Pathology

u Vertebral body osteomyelitis and discitis refer to infection of the vertebral body and/
or disc space. The terms are used interchangeably and have similar aetiology and
management.
u The pathogenesis involves bacterial spread to the spine, by one of 3 routes:
u Haematogenous spread (most common) due to high vascularity of vertebral

Spinal infection marrow and arterial structure, that predisposes to bacterial deposition
u Direct inoculation e.g. after trauma, spinal procedures (such as injections)
u Contiguous spread from soft tissue

u Causative organisms
u Staph aureus in >50%
u Others are rare include gram negative bacilli from urinary tract, TB

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Clinical presentation Diagnosis

u Back pain is almost universally present u Blood tests FBC, inflammatory markers
u Localised tenderness u Cultures may isolate Staph Aureus
u Focal neurology u Spinal imaging
u May suggest an epidural abscess u MRI is most sensitive, CT is 2nd line
u More common with Potts disease spinal TB, in which case neurological deficits u Classical appearance - enhancing lesions, with hypointensity and loss of disc
are usually due to associated spinal cord inflammation margins on T1-weighted MRI / hyperintensity on T2-weighted MRI
u Characteristic feature is involvement of the disc space
u Signs of sepsis u More diffuse soft tissue involvement may suggest TB/tumour
u Fevers u TB also more commonly affects the lower thoracic spine
u Night sweats, weight loss may suggest TB
u Biopsy

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Diagnosis - biopsy Management

u Usually required to confirm radiographic diagnosis + guide therapy u Conservative

u Remember that differential diagnosis includes tumours
u Open biopsy has a higher diagnostic yield than CT-guided, but has higher
risks associated with surgery
u If biopsy is negative, empirical antibiotics can be employed with a view to
repeat biopsy if there is no clinical improvement in 3-4 weeks
u Analgesia is very important
u Back brace
u Bed rest important for initial week or so, with non weight bearing physiotherapy
u Regular review of neurology particularly if surgery is not being considered
u Medical
u Targeted antibiotics for at least 6 weeks
u Staph aureus usually treated with flucloxacillin/vancomycin based regimens
u Empirical regimen in the setting of negative cultures/biopsy should target Staph,
strep and gram negative bacilli e.g. vancomycin + cefotaxime/ciprofloxacin

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Management Further reading

u Surgery u Perio-operative preparation: Thoracolumbar spine surgery: a guide to

u Indications are controversial. preoperative and postoperative patient care. http://www.aann.org/pdf/
u Usually warranted if presence of concurrent epidural abscess; acute cpg/aannlumbarspine
spinal cord compression or spinal instability; progressive disease despite
medical therapy.
u Surgery may involve debridement and drainage of abscesses,
discectomy, laminectomy (decompression) and pedicle screw fixation
+/- fusion if there is instability.
u Specific complications of surgery include metalwork failure that may
require repeat surgery, persistent pain, nerve damage.

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