Spondylodiscitis

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Original Editors - Lynn Leemans

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

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Definition/Description

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.[1][2][12][15] It can lead to osteomyelitis of the spinal column.[3][2] It has a high morbidity and mortality and is a rare but serious infection.[1][12][13][15][17]

Pathogens causing spondylodiscitis are staphylococci, Escheria coli and mycobacterium tuberculosis.[1][2][4][5][12][14][16]
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. [1][16]

Clinically Relevant Anatomy

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.[21] 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.[6]
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.[7]

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.[19][20] 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.[19]

Epidemiology /Etiology

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.[2][4][1] Men are up to three times more often affected than women, this is probably because of a higher frequency of comorbidities in men.[8][2][23]
The predisposing factors are:

• Diabetes mellitus[17][26]
• Age[17]
• Cardiovascular diseases or high blood pressure[8][26]
• Obestity[2][26]
• Drug abuse[2][17][26] or chronic steroid intake[2][26]
• Chronic alcoholism and nicotine abuse [2][17]
• HIV infection[2][26]
• A spinal abnormality or intervention[2] (catheter-associated infections[17], surgical interventions[17], prior visceral operations[2][26])
• Infection: endocarditis[2][26], urinary tract infection[2][26], previous infection loci[8]
• Multimorbidity[2][26]
• Serious traumas[8]
• Impaired immunocompetence (chemotherapy, human immunodeficiency virus infections, or chronic alcoholism) [2][17][26]
• Cancer[2][8][25][26]
• Sickle cell anemia[2][3]
• Renal failure[2][8][26]
• Liver failure: chronic hepatitis or lever cirrhosis[2][8][26]
• Rheumatic diseases[26]

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 [1][4][8] and mycobacterium tuberculosis.[4][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.[23]

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.[24]

Characteristics/Clinical Presentation

The symptoms are non-specific, diffuse[2] and treacherous[8].
• Back or neck pain [1][8]
• Constant pain, more worse at night [2][4][23]
• Radicular pain radiating to the chest or abdomen
• Fever (less common in patients with tuberculous spondylodiscitis, 1/2 of the cases)[1][8][1][23]
• Spinal deformities, predominantly kyphosis and gibbus formation (commoner in tuberculous spondylodiscitis)[1]
• Neurological deficits: leg weakness, paralysis, sensory deficit, radiculopathy and sphincter loss (1/3 of the cases)[1][8] [1][23]
• Cervical lesion[1]
• Spinal tenderness[1]
• restricted range of movement[1]
• paravertebral muscle spasm[1]
• Local tenderness[17]
• Motor deficits: limb weakness, para- or tetraplegia, para- or tetraparesis[26]
• 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)[23]
• Weight loss (when the delay in diagnosis is long)[23]
• Mortality 2-17%[2]
In children (symptoms are non-specific)
• Irritability
• Limping
• Refusal to crawl, sit or walk
• Hip pain or even abdominal pain
• Incontinence may be a presenting feature
• Loss of lumbar lordosis and lower back movement
• Compared with adults, children are less likely to have comorbidities and neurological deficits are uncommon [1]

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]

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