Advances in Medical Sciences 59 (2014) 57–60

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Advances in Medical Sciences

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Original Research Article

Infectious spondylodiscitis – A case series analysis

Adam Garkowski a,*, Agata Zajkowska a, Piotr Czupryna a, Wojciech Łebkowski b,
Michał Letmanowski a, Paweł Gołe˛bicki a, Anna Moniuszko a, Andrzej Ustymowicz c,
Sławomir Pancewicz a, Joanna Zajkowska a
a
Department of Infectious Diseases and Neuroinfections, Medical University of Bialystok, Bialystok, Poland
b
Department of Neurosurgery, Medical University of Bialystok, Bialystok, Poland
c
Department of Radiology, Medical University of Bialystok, Bialystok, Poland

A R T I C L E I N F O A B S T R A C T

Article history: Purpose: We aimed to describe the clinical and laboratory features as well as diagnostic difficulties in the
Received 15 October 2012 case series of spondylodiscitis.
Accepted 2 August 2013 Materials/methods: We retrospectively reviewed 11 cases of spondylodiscitis. The diagnosis of
Available online 19 March 2014
spondylodiscitis was based on clinical, radiological and microbiological evidence and by the response
to antimicrobial therapy.
Keywords: Results: There were 7 men and 4 women, and the age ranged from 21 to 74 years. Risk factors of
Spondylodiscitis
spondylodiscitis were observed in 7 patients. The approximate time from onset of symptoms to
Vertebral osteomyelitis
diagnosis was from 2 to 7 months (median 45 days). Back pain was the most common symptom. The
Back pain
Spine most frequent location of spondylodiscitis was lumbar spine. Pathogens were isolated in 6 cases and
Infection were as follows: Staphylococcus aureus (4 cases), Staphylococcus warneri (1 case) and Escherichia coli (1
case). After therapy, all patients had rapid regression of symptoms and no permanent neurological
impairments and recurrence of infection were observed.
Conclusions: Diagnosis of spondylodiscitis is frequently delayed. This disease should be taken into
consideration in differential diagnosis in patients with root syndromes accompanied by back pain and
usually fever as well as increased values of CRP and ESR.
ß 2014 Medical University of Bialystok. Published by Elsevier Urban & Partner Sp. z o.o. All rights
reserved.

1. Introduction
Spondylodiscitis is quite a rare disease characterized by insidious
onset and non-specific symptoms such as back pain and fever.
Consequently, early diagnosis is difficult and is often missed despite
repeated warnings in the medical journals and better access to
imaging techniques such as magnetic resonance imaging (MRI) and
computed tomography (CT). The term spondylodiscitis includes
vertebral osteomyelitis and discitis. The term vertebral osteomyelitis
means inflammation of the vertebral body and the term discitis
indicates infection of the intervertebral disk space. Spondylodiscitis
may take acute, subacute or chronic course [1–3].
The incidence of spondylodiscitis is about 2.4 cases per 100,000
annually, and it increases with age. The disease is diagnosed in males
more often than in females [2,4]. Aging, multi-morbidity, changes in
* Corresponding author at: Department of Infectious Diseases and Neuroinfec-
tions, Medical University of Bialystok, Żurawia 14, 15-540 Bialystok, Poland.
Tel.: +48 85 740 9514; fax: +48 85 740 9515.
E-mail address: adam.garkowski@gmail.com (A. Garkowski).
lifestyle leading to spinal injury, drug abuse, and increasing number of
patients with immunological deficits are important factors contrib-
uting to gradual increase of spondylodiscitis incidence [1,3,5,6].
2. Material and methods
The medical documentation of 11 patients with spondylodiscitis
hospitalized at the Department of Infectious Diseases and Neuroin-
fections of Medical University in Bialystok (Poland), between March
2002 and December 2011 was reviewed. Before admission to our
Department the majority of patients were treated at the Department
of Neurosurgery. The parameters analyzed were as follows:
demographic pattern, risk factors, clinical symptoms, localization
of the infection, blood tests, bacterial cultures, MRI findings and
outcome of the disease. The final diagnosis of spondylodiscitis was
based on clinical, radiological and microbiological evidence,
laboratory tests (acute phase parameters) and the response to
antimicrobial therapy. In the differential diagnosis diseases such as:
compression fracture, metastatic spinal lesions, erosive osteochon-
drosis, gout arthritis, aseptic bone necrosis were excluded.

http://dx.doi.org/10.1016/j.advms.2014.02.001
1896-1126/ß 2014 Medical University of Bialystok. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.
58 A. Garkowski et al. / Advances in Medical Sciences 59 (2014) 57–60

Table 1 At admission to the Department all patients complained about

Demographic data of analyzed patients.
localized back pain related to the sites of infection. Nine patients
Patient no. Gender Age Predisposing factors presented with pain in the lumbar spine region which radiated to
1 Female 52 Not present one or both lower limbs; in 1 patient with infection of the lumbar
2 Female 62 Not present spine pain radiated to the buttocks. In 1 case pain radiated to the
3 Male 64 Spine surgery (L3-L4-L5). Diabetes. right upper limb. Fever 38 8C was observed in 5 patients. One
4 Male 44 Chronic kidney failure patient had urinary incontinence. Sepsis developed in 4 cases (in 1
5 Male 74 Vascular prosthesis because of aortic aneurysm
case septic shock was present).
6 Male 67 Not present
7 Male 34 Spine surgery (L4-L5) The most frequent localization of spondylodiscitis was lumbar
8 Male 21 Not present spine (in 10 cases). Four patients presented with infection of two
9 Female 56 Not present adjacent vertebrae and intervening intervertebral disk space; in 2
10 Male 45 Spine surgery (L4-L5)
cases infection involved >2 contiguous vertebrae and intervening
11 Female 51 Spine surgery (L5-S1)
intervertebral disk space (vertebral osteomyelitis). In 4 patients
infection was limited to intervertebral disk space without adjacent
3. Results vertebrae (discitis). In 2 patients with lumbar spine involvement
the inflammatory process spread to the paravertebral tissues.
The median age of the patients was 52 years and ranged from 21 C-reactive protein concentration (CRP) was measured in all
to 74 years. The male to female ratio was 7:4. patients before treatment and was elevated in 7 patients
Risk factors for spondylodiscitis were observed in 6 patients. (>10.0 mg/L). The erythrocyte sedimentation rate (ESR) was
Four patients had a history of recent spine surgery (and one of increased in all patients (in all >30 mm/h). Leukocytosis
them also had diabetes); one patient had vascular prosthesis; one (>10,000 WBCs/mm3) was present in 5 cases.
patient suffered from chronic kidney disease and one patient had a Pathogens were isolated from repeated sets of blood cultures in
history of gangrenous cholecystitis and pleural empyema. Five 5 cases. Staphylococcus spp. was found in 4 cases. Escherichia coli
patients had no identifiable risk factors. One or more comorbidities was isolated in 1 patient. In 1 case histopathologic examination
were presented in 8 patients. Concomitant degenerative spinal and culture of the material from intervertebral space was
disease was found in 6 cases. performed. Staphylococcus aureus was isolated; histopathologic
Tables 1 and 2 present demographic and clinical characteristics examination revealed pyogenic inflammation.
of the patients. In most cases diagnosis was delayed. The Initial MRI scan was performed in 10 patients. Typical changes
approximate time from onset of symptoms to diagnosis was from were observed in 9 cases. Hypointensity of the vertebral bodies and
2 to 7 months (median 45 days). intervertebral discs in T1-weighted images was observed and

Table 2
Clinical characteristics and laboratory test of analyzed patients.

Patient no. Diagnosis Clinical symptoms Body ESR CRP WBCs count Localization Cultures
temperature (8C) (mm/h) (mg/l) (103/mm3)

1 Vertebral Pain of the cervical spine during 36.6 34 0.3 5.8 C6-C7 Blood – negative
osteomyelitis movement with radiation to the right
upper limb. Limb weakness. Pain on
palpation of the cervical spine.
2 Discitis Pain of the L-S spine region, radiating to 38.0 95 19.3 10.04 L2-L3 Material from intervertebral
right lower limb. Limb weakness. Pain space – Staphylococcus
on palpation of the spine L-S. aureus MSSA
Blood – negative
3 Vertebral Pain of the L-S spine region, radiating to 37.2 62 85.7 13.32 L3-L4-L5 Blood – Staphylococcus
osteomyelitis. both lower limbs, escalating during warneri
Sepsis movement. Limb weakness.
4 Vertebral Pain of the L-S spine region, radiating to 38.0 100 353.7 12.25 L3-L4-L5 Blood – Staphylococcus
osteomyelitis. both lower limbs. Limb weakness. aureus MSSA
Sepsis
5 Vertebral Pain of the L-S spine region, radiating to 36.8 98 64.6 10.4 L4-L5 Blood – Staphylococcus
osteomyelitis. both lower limbs. Limb weakness. Pain aureus MSSA (blood)
on palpation of the spine.
6 Vertebral Pain of the L-S spine, radiating to left 39.0 72 240.4 6.64 L4-L5 Blood – negative
osteomyelitis lower limb. Limb weakness. Pain on
palpation of the spine.
7 Discitis Pain of the L-S spine region, radiating to 36.6 37 0.8 5.04 L4-L5 Blood – negative
both lower limbs, escalating during
movement. Limb weakness.
8 Vertebral Pain of the L-S spine region, radiating to 40.0 116 81 7.7 L4-L5 Blood – Staphylococcus
osteomyelitis. buttocks muscles, escalating during aureus MSSA
Sepsis hips movements. Limb weakness.
9 Vertebral Pain of the L-S spine region, radiating to 39.0 76 204 10.8 L4-L5 Blood – Escherichia coli
osteomyelitis. right lower limb. Limb weakness. Pain
Sepsis + septic on palpation of the spine
shock
10 Discitis Pain of the L-S spine region, escalating 36.6 46 9.0 9.4 L4-L5 Blood – negative
during movement. Pain on palpation of
the L-S spine.
11 Discitis Pain of the L-S spine region, radiating to 37.0 42 7.4 6.49 L5-S1 Blood – negative
both lower limbs. Limb weakness.
Reduced mobility of the lumbar spine.
Urinary incontinence.
 A. Garkowski et al. / Advances in Medical Sciences 59 (2014) 57–60
Fig. 1. MRI scan showing inflammatory infiltrates in the course of discitis (T1
weighted–gadolinium enhanced). (A) sagittal plane, (B) transverse plane.
hyperintensity – in T2-weighted images. Representative MRI scans
are shown in Figs. 1 and 2. In 1 patient the diagnosis of
spondylodiscitis was made during neurosurgical operation. This
patient had surgery due to the concomitant lumbar discopathy;
and while previously performed MRI did not show any features of
discitis; the diagnosis was based on positive cultures of an infected
intervertebral space. In 1 patient MRI scan was not obtained. In this
case the diagnosis of discitis was based on spine X-ray -
radiographs that showed narrowing of the intervertebral space
L4-L5 without abnormalities in the vertebrae.
Length of hospital stay in our Department ranged from 7 days to
34 days (median 19 days). The duration of antimicrobial treatment
depended on the CRP and ESR levels. All the patients received
parenteral antibiotics, and the duration of IV antimicrobial therapy
in our Department ranged from 7 days to 31 days (median 18.5
days), and in some cases it was a continuation of treatment started
in other Departments. It was followed by several weeks (up to 4
weeks) peroral treatment. The most frequent intravenously
administered antibiotic was ceftriaxione. The most common oral
regimen was a combination of rifampicin plus ciprofloxacin. Two
patients underwent surgical decompression.
All patients showed favorable response to treatment mani-
fested by improvement in general condition and CRP and ESR
normalization. No recurrence of infection was observed.
4. Discussion
Spondylodiscitis may be a result of sepsis, pathogen migration
from the inflammation focus adjacent to the spine or may be a
complication of neurosurgical operation [2]. Intervertebral space is
59
Fig. 2. MRI scan showing inflammatory infiltrates in the course of discitis (T1
weighted–gadolinium enhanced). (A) sagittal plane, (B) transverse plane.
usually affected secondary to the inflammation in adjacent
vertebrae. Infection limited to intervertebral space (discitis) may
be a complication of deep wounds and surgical interventions
[1,2,4]. The majority of patients with spondylodiscitis have at least
one of the risk factors e.g. old age, diabetes, immunoincompetence,
steroid therapy, infection in other foci, vascular prosthesis, history
of spinal surgery or dialysotherapy [5–7]. Six of our 11 patients
presented with identifiable risk factors, most often spine surgery.
The most frequently isolated bacteria in spondylodiscitis are: S.
aureus (accounting for half of non-tuberculous cases) followed by
Enterobacteriaceae – about 30% (usually E. coli). Salmonella sp.,
Proteus sp., Klebsiella sp. and fungi are less often isolated.
Mycobacterium tuberculosis accounts for 9–46% of cases of spondy-
lodiscitis in developed countries [1,7,8]. In our study S. aureus was
the most common pathogen. In 1 patient repeated sets of blood
cultures revealed Staphylococcus warneri growth. This organism is a
very rare cause of spondylodiscitis and so far only 4 cases of S.
warneri spinal infections have been reported in the literature [9–12].
The clinical symptoms of spondylodiscitis are related to the
affected region of the spine. The disease in most cases affects the
lumbar region of the spine, followed by the thoracic and cervical
region (tuberculous spondylodiscitis involves the thoracic spine
more frequently than others) [5,6,8,13–16]. Similarly to other
reports majority of spondylodiscitis in our case series affected
lumbar spine. In two patients infection involved >2 contiguous
vertebrae.
As demonstrated in our patients, back pain is the earliest and
the most common symptom. It increases during movements and at
night followed by the sensation of stiffness and leads to limitation
of activity. These symptoms are frequently mistaken for overload
60 A. Garkowski et al. / Advances in Medical Sciences 59 (2014) 57–60
disorders of spine. In all our cases pain radiated from the spine.
Tenderness on palpation over the involved region of the spine is
common in spondylodiscitis but it may be present (although less
frequently) in other spinal disorders – such as disk herniation. We
observed pain on palpation of the spine in 6 cases. Symptoms
increase gradually for several weeks or months [3–5,7].
In patients with post-operative spondylodiscitis, the pain
symptoms appear just after a couple of days/weeks after the
procedure. Patients in this group usually do not feel any pain just
after the surgery but afterwards the pain increases as a result of
intervertebral space infection. Patients complain about pre-
surgery symptoms coming back, which can lead to incorrect
diagnosis, other than spondylodiscitis [4,17]. Also, all our patients
with post-operative spondylodiscitis had self-reported pain relief
after the procedures. Then the pain returned after a short period.
Spondylodiscitis of the thoracic or lumbar region can cause pain
radiating to the thorax or abdomen, imitating cholecystitis,
pancreatitis or appendicitis [1,14]. Fever occurs in about half of
all patients [5]. Neurological deficits including muscle weakness,
numbness, paralysis and loss of sphincters control are observed in
one third of patients [3]. In the present study, we observed root
syndrome in all patients and urinary incontinence in one case.
If spondylodiscitis is a complication of a distant localized
infection spreading hematogenously, the symptoms of primary
infection may dominate in the early phase of spondylodiscitis for
example bacterial endocarditis, urinary tract infection or abscess-
es. In case of strong spine tenderness after local or systemic
infection, spondylodiscitis should be taken into consideration in
differential diagnosis [2,5,8,15].
In the early stage of spondylodiscitis, the X-ray usually does not
show any abnormalities. Pathological changes are rarely seen
before 2–4 weeks. That is why the MRI is the imaging test of choice
as it may reveal changes in the early phase of the disease (<14
days). Sensitivity and specificity of the test exceeds 90%. In T1-
weighted images reduction in signal intensity from the vertebral
body and intervertebral space can be observed, while T2-weighted
images demonstrate increased intensity in the vertebral body and
disk space. Intervertebral space involvement gives an image of its
narrowing [18,19]. Most of our patients had typical MRI findings.
CT is an alternative diagnostic tool but it has lower sensitivity and
specificity than MRI.
CRP concentration and ESR are elevated in about 95% of patients
(approximately 2–4 times above normal). Leukocytosis occurs in
about 1/3 of patients and usually is mild [5,6,14]. In our series CRP
was elevated in 7 patients and ESR was elevated in all of the patients.
Antibiotics (administered initially intravenously for at least 2–4
weeks and subsequently orally) are the treatment of choice for
spondylodiscitis [20]. Shorter parenteral therapy is associated with
much higher risk of treatment failure. The optimal duration of
parenteral and oral antibiotics therapy is 12 weeks (6 weeks IV
therapy and 6 weeks oral therapy) [4,8,20]. The decision of
treatment discontinuation should be dependent on patient im-
provement, CRP and ESR normalization. If 50% decrease in CRP and
ESR values is observed oral therapy may be started [1,4,17]. As yet,
there is no firm guidelines for the duration and selection of antibiotic
therapy. Antibiotic treatment may be implemented after microbio-
logical sampling (blood culture, CT-guided or open biopsy for culture
and histology). If cultures are negative empirical antibiotic therapy
should target the most common pathogens, including staphylococci
(usually with vancomycin if MRSA is a possibility) and Gram-
negative bacteria (II and III generation Cephalosporins) [1,3,4]. Bed
rest and administration of low-molecular weight heparin for 2–4
weeks is recommended. Then patients should be mobilized with a
brace, corset or lumbar support belt [4].
Surgical treatment is recommended when progression of the
disease is not stopped despite the use of antibiotics. It consists of
spinal cord decompression or draining of epidural or paravertebral
abscesses [1,15].
5. Conclusions
Diagnosis of spondylodiscitis is frequently delayed. This disease
should be taken into consideration in differential diagnosis in
patients with root syndromes accompanied by back pain and
usually fever as well as increased values of CRP and ESR. However,
as it was shown in 4 of our patients, pain may be the only present
symptom, which makes the diagnostic process more complicated.
Accurate diagnosis in the early stage of the disease prevents
irreversible spinal cord damages and reduces the length of
antibiotic therapy.
Conflict of interests
The authors declare no conflict of interests.
Financial disclosure
The authors have no financing to disclose.
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