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]

Differential Diagnosis

Differential diagnoses include:

• Erosive osteochondrosis [18]
• Osteoporotic and pathological fracture
• Cancer related destruction
• Ankylosing spondylarthritis
• Scheuermann's kyphosis [1][2]
• Charcot joint
• Modic type I degenerative change
• Schmorl nodes
• Langerhans cell histiocytosis (LCH) [11][22]
• Disc herniation
• Metastatic seeding
• Inflammatory or degenerative spinal disease [23]

Spondylodiscitis is an important differential diagnosis of lower back, flank, groin, and buttock pain. [46]

Diagnostic Procedures

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. [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. [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.[1] The basic diagnostic examinations to establish spondylodiscitis are:

• Magnetic Resonance Imaging (MRI) [46] [2][8][25][26][30]
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. [35]

• Computed tomography (CT):
o Inferior to MRI, gives a more detailed image of bone destruction (second choice)

• PET and PET/CT[3][4][8]
o Due to its high specificity, [2] F-FDG PET/CT should be considered as a first-line imaging procedure in the diagnosis of spondylodiscitis. [33]

• Conventional x-ray[2]
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[8]

• 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[23]

• Microbiological tests[4][8]

• PCR method
o This method proves more and more the infection causes [4]

• 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.[8][26]

• Multiple phase scintigraphy
o No good diagnostic method. Provides a reliable evidence for the absence of osseous inflammation[8]

Outcome Measures

• 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

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Medical Management

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2. Surgery

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Physical Therapy Management

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Key Research

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