Spondylodiscitis: Difference between revisions
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• 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. | • 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. <ref name="35">Aagaard, T., Long-term prognosis and causes of death after spondylodiscitis: a danisch nationwide cohort study, Infect dis (Lond), 2015. Level Of Evidence: 2B</ref> | ||
• Computed tomography (CT):<br>o Inferior to MRI, gives a more detailed image of bone destruction (second choice)<br> | • Computed tomography (CT):<br>o Inferior to MRI, gives a more detailed image of bone destruction (second choice)<br> | ||
Revision as of 12:56, 26 April 2016
Original Editors - Lynn Leemans
Top Contributors - Ine Wittevrongel, Bo Hellinckx, Lucinda hampton, Admin, Kim Jackson, 127.0.0.1, WikiSysop and Claire Knott
Search Strategy[edit | edit source]
Keywords: Spondylodiscitis + Diagnosis / Therapy / Epidemiology / Rehabilitation / Rehabilitation / Examination / Symptoms / Characteristics / Clinical
Search engines: Pubmed Web of knowledge PEDro
Definition/Description[edit | edit source]
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.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title It can lead to osteomyelitis of the spinal column.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title It has a high morbidity and mortality and is a rare but serious infection.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Pathogens causing spondylodiscitis are staphylococci, Escheria coli and mycobacterium tuberculosis.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
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. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Clinically Relevant Anatomy[edit | edit source]
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. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title 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.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
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.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
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.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title 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.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Epidemiology /Etiology[edit | edit source]
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.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title All ages can be affected, but the appearance mostly increases with the age.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Men are up to three times more often affected than women, this is probably because of a higher frequency of comorbidities in men.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
The predisposing factors are:
• Diabetes mellitusCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Age Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Cardiovascular diseases or high blood pressure Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Obestity Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Drug abuse Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title or chronic steroid intake Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Chronic alcoholism and nicotine abuse Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• HIV infection Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• A spinal abnormality or intervention Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (catheter-associated infections Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, surgical interventions Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, prior visceral operations Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title)
• Infection: endocarditis Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, urinary tract infection Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, previous infection loci
• Multimorbidity Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Serious traumas Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Impaired immunocompetence (chemotherapy, human immunodeficiency virus infections, or chronic alcoholism) Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Cancer Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Sickle cell anemia Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Renal failure Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Liver failure: chronic hepatitis or lever cirrhosis Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Rheumatic diseases Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
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 Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title and mycobacterium tuberculosis. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title 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.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
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.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Characteristics/Clinical Presentation[edit | edit source]
The symptoms are non-specific, diffuse Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title and treacherous Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.
• Back or neck pain Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Constant pain, more worse at night Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title[1]
• Radicular pain radiating to the chest or abdomen
• Fever (less common in patients with tuberculous spondylodiscitis, 1/2 of the cases)Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Spinal deformities, predominantly kyphosis and gibbus formation (commoner in tuberculous spondylodiscitis)Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Neurological deficits: leg weakness, paralysis, sensory deficit, radiculopathy and sphincter loss (1/3 of the cases)Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Cervical lesion Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Spinal tenderness
• restricted range of movementCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• paravertebral muscle spasmCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Local tendernessCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Motor deficits: limb weakness, para- or tetraplegia, para- or tetraparesisCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• 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)Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Weight loss (when the delay in diagnosis is long)Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Mortality 2-17% Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
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 Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
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. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Spontaneous pyogenic spondylodiscitis usually spreads hematogenously from infections of the skin, subcutaneous tissues, and urinary tract. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Differential Diagnosis[edit | edit source]
Differential diagnoses include:
• Erosive osteochondrosis Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Osteoporotic and pathological fracture
• Cancer related destruction
• Ankylosing spondylarthritis
• Scheuermann's kyphosis Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Charcot joint
• Modic type I degenerative change
• Schmorl nodes
• Langerhans cell histiocytosis (LCH) Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Disc herniation
• Metastatic seeding
• Inflammatory or degenerative spinal disease Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Spondylodiscitis is an important differential diagnosis of lower back, flank, groin, and buttock pain. [46]
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. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
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. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
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. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title The basic diagnostic examinations to establish spondylodiscitis are:
• Magnetic Resonance Imaging (MRI) [46] Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
o Golden standard. Detects any spread of the inflammation.
Contrast-enhanced images improve the sensitivity and specificity of
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. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Computed tomography (CT):
o Inferior to MRI, gives a more detailed image of bone destruction (second choice)
• PET and PET/CT Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
o Due to its high specificity, Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title F-FDG PET/CT should be considered as a first-line imaging procedure in the diagnosis of spondylodiscitis. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Conventional x-ray Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
o Acute phase: unreliable
o Chronic phase: difficult to distinguish from other degenerative diseases of the spinal column (Only use for distinguish other pathologies)
• Biopsy
o Pathogens are only successfully detected in about half of the patients. To obtain a definite diagnosis: Necessary in the acute phase Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Blood Culture [40]
o Acute Phase
> inflammatory markers [43]
• Leukocyte count
• C-reactive protein [43] [46]
• erythrocyte sedimentation rate [43] [46]
o Chronic phase
> increase C-reactive protein: Easiest and most successful procedure, min. 3 times. When blood cultures are negative, CT-guided or surgical biopsy is recommended Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Microbiological tests Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• PCR method
o This method proves more and more the infection causes Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Bony Fusion Rate [43] [44]
o using spine X-ray
• Cobb modified angle [45]
o to evaluate the sagittal balance restoration
• Haematochemical tests and inflammation indicators must be taken on weekly basis, then monthly until normal values. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Multiple phase scintigraphy
o No good diagnostic method. Provides a reliable evidence for the absence of osseous inflammation Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Outcome Measures[edit | edit source]
• Visual Analogue Scale (VAS): [42][43][44][45]
o to evaluate therapeutic effects
o for assessment of pain.
• Oswestry disability index (ODI): [42][43][44]
o to evaluate therapeutic effects
o assessment of quality of life
• Japanese Orthopaedic Association Back pain evaluation Questionnaire (JOA)
o surgeon based evaluation tools[43][45]
o Only the Japanese version is valide
• Lumbar function score[43]
• Kirkaldy-Willis functional criteria [45]
Examination[edit | edit source]
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.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (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.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title[35] (level of evidence 2A)
1. Anamnesis:Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title[48] (level of evidence 1B)
• -Gender, age
• -Risk factors (see clinical presentation)
o diabetes mellitus
o advanced aged
o steroid use
• -Comorbidity
• -Clinical symptomatology (see clinical presentation)
o Constant pain, more worse at night Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
o Radicular pain radiating to the chest or abdomen
o Fever
o Screening red flags Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
o Thoracic pain
o Widespread neurological deficit, vertebral level involved
o Lower limb weakness
o Drug abuse/human immunodeficiency virus
o Age <20 or >55 years
o Weight loss
o Persistent severe restriction of lumbar flexion
o Constant progressive, mechanical pain
o Positive cough/sneeze
o Previous history of cancer
o Recent history of a trauma
2. Clinical examination Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (level of evidence 2A)
Inspection concentrating on local changes and taking a detailed neurological status
• Spinal tenderness Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Loss of lumbar lordosis and lower back movement Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• 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 Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
3. Basic objective tools Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
See diagnostic procedures.
Medical Management[edit | edit source]
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]
Randomized trials are needed to assess the optimal treatment duration, route of administration, and the role of combination therapy and newer agents.
[LoE: 2A] Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
1. Conservative treatment:
This treatment is based on antibiotics and immobilization of the spine.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title 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 Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, or there’s no clinical improvement, it is not promising to continue conservative treatment beyond four to six weeks.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title 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.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
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 >30mg/l and we recommend 6 weeks of intravenous therapy, followed by 6 further weeks of oral therapy.[LoE: 2B] [34]
Treatment of spondylodiscitis at children should be conservative with antibiotics only. [40]
2. Surgery
Surgery has an important role in alleviating pain, correcting deformities and neural compromise and restoring function.[LoE: 2B]Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Indications for surgical intervention:
o compression of neural elements
o spinal instability due extensive bony destruction
o severe kyphosis
o failure of conservative management
o (sometimes) inatractable pain
o (sometimes) epidural abscess even in the absence of neurogical
deficits
• Indications for surgical emergency
o spinal cord compression
o outcomes are worse if paralysis has been present over 24-36h (there are also investigators who improve improvement with prolonged paralysis) [LoE: 2B] Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
• Methodes
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]
Physical Therapy Management[edit | edit source]
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) Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title[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) Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title[50][51]
Thoracal extension exercises
Early mobilization is important. (LOE 3A) Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title But also limb exercises are considered to be good for the therapy.(LOE 3B) Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title 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) Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title[47]
Respiratory exercises
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]
Flexibility exercises
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) Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
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]
Key Research[edit | edit source]
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Clinical Bottom Line[edit | edit source]
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.
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References[edit | edit source]
- ↑ 23
