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  • Rare but incidence is rising
  • High index of suspicion
  • Microbiological diagnosis
  • Bloods
  • Radiology
  • +- Biopsy
  • Randomized controlled trials needed for the following
  • Optimal treatment duration
  • Route of administration
  • Surgery
  • Role in alleviating pain
  • Correcting deformities
  • Restoring function
  • Children : Very good prognosis.

Thank you for your attention!

Definition

Epidemiology

Term Encompassing

  • Vertebral Osteomyelitis
  • Discitis
  • Spondylitis

Incidence in Developing countries

Male vs Female Ratio

Prevalence

References

  • 1) Grammatico, Baron, S, Rusch, E:. Epidemiology of vertebral osteomyelitis (VO) in France: analysis of hospital-discharge data 2002–2003. Epidemiol Infect2008;136:653
  • 2) Jensen AG, Espersen F, Skinhoj,P . Increasing frequency of vertebral osteomyelitis following Staphylococcus aureus bacteraemia in Denmark 1980–1990.J Infect 1997;34:113-8
  • 3)Fowler VG jr, Olsen MK, Corey GR etal. Clinical identifiers of complicatedStaphylococcus aureus bacteremia. Arch Intern Med 2003;163:2066-72. .
  • 4) McHenry MC,  Vertebral osteomyelitis: long-term outcome for 253 patients from 7 Cleveland-area hospitals. Clin Infect Dis
  • 5) Tuli SM : Tuberculosis of the spine: a historical review. Clin Orthop Relat Res2007;460:29-38.
  • 6)  Torda AJ, . Pyogenic vertebral osteomyelitis: analysis of 20 cases and review. Clin Infect Dis 1995;20:320-8.
  • 7) Mylona E, . Pyogenic vertebral osteomyelitis: a systematic review of clinical characteristics. Semin Arthritis Rheum 2009;39:10-7.
  • 8) Sapico FL, Pyogenic vertebral osteomyelitis: report of nine cases and review of the literature. Rev Infect Dis 1979;1:754-76.
  • 9) Zarrouk V et al. Imaging does not predict the clinical outcome of bacterial vertebral osteomyelitis.
  • 10) Beronius M et al. Vertebral osteomyelitis. A Retrospective study of patients during 1990 -1995
  • 11) Haematogenous pyogenic spinal infections, and their surgical management :2000; 25: 1668-79
  • 12) Modic MT, Feiglin et al. Vertebral osteomyelitis : assessment using MRI
  • 13) Diagnostic yield of CT-guided percutaneous aspiration procedures in suspected spontaneous infectious diskitis : Radiology 2001
  • 14) Modic MT, Feiglin DH, Piraino DW et al. Vertebral osteomyelitis assessment using radiology
  • 15) Legrand E. Strategie diagnostique et priciples. Rhum 2006; 73
  • 16) Sobottke R et al : Current diagnosis and treatment of spondylodiscitis.
  • 17) Garron E, et al : Nontuberculous spondylodiscitis in children 2002: 22: 321-8

Pathogenesis

Conclusion

Pathogens : 3 Routes

Vascular Supply

  • Children
  • Adults

is here

Areas of Involvement

Spondylodiscitis

11%

30%

58%

Spondylodiscitis in children

  • Investigations
  • Role of biopsy : Debatable
  • Two schools of thought
  • Biopsy straight away
  • Patients that does not respond to empirical therapy.
  • Very good prognosis
  • Study
  • 42 patients
  • 37 no functional sequelae
  • 3 had pain only on sporting activities
  • 1 had longterm neurological squelae.
  • Follow-up : 10 years post infection.
  • 80% completely asymptomatic
  • 20% had restricted spinal movement
  • Garron E et al

Aetiology and Microbiology

Monomicrobial

Tuberculosis

  • Skeletal involvement

Staph Aureus

  • Legrand et al
  • 1.7 %

Pseudomonas Aeruginosa

  • Patzakis et al
  • IVI drug users

Distant Focus

  • Mylona et al
  • UTI

Spondylodiscitis in Children

  • History
  • Non-specific
  • Irritability
  • Limping
  • Refusal to crawl, sit or walk
  • Hip and abdominal pain
  • Incontinence
  • Garron et al : Non-tuberculous spondylodiscitis
  • Examination
  • Fever less common in young children
  • Loss of lumbar lordosis
  • Loss of lower back movement (commonest)
  • Less likely to have co-morbidities and neurological deficit.

History

Non-Specific

  • Pain
  • Insidious onset
  • Torda et al

Outcome

  • Mortality < 5% (Range 0 to 11%)
  • Early mortality mostly d/t uncontrolled sepsis.
  • Relapse
  • Series of 253 patients followed up for 6.5 years : Documented in 14% : Timing 1 month to 12 months
  • Mostly due :
  • Recurrent bacteraemia
  • Chronically draining sinus
  • Paravertebral abscess.
  • Signs of relapse
  • Recurrent pain
  • Unexplained fever
  • Bacteremia; Weight loss or rising ESR

Examination

Surgical Management

Neurological Deficit

  • Leg weakness
  • Paralysis
  • Mylona et al

Spinal Tenderness

  • 78 - 97%
  • Sapico et al
  • Failed Medical Treatment
  • Neurologically intact : Conservative approach provided microbiological diagnosis available.
  • Close Monitoring nb.
  • Indications for surgery
  • Spinal instability due to bony destruction
  • Severe kyphosis
  • Intractable pain (some surgeons)
  • Sabottke et al
  • Paralysis : Spinal cord decompression :

Investigations

ESR

  • Patzakis et al
  • elevated > 90 % of cases

CRP

  • Raised
  • Response

HB

  • Anaemia

Treatment

Radiology

Blood Cultures

Medical

  • Aim
  • Eradicate infection
  • Restore and preserve structure
  • Alleviate pain
  • Non-pharmacological treatment

Initiation, Route and Duration

  • Varies
  • Legrand et al
  • Total : 6 to 14 weeks

Plain X-rays

CT Scan

  • Guidance : Biopsy

MRI

  • Modality of choice
  • Modic MT et al

Criteria to Discontinue

  • Symptom resolution
  • ESR and CRP
  • Legrand et al

Blood Culture

  • Causative organism
  • Negative : Biopsy

Percutaneous Biopsy

  • 75 % Yield

Negative Percutaneous biopsy

  • Indication for surgery
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