Vertebral osteomyelitis without disc involvement

The utility of disc space and vertebral body specimens cell count differential for the diagnosis of native vertebral osteomyelitis: a prospective cohort study

BACKGROUND

Diagnostic methods for native vertebral osteomyelitis (NVO) often yield inconclusive results. Image-guided spine biopsies for culture are specific but diagnose NVO in only 50% of cases. Pre-exposure to antimicrobials further reduces diagnostic yield. Our study assesses the value of neutrophil percentage in disc space fluid and vertebral body (DS/VB) samples for diagnosing NVO.

METHODS

Adults referred for spine biopsy at Mayo Clinic from August 2022 to September 2023 were consented and enrolled at the time of biopsy. Following routine specimen collection, the biopsy needle was rinsed in saline into an EDTA tube for cell analysis. NVO diagnosis required organism identification in spine tissue or blood and/or positive histopathology, and consistent symptoms and imaging.

RESULTS

Sixty-eight patients were prospectively enrolled, comprising 14 with NVO and 54 with alternative diagnoses. The median biopsy sample polymorphonuclear (PMN) percentage for NVO patients was 80.5% (IQR 72.5-85.2), compared to 64.5% (IQR 54.0-69.0) for those without NVO (p < 0.001). Nine (64.3%) NVO patients received antibiotics within 10 days prior to spine biopsy. As a continuous measure, PMN differential showed a moderately strong ability in classifying NVO status with an area under ROC curve of 0.795; an optimal point on the curve of 71.5% corresponded to a sensitivity of 78.6%, specificity of 79.6%, negative predictive value of 93.5% and positive predictive value of 50.0%.

CONCLUSION

PMN differential in DS/VB biopsies may serve as an effective diagnostic tool in the evaluation of patients with NVO particularly in ambiguous cases with an initially negative spine biopsy. Future efforts will aim to implement these findings within routine clinical practice.

Imaging of Spondylodiscitis: A Comprehensive Updated Review-Multimodality Imaging Findings, Differential Diagnosis, and Specific Microorganisms Detection

Spondylodiscitis is defined by infectious conditions involving the vertebral column. The incidence of the disease has constantly increased over the last decades. Imaging plays a key role in each phase of the disease. Indeed, radiological tools are fundamental in (i) the initial diagnostic recognition of spondylodiscitis, (ii) the differentiation against inflammatory, degenerative, or calcific etiologies, (iii) the disease staging, as well as (iv) to provide clues to orient towards the microorganisms involved. This latter aim can be achieved with a mini-invasive procedure (e.g., CT-guided biopsy) or can be non-invasively supposed by the analysis of the CT, positron emission tomography (PET) CT, or MRI features displayed. Hence, this comprehensive review aims to summarize all the multimodality imaging features of spondylodiscitis. This, with the goal of serving as a reference for Physicians (infectious disease specialists, spine surgeons, radiologists) involved in the care of these patients. Nonetheless, this review article may offer starting points for future research articles.

Dysphagia Secondary to Myotonic Dystrophy Unveiled in a Case of Destructive Spondylitis With Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis (SAPHO) Syndrome Presenting As Torticollis

To report an instructive case involving destructive spondylitis and synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) syndrome, presenting with torticollis and postoperative dysphagia without hoarseness, attributed to hidden myotonic dystrophy (DM). A 51-year-old male patient with a cervical deformity, who was previously managed conservatively for a metastatic tumor, underwent reconstruction surgery and subsequently experienced postoperative dysphagia. The presence of destructive spondylitis with torticollis, warranting prompt assessment to prevent paralysis, adds complexity to the delayed identification of DM. Given the rarity of DM, peculiar neurological symptoms and other systemic comorbidities did not lead to a preoperative diagnosis without prior knowledge. The patient's dysphagia induced respiratory arrest and required reintubation. Challenges in extubation and ventilator weaning arose due to hypercapnia. Superimposed COVID-19 infection elongated the duration of intubation. Extubation failed due to aspiration pneumonia and required a tracheotomy. Despite laryngeal elevation and preservation of the relaxation of the oesophageal entrance, the sensation and movement of the tracheopharynx were disturbed. The patient exhibited an oropharyngeal propulsive disorder, predominantly indicative of motor neuron disease. The patient's mother stated that his brother had been hospitalized for a long time after abdominal surgery. Finally, the patient was diagnosed with DM, which is known to cause post-anesthetic dysphagia. Recognizing the existence of severe destructive cervical spondylitis associated with SAPHO is crucial. Although DM is not very common, it is not classified as extremely rare. Therefore, surgeons should be mindful of the potential risks associated with general anesthesia in patients with DM. The complexity of preoperative conditions may hinder an accurate diagnosis. Recognizing and establishing preoperative expectations can assist surgeons in preventing complications, even if complex spinal surgery is required for patients with DM.

Osteomyelitis of the spine: treatments and future directions

BACKGROUND

Osteomyelitis of the spine is a serious condition that has been increasing with the intravenous drug pandemic and aging population. Multiple different organisms can cause osteomyelitis and mainstay of treatment is early recognition and antibiotics. The course can sometimes be indolent leading to delayed presentations. Once suspected, comprehensive workup and initiation of management should be employed. In rare circumstances, surgical evacuation or deformity correction is indicated. Continued antibiotic treatment should be considered post-operatively.

METHODS

Emerging treatment solutions are being developed to help target osteomyelitis in a more effective manner. In this review, we highlight the epidemiology and pathophysiology of spinal osteomyelitis. We overview the diagnostic workup and treatment options. Finally, we present new options that are currently being investigated and are on the near horizon.

CONCLUSION

This review offers a user friendly resource for clinicians and researchers regarding osteomyelitis of the spine and will serve as a catalyst for further discovery.

Spine Infections: the role of Fluorodeoxyglucose Positron Emission Tomography (FDG PET) in the context of the actual diagnosis guideline

Spondylodiscitis is an infectious process that requires numerous health care professionals to be clearly diagnosed and eventually successfully treated. It implies a variety of microbiological agents and conditions; during the diagnostic workup, it is difficult to correctly identify them, and the clinician has to rapidly choose the correct treatment to avoid permanent injuries to the patient. In this context, we conducted a review to better understand the most suitable use of Positron Emission Tomography with 18-Fluoro-deossi-glucose (FDG PET) in a patient suspected of spondylodiscitis, based on current guidelines and literature.. We wanted to review the role of FDG PET in the spondylodiscitis diagnosis and follow up in the context of the current guidelines.

Microbiology and epidemiology of infectious spinal disease

Objective

Infectious spinal disease is regarded as an infection by a specific organism that affects the vertebral body, intervertebral disc and adjacent perivertebral soft tissue. Its incidence seems to be increasing as a result of larger proportion of the older patients with chronic debilitating disease, the rise of intravenous drug abuser, and the increase in spinal procedure and surgery. In Korea, studies assessing infectious spinal disease are rare and have not been addressed in recent times. The objectives of this study are to describe the epidemiology of all kind of spinal infectious disease and their clinical and microbiological characteristics as well as to assess the diagnostic methodology and the parameters related to the outcomes.

Methods

A retrospective study was performed in all infectious spinal disease cases presenting from January 2005 to April 2010 to three tertiary teaching hospitals within a city of 1.5 million in Korea. Patient demographics, risk factors, clinical features, and outcomes were assessed. Risk factors entailed the presence of diabetes, chronic renal failure, liver cirrhosis, immunosuppressants, remote infection, underlying malignancy and previous spinal surgery or procedure. We comparatively analyzed the results between the groups of pyogenic and tuberculous spinal infection. SPSS version 14 statistical software was used to perform the analyses of the data. The threshold for statistical significance was established at p<0.05.

Results

Ninety-two cases fulfilled the inclusion criteria and were reviewed. Overall, patients of tuberculous spinal infection (TSI) and pyogenic spinal infection (PSI) entailed 20 (21.7%) and 72 (78.3%) cases, respectively. A previous spinal surgery or procedure was the most commonly noted risk factor (39.1%), followed by diabetes (15.2%). The occurrence of both pyogenic and tuberculous spondylitis was predominant in the lumbar spine. Discs are more easily invaded in PSI. At initial presentation, white cell blood count and C-reactive protein levels were higher in PSI compared to TSI (p<0.05). Etiological agents were identified in 53.3%, and the most effective method for identification of etiological agents was tissue culture (50.0%). Staphyococcus aureus was the most commonly isolated infective agent associated with pyogenic spondylitis, followed by E. coli. Surgical treatment was performed in 31.5% of pyogenic spondylitis and in 35.0% of tuberculous spondylitis cases.

Conclusion

Many previous studies in Korea usually reported that tuberculous spondylitis is the predominant infection. However, in our study, the number of pyogenic infection was 3 times greater than that of tuberculous spinal disease. Etiological agents were identified in a half of all infectious spinal disease. For better outcomes, we should try to identify the causative microorganism before antibiotic therapy and make every effort to improve the result of culture and biopsy.

Cervical spinal brucellosis with epidural abscess causing neurologic deficit with negative serologic tests

BACKGROUND

Here we present a case of cervical spinal epidural abscess causing neurologic deficits despite negative serologic tests.

CASE DESCRIPTION

Unlike a previously reported case, blood cultures and serologic tests were negative for this 50-year-old male with cervical brucellar spondylodiscitis and neurologic deficits. The diagnosis was made based on magnetic resonance imaging (MRI) findings and tissue culture. We drained the epidural abscess, performed anterior cervical discectomy fusion with an iliac strut bone graft, and administered antimicrobial therapy (gentamicin and doxycycline). At the 1-year follow-up visit, a C-spine lateral plain radiograph revealed solid fusion achieved by autogenous strut bone grafting at C4-C5 and C5-C6, and a T2-weighted image showed that epidural abscess and granulation tissue causing spinal cord compression were absent. In addition, the patient had recovered from all of the neurologic deficits with the exception of voiding difficulty.

CONCLUSION

It is important for clinicians to consider brucellar cervical spondylodiscitis when an epidural abscess is identified in a patient with a history of potential exposure. We recommend both blood and tissue cultures for diagnosis when serologic tests are negative.

Spondylodiscitis: update on diagnosis and management

Spondylodiscitis, a term encompassing vertebral osteomyelitis, spondylitis and discitis, is the main manifestation of haematogenous osteomyelitis in patients aged over 50 years. Staphylococcus aureus is the predominant pathogen, accounting for about half of non-tuberculous cases. Diagnosis is difficult and often delayed or missed due to the rarity of the disease and the high frequency of low back pain in the general population. In this review of the published literature, we found no randomized trials on treatment and studies were too heterogeneous to allow comparison. Improvements in surgical and radiological techniques and the discovery of antimicrobial therapy have transformed the outlook for patients with this condition, but morbidity remains significant. Randomized trials are needed to assess optimal treatment duration, route of administration, and the role of combination therapy and newer agents.

Eosinophilia and multifocal vertebral involvement with Hodgkin lymphoma

Patients with Hodgkin lymphoma (HL) usually present with lymphadenopathies. Osseous involvement at presentation is extremely rare. Occurrence of both eosinophilia and osseous involvement has not been reported frequently. We present an adolescent female complaining of lower back pain for 6 months, in whom, multifocal vertebral involvement and peripheral blood eosinophilia preceded the final diagnosis of HL.

Spondylodiscitis associated with multiple level involvement and negative microbiological tests: an unusual case

STUDY DESIGN

A case report.

OBJECTIVE

To report an unusual case of spondylodiscitis with multiple level involvement.

SUMMARY OF BACKGROUND DATA

Spondylodiscitis, an infection of the intervertebral disc space, vertebral bodies, or the paraspinal epidural space can be a serious disease because of diagnostic delay and inadequate treatment.

METHODS

A previously healthy, 52-year-old man was presented to our outpatient clinic with a complaint of acute, atraumatic onset of severe back pain for more than 1 month. Initially, he was misdiagnosed at another clinic as myofascial pain and treated with nonsteroidal anti-inflammatories and physical therapy, which he did not benefit from. He never complained of fever; however, laboratory tests revealed raised erythrocyte sedimentation values, increased C-reactive protein values but normal leukocyte count. Thoracal and lumbal plain radiographs were nonspecific. Magnetic resonance imaging demonstrated increased signal intensity in vertebral bodies and intervertebral disc space through T12-L4 and in the paravertebral musculature at L2-L3 with contrast enhancement. Blood cultures and computed tomography-guided needle biopsy and cultures were negative.

RESULTS

The patient was treated with oral amoxicillin and clavulanate and responded very well clinically; however, imaging examinations were repeated up to 6 months because of multilevel involvement. Follow-up magnetic resonance imaging findings at 3 months and 6 months showed decreased signal intensity, and luckily, there was no evidence of vertebral destruction.

CONCLUSION

Diagnosis of spondylodiscitis could be challenging and commonly missed; however, it should always be included in the differential diagnoses of back pain in the middle aged and healthy population.

Spinal involvement in chronic recurrent multifocal osteomyelitis (CRMO) in childhood and effect of pamidronate

There are only a few studies that address the frequency and type of spinal involvement in patients with chronic recurrent multifocal osteomyelitis (CRMO) as well as the outcome of these patients treated with pamidronate (PAM). We performed a retrospective study on patients with CRMO and analyzed clinical and pain assessments as well as regional and whole body MRI findings and compared with posttreatment findings. Of 102 children and adolescents with CRMO, 27 (26%) had involvement of the spine. Vertebral deformities were seen in 14 of these 27 patients, scoliosis or kyphosis in 6. After routine whole body MRI, 19 complained of back pain, whereas eight were asymptomatic with spinal lesions detected incidentally. A total of 72 spinal lesions were detected, thoracic vertebrae being the most commonly affected. Seven patients were treated with PAM; all of whom had vertebral deformities and ongoing back pain. Pain resolution was achieved within 3 months of PAM treatment in every case. One patient subsequently developed a pain amplification syndrome. Repeat MRI performed at a mean interval of 13 months revealed partial or complete resolution of vertebral hyperintensities in every patient. Improvement of vertebral height was seen in a total of three vertebrae in two patients. Severe side effects were not observed. In conclusion, we demonstrated that spinal involvement and associated vertebral deformities with or without kyphoscoliosis are not rare in CRMO, and PAM appears to be an effective and safe treatment for this condition. Although controlled studies are urgently needed, the use of PAM for refractory CRMO with extended spinal involvement (vertebral deformities, kyphosis, and scoliosis) should be considered, especially after failing of conventional therapy.

Hodgkin's lymphoma masquerading as vertebral osteomyelitis in a man with diabetes: a case report

INTRODUCTION

Infection and malignancy often have common characteristics which render the differential diagnosis for a prolonged fever difficult. Imaging and tissue biopsy are crucial in making a correct diagnosis, though differentiating between chronic osteomyelitis and malignancy is not always straightforward as they possess many overlapping features.

CASE PRESENTATION

A 52-year-old Caucasian man was treated with antibiotics for his diabetic foot infection after a superficial culture showed Staphylococcus aureus. He had persistent fevers for several weeks and later developed acute onset of back pain which was treated with several courses of antibiotics. Radiographic and pathological findings were atypical, and a diagnosis of Hodgkin's lymphoma was made 12 weeks later.

CONCLUSION

Clinicians should maintain a suspicion for Hodgkin's lymphoma or other occult malignancy when features of presumed osteomyelitis are atypical. Chronic vertebral osteomyelitis in particular often lacks features common to acute infectious disease processes, and the chronic lymphocytic infiltrates seen on histopathology have very similar features to Hodgkin's lymphoma, highlighting a similar inflammatory microenvironment sustained by both processes.

Pseudomonas mendocina spondylodiscitis: A case report and literature review

Pseudomonas mendocina is rarely recovered as a human pathogen. Only 2 human cases have been reported in the literature. Here, we report the third human case and possibly the first 1 to involve spinal infection caused by such an unusual bacterium.

Garré's chronic diffuse sclerosing osteomyelitis of the sacrum: a rare condition mimicking malignancy

Garré's chronic diffuse sclerosing osteomyelitis (DSOM) is a rare disease that occurs most commonly in the mandible. We present a case of sacral DSOM that simulated an expanding destructive sacral tumour. Treatment was conducted on the basis of the available experience with the mandibular form of the disease, with partial symptomatic relief, but progressive sclerosis of the sacral lesion. To the best of our knowledge, this is the first case initially presenting in the sacrum. As an osteolytic expanding lesion simulating malignancy, it is important to recognize this entity in the sacrum.

Thoracic vertebral osteomyelitis secondary to chronic esophageal perforation

BACKGROUND CONTEXT

Osteomyelitis secondary to perforation of the esophagus is a rare condition. Thoracic osteomyelitis after chronic esophageal perforation has never been described in the literature.

PURPOSE

We report a case of vertebral osteomyelitis resulting from a chronic esophageal perforation.

STUDY DESIGN/SETTING

Case report/University hospital.

METHODS

A 52-year-old woman presented with dysphagia, severe mid back, and epigastric pain over a 6-week period. Endoscopic and radiological investigations revealed the presence of a paraspinal inflammatory mass protruding into the posterior esophageal wall. Two weeks after admission, the patient developed septic complications which required surgical intervention. This revealed the presence of an esophageal perforation and osteomyelitis of the T4-T5 and T7-T8 vertebrae. After T-tube closure of the esophageal perforation along with surgical debridement of the vertebrae and a 6-week course of antibiotics, the patient made a sound recovery. However, there was persistence of back pain with exaggerated thoracic spine kyphosis at T7-T8 which needed thoracic spine stabilization with pedicle screw instrumentation and fusion.

RESULTS

This treatment led to complete recovery with no recurrence of symptoms at 8-months' follow-up.

CONCLUSIONS

To date this is the first case of thoracic osteomyelitis secondary to a chronic esophageal perforation to be reported in the literature. A high index of suspicion of this diagnosis is warranted in patients who present with similar clinical and radiological findings to enable prompt diagnosis and avoid the high mortality of esophageal perforation.

SAPHO syndrome with rapidly progressing destructive spondylitis: two cases treated surgically

The authors present two cases of synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome with rapidly progressing destructive spondylitis treated surgically. The spinal lesions in SAPHO syndrome generally have a good prognosis and rarely cause the structural destruction or neurological deterioration. Case 1: a 63-year-old female had palmoplantar pustulosis for 2 years. At first, she only felt a pain in the nape with no inducing factor. Two months later, she had incomplete quadriplegia (ASIA scale C). Magnetic resonance imaging showed destruction of C4-C7, kyphotic deformity, and severe compression of the spinal cord. Decompression and reconstruction surgery using anterior and posterior approach improved her paralysis. Case 2: a 69-year-old female complained of persistent back pain. Magnetic resonance imaging revealed spondylitis of T7-T9. Although there were no typical skin lesions, we diagnosed SAPHO syndrome by hyperostosis of the sternocostoclavicular joint and sacral joint. Destruction with kyphotic deformity of the spine progressed gradually for 3 months. Curettage and reconstruction surgery using thoracic endoscope relieved her pain and prevented the destruction of the spine. The histopathology of the specimen obtained surgically showed non-specific inflammation in both cases. Spondylitis in SAPHO syndrome may cause severe destruction and kyphotic deformity followed by paralysis.

Advanced Multifocal Tuberculous Spondylitis without Disk Involvement and with Multidrug-Resistant Bacilli

In this brief report, we describe a 23-year-old immunocompetent Nigerian patient with extensive multifocal tuberculous spondylitis without disk involvement. Cultures of sputum samples and biopsy samples from the L4 vertebra were positive for tuberculosis; drug-susceptibility testing of the isolates revealed multidrug resistance. Treatment with second-line drugs resulted in an excellent interim outcome after 6 months, without the need for surgical intervention.

Magnetic resonance imaging of spinal infection

This article reviews the pathophysiology of spinal infection and its relevance for imaging. Magnetic resonance imaging (MRI) is the modality with by far the best sensitivity and specificity for spinal infection. The imaging appearances of spinal infection in MRI are outlined, and imaging techniques are discussed. The problems of clinical diagnosis are outlined. There is some emphasis on the MRI differentiation of pyogenic and nonpyogenic infection and on the differential diagnosis of spinal infection centered on the imaging presentation.

The Incidence of Multiple Level Noncontiguous Vertebral Tuberculosis Detected Using Whole Spine MRI

The commonest site of osseous tuberculosis is the spine. Most vertebral lesions are contiguous. Current research indicates the incidence of multiple level noncontiguous vertebral tuberculosis is 1.1% to 16%. The aim of this study was to identify the incidence of multiple level noncontiguous vertebral tuberculosis using whole spine magnetic resonance imaging (MRI). A retrospective review was undertaken of case notes and whole spine MRI studies of all acute spinal infection cases that presented to a regional Spinal Unit over 3 years. Patients were included if spinal infection was identified by whole spine MRI and confirmed as tuberculosis by a combination of histology and microbiology. The incidence of multiple level noncontiguous vertebral tuberculosis was 71.4%. This is higher than previously quoted when MRI is not undertaken. Tuberculosis may affect the spine at multiple noncontiguous sites more frequently than thought previously. A large proportion of the affected noncontiguous sites may also be asymptomatic. We currently perform whole spine MRI on all patients with suspected spinal infection to aid detection of multiple level noncontiguous tuberculosis.

Vertebral Osteomyelitis

Vertebral osteomyelitis (VO) is an infectious disease of the vertebral body that requires early diagnosis with identification of the infecting organism to direct antibiotic therapy. Most VO can be treated nonsurgically, but 10% to 20% of cases require open surgical treatment. Excellent clinical outcomes can be achieved with appropriate medical and surgical treatment.

Vertebral collapse in an 8-year-old girl

We present a case of an 8-year-old girl with collapse of her T6 and T7 vertebrae secondary to chronic recurrent multifocal osteomyelitis. She presented with chronic abdominal pain and was found to have multiple bony lesions involving her spine, clavicle and mandible. Extensive investigations, including tissue biopsy, were unable to identify an infective cause and there was no response to a prolonged course of intravenous antibiotics. She made a good response to regular non-steroidal anti-inflammatory medication.

Imaging of infectious spinal disorders in children and adults

The aim of this review article is to outline the imaging of infectious disorders of the spine in adults and children. The clinical presentation, potential routes of infection and the pathogens commonly identified are discussed. The value of different imaging modalities in the diagnosis of spinal infection is presented including radiographic, CT, MR imaging and Nuclear Medicine including PET. The use of image guided techniques for diagnosis and subsequent treatment is briefly covered. The major differential diagnoses of infectious disorders of the spine are identified and contrasted with the typical findings in infection. The use of follow up imaging is evaluated.