[Spondylodiscitis]

Imaging in the Diagnosis of Nonspecific Pyogenic Spondylodiskitis

The prevalence of nonspecific pyogenic spondylodiskitis, associated with both a high morbidity and a high mortality, has increased in the last few decades. The diagnosis is often delayed because of the nonspecific clinical manifestation at the early stage. The reliability of radiographs is limited, particularly in early stage after the onset of infection. Computed tomography (CT) can reliably assess the bony condition with the possibility of spatial visualization. Contrast enhancement supports the detection of affected soft tissue. Magnetic resonance imaging (MRI) continues to be the gold standard in the diagnosis of spondylodiskitis. Sophisticated investigation protocols supported by gadolinium enhancement secure the diagnosis. MRI has a high resolution without radiation exposure. Different nuclear investigation techniques extend the diagnostic options. Reports of 18F-fluorodeoxyglucose-positron emission tomography (18-FDG-PET) are particularly promising to confirm the diagnosis. The drawback of the reduced image quality with respect to detailed anatomical information can be overcome by a combined simultaneous acquisition of CT or MRI. With respect to one of the greatest challenges, the differentiation between degenerative changes (Modic type 1) and infection at an early stage using differentiated MRI protocols and FDG-PET is promising. This overview presents a concise state-of-the-art look at radiologic investigations in case of suspected nonspecific pyogenic spondylodiskitis with the focus on a pragmatic approach.

SponDT (Spondylodiscitis Diagnosis and Treatment): spondylodiscitis scoring system

BACKGROUND

Spondylodiscitis is a chameleon among infectious diseases due to the lack of specific symptoms with which it is associated. It is nevertheless a serious infection, with 7% mortality of hospitalized patients, in large part because of delayed diagnosis. The aim of this study was to develop a diagnosis and course-of-disease index to optimize its treatment.

MATERIAL AND METHODS

Through analysis of 296 patients between January 1998 and December 2013, we developed a scoring system for spondylodiscitis, which we term SponDT (Spondylodiscitis Diagnosis and Treatment) based on three traits: (1) the inflammatory marker C-reactive protein (CRP) (mg/dl), (2) pain according to a numeric rating scale (NRS) and (3) magnetic resonance imaging (MRI), to monitor its progression following treatment.

RESULTS

The number of patients receiving treatment increased over the past 15 years of our study. We also found an increasing age of patients at the point of diagnosis across the study, with an average age of 67.7 years. In 34% of patients, spondylodiscitis developed spontaneously. Almost 70% of them did not receive treatment until the first diagnosis using SponDT. Following treatment against spondylodiscitis, pain intensity decreased from 6.0 to 3.1 NRS. The inflammatory markers also decreased (CRP from 119.2 to 46.7 mg/dl). Similarly, MRI revealed a regression in inflammation following treatment. By employing SponDT, patients were diagnosed and entered into treatment with a score of 5.6 (severe spondylodiscitis) and discharged with a score of 2.4 (light/healed spondylodiscitis).

CONCLUSION

SponDT can be used to support the diagnosis of spondylodiscitis, particularly in patients suffering from back pain and elevated levels of inflammation, and can be used during the course of treatment to optimize control of therapy.

LEVEL OF EVIDENCE

IIa-evidence from at least one well-designed controlled trial which is not randomized.

Diagnostics and antibiotic therapy for spondylodiscitis

Purpose. Spondylodiscitis as a rare disease has increased in recent years; there are only a few recommendations regarding the diagnostics and treatment. The objective of this retrospective study was to characterise these patients and identify factors for a favourable healing process - with an emphasis on antibiotic therapy.Methodology. Findings/treatment regimens for all patients with spondylodiscitis treated at a tertiary care hospital in 2012/2013 were recorded. The patients were classified into two groups, depending on the healing process.Results. Fifty-seven patients met the clinical/radiological criteria for spondylodiscitis. The main symptom was massive back pain, combined with a moderate CRP elevation (median 96 mg l^-1), and occasionally fever (39 %). CT-guided aspiration - in addition to blood cultures - improved the detection rate for the causative pathogen from 49 to 82 %. Thirty patients had a favourable clinical course; 25 had an unfavourable clinical course (prolonged clinical course, recurrence, death). Pathogen-specific antibiotic therapy had a decisive effect on the clinical course: initial high-dose intravenous therapy for at least 14 days was associated significantly more often with a favourable clinical course (90 vs 30 % after 24 months, P<0.001). Fourteen days after the start of treatment, marked pain reduction and a CRP reduction of at least 50 % were good prognostic parameters and markers of effective antibiotic therapy.Conclusion. Pathogen detection and establishment of an optimal antibiotic regimen are cornerstones of successful conservative therapy for spondylodiscitis. Targeted initial intravenous therapy for at least 14 days with a bactericidal antibiotic leads to a better clinical course.

Spondylodiscitis severity code: scoring system for the classification and treatment of non-specific spondylodiscitis

INTRODUCTION

Established treatment options of spondylodiscitis, a rare but serious infection of the spine, are immobilization and systemic antibiosis. However, the available data for specific treatment recommendations are very heterogeneous. Our intention was to develop a classification of the severity of spondylodiscitis with appropriate treatment recommendations.

MATERIALS AND METHODS

From 10/1/1998 until 12/31/2004, 37 cases of spondylodiscitis were examined regarding medical history, gender status, location and extent of spondylodiscitis, type and number of operations. Subsequently, a classification of six grades according to severity has been developed with specific treatment recommendations. The further evaluation of our classification and corresponding treatment modalities from 1/1/2005 to 12/31/2009 including further 132 cases, resulted in a classification of only three grades of severity (the SSC--spondylodiscitis severity code), with a follow-up until 12/31/2011. Between 01/01/2012 and 12/31/2013, a prospective study of 42 cases was carried out. Overall, 296 cases were included in the study. 26 conservatively treated cases were excluded.

RESULTS AND CONCLUSION

The main localization of spondylodiscitis was the lumbar spine (55%) followed by the thoracic spine (34%). The classification of patients into 3 grades of severity depends on clinical and laboratory parameters, the morphological vertebral destruction seen in radiological examinations and the current neurological status. Therapies are adapted according to severity and they include a specific surgical management, systemic antibiotic therapy according to culture and sensitivity tests, physiotherapy and initiation of post-hospital follow-up. 40.6% of patients are associated with neurological deficits, classified as severity grade 3 and treated surgically with spinal stabilization and decompression. 46.9% of patients corresponded to severity grade 2, with concomitant vertebral destruction were dorsoventrally stabilized. The 31 patients of severity Grade 1 were treated surgically with dorsal stabilization. From 1998 to 2013, the time from the onset of symptoms to the first surgical treatment was about 69.4 days and has not changed significantly. However, the time from admission to surgical treatment had been reduced to less than 2 days. Also the time of hospitalization was reduced and we see positive effects regarding the sensation of pain. 270 patients underwent surgery. We treated 89% dorsally and 21% dorsoventrally. With the spondylodiscitis severity code, a classification of the severity of spondylodiscitis could be established and used for a severity-based treatment. In addition, specific parameters for the treatment of individual grades of severity can be determined in a clinical pathway.