillin susceptibility results by amplification of the mecA gene [23]. However, 16S rDNA PCR is inferior to culture at detecting mixed organisms due to preferential primer binding, and care should be taken in interpreting all results when deciding on antibiotic treatment.…”