Spondylodiscitis: Difference between revisions

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<div class="noeditbox">Welcome to [[Vrije Universiteit Brussel Evidence-based Practice Project|Vrije Universiteit Brussel's Evidence-based Practice project]]. This space was created by and for the students in the Rehabilitation Sciences and Physiotherapy program of the Vrije Universiteit Brussel, Brussels, Belgium. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div><div class="editorbox">
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'''Original Editors '''- [[User:Lynn Leemans|Lynn Leemans]]  


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== Search Strategy  ==
== Introduction ==
Spondylodiscitis, also referred to as discitis-osteomyelitis, is characterised by infection involving the [[intervertebral disc]] (IVD) and adjacent vertebrae.<ref name=":0">Radiopedia Spondylodiscitis Available:https://radiopaedia.org/articles/spondylodiscitis (accessed 26.11.2022) </ref> The condition is difficult to treat due to the the limited blood supply to these segments, a factor that makes it also rare. Treatment consists of an extended [[Antibiotics|antibiotic]] course, with good outcomes but misdiagnosis or a delay in treatment may result in significant morbidity/mortality.<ref name=":1">Muscara JD, Blazar E. Diskitis. InStatPearls [Internet] 2022 May 13. StatPearls Publishing. Available: https://www.ncbi.nlm.nih.gov/books/NBK541047/ (accessed 26.11.2022)</ref>


<u>Keywords</u>: Spondylodiscitis + Diagnosis / Therapy / Epidemiology / Rehabilitation / Rehabilitation / Examination / Symptoms / Characteristics / Clinical
'''Terminology''': Discitis is discouraged as a term as isolated infection of the spinal disc rarely occurs. Normally the initial infection is the vertebral endplate with secondary involvement of the disc. The terms spondylodiscitis or vertebral [[osteomyelitis]] are preferred as they are more accurate.


<u>Search&nbsp;</u><u>engines</u>: Pubmed Web of knowledge PEDro <br>
== Pathology ==
In adults, infection starts at the vertebral body endplate, extending into the IVD space and then into the adjacent vertebral body endplate.


== Definition/Description  ==
Paediatrics present differently with infection often starting in the intervertebral disc itself as a good direct blood supply still present).<ref name=":0" />


Spondylodiscitis can be defined as a primary infection (accompanied by destruction) of the intervertebral disc (discitis), with secondary infections of the vertebrae (spondylitis), starting at the endplates.<ref name="1">R. Sobottke et al., Current Diagnosis and Treatment of Spondylodiscitis. Deutsches ärzteblatt International, 2008. (Level of evidence 2A)</ref><ref name="2">F. Postacchini, 1999, Lumbar disc herniation, Springer, 481p. (Level of evidence 5)</ref><ref name="12">Fransen B.L. et al., Recommendations for diagnosis and treatment of spondylodiscitis, The Netherlands Journal of Medicine 2014. (level of evidence 2B)</ref><ref name="12" /><ref name="15">Enrique G. et al., Surgical treatment of spondylodiscitis. An update, International Orthopaedics 2012. (level of evidence 5)</ref> It can lead to osteomyelitis of the spinal column.<ref name="3">M. Titlic et al., Spondylodiscitis, Journal Citation/ Science Edition, 2008; 109(8) 345-347. (Level of evidence 2A)</ref><ref name="2" /> It has a high morbidity and mortality and is a rare but serious infection.<ref name="1" /><ref name="12" /><ref name="13">Jensen AG. et al., Bacteremic Staphylococcus aureus spondylitis, Archives of Internal Medicine 1998. (level of evidence 2C)</ref><ref name="15" /><ref name="17">Sans N. et al., Infections of the spinal column — Spondylodiscitis, Diagnostic and Interventional Imaging 2012. (level of evidence 5)</ref>  
== Etiology ==
Most cases of  Spondylodiscitis arise from one of three initial events: direct inoculation, hematogenous spread, or less commonly contiguous spread. Finding the causative agent is very difficult, the most commonly identified organism is being Staphylococcus aureus.<ref name=":1" />


Pathogens causing spondylodiscitis are staphylococci, Escheria coli and mycobacterium tuberculosis.<ref name="1" /><ref name="2" /><ref name="4">M. Hasenbring et al., Intervertebral disk diseases, Thieme, 2008, 236p. (Level of evidence 5)</ref><ref name="5">A.L. Baert et al., Imaging in percutaneous musculoskeletal interventions, Springer, 2009, 120p. (Level of evidence 5)</ref><ref name="12" /><ref name="14">Gerometta A. et al., Postoperative spondilodiscitis, International Othopaedics 2012. (level of evidence 4)</ref><ref name="16">Kapsalaki E. et al., Spontaneous spondylodiscitis: presentation, risk factors, diagnosis, management, and outcomes, International Journal of Infectious Diseases 2009. (level of evidence 1B)</ref><br>Spinal infections can be described aetiologically as pyogenic, granulomatous (tuberculous, brucellar, fungal) and parasitic. Pyogenic spinal infections include: spondylodiscitis, a term encompassing vertebral osteomyelitis, spondylitis and discitis. <ref name="1" /><ref name="16" /><br><br>
== Epidemiology ==


== Clinically Relevant Anatomy  ==
Spondylodiscitis has a bimodal age distribution


The intervertebral disc is located between adjacent superior and inferior vertebral bodies and links them together. The function of the disc is particularly mechanical, namely transmitting loads arising from body weight and muscle through the spinal column.&nbsp;<ref name="21">Gaillard F. et al., Spondylodiscitis, Radiopedia 2015. (level of evidence 5)</ref> It has a central nucleus pulposus, which surrounds the annulus fibrosis and cartilaginous endplates. When the intervertebral disc is axially loaded, most of the weight will be absorbed by the nucleus pulposus while the annulus assists in diffusing compression forces, carried out on the nucleus. The cartilaginous endplates are located along the central osseous endplates of adjacent vertebral bodies, and overlie the superior and inferior margins of the nucleus pulposus.<ref name="6">V. Singh, General anatomy, Elsevier, 2008, 113p. (Level of evidence 5)</ref><br>A typical vertebra (vertebral body) is composed by the following parts: <br>• Body, the weight bearing part. <br>• Vertebral arch, which protects the spinal cord. <br>• Process spinosus <br>• Processes transverse, left and right. Articular processes, two superior and two inferior, that help to restrict the movements.<ref name="7">N. Bettini et al., Evaluation of conservative treatment of non specific spondylodiscitis, Eur Spine Journal, 2009, 18 (Suppl 1):S143–S150. (Level of evidence 2B)</ref>  
# More common in pediatric patients than in the adult population, as consequence of the greater vascular supply of the IVD.
# Older population ~50 years, more often men<ref name=":0" /><ref name=":1" />


<br>In the beginning of pyogenic spondylodiscitis the anterior aspect of the vertebral end plate will abrade. Also loss of disc height, gradual development of osteolysis and further destruction of the subchondral plate will manage. Later on there will be more destruction of the vertebral body, new bone formation and kyphotic deformity. Because of the erosion of the vertebral end plates, the vertebra can collapse.<ref name="19" /><ref name="20">P. Prithvi, et al., Intervertebral Disc: Anatomy-Physiology-Pathophysiology-Treatment, Department of Anesthesiology and Pain Management, World Institute of Pain, 2008 (level of evidence 2A)</ref> Tuberculous spondylodiscitis is also identified by the loss of the anterior subchondral part of the vertebral body. The difference between the two types, is that the intervertebral disc and the joint space are preserved longer in the tuberculous spondylodiscitis.<ref name="19">A. Hegde, et al., Infections of the deep neck spaces, Singapore Med J. 2012 May;53(5):305-312 (level of evidence 5)</ref><br>
== Risk Factors ==
Include


== Epidemiology /Etiology  ==
* remote infection (present in ~25%)
 
* ascending infection, e.g. from urogenital tract instrumentation
According to scarce researches, the incidence of spondylodiscitis is 2.4/100,000 inhabitants. In England and Wales there is a 150% increase from the incidence between 1995-1999 and 2008-2011.[34] All ages can be affected, but the appearance mostly increases with the age.<ref name="2" /><ref name="4" /><ref name="1" /> Men are up to three times more often affected than women, this is probably because of a higher frequency of comorbidities in men.<ref name="8">Erhard R, Relative Effectiveness of an Extension Program and a Combined Program of Manipulation and Flexion and Extension Exercises in Patients With Acute Low Back Syndrome, Journal of The American Physical Therapy Association 1994. (level of evidence 1A)</ref><ref name="2" />[23] <br>The predisposing factors are:<br><br>• Diabetes mellitus<ref name="17" /><ref name="26" /><br>• Age <ref name="17" /><br>• Cardiovascular diseases or high blood pressure <ref name="8" /><ref name="26" /><br>• Obestity <ref name="2" /><ref name="26" /><br>• Drug abuse <ref name="2" /><ref name="17" /><ref name="26" /> or chronic steroid intake <ref name="2" /><ref name="26" /><br>• Chronic alcoholism and nicotine abuse <ref name="2" /><ref name="17" /><br>• HIV infection <ref name="2" /><ref name="26" /><br>• A spinal abnormality or intervention&nbsp;<ref name="8" /> (catheter-associated infections <ref name="17" />, surgical interventions <ref name="17" />, prior visceral operations <ref name="2" /><ref name="26" />) <br>• Infection: endocarditis <ref name="2" /><ref name="26" />, urinary tract infection <ref name="2" /><ref name="26" />, previous infection loci <br>• Multimorbidity <ref name="2" /><ref name="26" /><br>• Serious traumas <ref name="8" /><br>• Impaired immunocompetence (chemotherapy, human immunodeficiency virus infections, or chronic alcoholism) <ref name="2" /><ref name="17" /><ref name="26" /><br>• Cancer <ref name="2" /><ref name="8" /><ref name="25">Mann S. et al., Nonspecific pyogenic spondylodiscitis: Clinical manifestations, surgical treatment, and outcome in 24 patients. Neurosurgery, 2004. (level of evidence 3B)</ref><ref name="26">Gatti R. et al., Efficacy of trunk balance exercises for individuals with chronic low back pain: a randomized clinical trial, Journal of Orthopaedic &amp;amp; Sports Physical Therapy 2011. (level of evidence 1A)</ref><br>• Sickle cell anemia <ref name="2" /><ref name="3" /><br>• Renal failure <ref name="2" /><ref name="8" /><ref name="26" /><br>• Liver failure: chronic hepatitis or lever cirrhosis <ref name="2" /><ref name="8" /><ref name="26" /><br>• Rheumatic diseases&nbsp; <ref name="26" />
* spinal instrumentation or [[Spinal Cord Injury|trauma]]
 
* intravenous drug use (IVDU)
<br>The causes of spondylodiscitis are assigned to a large number of bacteria, fungi, which is to be taken into consideration in diagnostic treatment of patients. The main causative organisms are staphylococci <ref name="1" /><ref name="4" /><ref name="8" /> and mycobacterium tuberculosis. <ref name="4" /><ref name="5" /> Especially the lumbar spine (55%) and the thoracic spine (34%) suffer from spondylodiscitis.[41] Pyogenic spondylodiscitis, which expanded the last years because of the higher life expectancy of older patients with chronic debilitating diseases, is frequently caused by the staphylococcus. This type of spondylodiscitis represents 2-5% of all cases of osteomyelitis, and is more prevalent in patients older than 50 years.<ref name="23" /> <br>
* [[Immunocompromised Client|immunosuppression]]
 
* long-term systemic administration of [[Corticosteroid Medication|steroids]]
Another frequent form of spondylodiscitis is tuberculous spondylodiscitis. The causative microorganism in this case is the mycobacterium tuberculosis. This kind of spondylodiscitis is most common in patients aged between 30 to 40 years.<ref name="24">Van Goethem M. et al., The value of MRI in the diagnosis of postoperative spondylodiscitis. Diagnostic Neuroradiology, 2000. (level of evidence 3B)</ref><br><br>
* advanced age
* [[Diabetes|diabetes mellitus]]
* organ transplantation
* [[malnutrition]]
* cancer<ref name=":0" />


== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==


The symptoms are non-specific, diffuse&nbsp;<ref name="2" /> and treacherous <ref name="8" />.<br><br>• Back or neck pain&nbsp;<ref name="1" /><ref name="8" /> <br>• Constant pain, more worse at night <ref name="2" /><ref name="4" /><ref>23</ref><br>• Radicular pain radiating to the chest or abdomen <br>• Fever (less common in patients with tuberculous spondylodiscitis, 1/2 of the cases)<ref name="1" /><ref name="8" /><ref name="23" /><br>• Spinal deformities, predominantly kyphosis and gibbus formation (commoner in tuberculous spondylodiscitis)<ref name="1" /><br>• Neurological deficits: leg weakness, paralysis, sensory deficit, radiculopathy and sphincter loss (1/3 of the cases)<ref name="1" /><ref name="8" /><ref name="23" /><br>• Cervical lesion <ref name="1" /><br>• Spinal tenderness <br>• restricted range of movement<ref name="1" /><br>• paravertebral muscle spasm<ref name="1" /><br>• Local tenderness<ref name="17" /><br>• Motor deficits: limb weakness, para- or tetraplegia, para- or tetraparesis<ref name="26" /><br>• Epidural abcess formation (cervical: severe cervical rigidity, dysphagia or torticollis; thoracal: symptoms are localized at the legs; lumbar: spread through the ischiatic foramen and involve gluteus muscles; lumbosacral: cauda equine syndrome)<ref name="23" />
The symptoms are non-specific, diffuse&nbsp;<ref name="p2">F. Postacchini, 1999, Lumbar disc herniation, Springer, 481p. (Level of evidence 5)</ref> and treacherous <ref name="p8">Erhard R, Relative Effectiveness of an Extension Program and a Combined Program of Manipulation and Flexion and Extension Exercises in Patients With Acute Low Back Syndrome, Journal of The American Physical Therapy Association 1994. (level of evidence 1A)</ref>. However the usual presentation is back pain (over 90% of patients) and possibly fever (under 20% of patients). Patients are often bacteraemic , originating from eg endocarditis, intravenous drug use.<ref name=":0" />Symptoms may include:
 
• Weight loss (when the delay in diagnosis is long)<ref name="23" /><br>• Mortality 2-17% <ref name="2" /><br>In children (symptoms are non-specific) <br>• Irritability<br>• Limping<br>• Refusal to crawl, sit or walk<br>• Hip pain or even abdominal pain<br>• Incontinence may be a presenting feature <br>• Loss of lumbar lordosis and lower back movement <br>• Compared with adults, children are less likely to have comorbidities and neurological deficits are uncommon&nbsp;<ref name="1" />  


<br>The severity of the infection does not always correspond with the severity symptoms of pain. According to N. Bettini et al, an increase in the pain symptoms is observed when digital pressure was applied to the vertebral area and the pain also irradiated to the homolateral periumbilical area. Also patients suffered radicular irradiation in the sciatica or crural fascia area. Untreated chronic infections can progress to sinus formation. Also secondary instability can occur towards kyphosis deformity with paraplegia or tetraplegia. Cervical spondylodiscitis may manifest with dysphagia or torticollis. [8] Spontaneous pyogenic spondylodiscitis usually spreads hematogenously from infections of the skin, subcutaneous tissues, and urinary tract.[17]<br><br>
*Spinal tenderness <ref name="p1" />
*Loss of lumbar lordosis and lower back movement <ref name="p1" />
*Inspection on local changes and neurological status (parese, paralyse,..)
*Pain on heelstrike, impactation and percussion
*Relieving posture (avoid stressing the ventral sections of the spinal column
*Inclination and re-erection are painful
*Reduction of mobility
*[[Erector Spinae|Paravertebral muscle spasm]]&nbsp;<ref name="p1" />


== Differential Diagnosis  ==
== Differential Diagnosis  ==
Line 42: Line 56:
Differential diagnoses include:  
Differential diagnoses include:  


• Erosive osteochondrosis <ref name="18">A. Leone, et al., Imaging of spondylodiscitis, European Review for Medical and Pharmacological Sciences, 2012;16(Suppl 2): 8-19 (level of evidence 2C)</ref><br>• Osteoporotic and pathological fracture <br>• Cancer related destruction <br>• Ankylosing spondylarthritis <br>• Scheuermann's kyphosis <ref name="1" /><ref name="2" /><br>• Charcot joint<br>• Modic type I degenerative change<br>• Schmorl nodes<br>• Langerhans cell histiocytosis (LCH) <ref name="11">Kourosh Z. et al., Treatment of spondylodiscitis,  International Orthopaedics 2012. (level of evidence 2C)</ref><ref name="22">M. Fantoni, et al., Epidemiological and clinical features of pyogenic spondylodiscitis, European Review for Medical and Pharmacological Sciences, 2012; 16(suppl 2): 2-7 (level of evidence 2A)</ref><br>• Disc herniation<br>• Metastatic seeding<br>• Inflammatory or degenerative spinal disease&nbsp;<ref name="23">Trecarichi E., et al., Tuberculous spondylodiscitis: epidemiology, clinical features, treatment, and outcome. Institute of infectious Diseases, 2012. (level of evidence 2A)</ref>
*Erosive osteochondrosis <ref name="p8"/>
 
*[[Insufficiency Fracture|Osteoporotic and pathological fracture]]
Spondylodiscitis is an important differential diagnosis of lower back, flank, groin, and buttock pain. [46]<br><br>
*Cancer related destruction  
*[[Ankylosing Spondylitis (Axial Spondyloarthritis)|Ankylosing spondylarthritis]]
*[[Scheuermann's Kyphosis|Scheuermann's kyphosis]] <ref name="p1">R. Sobottke et al., Current Diagnosis and Treatment of Spondylodiscitis. Deutsches ärzteblatt International, 2008. (Level of evidence 2A)</ref><ref name="p2" />
*[[Charcot-Marie-Tooth Disease|Charcot joint]]
*[[Modic Changes|Modic]] type I degenerative change
*Schmorl nodes
*Langerhans cell histiocytosis (LCH) <ref name="p1"/><ref name="p2"/>
*[[Disc Herniation|Disc herniation]]
*Metastatic seeding
*Inflammatory or [[Degenerative Disc Disease|degenerative spinal disease]]&nbsp;<ref name="p3">M. Titlic et al., Spondylodiscitis, Journal Citation/ Science Edition, 2008; 109(8) 345-347. (Level of evidence 2A)</ref>


== Diagnostic Procedures  ==
== Diagnostic Procedures  ==


It is important to identify and treat spondylodiscitis as early as possible.  
It is important to identify and treat spondylodiscitis as early as possible. The clinical presentation of spondylodiscitis are manifold. This commonly leads to a several months from initial symptoms to final diagnosis.&nbsp;<ref name="p9">A. Hegde, et al., Infections of the deep neck spaces, Singapore Med J. 2012 May;53(5):305-312 (level of evidence 5)</ref> A number of different tests and tools help in diagnosis including:  
 
The clinical presentation of spondylodiscitis are manifold. This commonly leads to a several months from initial symptoms to final diagnosis.&nbsp;<ref name="29" />  
 
A high index of suspicion is needed for prompt diagnosis to ensure improved long-term outcomes. A microbiological diagnosis is essential to enable appropriate choice of therapeutic agents.&nbsp;<ref name="30" />
 
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.&nbsp;<ref name="1" /> The basic diagnostic examinations to establish spondylodiscitis are:
 
<br>
 
• Magnetic Resonance Imaging (MRI) [46] <ref name="2" /><ref name="8" /><ref name="25" /><ref name="26" /><ref name="30">Nas K. et al., Rehabilitation in spinal infection diseases, World Journal of Orthopedics 2014. (level of evidence 5)</ref><br>o Golden standard. Detects any spread of the inflammation.<br>Contrast-enhanced images improve the sensitivity and specificity of <br>detection and differentiation of tubercular and pyogenic spondylodiscitis.[30]When the MRI shows a high suspicion of spondylodiscitis, there is a high chance that it is actually there (tested via biopt). As the correlation is high, we find MRI to be a better detection method as it is less invasive and thus represents less risk for the patient. [35]
 
• Computed tomography (CT):<br>o Inferior to MRI, gives a more detailed image of bone destruction (second choice)
 
<br>
 
• PET and PET/CT <ref name="3" /><ref name="4" /><ref name="8" /><br>o Due to its high specificity,&nbsp;<ref name="2" /> F-FDG PET/CT should be considered as a first-line imaging procedure in the diagnosis of spondylodiscitis. [33]
 
<br>
 
• Conventional x-ray <ref name="2" /><br>o Acute phase: unreliable <br>o Chronic phase: difficult to distinguish from other degenerative diseases of the spinal column (Only use for distinguish other pathologies)
 
<br>
 
• Biopsy<br>o Pathogens are only successfully detected in about half of the patients. To obtain a definite diagnosis: Necessary in the acute phase&nbsp;<ref name="8" />
 
<br>
 
• Blood Culture [40]<br>o Acute Phase<br>&gt; inflammatory markers [43]
 
<br>• Leukocyte count
 
<br>• C-reactive protein [43] [46]
 
<br>• erythrocyte sedimentation rate [43] [46]
 
o Chronic phase<br>&gt; increase C-reactive protein: Easiest and most successful procedure, min. 3 times. When blood cultures are negative, CT-guided or surgical biopsy is recommended&nbsp;<ref name="23" />
 
<br>
 
• Microbiological tests <ref name="4" /><ref name="8" />
 
<br>
 
• PCR method<br>o This method proves more and more the infection causes&nbsp;<ref name="4" />
 
<br>
 
• Bony Fusion Rate [43] [44]<br>o using spine X-ray
 
<br>
 
• Cobb modified angle [45]<br>o to evaluate the sagittal balance restoration
 
<br>
 
• Haematochemical tests and inflammation indicators must be taken on weekly basis, then monthly until normal values. <ref name="28" /><ref name="26" />
 
<br>
 
• Multiple phase scintigraphy <br>o No good diagnostic method. Provides a reliable evidence for the absence of osseous inflammation&nbsp;<ref name="8" />
 
<br>
 
== Outcome Measures ==
 
• Visual Analogue Scale (VAS): [42][43][44][45] <br>o to evaluate therapeutic effects<br>o for assessment of pain. <br> <br>• Oswestry disability index (ODI): [42][43][44]<br>o to evaluate therapeutic effects <br>o assessment of quality of life <br> <br>• Japanese Orthopaedic Association Back pain evaluation Questionnaire (JOA) <br>o surgeon based evaluation tools[43][45]<br>o Only the Japanese version is valide
 
• Lumbar function score[43]
 
• Kirkaldy-Willis functional criteria [45]<br><br>
 
== Examination  ==
 
It is important to identify and treat spondylodiscitis as early as possible. Diagnosis by means of blood culture and MRI and treatment of the infection with antibiotics and possibly surgical interventions seem be very suitable, but need to be individualized to each and every patient.<ref name="29">Galhotra, RD., Utility of magnetic resonance imaging in the differential diagnosis of tubercular and pyogenic spondylodiscitis, J Nat Sci Biol Med, 2015, 388-393. (Level of evidence 2B)</ref> (level of evidence 2B)
 
Diagnosis is based on clinical, laboratory and radiological features and can be difficult. It is often delayed or missed due to the rarity of the disease, the insidious onset of symptoms and the high frequency of low back pain in the general population.<ref name="24" /><ref name="26" />[35] (level of evidence 2A)
 
1. Anamnesis:<ref name="17" />[48] (level of evidence 1B)
 
• -Gender, age<br>• -Risk factors (see clinical presentation)<br>o diabetes mellitus<br>o advanced aged <br>o steroid use<br>• -Comorbidity <br>• -Clinical symptomatology (see clinical presentation)<br>o Constant pain, more worse at night <ref name="1" /><br>o Radicular pain radiating to the chest or abdomen<br>o Fever<br>o Screening red flags <ref name="8" /><br>o Thoracic pain<br>o Widespread neurological deficit, vertebral level involved<br>o Lower limb weakness <br>o Drug abuse/human immunodeficiency virus<br>o Age &lt;20 or &gt;55 years<br>o Weight loss<br>o Persistent severe restriction of lumbar flexion<br>o Constant progressive, mechanical pain<br>o Positive cough/sneeze<br>o Previous history of cancer<br>o Recent history of a trauma
 
<br>2. Clinical examination&nbsp;<ref name="2" /> (level of evidence 2A)<br>Inspection concentrating on local changes and taking a detailed neurological status<br>• Spinal tenderness <ref name="1" /><br>• Loss of lumbar lordosis and lower back movement <ref name="1" /><br>• Inspection on local changes and neurological status (parese, paralyse,..)<br>• Pain on heelstrike, impactation and percussion<br>• Relieving posture (avoid stressing the ventral sections of the spinal column<br>• Inclination and re-erection are painful<br>• Reduction of mobility<br>• Paravertebral muscle spasm&nbsp;<ref name="1" />
 
3. Basic objective tools <ref name="2" /><br>See diagnostic procedures.<br><br>
 
== Medical Management  ==
 
There are several treatments for spondylodiscitis, par example: surgical and conservative treatment. Surgical and conservative treatment for postoperative lumbar spondylodiscitis is effective. Surgical treatment is superior to conservative treatment in a short time, while conservative treatment can achieve long-term satisfactory curative effects. [LoE: 2B] [42]<br>Randomized trials are needed to assess the optimal treatment duration, route of administration, and the role of combination therapy and newer agents.<br>[LoE: 2A][1]<u></u><br>
 
<br>
 
<u></u>1. <u>Conservative treatmen</u>t:
 
This treatment is based on antibiotics and immobilization of the spine.[3] It can be considered when the clinical symptoms and destruction are relatively mild or the risk of operation is too great. The main problem in conservative treatment is to achieve adequate fixation of the affected section of the spinal column. Reclining orthosis distribute the stress over the unaffected spinal column joints, thus decreasing stress in the infected ventral area. The mobilization of the patient is only recommended once osseous infiltration becomes visible. Aside from the risk of immobilization, there is a high rate of pseudoarthroses (16% to 50%), which may eventually lead to kyphotic malposition and chronic pain syndrome. If there is no fusion reaction, continuing destruction, when the symptoms persist or worsen[8], or there’s no clinical improvement, it is not promising to continue conservative treatment beyond four to six weeks.[2] Although protracted bed rest used to be prescribed, this practice is now being abandoned. There’s also a correlation between early diagnosis and successful results obtained with suitable conservative treatment.[2]<br>A review of case series has demonstrated the effectiveness of intravenous antibiotic therapy. While no official guidance exists for when to switch from intravenous to oral antibiotics, our study shows that CRP at 1 month is &gt;30mg/l and we recommend 6 weeks of intravenous therapy, followed by 6 further weeks of oral therapy.[LoE: 2B] [34]<br>Treatment of spondylodiscitis at children should be conservative with antibiotics only. [40]<br><br>
 
2. <u>Surgery</u>


Surgery has an important role in alleviating pain, correcting deformities and neural compromise and restoring function.[LoE: 2B][29]<br>• Indications for surgical intervention: <br>o compression of neural elements<br>o spinal instability due extensive bony destruction<br>o severe kyphosis<br>o failure of conservative management<br>o (sometimes) inatractable pain<br>o (sometimes) epidural abscess even in the absence of neurogical <br>deficits
* [[Medical Imaging|Medical imaging:]] [[MRI Scans|Magnetic Resonance Imaging]] (MRI) : Golden standard. Detects any spread of the inflammation. <ref name="p2" /><ref name="p8" /><ref name="p5">Enrique G. et al., Surgical treatment of spondylodiscitis. An update, International Orthopaedics  2012. (level of evidence 5)</ref><ref name="p6">Kapsalaki E. et al., Spontaneous spondylodiscitis: presentation, risk factors, diagnosis, management, and outcomes, International Journal of Infectious Diseases 2009. (level of evidence 1B)</ref><ref name="p0">P. Prithvi, et al., Intervertebral Disc: Anatomy-Physiology-Pathophysiology-Treatment, Department of Anesthesiology and Pain Management, World Institute of Pain, 2008 (level of evidence 2A)</ref><ref name="p6" />; PET and PET/CT <ref name="p3" /><ref name="p4">M. Hasenbring et al., Intervertebral disk diseases, Thieme, 2008, 236p. (Level of evidence 5)</ref><ref name="p8" />: Due to its high specificity,&nbsp;<ref name="p2" /> F-FDG PET/CT should be considered as a first-line imaging procedure in the diagnosis of spondylodiscitis. <ref name="p3" />And others
* Biopsy: Pathogens are only successfully detected in about half of the patients. To obtain a definite diagnosis: Blood Culture <ref name="p9" /><ref name="p0" />
* [[Blood Tests|Blood tests]]<br>-


• Indications for surgical emergency<br>o spinal cord compression<br>o outcomes are worse if paralysis has been present over 24-36h (there are also investigators who improve improvement with prolonged paralysis) [LoE: 2B] [30]
== Outcome Measures  ==
Include:
*[[Visual Analogue Scale]] (VAS): <ref name="p2" /><ref name="p3" /><ref name="p4" /><ref name="p5" /> to evaluate therapeutic effects, for assessment of pain.
*[[Oswestry Disability Index|Oswestry disability index]] (ODI):&nbsp;<ref name="p2" /><ref name="p3" /><ref name="p4" /> to evaluate therapeutic effects, assessment of quality of life<br>


• Methodes<br>o While radical surgical debridement, stable reconstruction together with antibiotic therapy remained a reliable approach to achieve complete healing of the inflammation, anterior alone surgery became more applicable. [2B][37]
*


A debridement and fixation with anterior column support in combination with an antibiotic therapy appear to be the key points for successful treatment of pyogenic spondylodiscitis. [2B] [38]<br><br>
== Treatment ==
The aim of treatment is to eliminate the infection, restore and preserve structure and function of the spine, and ease the pain. Conservative management consists of antimicrobial therapy and non-pharmacological treatments, for example physiotherapy and immobilization. Immobilization is advocated when pain is significant or there is a risk of spinal instability.<ref>Gouliouris T, Aliyu SH, Brown NM. Spondylodiscitis: update on diagnosis and management. Journal of Antimicrobial Chemotherapy. 2010 Nov 1;65(suppl_3):iii11-24. Available:https://academic.oup.com/jac/article/65/suppl_3/iii11/923760 (accessed 27.11.2022)</ref>


== Physical Therapy Management  ==
== Physical Therapy Management  ==
[[File:Thoracic_extension_2.jpg|alt=|thumb|Spinal extension]]
Spondylodiscitis has several clinical symptoms, a severe one is low back pain.  This can be treated with exercises.<ref name="p2" />
[[File:Thoracic.jpg|alt=|thumb|Thoracic extension]]
[[File:Resp.jpg|alt=|thumb|268x268px|Breathing exercises]]
[[File:Hamstr.png|alt=|thumb|Flexibility exercises ]]
Prognosis seems to be good with conservative treatment including [[NSAIDs|NSAID’S]], physiotherapy (exercises), and a corset.


Spondylodiscitis has several clinical symptoms, a severe one is low back pain. This can be treated with exercises. (LOE 3B) [52] Prognosis seems to be good with conservative treatment including NSAID’S, physiotherapy (exercises), and a corset. Wearing the corset for a period of 6–10 weeks is instead confirmed by most authors. (LOE 5) <ref name="8" /><ref name="10">Kan H.J. et al., Pediatric and Adolescent Musculoskeletal MRI, Orthopedic Consultants 2007. (level of evidence 3A)</ref>[51] Several exercises can be done with the emphasis on extension exercises and exercises for trunk balance. This is important to maintain a good posture. (LOE 5, 3B, 3A, 1A) <ref name="9">J.J. Rasker et al., Spondylodiscitis in Ankylosing Spondylitis, Inflammation or Trauma?, Scand J Rheumatol, 1996; 25: 52-7. (Level of evidence 4)</ref><ref name="27" /><ref name="28">Bornemann,R., Diagnostis and threatment of spondylodiscitis/spondylitis in clinical  practice, Z Orthop Unfall, 2015, 153-5, p540-545. Level Of Evidence: 2B</ref>[50][51]<br>
'''Immobilization''' is advocated when pain is significant or there is a risk of spinal instability. Wearing the corset for a period of 6–10 weeks is confirmed by most authors. <ref name="p8" /><ref name="p0" /><ref name="p1" />
 
''Thoracal extension exercises''<br> <br> Early mobilization is important. (LOE 3A) <ref name="28" /> But also limb exercises are considered to be good for the therapy.(LOE 3B)&nbsp;<ref name="28" /> These exercises should be done daily at home. Also general fitness, like swimming, should be encouraged. This therapy can lead to a decrease in pain and the ability to accomplish activities of daily living. (LOE 5, 3B) [50][51] In a severe disease TNF therapy can be done. (LOE 5) [51] Lung re-expansion exercises (breathing exercises) are taken into the physical therapy. These exercises help the stability in the lower back. (LOE 3B, 3A) <ref name="28" />[47]
 
<br> ''Respiratory exercises''
 
<br>
 
Low back pain is strongly related with tight and strained hamstrings. Patients should do flexibility exercises for the hamstrings, maintain a good position while sitting and move enough to help this. Keeping the hamstrings flexible is important for pain control as well as in prevention of spinal pain flare-ups. (LOE 5) [49]<br><br>
 
''Flexibility exercises''
 
<br> In general the rehabilitation program will improve the patient’s sensory and motor skills, develop the balance and proprioception and will help the patient’s to do their daily living activities. During the total program the onset and increase of pain should be evaluated. Pain intensity increases or exercises that provoke too much pain or exhaust the patient should not be in the rehabilitation program and there has to be enough rest after the exercises. It is important that when there is a resting period, this one has to be kept minimal. Immobilization lead to weakness of the trunk and lower extremity muscles and will contribute to complications. Secondary problems because of immobilization and musculoskeletal problems should be looked after and prevented. The patient also gets a home exercise program that is based on the patient’s capacity. (LOE 5)[31]
 
<br>
 
Back school is less effective compared to the active programme. (LOE 1A) [53] Exercises were significantly better than no intervention and reduced back pain experience and work absenteeism. Exercises may be effective in prevention of back pain (LOE 1A) [53] <br>
 
== Key Research  ==


add links and reviews of high quality evidence here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br>
'''Exercise''':  


== Resources <br>  ==
* Several exercises can be done with the emphasis on extension exercises and exercises for trunk balance. This is important to maintain a good posture. <ref name="p9" /><ref name="p1" /><ref name="p2" /><ref name="p8" /><ref name="p0" /><ref name="p1" /><ref name="p0" /><ref name="p1" /> Early mobilization is important. <ref name="p8" />
* Limb exercises are considered to be good for the therapy.<ref name="p8" /> These exercises should be done daily at home.
* General fitness, like swimming, should be encouraged. This therapy can lead to a decrease in pain and the ability to accomplish activities of daily living. <ref name="p0" /><ref name="p1" />
* [[Breathing Exercises|Breathing exercises.]] These exercises help the stability in the lower back. <ref name="p8" /><ref name="p7">Sans N. et al., Infections of the spinal column — Spondylodiscitis, Diagnostic and Interventional Imaging 2012. (level of evidence 5)</ref>
* Low back pain is strongly related with tight and strained hamstrings. Patients should do [[flexibility]] exercises for the hamstrings, maintain a good position while sitting and move enough to help this. Keeping the hamstrings flexible is important for pain control as well as in prevention of spinal pain flare-ups. <ref name="p9" />


*Pubmed (VUB BIBLIO)
In general the rehabilitation program will improve the patient’s sensory and motor skills, develop the balance and proprioception and will help the patient’s to do their daily living activities. During the total program the onset and increase of pain should be evaluated. Pain intensity increases or exercises that provoke too much pain or exhaust the patient should not be in the rehabilitation program and there has to be enough rest after the exercises. It is important that when there is a resting period, this one has to be kept minimal. Immobilization lead to weakness of the trunk and lower extremity muscles and will contribute to complications. Secondary problems because of immobilization and musculoskeletal problems should be looked after and prevented. The patient also gets a home exercise program that is based on the patient’s capacity. <ref name="p1" />
*Web of Knowledge &nbsp;
*Pedro <br>  
*Google Scholar


== Clinical Bottom Line  ==
== Clinical Bottom Line  ==


Spondylodiscitis can be defined as a primary infection of the intervertebral disc (discitis), with secondary infections of the vertebrae (spondylitis). It can lead to osteomyelitis of the spinal column. Pyogenic spondylodiscitis is frequently caused by the staphylococcus. Tuberculous spondylodiscitis is caused by the mycobacterium tuberculosis. The symptoms are non-specific, diffuse and treacherous. Diagnosis is difficult and often delayed or missed due to the rarity of the disease. The basic diagnostic examination to establish spondylodiscitis is MRI. Surgical and conservative treatment for postoperative lumbar spondylodiscitis is effective. Prognosis seems to be good with conservative treatment including NSAID’S, physiotherapy (exercises), and a corset.<br>
Spondylodiscitis can be defined as a primary infection of the intervertebral disc, with secondary infections of the vertebrae (spondylitis). It can lead to osteomyelitis of the spinal column. Pyogenic spondylodiscitis is frequently caused by the staphylococcus. Tuberculous spondylodiscitis is caused by the mycobacterium tuberculosis. The symptoms are non-specific, diffuse and treacherous. Diagnosis is difficult and often delayed or missed due to the rarity of the disease. The basic diagnostic examination to establish spondylodiscitis is MRI. Surgical and conservative treatment for postoperative lumbar spondylodiscitis is effective. Prognosis seems to be good with conservative treatment including NSAID’S, physiotherapy (exercises), and a corset.
 
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
 
see tutorial on [[Adding PubMed Feed|Adding PubMed Feed]]
<div class="researchbox">
<rss>Feed goes here!!|charset=UTF-8|short|max=10</rss>
</div>


== References  ==
== References  ==
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[[Category:Vrije_Universiteit_Brussel_Project|Template:VUB]]
[[Category:Vrije_Universiteit_Brussel_Project]] [[Category:Primary Contact]]

Latest revision as of 23:24, 26 November 2022

Original Editors - Lynn Leemans

Top Contributors - Ine Wittevrongel, Bo Hellinckx, Lucinda hampton, Kim Jackson, Admin, WikiSysop, 127.0.0.1 and Claire Knott  

Introduction[edit | edit source]

Spondylodiscitis, also referred to as discitis-osteomyelitis, is characterised by infection involving the intervertebral disc (IVD) and adjacent vertebrae.[1] The condition is difficult to treat due to the the limited blood supply to these segments, a factor that makes it also rare. Treatment consists of an extended antibiotic course, with good outcomes but misdiagnosis or a delay in treatment may result in significant morbidity/mortality.[2]

Terminology: Discitis is discouraged as a term as isolated infection of the spinal disc rarely occurs. Normally the initial infection is the vertebral endplate with secondary involvement of the disc. The terms spondylodiscitis or vertebral osteomyelitis are preferred as they are more accurate.

Pathology[edit | edit source]

In adults, infection starts at the vertebral body endplate, extending into the IVD space and then into the adjacent vertebral body endplate.

Paediatrics present differently with infection often starting in the intervertebral disc itself as a good direct blood supply still present).[1]

Etiology[edit | edit source]

Most cases of Spondylodiscitis arise from one of three initial events: direct inoculation, hematogenous spread, or less commonly contiguous spread. Finding the causative agent is very difficult, the most commonly identified organism is being Staphylococcus aureus.[2]

Epidemiology[edit | edit source]

Spondylodiscitis has a bimodal age distribution

  1. More common in pediatric patients than in the adult population, as consequence of the greater vascular supply of the IVD.
  2. Older population ~50 years, more often men[1][2]

Risk Factors[edit | edit source]

Include

Characteristics/Clinical Presentation[edit | edit source]

The symptoms are non-specific, diffuse [3] and treacherous [4]. However the usual presentation is back pain (over 90% of patients) and possibly fever (under 20% of patients). Patients are often bacteraemic , originating from eg endocarditis, intravenous drug use.[1]Symptoms may include:

  • Spinal tenderness [5]
  • Loss of lumbar lordosis and lower back movement [5]
  • Inspection on local changes and neurological status (parese, paralyse,..)
  • Pain on heelstrike, impactation and percussion
  • Relieving posture (avoid stressing the ventral sections of the spinal column
  • Inclination and re-erection are painful
  • Reduction of mobility
  • Paravertebral muscle spasm [5]

Differential Diagnosis[edit | edit source]

Differential diagnoses include:

Diagnostic Procedures[edit | edit source]

It is important to identify and treat spondylodiscitis as early as possible. The clinical presentation of spondylodiscitis are manifold. This commonly leads to a several months from initial symptoms to final diagnosis. [7] A number of different tests and tools help in diagnosis including:

Outcome Measures[edit | edit source]

Include:

Treatment[edit | edit source]

The aim of treatment is to eliminate the infection, restore and preserve structure and function of the spine, and ease the pain. Conservative management consists of antimicrobial therapy and non-pharmacological treatments, for example physiotherapy and immobilization. Immobilization is advocated when pain is significant or there is a risk of spinal instability.[12]

Physical Therapy Management[edit | edit source]

Spinal extension

Spondylodiscitis has several clinical symptoms, a severe one is low back pain. This can be treated with exercises.[3]

Thoracic extension
Breathing exercises
Flexibility exercises

Prognosis seems to be good with conservative treatment including NSAID’S, physiotherapy (exercises), and a corset.

Immobilization is advocated when pain is significant or there is a risk of spinal instability. Wearing the corset for a period of 6–10 weeks is confirmed by most authors. [4][10][5]

Exercise:

  • Several exercises can be done with the emphasis on extension exercises and exercises for trunk balance. This is important to maintain a good posture. [7][5][3][4][10][5][10][5] Early mobilization is important. [4]
  • Limb exercises are considered to be good for the therapy.[4] These exercises should be done daily at home.
  • General fitness, like swimming, should be encouraged. This therapy can lead to a decrease in pain and the ability to accomplish activities of daily living. [10][5]
  • Breathing exercises. These exercises help the stability in the lower back. [4][13]
  • Low back pain is strongly related with tight and strained hamstrings. Patients should do flexibility exercises for the hamstrings, maintain a good position while sitting and move enough to help this. Keeping the hamstrings flexible is important for pain control as well as in prevention of spinal pain flare-ups. [7]

In general the rehabilitation program will improve the patient’s sensory and motor skills, develop the balance and proprioception and will help the patient’s to do their daily living activities. During the total program the onset and increase of pain should be evaluated. Pain intensity increases or exercises that provoke too much pain or exhaust the patient should not be in the rehabilitation program and there has to be enough rest after the exercises. It is important that when there is a resting period, this one has to be kept minimal. Immobilization lead to weakness of the trunk and lower extremity muscles and will contribute to complications. Secondary problems because of immobilization and musculoskeletal problems should be looked after and prevented. The patient also gets a home exercise program that is based on the patient’s capacity. [5]

Clinical Bottom Line[edit | edit source]

Spondylodiscitis can be defined as a primary infection of the intervertebral disc, with secondary infections of the vertebrae (spondylitis). It can lead to osteomyelitis of the spinal column. Pyogenic spondylodiscitis is frequently caused by the staphylococcus. Tuberculous spondylodiscitis is caused by the mycobacterium tuberculosis. The symptoms are non-specific, diffuse and treacherous. Diagnosis is difficult and often delayed or missed due to the rarity of the disease. The basic diagnostic examination to establish spondylodiscitis is MRI. Surgical and conservative treatment for postoperative lumbar spondylodiscitis is effective. Prognosis seems to be good with conservative treatment including NSAID’S, physiotherapy (exercises), and a corset.

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Radiopedia Spondylodiscitis Available:https://radiopaedia.org/articles/spondylodiscitis (accessed 26.11.2022)
  2. ↑ 2.0 2.1 2.2 Muscara JD, Blazar E. Diskitis. InStatPearls [Internet] 2022 May 13. StatPearls Publishing. Available: https://www.ncbi.nlm.nih.gov/books/NBK541047/ (accessed 26.11.2022)
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 F. Postacchini, 1999, Lumbar disc herniation, Springer, 481p. (Level of evidence 5)
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 Erhard R, Relative Effectiveness of an Extension Program and a Combined Program of Manipulation and Flexion and Extension Exercises in Patients With Acute Low Back Syndrome, Journal of The American Physical Therapy Association 1994. (level of evidence 1A)
  5. ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 R. Sobottke et al., Current Diagnosis and Treatment of Spondylodiscitis. Deutsches ärzteblatt International, 2008. (Level of evidence 2A)
  6. ↑ 6.0 6.1 6.2 6.3 6.4 M. Titlic et al., Spondylodiscitis, Journal Citation/ Science Edition, 2008; 109(8) 345-347. (Level of evidence 2A)
  7. ↑ 7.0 7.1 7.2 7.3 A. Hegde, et al., Infections of the deep neck spaces, Singapore Med J. 2012 May;53(5):305-312 (level of evidence 5)
  8. ↑ 8.0 8.1 Enrique G. et al., Surgical treatment of spondylodiscitis. An update, International Orthopaedics 2012. (level of evidence 5)
  9. ↑ 9.0 9.1 Kapsalaki E. et al., Spontaneous spondylodiscitis: presentation, risk factors, diagnosis, management, and outcomes, International Journal of Infectious Diseases 2009. (level of evidence 1B)
  10. ↑ 10.0 10.1 10.2 10.3 10.4 10.5 P. Prithvi, et al., Intervertebral Disc: Anatomy-Physiology-Pathophysiology-Treatment, Department of Anesthesiology and Pain Management, World Institute of Pain, 2008 (level of evidence 2A)
  11. ↑ 11.0 11.1 11.2 M. Hasenbring et al., Intervertebral disk diseases, Thieme, 2008, 236p. (Level of evidence 5)
  12. ↑ Gouliouris T, Aliyu SH, Brown NM. Spondylodiscitis: update on diagnosis and management. Journal of Antimicrobial Chemotherapy. 2010 Nov 1;65(suppl_3):iii11-24. Available:https://academic.oup.com/jac/article/65/suppl_3/iii11/923760 (accessed 27.11.2022)
  13. ↑ Sans N. et al., Infections of the spinal column — Spondylodiscitis, Diagnostic and Interventional Imaging 2012. (level of evidence 5)
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