Spondylodiscitis

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Original Editors - Lynn Leemans

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

Search Strategy

Keywords: Spondylodiscitis + Diagnosis / Therapy / Epidemiology / Rehabilitation / Rehabilitation / Examination / Symptoms / Characteristics / Clinical

Search engines: Pubmed Web of knowledge PEDro

Definition/Description

Spondylodiscitis can be defined as a primary infection (accompanied by destruction) of the intervertebral disc, with secondary infections of the vertebrae., It can lead to osteomyelitis of the spinal column., A difference has to be made between endogenous and exogenous paths of infection. Endogenous spondylodiscitis is mostly preceded by infection distant from the vertebral bodies. This infection is then spread by the blood. Inflammation usually spreads in the ventral sections of the spinal column. Exogenous spondylodiscitis can be caused by operations or by injections near the spinal column.Pathogens causing spondylodiscitis are staphylococci ,,5 and mycobacterium tuberculosis.,

Clinically Relevant Anatomy

The intervertebral disc is located between adjacent superior and inferior vertebral bodies. It has a central nucleus pulposus, which surrounds the annulus fibrosis and cartilaginous endplates. When the intervertebral disc is axially loaded, most 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.

A typical vertebra (vertebral body) is composed by the following parts:

• Body, the weight bearing part.
• Vertebral arch, which protects the spinal cord.  
• Process spinosus
• Processes transverse, left and right.
• Articular processes, two superior and two inferior, that help to restrict the movements.

Epidemiology /Etiology

According to scarce researches, the incidence of spondylodiscitis is 2.4/100,000 inhabitants. It increases with age. , Men are up to three times more often affected than women., Predisposing factors include age, multimorbidity, diabetes mellitus, cardiovascular diseases. 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 ,, and mycobacterium tuberculosis.,

Characteristics/Clinical Presentation

The clinical examination includes inspection concentrating on local changes and taking a detailed neurological status. There is pain on heel strike, impaction, and percussion, but little local pain on pressure. The patient takes a relieving posture and avoids stressing the ventral sections of the spinal column. In particular, inclination and re-erection are described as being painful.

The symptoms of spondylodiscitis are non-specific.

• Back or neck pain ,,
• Radicular pain radiating to the chest or abdomen is not uncommon.
• Neurological deficits, such as leg weakness, paralysis, sensory deficit and sphincter loss, are present in a third of cases.
• Fever (less commonly)
• Spinal deformities, predominantly kyphosis and gibbus formation, are commoner in tuberculous spondylitis.
• Weight loss

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.

Differential Diagnosis

Differential diagnoses include:

• Erosive osteochrondrosis  
• Osteoporotic and pathological fracture
• Cancer related destruction
• Ankylosing spondylarthritis
• Scheuermann's kyphosis.

Diagnostic Procedures

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. The basic diagnostic examinations to establish spondylodiscitis are:

• MRI Biopsy
• CT
• Microbiological tests.

Outcome Measures

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Examination

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Medical Management

1. Conservative treatment:

This treatment is based on antibiotics and immobilization of the spine. 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 ortheses 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 , or there’s no clinical improvement, it is not promising to continue conservative treatment beyond four to six weeks. 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. Surgery

Physical Therapy Management

Prognosis seems to be good with conservative treatment including NSAID’s, rest, physiotherapy, and a corset. Wearing the corset for a period of 6–10 weeks is instead confirmed by most authors

The role of the physiotherapist contains function recovering therapy (strength, coordination stability, mobility) if necessary. Exercises that increase muscle force and coordination are required, and back stability should be trained as well.

Key Research

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Resources

• Pubmed (VUB BIBLIO)
• Web of Knowledge  
• Pedro
  

Recent Related Research (from Pubmed)

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References

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