- 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
is here
Areas of Involvement
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
Staph Aureus
Pseudomonas Aeruginosa
- Patzakis et al
- IVI drug users
Distant Focus
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
- 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
HB
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
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
Negative Percutaneous biopsy