Spinal infections in children: a review

Spondylodiscitis Following Perforated Acute Appendicitis: A Case Report

Spondylodiscitis is a multifactorial disease of significant medical and socioeconomic importance, the treatment of which presents a challenge to clinicians and surgeons. Acute appendicitis is a common inflammatory disease in children, with postoperative complications occurring in up to 55% of cases. We present the case of a 15-year-old male with symptoms of severe back pain and fever two months following surgery for perforated appendicitis. The computed tomography (CT) revealed spondylodiscitis of T12-L1 spinal level. Discectomy and posterior pedicle-screw fixation were performed, followed by antibiotic treatment resulted in the resolution of preoperative symptoms. To the best of our knowledge, this is the third case of spondylodiscitis after perforated acute appendicitis in literature. Timely diagnosis and treatment in cases of spondylodiscitis are prerequisites for lowering the rate of permanent neurological deficits in these patients.

Sonographic diagnosis of spondylodiscitis in a young child

Sonographic diagnosis of spondylodiscitis is described in a 21-month-old girl who presented with altered gait. Spondylodiscitis, also referred to as discitis-osteomyelitis, is an infection of the intervertebral disc and adjacent vertebrae. The imaging modality of choice is spinal magnetic resonance imaging. Our case is the first description in the English language of the sonographic diagnosis of spondylodiscitis. Pediatric radiologists and sonographers should be acquainted with its features, for both incidental and intentional diagnosis.

Laboratory diagnostics for primary spinal infections in pediatric and adult populations: a narrative review

Primary spinal infection (PSI) is a generic term covering a heterogeneous group of infections that can affect the vertebral body, intervertebral disks, the content of the medullary cavity, and adjacent paraspinal tissues. Patients' characteristics can vary significantly, notably according to their age, and some of these characteristics undoubtedly play a primordial role in the occurrence of a PSI and in the type of offending pathogen. Before approaching the subject of laboratory diagnostics, it is essential to define the characteristics of the patient and their infection, which can then guide the physician toward specific diagnostic approaches. This review critically examined the roles and usefulness of traditional and modern laboratory diagnostics in supporting clinicians' decision-making in cases of pediatric and adult primary spinal infection (PSI). It appears impossible to compare PSIs in children and adults, whether from an epidemiological, clinical, bacteriological, or biological perspective. The recipients are really too different, and the responsible germs are closely correlated to their age. Secondly, the interpretation of traditional laboratory blood tests appears to contribute little guidance for clinicians attempting to diagnose a PSI. Biopsy or needle aspiration for bacterial identification remains a controversial subject, as the success rates of these procedures for identifying causative organisms are relatively uncertain in pediatric populations.Using nucleic acid amplification assays (NAAAs) on biopsy samples has been demonstrated to be more sensitive than conventional cultures for diagnosing PSI. Recent advances in next-generation sequencing (NGS) are particularly interesting for establishing a microbiological diagnosis of a PSI when standard cultures and NAAAs have failed to detect the culprit. We can even imagine that plasma metagenomic NGS using plasma (known as "liquid biopsy") is a diagnostic approach that can detect not only pathogens circulating in the bloodstream but also those causing focal infections, and thus eliminate the need for source sample collection using costly invasive surgical procedures.

Tumors and infections of the growing spine

The growing spine differs from the adult spine in several ways. Although tumors and infections cause only a small percentage of pediatric back pain incidences, delayed proper diagnosis and treatment may be disastrous. Benign lesions, such as osteoid osteoma, osteoblastoma, and aneurysmal bone cyst in the spine, are predominant during the first two decades of life, whereas malignant bony spinal tumors are rare. In the pediatric population, malignant spine tumors include osteosarcoma, Ewing's sarcoma, lymphoma, and metastatic neuroblastoma. Infections of the growing spine are rare, with the incidence of discitis peaking in patients under the age of 5 years and that of vertebral osteomyelitis peaking in older children. Spondylodiscitis is often a benign, self-limiting condition with low potential for bone destruction. Conservative treatments, including bedrest, immobilization, and antibiotics, are usually sufficient. Spinal tuberculosis is a frequently observed form of skeletal tuberculosis, especially in developing countries. Indications for surgical treatment include neurologic deficit, spinal instability, progressive kyphosis, late-onset paraplegia, and advanced disease unresponsive to nonoperative treatment. Spinal tumors and infections should be considered potential diagnoses in cases with spinal pain unrelated to the child's activity, accompanied by fever, malaise, and weight loss. In spinal tumors, early diagnosis, fast and adequate multidisciplinary management, appropriate en bloc resection, and reconstruction improve local control, survival, and quality of life. Pyogenic, hematogenous spondylodiscitis is the most common spinal infection; however, tuberculosis-induced spondylodiscitis should also be considered. Level of evidence: level 4.

Understanding the management of pediatric spondylodiscitis based on existing literature; a systematic review

BACKGROUND

Spondylodiscitis (SD), a rare disease in children, poses diagnostic challenges due to non-specific presenting symptoms, scarcity in incidence, and difficulty expressing pain in non-verbal children.

METHOD

A comprehensive search was conducted on three databases, including PubMed/Medline, Web of Science, and Scopus until March 2023. The inclusion criteria were studies that investigated the clinical characteristics, treatment, and complications of children's spondylodiscitis. Full text of cross-sectional and cohort studies were added. The quality assessment of cohort studies was conducted using the Newcastle-Ottawa Quality Assessment Scale. The search, screening, and data extraction were performed by two researchers independently.

RESULT

Clinical manifestations of discitis in children are nonspecific, such as back pain, fever, reduced ability or inability to walk or sit, limping, and reduced range of movements. The mean delay in the time of diagnosis was 4.8 weeks. The most affected site of all the studies was the lumbar spine. 94% of studies reported increased inflammatory markers such as white blood cell count, C-reactive protein, and erythrocyte sedimentation rate. Less than 30% of patients had positive blood cultures and biopsy findings. The most common microbiological results (64%) were Staphylococcus Aureus and Kingella kingae. In radiographic evaluation, intervertebral disk narrowing, lumbar lordosis reduction, loss of disk height, and destruction of the vertebral body have been reported. In all studies, antibiotic therapy was initiated; in 52% immobilization was employed, and 29% of studies reported surgery was performed, and the follow-up period differed from 1.5 months to 156 months. 94% of studies reported complications such as vertebral body destruction, back pain, kyphosis, reduced range of movement, scoliosis, and neurological complications.

CONCLUSION

Spondylodiscitis is an uncommon, heterogeneous, multifactorial disease with resulting difficult and delayed diagnosis. Due to its morbidity, it is essential to investigate children with refusal to walk, gait disturbances, or back pain, particularly when associated with elevated inflammatory markers.

Update on Pediatric Spine Imaging

The spine is often difficult to evaluate clinically in children, increasing the importance of diagnostic imaging to detect a wide variety of spinal disorders ranging from congenital abnormalities to severe infections. Clinical history and physical examination can help determine whether imaging is needed and which imaging technique would be best. The most common cause for back pain, even in children, is muscular strain/spasm that does not require any imaging. However, red flags such as pain at age < 5 years, constant pain, night pain, radicular pain, pain lasting > 4 weeks, or an abnormal neurologic examination may require further investigation. Imaging can be of great value for diagnosis but must be interpreted along with the clinical history, physical examination, and laboratory findings to achieve an accurate diagnosis. We discuss imaging for the most common and/or important spine pathologies in children: congenital and developmental pathologies, trauma, infectious processes, inflammatory causes, and tumors.

Single-cell transcriptomics reveals heterogeneity and intercellular crosstalk in human intervertebral disc degeneration

The complexity of the human intervertebral disc (IVD) has hindered the elucidation of the microenvironment and mechanisms underlying IVD degeneration (IVDD). Here we determined the landscapes of nucleus pulposus (NP), annulus fibrosus (AF), and immunocytes in human IVD by scRNA-seq. Six NP subclusters and seven AF subclusters were identified, whose functional differences and distribution during different stages of degeneration (Pfirrmann I-V) were investigated. We found MCAM⁺ progenitor in AF, as well as CD24⁺ progenitor and MKI67⁺ progenitor in NP, forming a lineage trajectory from CD24⁺/MKI67⁺ progenitors to EffectorNP_⅓ during IVDD. There is a significant increase in monocyte/macrophage (Mφ) in degenerated IVDs (p = 0.044), with Mφ-SPP1 exclusively found in IVDD but not healthy IVDs. Further analyses of the intercellular crosstalk network revealed interactions between major subpopulations and changes in the microenvironment during IVDD. Our results elucidated the unique characteristics of IVDD, thereby shedding light on therapeutic strategies.

A Systematic Review of the Diagnosis and Treatment of Non-Typhoid Salmonella Spondylodiscitis in Immunocompetent Children

The aim of this systematic review is to distinguish the clinical features of immunocompetent children with non-typhoid Salmonella spondylodiscitis and summarize the diagnosis, diagnostic tools, and treatment methods to guide clinicians. The review was conducted according to the preferred PRISMA guidelines. We conducted a literature search in the PubMed, Embase, and Cochrane Library databases. Article screening, data extraction, and study evaluation were performed by two independent reviewers. A total of 20 articles, published between 1977 and 2020, were selected, which included 21 patients with average age of 12.76 years (range, 2-18) without comorbidities; in total, 19% of the patients had positive blood cultures for non-typhoid Salmonella, and 80.9% underwent either CT-guided or open biopsy, which were positive for NTS. All infections were monomicrobial, and 11 different serotypes of non-typhoid Salmonella were identified. Analyzing the reviewed cases, 52.4% of the patients presented with fever, 90.5% had localized pain, and only 19% had gastroenteritis. The most common level of discitis was the lumbar region, especially the L4/L5 level. Primarily, third-generation cephalosporin was administered, and antibiotic treatment was given for an average of 9.6 weeks. Non-typhoid Salmonella spondylodiscitis is a rare clinical entity in healthy and immunocompetent children. The identification of the responsible organism is essential to guide antibiotic therapy and define the treatment duration. A significant limiting factor in this systematic review was the lack of published research articles and case series due to the rarity of the disease.

Evaluation of the metagenomic next-generation sequencing performance in pathogenic detection in patients with spinal infection

Spinal infection is a rarely occurred pathology, whose diagnosis remains a major challenge due to the low sensitivity of culturing techniques. Metagenomic next-generation sequencing (mNGS) is a novel approach to identify the pathogenic organisms in infectious diseases. In this study, mNGS technology was adopted for pathogenic detection in spinal infection from the tissue and pus samples. Additionally, the diagnostic performance of mNGS for spinal infection was evaluated, by comparing it with that of the conventional microbial culture, with the histopathological results as the gold standard. Overall, 56 samples from 38 patients were enrolled for mNGS testing, and 69 samples were included for microbial culture. 30 patients (78.95%) were identified to be positive by the mNGS method, which was higher than that of microbial culture (17, 44.74%). The sensitivity and specificity of mNGS with pus samples were 84.2% and 100.0%, respectively, which outperformed those of microbial culture (42.1% and 100.0%). The pathogen identification results were applied to medication guidance, and all 38 patients experienced favorable outcomes at three months, followed-up post-treatment, without any adverse effects. These findings proved that mNGS was superior to microbial culture in pathogenic identification of the spinal infection, thereby showing great promise in guiding drug administration and improving clinical outcomes.

Surgical treatment in primary spinal infections in a pediatric population: illustrative case

BACKGROUND

Primary spinal infections (PSIs) are a group of uncommon but serious infectious diseases that are characterized by inflammation of the endplate-disc unit. Pediatric spinal infection is rare and challenging to diagnose due to vague presenting symptoms. Most cases are conservatively managed with surgery rarely indicated. The authors performed a systematic review to study the baseline characteristics, clinical presentation, and outcomes of pediatric patients with PSIs who underwent surgical treatment.

OBSERVATIONS

PSI in pediatric patients might behave differently in terms of epidemiology, clinical presentation, and outcomes when compared with nonpediatric patients. Overall, PSI ultimately managed surgically in pediatric patients is associated with a high rate of localized pain, neurological compromise, and treatment failure when compared with nonsurgically managed pediatric spinal infections.

LESSONS

PSIs managed surgically in the pediatric population were found to be caused by Mycobacterium tuberculosis in 74.4% of cases and were associated with higher rates of localized pain, neurological compromise, and treatment failure than nonsurgically managed pediatric spinal infections. Thoracic involvement (71.8%) in the spinal infection was reported most commonly in our review. When omitting the cases involving M. tuberculosis infection, it was revealed that 50% of the pediatric cases involved infection in the cervical region, suggesting increased severity and disease course of cervical spinal infections in the pediatric population. Surgical treatment is indicated only in cases of severe neurological compromise and treatment failure.

Spondylodiscitis in Pediatric Age: A Retrospective Cohort Study

BACKGROUND

Pediatric spondylodiscitis is rare, hardly diagnosed and treated due to the nonspecificity of clinical presentation and laboratory investigations, difficulty of etiologic identification and lack of management guidelines.

METHODS

A retrospective study was conducted on 29 children with spondylodiscitis. Clinical, hematic and radiologic data were collected and compared between 2 age-subgroups (below and from 4 years old on) to investigate age-related differences. Epidemiologic, management and follow-up data were also described.

RESULTS

Slight male predominance and a peak of incidence <2 years were observed. Symptoms were significantly differently distributed in the 2 age-subgroups: children <4 years showed mainly refusal/inability to sit or bear weight, irritability, limping and poor general conditions; children ≥4 years most frequently had back pain and fever, and pain upon palpation of the spine. The lumbar spine and more than 1 vertebra were most frequently involved. Median diagnostic delay of 12 days was observed, without significant difference between age-subgroups, and delay >2 months was always associated with multivertebral involvement and complications. All children were treated with broad-spectrum antibiotics for a median of 12 weeks. Only in 1 complicated case, surgical treatment was also required.

CONCLUSIONS

The clinical presentation of spondylodiscitis may be age-specific, with younger children often exhibiting subtle signs and symptoms. Broad-spectrum antibiotics covering for Staphylococcus aureus should be initiated as soon as possible and performed many weeks, being effective in treating the infection without clinical sequelae, even in patients with comorbidities. Surgical treatment should be reserved for complicated cases with neurologic involvement.

Presumptive bacteriological diagnosis of spondylodiscitis in infants less than 4 years by detecting K. kingae DNA in their oropharynx: Data from a preliminar two centers study

Background and Objectives

Most cases of spondylodiscitis in children aged between 6 and 48 months old could be caused primarily by K. kingae. The present prospective study aimed to determine whether an innovative and indirect diagnosis approach - based on detection of K. kingae DNA in the oropharynx of children with suspected spondylodiscitis - provides sufficient evidence that this microorganism is responsible for the infection.

Methods

We prospectively analysed infants admitted for spondylodiscitis, considering above all the results of PCR realized in oropharyngeal swabs and in blood samples.

Results

Four of the 29 performed K. kingae-specific real-time PCR assay in blood were positive (13.8%), whereas 28 of the 32 K. kingae-specific real-time PCR assay realized on throat swabs were positive (87.5%).

Conclusions

This study demonstrates that performing oropharyngeal swab PCR is able to detect K. kingae in almost 90% of the toddlers with confirmed spondylodiscitis. That provides strong arguments for the hypothesis that K. kingae should be considered as the main aetiological pathogen to suspect in children between 6 and 48 months old with spondylodiscitis. Finally, it seems to us reasonable that oropharyngeal swab may become an early decision-making tool for the indirect identification of K. kingae in spondylodiscitis.

Delayed diagnosis of osteodiscitis in an adolescent athlete: a case report

BACKGROUND

Vertebral osteomyelitis (OM) is an infectious condition of bone caused by an infecting organism, most commonly Staphylococcus aureus (S. aureus). Though rare in adolescents, it is important to remember that this population has vascularized intervertebral discs prior to skeletal maturity and, therefore, is more susceptible to an osteodiscitis infection.

PURPOSE

To determine the possible factors that lead to a delayed diagnosis of osteodiscitis compared to an early diagnosis in an adolescent athlete.

SUMMARY

This case provides a unique example of osteodiscitis in an adolescent rowing athlete where an infected heel blister was the only indication toward a diagnosis. Early diagnosis and successful management of osteodiscitis are dependent on recognizing constitutional and non-constitutional signs and symptoms of infection.

CLINICAL RELEVANCE

In sport, when skin barriers may be compromised more readily, the risk of infection should be considered in the differential diagnosis of unprovoked back pain.

Pediatric back pain-Diagnostic algorithm

BACKGROUND

Back pain in the pediatric population is common. History and a thorough physical examination and a systematic work-up approach are key components to guide the physician in evaluating the possible causes of pain and providing appropriate treatment.

OBJECTIVE

The main aim of this review was to develop an algorithmic approach to assist physicians in the assessment of pediatric back pain. A comprehensive review of prevalence, differential diagnoses and proper management of pediatric back pain are also presented.

MATERIAL AND METHODS

An extensive literature search was performed in PubMed to gather articles on the prevalence, risk factors, diagnostic tools, differential diagnoses and appropriate management of pediatric back pain.

RESULTS

Available literature revealed that pediatric back pain is a common complaint. Although most cases are non-specific and self-limiting, there is a wide differential that should be considered including inflammatory, neoplastic, infectious and mechanical causes. Sedentary lifestyle, obesity and vigorous physical activity have been shown to increase the likelihood of developing back pain. We proposed an algorithm to guide the physician's decision about the next step in the diagnostic process.

CONCLUSION

A well-defined strategy in the diagnostic process is needed in approaching children/adolescents with back pain. This would have the benefit of minimizing costs, unnecessary tests and child/family anxiety as well as increasing the likelihood of early diagnosis and proper treatment.

ACR Appropriateness Criteria® Suspected Spine Infection

Spine infection is both a clinical and diagnostic imaging challenge due to its relatively indolent and nonspecific clinical presentation. The diagnosis of spine infection is based upon a combination of clinical suspicion, imaging evaluation and, when possible, microbiologic confirmation performed from blood cultures or image-guided percutaneous or open spine biopsy. With respect to the imaging evaluation of suspected spine infection, MRI without and with contrast of the affected spine segment is the initial diagnostic test of choice. As noncontrast MRI of the spine is often used in the evaluation of back or neck pain not responding to conservative medical management, it may show findings that are suggestive of infection, hence this procedure may also be considered in the evaluation of suspected spine infection. Nuclear medicine studies, including skeletal scintigraphy, gallium scan, and FDG-PET/CT, may be helpful in equivocal or select cases. Similarly, radiography and CT may be appropriate for assessing overall spinal stability, spine alignment, osseous integrity and, when present, the status of spine instrumentation or spine implants. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The Diagnosis and Management of Pediatric Spine Infections

The management of pediatric spine infections requires a multidisciplinary approach that includes orthopedic surgeons, infectious disease specialists, interventional radiologists, and others. The prevalence of the disease has increased in frequency, virulence, and degree of soft tissue involvement over the past several years; there has also been a resurgence of some types of infections, such as tuberculosis, fungal, and viral pathogens. The diagnosis can often be reached with a detailed history, physical examination, laboratory tests, and imaging studies. Pathologies mimicking infection require a more invasive approach for diagnosis, including core or open biopsy. The treatment of discitis, spondylodiscitis, vertebral osteomyelitis, spinal epidural, and intramedullary abscesses in children is at times complex, and although many infections can be treated non-surgically with antibiotic therapy, some more extensive infections require surgical management. A timely diagnosis is important as it allows the initiation of the appropriate antimicrobial therapy and would decrease the complexity of the subsequent surgical intervention.

Epidemiology and Management of Acute Hematogenous Osteomyelitis, Neonatal Osteomyelitis and Spondylodiscitis in a Third Level Paediatric Center

Acute hematogenous osteomyelitis (AHOM) is a rare pathology in pediatric population. The aim of this study is to analyse the epidemiological data and the management, compared to European Society for Paediatric Infectious Disease (ESPID, European Society for Pediatric Infectious Diseases) guidelines 2017 of 216 children with AHOM, divided in three cohorts (neonatal-onset osteomyelitis, those with vertebral involvement and other types of osteomyelitis). We conducted a retrospective single center study, evaluating data from all the children (aged 0–18 years) consecutively admitted to the Meyer Children’s Hospital, during a period of ten years (1 January 2010–31 December 2019). Isolation of pathogen was possible in 65 patients and S. aureus was the most frequently involved (43/65 children). Magnetic Resonance Imaging (MRI, magnetic resonance imaging) was performed in 201/216 cases and was compatible with osteomyelitis in 185/201 of these children (92.03%). In the neonatal-onset osteomyelitis group the percentage of diagnostic ultrasound for osteomyelitis was 36.36% significantly higher than the other groups. The median duration of total antibiotic therapy was 37.5 days. In total, 186/199 children recovered without complications. The present study delineates three heterogeneous cohorts of patients. S. aureus is confirmed as the first pathogen for isolation in all three groups analysed. MRI represent a gold standard for diagnosis. Longer duration of antibiotics treatment was performed in neonatal and spondylodiscitis group, compared to the other types of osteomyelitis.

THE PROFILE OF POTT’S DISEASE IN A SOUTH AMERICAN REFERENCE SERVICE

ABSTRACT Objective: Tuberculosis (TB) represents one of the top ten causes of death in the world. Its insidious onset and nonspecific symptoms usually result in delayed diagnosis. The objective is to evaluate the characteristics of patients with tuberculous spondylodiscitis in follow-up at a South American reference hospital. Method: Retrospective evaluation of the medical records of patients of both sexes and between 0 and 80 years of age diagnosed with tuberculosis of the spine between 2009 and 2018. The variables were analyzed based on groups: epidemiological, clinical, laboratorial, microbiological, imaging tests and treatment. Results: Total of 26 cases, about 80.8% male, mean age 41.6 ± 22.46 years. Axial pain was the most prevalent symptom (84.6%), the VAS score was 6.85 ± 2.87. The mean time between symptom onset and diagnosis was 23.8 ± 24.1 weeks (4-96). The most affected region was the thoracic spine (50% of the cases). Most participants (61.4%) had no change in neurological function (Frankel D and E) at the beginning of treatment and after 6 months, and 84.5% improved. During treatment 34.6% required surgery and the main indication was isolated neurological deficit (55.5%). The most frequently performed procedure was decompression and arthrodesis (55.5%). The average time to cure was 12.0 ± 8.8 months (8-48). Conclusion: Disease with insidious onset, nonspecific symptoms, high frequency of negative microbiological tests in cases with the disease. A small number of the cases required surgical treatment and most of them achieved good neurological recovery. Level of evidence IV; Case series.

Difficulties in diagnosing vertebral osteomyelitis in a child

Vertebral osteomyelitis is a rare diagnosis and often delayed diagnosis in children. This is a case of a child presenting with fever, back pain and raised C reactive protein who was found to have a Staphylococcus aureus (S.aureus) bacteraemia. Initial imaging with CT, MRI of the spine and abdominal ultrasound failed to demonstrate a vertebral osteomyelitis or identify another source of the bacteraemia. Due to the high clinical suspicion of a spinal source of the infection, second-line investigations were arranged. A bone scan identified an area of increase metabolic activity in the 12th thoracic vertebrae (T12) and subsequently a diagnosis was confirmed with a focused MRI of T12. This serves as an opportunity to discuss the diagnostic difficulty presented by paediatric vertebral osteomyelitis and more generally the need for clinicians to pursue their clinical suspicion in the face of false negative results to make an accurate and timely diagnosis.

A Case of Osteodiscitis in a Preschool-Aged Child

Infectious discitis and osteodiscitis in children are rare. The usual age of occurrence is between two and five years. The diagnosis is most often delayed due to mild presenting symptoms.

We present the case of a five and half year old child who presented with progressively worsening lower back pain over a period of two weeks, which was made worse with bending forward. He did not have fever, pain in his lower extremities, or any other accompanying symptoms. He did not have a history of recent illnesses or trauma to the lower back. The laboratory work revealed an elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), and rest of the parameters were within normal limits. CT scan of his spine showed findings of well-defined defects on the endplates of L4-L5 with prevertebral soft tissue thickening. MRI with and without contrast of the spine confirmed the findings and detected mild focal erosive changes at the opposing endplates of L4-L5 with disc space narrowing, thin fluid along the anterior margin of the disc, and shallow disc bulging, which were consistent with osteodiscitis.

A conservative approach with intravenous antibiotics followed by a switch to oral antibiotics was undertaken with good clinical recovery.

Treatment strategy for osteodiscitis in children is generally antibiotic therapy. Prognosis in children is good. In some cases based on the pain severity, other measures such as bed rest, analgesics, and casting for immobilization may be required. Biopsy tends to be reserved in uncertain cases or in those that have poor response to pain control measures and antibiotics.

Update on Acute Bone and Joint Infections in Paediatrics: A Narrative Review on the Most Recent Evidence-Based Recommendations and Appropriate Antinfective Therapy

Acute bone and joint infections (BJIs) in children may clinically occur as osteomyelitis (OM) or septic arthritis (SA). In clinical practice, one-third of cases present a combination of both conditions. BJIs are usually caused by the haematogenous dissemination of septic emboli carried to the terminal blood vessels of bone and joints from distant infectious processes during transient bacteraemia. Early diagnosis is the cornerstone for the successful management of BJI, but it is still a challenge for paediatricians, particularly due to its nonspecific clinical presentation and to the poor specificity of the laboratory and imaging first-line tests that are available in emergency departments. Moreover, microbiological diagnosis is often difficult to achieve with common blood cultures, and further investigations require invasive procedures. The aim of this narrative review is to provide the most recent evidence-based recommendations on appropriate antinfective therapy in BJI in children. We conducted a review of recent literature by examining the MEDLINE (Medical Literature Analysis and Retrieval System Online) database using the search engines PubMed and Google Scholar. The keywords used were “osteomyelitis”, OR “bone infection”, OR “septic arthritis”, AND “p(a)ediatric” OR “children”. When BJI diagnosis is clinically suspected or radiologically confirmed, empiric antibiotic therapy should be started as soon as possible. The choice of empiric antimicrobial therapy is based on the most likely causative pathogens according to patient age, immunisation status, underlying disease, and other clinical and epidemiological considerations, including the local prevalence of virulent pathogens, antibiotic bioavailability and bone penetration. Empiric antibiotic treatment consists of a short intravenous cycle based on anti-staphylococcal penicillin or a cephalosporin in children aged over 3 months with the addition of gentamicin in infants aged under 3 months. An oral regimen may be an option depending on the bioavailability of antibiotic chosen and clinical and laboratory data. Strict clinical and laboratory follow-up should be scheduled for the following 3–5 weeks. Further studies on the optimal therapeutic approach are needed in order to understand the best first-line regimen, the utility of biomarkers for the definition of therapy duration and treatment of complications.

Paediatric spondylodiscitis: a 10-year single institution experience in management and clinical outcomes

PURPOSE

Discitis in the paediatric population poses diagnostic challenges due to non-specific presenting symptoms and difficulty with expressing pain in non-communicating children. Discitis remains a relatively rare condition in the paediatric population and previous reports are limited to small cohorts. In this article, we report our experience in management of discitis over a 10-year period and review the literature on this topic.

METHODS

We retrospectively reviewed cases of paediatric discitis/spondylodiscitis over a 10-year period between 2008 and 2018 managed in our regional paediatric neurosurgery unit. Relevant demographic information, microbiological data, blood investigation profile, antibiotic treatment duration and clinical outcomes were interrogated from clinical notes and electronic databases and further analysed.

RESULTS

Overall, 21 cases of paediatric discitis were identified from year 2008 to 2018 with a female to male ratio of 1.3:1. The mean age at presentation was 4.3 years (range 1 to 15 years). Overall, there were 19 cases of lumbosacral/lumbar, 1 thoracic and 1 cervical discitis. The mean duration of follow-up was 20 months (range 6 to 69 months). The most common presenting features were back pain and refusal to walk/sit or weight bear. Erythrocyte sedimentation rate (ESR) was found to be more sensitive than C-reactive protein (CRP) (sensitivity 78% versus 38%) in our cohort. Computer tomography (CT)-guided biopsy was performed in five cases and only one of these was positive (20%). All patients were treated with intravenous antibiotics with resolution of discitis.

CONCLUSIONS

Presentation of discitis in children can be non-specific and requires high index of suspicion. CT-guided biopsy in our cohort revealed a low rate of positive cultures. Despite negative blood cultures and CT-guided biopsy results, empirical intravenous antibiotics were effective in treating discitis successfully. In our cohort, low yield of CT-guided biopsy does not support its use on each case and this may be reserved for cases resistant to antimicrobial therapy or concerns regarding other pathology mimicking infection. Better understanding and awareness of this condition and its pathophysiology can lead to timely imaging, diagnosis and treatment.

Pediatric parapharyngeal infection resulting in cervical instability and occipital-cervical fusion-case report and review of the literature

Parapharyngeal infection is the most common deep neck space infection in children and, in rare instances, can result in bony destruction of the cervical spine. We report one such case that required occipital to cervical fusion and halo-vest fixation. We also review the literature and discuss the etiology, diagnosis, and treatment options for managing pediatric cervical bony destruction secondary to infection.

Pyogenic spondylitis and paravertebral abscess caused by Salmonella Saintpaul in an immunocompetent 13-year-old child: a case report

Background

Salmonella spondylitis is an uncommon complication of Salmonella infection in immunocompetent children. To prevent treatment failure and neurological deficits, it needs prompt diagnosis and sufficient effort to identify the causative organism. There are some options to identify the causative organism such as Computed Tomography (CT) guided biopsy or surgical debridement, however when to perform these invasive interventions remains controversial.

Case presentation

A 13-year-old boy presented with occasional high fever and lower back pain. He was diagnosed with spondylitis of the L4–5 vertebral bodies and paravertebral abscess. Initial blood cultures were negative, therefore empirical antibiotic treatment was started. He responded well to conservative management, and was discharged after clinical improvement. However, he was re-hospitalized 2 weeks after discharge, and surgical debridement was performed which led to the detection of Salmonella Saintpaul as the causative pathogen. It was revealed that the possible source of infection was consumption of raw poultry eggs, or contact with poultry. Definitive antibiotic therapy was started. He was discharged with good recovery after a 6-week hospitalization.

Conclusions

This is the very first case report of pyogenic spondylitis caused by Salmonella Saintpaul. Salmonella should be considered as a causative pathogen of pyogenic spondylitis in immunocompetent children. Identifying the causative organism is essential to prevent treatment failure, and a high index of suspicion is needed for prompt diagnosis especially when blood cultures are negative. Invasive interventions such as CT-guided biopsy should be considered even if the clinical course seems to be uncomplicated.

Pediatric spinal infections-a review of non-tuberculous infections

Pediatric spinal infection includes spinal epidural abscess, spondylodiscitis and intradural (extramedullary and intramedullary) spinal infections. However, these entities are extremely rare and no clear guidelines exist for their management. Pertinent literature was searched and a detailed narrative review of this topic is presented.

Spinal infections in children: a multicentre retrospective study

Aims

This multicentre, retrospective study aimed to improve our knowledge of primary pyogenic spinal infections in children by analyzing a large consecutive case series.

Patients and Methods

The medical records of children with such an infection, treated at four tertiary institutions between 2004 and 2014, were analyzed retrospectively. Epidemiological, clinical, paraclinical, radiological, and microbiological data were evaluated. There were 103 children, of whom 79 (76.7%) were aged between six months and four years.

Results

We confirmed a significant male predominance in the incidence of primary pyogenic spinal infections in children (65%). The lumbar spine was the most commonly affected region, and 27 infections (26.2%) occurred at L4/5. The white blood cell count was normal in 61 children (59%), and the CRP level was normal in 43 (42%). Blood cultures were performed in 95 children, and were positive in eight (8%). A total of 20 children underwent culture of biopsy or aspiration material, which was positive in eight (40%). Methicillin-sensitive Staphylococcus aureus (MSSA) and Kingella ( K.) kingae were the most frequently isolated pathogens.

Conclusion

MSSA remains the most frequently isolated pathogen in children with primary pyogenic infection of the spine, but K. kingae should be considered as an important pathogen in children aged between six months and four years. Therefore, an empirical protocol for antibiotic treatment should be used, with consideration being made for the triphasic age distribution and specific bacteriological aetiology. In the near future, the results of polymerase chain reaction assay on throat swabs may allow the indirect identification of K. kingae spondylodiscitis in young children and thus aid early treatment. However, these preliminary results require validation by other prospective multicentre studies. Cite this article: Bone Joint J 2018;100-B:542-8.

Prolonged back pain attributed to suspected spondylodiscitis

Objective: This study aimed at investigating the diagnostic value of 18F-FDG PET/CT in cases of suspected spondylodiscitis after inconclusive results in initial diagnostic imaging. Patients, methods: We analysed 38 consecutive cases of suspected spondylodiscitis (mean age: 67 ± 14 years) with chronic back pain referred to our Department during a fouryear- period after inconclusive results in MRI or other conventional modalities. Clinical histories were retrospectively worked up and results of 18F-FDG PET/CT and MRI were analysed and related to the results of biopsy, blood culture and a one-year clinical followup. 18F-FDG PET/CT was analysed qualitatively by visual analysis and quantitatively. We measured the maximum standardized uptake value (SUVmax) in the region of back pain and in a corresponding reference region (RR) in each patient and calculated a SUVmax-ratio. Results: 22/38 patients had confirmed spondylodiscitis, while 16 were negative. 18F-FDG PET/CT established a correct diagnosis in 34 out of 38 patients by visual analysis. 18F-FDG PET/CT reached a sensitivity, specificity and accuracy of 81.8%, 100%, 89.5% and a PPV and NPV of 100% and 80%. MRI, performed in 27 patients reached a sensitivity, specificity and accuracy of 75%, 71.4%, 74.1% and a PPV and NPV of 88.2% and 50%. Patients with confirmed spondylodiscitis showed a significantly (p < 0.05) higher SUVmax of 5.1 ± 1.9 and SUVmax-ratio of 1.9 ± 0.8 than patients without it (SUVmax (3.8 ± 1.5), SUVmaxratio (1.2 ± 0.3). Conclusion: 18F-FDG PET/CT provided diagnostic information in most patients with chronic back pain and suspected spondylodiscitis. It was helpful in establishing a correct diagnosis in challenging cases of spondylodiscitis with mostly unclear findings in previous MRI.

Spondylodiscitis revisited

Spondylodiscitis may involve the vertebral bodies, intervertebral discs, paravertebral structures and spinal canal, with potentially high morbidity and mortality rates.

A rise in the susceptible population and improved diagnosis have increased the reported incidence of the disease in recent years.

Blood cultures, appropriate imaging and biopsy are essential for diagnosis and treatment.

Most patients are successfully treated by conservative means; however, some patients may require surgical treatment.

Surgical indications include doubtful diagnosis, progressive neurological deficits, progressive spinal deformity, failure to respond to treatment, and unresolved pain.

Cite this article: EFORT Open Rev 2017;2:447–461. DOI: 10.1302/2058-5241.2.160062

Lumbar Spine Osteomyelitis in an Adolescent Girl With Nonspecific Low Back Pain

A 13-year-old adolescent girl presented to the emergency department with low back pain of acute onset after bending forward. Lumbar spine radiographs were taken and found to be unremarkable, and the patient was referred to physical therapy. Following examination, the patient was referred to her physician for a suspected nonmechanical cause. Magnetic resonance imaging assessment revealed L3-4 discitis, with osteomyelitis extending into the adjacent right iliopsoas muscle. Further testing and bone biopsy confirmed osteomyelitis. J Orthop Sports Phys Ther 2017;47(10):814. doi:10.2519/jospt.2017.6883.

[Spondylodiscitis in children and adolescents]

BACKGROUND

Spondylodiscitis in children is rare. The condition has an incidence of 2 to 4 % of all infectious skeletal diseases in children.

AIM

Aim of the article is the presentation of epidemiology, the clinical signs, radiological findings as well the treatment options of non-specific and specific spondylodiscitis in children.

METHODS

The available literature was reviewed.

RESULTS

Non-specific spondylodiscitis in children is caused by haematogenous spread of pathogens. Staphylococcus aureus is the most frequently detected bacterium. The clinical signs are unspecific and an Magnetic Resonance Imaging of the spine is the standard radiological procedure to detect spondylodiscitis. In general, the treatment is conservative and includes an antibiotic therapy as well an immobilization of the spine. In endemic areas of the world, specific spondylodiscitis is more common and is caused by Mycobacterium tuberculosis or Brucellae. The treatment is also conservative. For all entities of spondylodiscitis in children, a surgical intervention is only necessary in the case of severe deformities due to the infection or in the case of neurological symptoms.

CONCLUSION

Elevated infectious laboratory values and back pain or other unspecific symptoms can indicate spondylodiscitis in children. MRI of the spine is necessary to rule out spondylodiscitis.

Pediatric Emergency Magnetic Resonance Imaging: Current Indications, Techniques, and Clinical Applications

MR imaging plays an important role in the detection and characterization of several pediatric disease entities that can occur in the emergent setting because of its cross-sectional imaging capability, lack of ionizing radiation exposure, and superior soft tissue contrast. In the age of as low as reasonably achievable, these advantages have made MR imaging an increasingly preferred modality for diagnostic evaluations even in time-sensitive settings. In this article, the authors discuss the current indications, techniques, and clinical applications of MR imaging in the evaluation of pediatric emergencies.

The Etiology, Clinical Presentation and Long-term Outcome of Spondylodiscitis in Children

BACKGROUND

Spondylodiscitis (SD) is a rare disease in children and diagnosis can be delayed because of the scarcity in incidence and lack of awareness. The purpose of this study was to evaluate and report the microbiologic epidemiology and clinical features of pediatric SD in South Korea.

METHODS

This was a retrospective study of children <19 years old admitted for the treatment of SD between 2000 and 2014. Electronic medical records were reviewed for clinical parameters and etiologic agents.

RESULTS

During the 15-year period, 25 patients were diagnosed with SD. The median age was 13.8 years, and 60% were male. Back pain was the most common presenting symptom (n = 17; 68%), and only 52% (n = 13) of the patients had a history of fever (≥38.0°C). In patients younger than 3 years, irritability (n = 5; 62.5%) was the most predominant symptom. Microorganisms were isolated in 22 cases, the most common being Staphylococcus aureus (40%) and Mycobacterium tuberculosis (32%). Of the 25 patients, 64% (n = 16) had blood cultures taken, 56% (n = 14) underwent percutaneous fluoroscopy-guided biopsy, and 48% (n = 12) underwent open surgical biopsy. The positive rate for microbiologic diagnosis of each method was 18.8% (n = 3) for blood culture, 71.4% (n = 10) for percutaneous biopsy and 100% (n = 12) for surgical biopsy. Overall, 52% (n = 13) needed surgical treatment along with antibiotic therapy. Patients who needed surgery had a significant delay in diagnosis compared with those that did not (median, 60 vs. 31 days; P = 0.014).

CONCLUSIONS

S. aureus and M. tuberculosis are the predominant causes of SD in children in South Korea. Obtaining tissue culture is important to confirm the bacterial etiology of the infection and appropriately guide antibiotic therapy in a community in which the endemic organisms require treatment pathways that are widely divergent.

Evaluation and Diagnosis of Back Pain in Children and Adolescents

Although traditionally it has been accepted that back pain in young children and adolescents most often has an organic etiology, nonorganic back pain in this population is becoming more common. The most common identifiable clinical entities responsible for such pain are spondylolysis, spondylolisthesis, Scheuermann kyphosis, overuse syndromes, disk herniation, apophyseal ring fracture, spondylodiscitis, vertebral osteomyelitis, and neoplasm. Appropriate clinical workup leads to earlier diagnosis and management of back pain and avoids unnecessary cost. Knowledge of the most common diagnoses associated with back pain in children and adolescents and the use of a systematic method to select the appropriate diagnostic tests can help the clinician to minimize costs and maximize the likelihood of making the correct diagnosis and providing appropriate treatment.

Spondylodiscitis associated with button battery ingestion: prompt evaluation with MRI

Spondylodiscitis is a rare complication of unwitnessed button battery ingestion in children. We report a case of a 20-month-old girl who presented to the emergency room 2 weeks after endoscopic removal of unwitnessed, impacted esophageal battery. Delayed presentation of spondylodiscitis after foreign body removal is related to local injury, pressure necrosis, and perforation. The bilaminar shape of an unknown ingested foreign body should alert the treating physician that it might be a battery rather than a coin. Prompt evaluation with magnetic resonance imaging is essential to prevent neurological deficit and/or spinal deformities.

The utility of image-guided percutaneous needle aspiration biopsy for the diagnosis of spontaneous vertebral osteomyelitis: a systematic review and meta-analysis

BACKGROUND CONTEXT

Spontaneous vertebral osteomyelitis (SVOM) is mostly acquired via hematogenous seeding. Diagnosis of SVOM is often delayed because of the insidious nature and rarity of this disease. The microbiological yield of image-guided needle biopsy varies between 36% and 91%. The utility and accuracy of this procedure have not been systematically reviewed.

PURPOSE

To systematically review and assess the diagnostic accuracy of image-guided spinal biopsy for SVOM in adults when compared with combined reference standards.

STUDY DESIGN

A systematic review and meta-analysis.

SAMPLE

Seven retrospective studies involving 482 patients with clinical and/or radiologic suspicion of SVOM who underwent image-guided spinal biopsy were included.

OUTCOME MEASURES

The primary outcome measure was diagnostic odds ratio (DOR). Other outcomes included likelihood ratio of a positive test (LRP), likelihood ratio of a negative test (LRN), sensitivity, and specificity.

METHODS

We searched in six medical databases through September 1, 2013 for studies evaluating the performance of image-guided spinal biopsy for SVOM with no limits on language or publication date. Combined reference standards, which included histopathologic findings consistent with vertebral osteomyelitis, identifications of pathogens from open surgery and/or blood cultures, and/or evidence of clinical and radiologic improvement after empiric antimicrobial therapy, were used for comparison. The random-effect model was used for meta-analysis. Two reviewers independently selected the studies.

RESULTS

Three hundred fifty-eight potentially relevant studies were identified. Seven studies were included in our analysis. Two studies that used only single reference standard were excluded in the sensitivity analysis, and five studies involving 352 patients were pooled. Image-guided spinal biopsy had a DOR of 45.50 (95% confidence interval [CI], 13.66-151.56), an LRP of 16.76 (95% CI, 5.51-50.95), an LRN of 0.39 (95% CI, 0.24-0.64), a sensitivity of 52.2% (95% CI, 45.8-58.5), and a specificity of 99.9% (95% CI, 94.5-100). This is based on the assumption that combined reference standards are a valid standard for comparison.

CONCLUSIONS

Image-guided spinal biopsy is highly specific and performs well in predicting SVOM, but has a moderate accuracy for ruling out this diagnosis. This procedure should be considered in the diagnostic work-up of adults suspected with SVOM.

Spinal infection: state of the art and management algorithm

INTRODUCTION

Spinal infection is a rare pathology although a concerning rising incidence has been observed in recent years. This increase might reflect a progressively more susceptible population but also the availability of increased diagnostic accuracy. Yet, even with improved diagnosis tools and procedures, the delay in diagnosis remains an important issue. This review aims to highlight the importance of a methodological attitude towards accurate and prompt diagnosis using an algorithm to aid on spinal infection management.

METHODS

Appropriate literature on spinal infection was selected using databases from the US National Library of Medicine and the National Institutes of Health.

RESULTS

Literature reveals that histopathological analysis of infected tissues is a paramount for diagnosis and must be performed routinely. Antibiotic therapy is transversal to both conservative and surgical approaches and must be initiated after etiological diagnosis. Indications for surgical treatment include neurological deficits or sepsis, spine instability and/or deformity, presence of epidural abscess and upon failure of conservative treatment.

CONCLUSIONS

A methodological assessment could lead to diagnosis effectiveness of spinal infection. Towards this, we present a management algorithm based on literature findings.

A special case of lower back pain in a 3-year-old girl

We describe the case of a 3-year-old girl with a 15-day clinical history of lower back pain. We diagnosed a spondylodiscitis of vertebral bodies L5-S1 caused by Salmonella species group B that totally recovered with appropriate antibiotic therapy. Spondylodiscitis in children is a rare condition and Salmonella infection is one of the rarest aetiology. A high index of suspicion is needed for prompt diagnosis to ensure better long-term outcome. Microbiological diagnosis is essential for the appropriate choice of antibiotic treatment.

A toddler who refused to stand or walk: lumbar spondylodiscitis

A young mother presented her 19-month-old boy to the general practitioner (GP) with a 24 h history of reluctance to stand or walk and a slightly raised temperature. The GP arranged an assessment by the paediatrician, who organised an ultrasound of the hips which was normal. Approximately 1 week later the patient became constipated as well, was seen again by another GP but no cause was found. Another week later mother consulted the initial GP again as the boy had not shown any signs of improvement and had become more irritable. The GP arranged a review by the paediatrician and MRI scans of the hips and back were performed. These scans showed normal hips but lumbar spine changes suggestive of a spondylodiscitic event. The patient was treated with intravenous antibiotics, a corset and analgesia and made an excellent recovery.