Non-pyogenic infections of the spine

Magnetic resonance imaging features for differentiating tuberculous from pyogenic spondylitis: a meta-analysis

OBJECTIVE

To perform a meta-analysis comparing the MRI features of tuberculous and pyogenic spondylitis, using histopathological results and/or blood culture as the standard reference.

MATERIALS AND METHODS

PubMed, Embase, Web of Science, and Cochrane Library were searched for English-language studies on the MRI features of tuberculous and pyogenic spondylitis published between January 2010 and February 2023. Risk for bias and concerns regarding applicability were assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Pooled MRI features' proportions were calculated using a bivariate random-effects model.

RESULTS

Thirty-two studies met the inclusion criteria: 21 for tuberculous spondylitis, three for pyogenic spondylitis, and eight for both. Of the nine informative MRI features comparing tuberculous spondylitis to pyogenic spondylitis, involvement of ≥ 2 vertebral bodies (92% vs. 88%, P = .004), epidural extension (77% vs. 25%, P < .001), paravertebral collection (91% vs. 84%, P < .001), subligamentous spread (93% vs. 24%, P < .001), thin and regular abscess wall (94% vs. 18%, P < .001), vertebral collapse (68% vs. 24%, P < .001), and kyphosis (39% vs. 3%, P < .01) were more suggestive of tuberculous spondylitis, while disc signal change (82% vs. 95%, P < .001) and disc height loss (22% vs. 59%, P < .001) were more suggestive of pyogenic spondylitis.

CONCLUSION

Involvement of ≥ 2 vertebral vertebral bodies, soft tissue attribution, thin and regular abscess wall, vertebral collapse, and kyphosis were MRI features more common in tuberculous spondylitis, while disc signal change and height loss were more common in pyogenic spondylitis.

Spinal infection caused by Aspergillus flavus in a diabetic: a case report and literature review

Spinal infections, notably those induced by Aspergillus flavus (A. flavus), represent a complex and uncommon clinical challenge. In individuals with diabetes mellitus, the risk is exacerbated due to a compromised immune response and a heightened vulnerability to non-standard pathogens. This case report chronicles the intricate diagnostic and treatment journey of a 59-year-old diabetic patient grappling with a spinal infection attributed to A. flavus. The diagnosis was delayed due to non-specific symptoms and unclear radiological signs. The administration of voriconazole, a targeted antifungal treatment, resulted in a significant clinical and radiological improvement, underscoring its effectiveness in treating such unusual fungal spinal infections; meanwhile, we found that terbinafine hydrochloride also has a similar effect in treating fungal spinal infections. This case underscores the importance of considering fungal causes in spinal infections among diabetic patients and highlights prompt diagnosis and individualized targeted antifungal therapy.

Development of a Diagnostic Model for Differentiating Tuberculous Spondylitis and Pyogenic Spondylitis With MRI: A Multicenter Retrospective Observational Study

STUDY DESIGN

Multicenter retrospective observational study.

OBJECTIVE

This study aimed to distinguish tuberculous spondylitis (TS) from pyogenic spondylitis (PS) using magnetic resonance imaging (MRI). Further, a novel diagnostic model for differential diagnosis was developed.

SUMMARY OF BACKGROUND DATA

TS and PS are the two most common spinal infections. Distinguishing between these types clinically is challenging. Delayed diagnosis can lead to deficits or kyphosis. Currently, there is a lack of radiology-based diagnostic models for TS and PS.

METHODS

We obtained radiologic images from MRI imaging of patients with TS and PS and applied the least absolute shrinkage and selection operator regression to select the optimal features for a predictive model. Predictive models were built using multiple logistic regression analysis. Clinical utility was determined using decision curve analysis, and internal validation was performed using bootstrap resampling.

RESULTS

A total of 201 patients with TS (n=105) or PS (n=96) were enrolled. We identified significant differences in MRI features between both groups. We found that noncontiguous multivertebral and single-vertebral body involvement were common in TS and PS, respectively. Vertebral bone lesions were more severe in the TS group than in the PS group (Z=-4.553, P <0.001). The patients in the TS group were also more prone to vertebral intraosseous, epidural, and paraspinal abscesses ( P <0.001). A total of 8 predictors were included in the diagnostic model. Analysis of the calibration curve and area under the receiver operating characteristic curve suggested that the model was well-calibrated with high prediction accuracy.

CONCLUSIONS

This is the largest study comparing MRI features in TS and PS and the first to develop an MRI-based nomogram, which may help clinicians distinguish between TS and PS.

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.

A Comprehensive Review of Pyogenic Spondylitis Management for Neurosurgeons

Older populations have been increasing recently, resulting in an increase in cases of pyogenic spondylitis. Neurosurgeons who frequently treat the elderly are at a higher risk of encountering this condition. Therefore, this article provides a summary of the literature and our experience to help neurosurgeons effectively manage pyogenic osteomyelitis. It is important not to rule out pyogenic spondylosis when examining a patient with back pain, even in the absence of a fever. This is because the chronic type is common, easily overlooked, and early diagnosis and treatment are crucial. Empirical antibiotics should be avoided in cases where blood culture and biopsy are negative, to prevent microbial resistance and an increase in difficult-to-treat cases. Biopsies, such as computed tomography-guided percutaneous biopsy and full endoscopic debridement and drainage, should be attempted. Currently, 6 weeks of parenteral antibiotic therapy is the main treatment for pyogenic spondylitis. Surgical treatment is recommended if this method is ineffective. However, in the early stages, full endoscopic debridement and drainage and percutaneous pedicle screw fixation are optional.

[Spondylodiscitis]

Spondylodiscitis is a severe infectious disease of the spine that affects the intervertebral discs and adjacent vertebrae. It can lead to nonspecific pain, limited mobility, and destruction of spinal structures. Various pathogens, such as bacteria, fungi, or parasites, can trigger the disease. An early diagnosis and targeted treatment are crucial to reduce the risk of serious complications. Magnetic resonance imaging (MRI) with contrast agent and blood tests are essential for the diagnosis and assessing the course of the disease. The treatment includes conservative and surgical approaches. Conservative treatment consists of a minimum 6‑week antibiotic course and immobilization of the affected area. Surgical interventions, along with several weeks of antibiotic therapy, are indicated for instabilities or complications in order to eliminate the infection focus and to restore spinal stability.

Fungal Arthritis of a Lumbar Facet Joint Because of Candida albicans: A Case Report

CASE

A 73-year-old man who was treated in our hospital for pyelonephritis because of left ureteral stones and fungemia was referred to our orthopaedic department for persistent right lower-back pain. Magnetic resonance imaging and computed tomography findings showed pyogenic arthritis of the right L4/5 facet joint with a paraspinal muscle abscess. Based on cultures of samples aspirated from the lesions, we diagnosed the patient with fungal arthritis of the lumbar facet joint. We treated him conservatively with an antifungal agent for a year, and the infection resolved.

CONCLUSION

This is the first report of hematogenous fungal arthritis of a lumbar facet joint.

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.

Atlantoaxial instability and cervical noninfectious spondylodiscitis in a patient with Wegener’s granulomatosis: A case report

A 61‐year‐old male patient with Wegener's granulomatosis was admitted due to neck pain and quadriparesis. Clinical evaluation showed severe cervical noninfectious spondylodiscitis, myelopathy, sagittal imbalance, and atlantoaxial instability. A combined anterior and posterior approach was implemented. Postoperative clinical evaluation showed improved neurologic status.

Klebsiella Discitis in a 15-Year-Old Male Diagnosed With Plasma Microbial Cell-Free DNA Next-Generation Sequencing Test: A Case Report

Spinal discitis (SD) is a rare condition, particularly in the pediatric population. The course of SD may be acute or chronic, and the non-specificity of symptoms leads to great delays in diagnosis. The most commonly isolated causative organism is Staphylococcus aureus whereas gram-negative infections are hardly ever reported in the literature. Comorbidities that increase the risk of bacteremia such as diabetes, chronic kidney disease, HIV, and cancer are major risk factors for SD. Hereby, we present an atypical case of SD in a previously healthy 15-year-old male with an unusual organism, Klebsiella aerogenes, diagnosed by plasma microbial cell-free DNA with negative blood cultures. The clinical course was complicated by antibiotic resistance and subsequent development of a ventral epidural abscess requiring readmission followed by surgical drainage of the abscess with a prolonged course of antibiotics.

[Common infectious challenges of the thoracic and lumbar spine : Spondylodiscitis and postoperative wound infection]

Spondylodiscitis and postoperative wound infections are the most frequent infectious diseases of the thoracic and lumbar spine. Every spinal surgeon will come into contact with such patients during his or her career. Knowledge particularly of the diagnostics, conservative and surgical treatment as well as microbiological considerations of antibiotic treatment are therefore of particular importance and are explained in this article.

Case Report: SARS-CoV-2 Infection-Are We Redeemed? A Report of Candida Spondylodiscitis as a Late Complication

Background: We describe a case of candida spondylodiscitis secondary to coronavirus disease (COVID-19). Case report: A 47-year-old man diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) required prolonged admission to the intensive care unit (ICU). Four months later, he was diagnosed with thoracic candida spondylodiscitis. Medical management was insufficient, so he eventually underwent surgery. Discussions: Fungal infections seem to be more likely in patients with COVID-19, but it is unknown whether they are directly attributed to COVID-19 or other surrounding factors. Regardless of the answer, the diagnosis is complicated, and the mortality rate is high. Lessons: COVID-19 is posing a challenge to the society, and new and unexpected diseases that had once disappeared have risen again. It is our duty to suspect them and to treat them in the most effective way possible.

Cervical osteomyelitis and soft tissue polymicrobial abscess in an immunocompetent 16-year-old patient

A 16-year-old man was hospitalised with a painful space-occupying lesion in his posterior neck involving muscles, soft tissues, C1 cervical vertebra and vital cervical blood vessels. The true-cut biopsy showed inflammatory tissue. The microbiological analysis, which combined classical bacteriological and molecular methods, yielded at least four different anaerobic species. The patient was treated successfully with a prolonged course of ceftriaxone and metronidazole.

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.

Spinal Tuberculosis

Tuberculosis is one of the most common infectious diseases worldwide. The frequency in Germany is low, however, an increase has been observed in the past few years. The incidence of extrapulmonary manifestation accounts for up to 10 to 20%. In 50% of these cases the spinal column is affected. Although literature reveals worldwide experiences in the treatment, in Germany spinal tuberculosis remains a rarity. Different pitfalls and specific characteristics regarding diagnosis and therapy are to consider. Therefore, a presentation of these specifics and their discussion based on the available literature will be presented. The purpose is to achieve an increase in awareness regarding this, in our latitudes, rare disease.

Successful treatment of total paraplegic patient due to tuberculous spondylitis

A 12-year-old boy presented with progressive disability to walk for four months, which was so severe that he could no longer perform daily activities. No respiratory symptom was found. On physical examination, there was a soft tissue mass in the thoracic vertebrae. Physiological reflexes of both limbs were diminished. Tuberculin skin test was positive with a 12 mm induration. Magnetic resonance imaging (MRI) of the spine showed a kyphotic cervico-thoracal region with predominantly anterior paravertebral mass that was enhanced with contrast, compressing the spinal cord at level Th-3 and Th-4, suggestive of tuberculous spondylitis. He was treated with regular anti-tuberculosis drugs. In the first four months, he began being able to sit, and two months later, he could walk again. After 12 months of treatment without surgery, MRI showed no more compression of the spine and remarkable resolution of paravertebral soft tissue mass. He then resumed his daily life again.

Fungal spondylodiscitis in a patient recovered from H7N9 virus infection: a case study and a literature review of the differences between Candida and Aspergillus spondylodiscitis

To report a rare case of fungal spondylodiscitis in a patient recovered from H7N9 virus infection and perform a literature review of the different characteristics of Candida and Aspergillus spondylodiscitis, we reviewed cases of spondylodiscitis caused by Candida and Aspergillus species. Data, including patients' information, pathogenic species, treatment strategy, outcomes, and relapses, were collected and summarized. The characteristics of Candida and Aspergillus spondylodiscitis were compared to see if any differences in clinical features, management, or consequences could be detected. The subject of the case study was first misdiagnosed as having a vertebral tumor, and then, following open biopsy, was diagnosed as having fungal spondylodiscitis. The patient made a good recovery following radical debridement. Seventy-seven additional cases of Candida spondylodiscitis and 94 cases of Aspergillus spondylodiscitis were identified in the literature. Patients with Candida spondylodiscitis tended to have a better outcome than patients with Aspergillus spondylodiscitis (cure rate 92.3% vs. 70.2%). Candida was found more frequently (47.8%) than Aspergillus (26.7%) in blood cultures, while neurological deficits were observed more often in patients with Aspergillus spondylodiscitis (43.6% vs. 25.6%). Candida spinal infections were more often treated by radical debridement (60.5% vs. 39.6%). Patients with Candida spondylodiscitis have better outcomes, which may be associated with prompt recognition, radical surgical debridement, and azoles therapy. A good outcome can be expected in fungal spondylodiscitis with appropriate operations and anti-fungal drugs.

Infectious Discitis and Spondylodiscitis in Children

In children, infectious discitis (D) and infectious spondylodiscitis (SD) are rare diseases that can cause significant clinical problems, including spinal deformities and segmental instabilities. Moreover, when the infection spreads into the spinal channel, D and SD can cause devastating neurologic complications. Early diagnosis and treatment may reduce these risks. The main aim of this paper is to discuss recent concepts regarding the epidemiology, microbiology, clinical presentation, diagnosis, and treatment of pediatric D and SD. It is highlighted that particular attention must be paid to the identification of the causative infectious agent and its sensitivity to antibiotics, remembering that traditional culture frequently leads to negative results and modern molecular methods can significantly increase the detection rate. Several different bacterial pathogens can cause D and SD, and, in some cases, particularly those due to Staphylococcus aureus, Kingella kingae, Mycobacterium tuberculosis, Brucella spp., the appropriate choice of drug is critical to achieve cure.

Vertebral osteomyelitis in adults: an update

INTRODUCTION

The incidence of vertebral osteomyelitis is increasing, attributed to an ageing population with inherent co-morbidities and improved case ascertainment.

SOURCES OF DATA

References were retrieved from the PubMed database using the terms 'vertebral osteomyelitis' and 'spondylodiscitis' between January 1, 2009 and April 30, 2014 published in English as checked in May 2014 (>1000 abstracts checked).

AREAS OF AGREEMENT

Blood cultures and whole spine imaging with magnetic resonance imaging are essential investigations. Thorough debridement is the mainstay of surgical management, although placing metalwork in active infection is becoming increasingly common.

AREAS OF CONTROVERSY

The extent of pursuing spinal biopsies to determine aetiology, antimicrobial choices and duration, monitoring the response to treatment, and surgical techniques and timing all vary widely in clinical practice with heterogeneous studies limiting comparisons. Surgery, rather than conservative approaches, is being proposed as the default management choice, because it can, in carefully selected patients, offer faster reduction in pain scores and improved quality of life.

AREAS TIMELY FOR DEVELOPING RESEARCH

Further studies are needed to define the most effective technique for spinal biopsies to maximize determining aetiology. High-quality trials are required to provide an evidence base for both the medical and surgical management of vertebral osteomyelitis, including challenging medical management as the default option.

2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adultsa

These guidelines are intended for use by infectious disease specialists, orthopedic surgeons, neurosurgeons, radiologists, and other healthcare professionals who care for patients with native vertebral osteomyelitis (NVO). They include evidence and opinion-based recommendations for the diagnosis and management of patients with NVO treated with antimicrobial therapy, with or without surgical intervention.

Surgical treatment for spinal tuberculosis with bilateral paraspinal abscess or bilateral psoas abscess: one-stage surgery

STUDY DESIGN

This was a prospective study on the clinical outcomes of single-stage surgery for thoracic and lumbar spine tuberculosis patients with bilateral paraspinal or bilateral psoas abscesses.

OBJECTIVE

The aim of this study was to investigate the feasibility of, indications for, and clinical effects of single-stage posterior surgery for the treatment of thoracic and lumbar spinal tuberculosis with bilateral paraspinal or bilateral psoas abscesses.

SUMMARY OF BACKGROUND DATA

An increasing number of articles have been published on the use of single-stage surgery for spinal tuberculosis; however, none of these articles have discussed the use of such surgery in patients with bilateral abscesses.

METHODS

Between January 2003 and January 2011, 41 patients with thoracic and lumbar spinal tuberculosis and bilateral paraspinal or bilateral psoas abscesses were treated with single-stage posterior surgery. All of the patients were treated preoperatively with 1-2 weeks of antituberculosis drugs. All patients were managed postoperatively with standard courses of chemotherapy with triple or quadruple antituberculosis drugs. The clinical symptoms, complications, and laboratory and image indicators were recorded.

RESULTS

There were no local recurrences except in one L3-L4 tuberculosis patient. Two patients presented with extraspinal tuberculosis in the third year. There were no incision complications. Bone fusion was observed 6 months after the operation. The erythrocyte sedimentation rate was normal at 3 weeks-3 months postoperatively. There were no internal fixation failures. The internal fixations in 6 young patients were removed after the spinal tuberculosis was cured.

CONCLUSIONS

Single-stage posterior surgery with instrumentation results in less operative trauma and can be a suitable alternative for treating thoracic and lumbar tuberculosis with bilateral paraspinal or bilateral psoas abscesses.

Surgical treatment of patients with spondylodiscitis and neurological deficits caused by spinal epidural abscess (SEA) is a predictor of clinical outcome

STUDY DESIGN

Retrospective study.

OBJECTIVE

The purpose of this study was to investigate the question whether surgical treatment of patients with spondylodiscitis and neurological deficits caused by a spinal epidural abscess (SEA) is a predictor of clinical outcome.

SUMMARY OF BACKGROUND DATA

Spondylodiscitis with an accompanying SEA is a serious medical condition that is associated with potentially high risk for long-term neurological morbidity. In the literature, up to 75% of patients suffer from neurological deficits related to SEA in spondylodiscitis. Independent of treatment, residual neurology persists at a high rate.

METHODS

A retrospective analysis of 135 patients admitted to our department due to a diagnosis of spondylodiscitis was performed. Presence of SEA was evaluated based on computed tomography and magnetic resonance imaging. Neurological status was documented on admission and at discharge according to the Frankel Score. In addition, our patient population was separated into group I without neurological deficits (Frankel E) and group II with abnormal Frankel A-D. Surgical and nonsurgical therapy was retrospectively evaluated. Data were statistically analyzed using the 2-sided Fisher exact test.

RESULTS

On admission, 102 patients were graded as Frankel E in group I. In group II, 15 were Frankel D, 8 Frankel C, 8 Frankel B, and 2 Frankel A. After treatment, 105 patients were Frankel E, 19 Frankel D, 4 Frankel C, 3 Frankel B, and none Frankel A. Four patients died because of severe comorbidities. In group II, 13 of 33 patients had a SEA. Twelve patients showed improvement in Frankel grade, 1 remained unchanged. Of the 20 patients in group II without a SEA, 11 improved and 9 remained unchanged. Twenty-eight of the 33 patients in group II were treated surgically. Patients in both groups with improved neurology showed an upgrade by 1 or 2 Frankel scores. There was no deterioration of neurology. The correlation between surgically treated patients with SEA in comparison with patients without SEA is considered to be statistically significant.

CONCLUSION

Surgical treatment of patients with spondylodiscitis and neurological deficits caused by SEA is a predictor of clinical outcome.

Pyogenic and non-pyogenic spinal infections: emphasis on diffusion-weighted imaging for the detection of abscesses and pus collections

The incidence of spinal infections has increased in the past two decades, owing to the increasing number of elderly patients, immunocompromised conditions, spinal surgery and instrumentation, vascular access and intravenous drug use. Conventional MRI is the gold standard for diagnostic imaging; however, there are still a significant number of misdiagnosed cases. Diffusion-weighted imaging (DWI) with a b-value of 1000 and apparent diffusion coefficient (ADC) maps provide early and accurate detection of abscess and pus collection. Pyogenic infections are classified into four types of extension based on MRI and DWI findings: (1) epidural/paraspinal abscess with spondylodiscitis, (2) epidural/paraspinal abscess with facet joint infection, (3) epidural/paraspinal abscess without concomitant spondylodiscitis or facet joint infection and (4) intradural abscess (subdural abscess, purulent meningitis and spinal cord abscess). DWI easily detects abscesses and demonstrates the extension, multiplicity and remote disseminated infection. DWI is often a key image in the differential diagnosis. Important differential diagnoses include epidural, subdural or subarachnoid haemorrhage, cerebrospinal fluid leak, disc herniation, synovial cyst, granulation tissue, intra- or extradural tumour and post-surgical fluid collections. DWI and the ADC values are affected by susceptibility artefacts, incomplete fat suppression and volume-averaging artefacts. Recognition of artefacts is essential when interpreting DWI of spinal and paraspinal infections. DWI is not only useful for the diagnosis but also for the treatment planning of pyogenic and non-pyogenic spinal infections.

Candida albicans spondylodiscitis following an abdominal stab wound: forensic considerations

Candida albicans spondylodiscitis is a fungal infection of the spine which is still unusual in spite of the increasing frequency of predisposing factors. A 22-year-old man received an abdominal stab wound during a physical assault. Initial medical care included surgery, prolonged use of indwelling vascular catheters with administration of broad-spectrum antibiotics, and hospitalization in intensive care. Two months after the event, the victim experienced back pain in the right lumbar region and septic spondylodiscitis secondary to C. albicans was diagnosed three weeks later. This case is noteworthy because of its clinical forensic context. In France, the public prosecutor orders a medico-legal assessment after an assault for all living victims in order to establish a causal relationship between the assault and its complications. In our case, the patient presented numerous risk factors for candidemia and the forensic specialist reasonably accepted that the causal relationship was certain but indirect. We have only found one published case of spondylodiscitis after an abdominal penetrating injury and the pathogenic agent was not mentioned. We have found no case reported in a forensic context. This unusual observation shows that it may be genuinely difficult to prove the causal relationship between an abdominal penetrating injury and an unusual infectious complication such as fungal spondylodiscitis.

Candida dubliniensis spondylodiscitis in an immunocompetent patient. Case report and review of the literature

We describe what appears to be the first case of spondylodiscitis due to Candida dubliniensis. Our case adds to the current literature of the importance of C. dubliniensis as a cause of fungemia and subsequent deep seated infections. It highlights the importance of taking fungal as well as bacterial culture from biopsy specimens in patients with spondylodiscitis. We also review the literature covering the reported cases of Candida spondylodiscitis, which amount to about 100 over the last 5 decades.

[Systemic and local antibiotic therapy of conservative and operative treatment of spondylodiscitis]

An evidence-based recommendation for a standardized antibiotic therapy of spondylodiscitis has not yet been published. Crucial for conservative therapy is the verification of the causative organism and an appropriate antibiotic therapy. Intravenous antibiotic therapy should be administered for 2-3 weeks and a switched to oral administration for 6-12 weeks is then possible. If an empirical antimicrobial therapy is required a combination of ciprofloxacin and clindamycin, alternatively a combination of cefotaxim and flucloxacillin is recommended. Surgical removal of the infection by extensive debridement with stabilization and filling the resulting bone defect is desirable. Under the perception of a high local dose of antibiotic the defect filling with a mixture of cancellous bone and antibiotic-loaded hydroxyapatite and calcium sulfate is advisable.

Imaging of spine infection

This article reviews the imaging and relevant clinical details of infection of the extradural spine. Spine infections are increasing in incidence and in frequency of diagnosis. They are clinically important despite their relative rarity, because they may be life-threatening, and because early diagnosis leads to improved outcomes. The focus is on pyogenic spondylodiscitis. The also typically pyogenic conditions of epidural and subdural abscess, facet joint infection, and pyomyositis are discussed. Nonpyogenic, granulomatous infections are also addressed. Magnetic resonance imaging is emphasized. The radiologist's role in performing minimally invasive sampling procedures is highlighted.

Infectious, inflammatory, and metabolic diseases affecting the athlete's spine

Sports and weight-bearing activities can have a positive effect on bone health in the growing, mature, or aging athlete. However, certain athletic activities and training regimens may place the athlete at increased risk for stress fractures in the spine. In addition, some athletes have an underlying susceptibility to fracture due to either systemic or focal abnormalities. It is important to identify and treat these athletes in order to prevent stress fractures and reduce the risk of osteoporosis in late adulthood. Therefore, the pre-participation physical examination offers a unique opportunity to screen athletes for metabolic bone disease through the history and physical examination. Positive findings warrant a thorough workup including a metabolic bone laboratory panel, and possibly a DEXA scan, which includes a lateral spine view.

'Fungal spondylodiscitis in a non-immunocompromised patient'

Spondylodiscitis is an inflammatory disease, usually infectious, of one or more vertebral bodies and of corresponding intervertebral discs. The fungal aetiology is rare (less than 5% of cases), affecting mostly immunocompromised individuals. It is often a delayed diagnosis by the indolence of symptoms, presenting itself as a serious infection, which may result in important functional consequences. The authors present the case of a 75-year-old male, with constitutional complaints and intense back pain. Prior recent history of left hemicolectomy due to diverticulitis with multiple surgical complications, resulted in prolonged intensive care unit hospitalisation, and, later on, an episode of fungal endophthalmitis. The diagnosis of spondylodiscitis L5/S1 was performed by MRI. The patient underwent surgical disco-vertebral debridement and isolation of a Candida albicans was seen in the collected surgical material. No evidence of an immunossupressive status was found. Treatment was complemented with liposomal amphotericin B in the maximum recommended dose.

Spinal tuberculosis: a review

Spinal tuberculosis is a destructive form of tuberculosis. It accounts for approximately half of all cases of musculoskeletal tuberculosis. Spinal tuberculosis is more common in children and young adults. The incidence of spinal tuberculosis is increasing in developed nations. Genetic susceptibility to spinal tuberculosis has recently been demonstrated. Characteristically, there is destruction of the intervertebral disk space and the adjacent vertebral bodies, collapse of the spinal elements, and anterior wedging leading to kyphosis and gibbus formation. The thoracic region of vertebral column is most frequently affected. Formation of a 'cold' abscess around the lesion is another characteristic feature. The incidence of multi-level noncontiguous vertebral tuberculosis occurs more frequently than previously recognized. Common clinical manifestations include constitutional symptoms, back pain, spinal tenderness, paraplegia, and spinal deformities. For the diagnosis of spinal tuberculosis magnetic resonance imaging is more sensitive imaging technique than x-ray and more specific than computed tomography. Magnetic resonance imaging frequently demonstrates involvement of the vertebral bodies on either side of the disk, disk destruction, cold abscess, vertebral collapse, and presence of vertebral column deformities. Neuroimaging-guided needle biopsy from the affected site in the center of the vertebral body is the gold standard technique for early histopathological diagnosis. Antituberculous treatment remains the cornerstone of treatment. Surgery may be required in selected cases, e.g. large abscess formation, severe kyphosis, an evolving neurological deficit, or lack of response to medical treatment. With early diagnosis and early treatment, prognosis is generally good.