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Hijazi MM, Siepmann T, Disch AC, Platz U, Juratli TA, Eyüpoglu IY, Podlesek D. Diagnostic Sensitivity of Blood Culture, Intraoperative Specimen, and Computed Tomography-Guided Biopsy in Patients with Spondylodiscitis and Isolated Spinal Epidural Empyema Requiring Surgical Treatment. J Clin Med 2023; 12:jcm12113693. [PMID: 37297888 DOI: 10.3390/jcm12113693] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND the successful treatment of spondylodiscitis (SD) and isolated spinal epidural empyema (ISEE) depends on early detection of causative pathogens, which is commonly performed either via blood cultures, intraoperative specimens, and/or image-guided biopsies. We evaluated the diagnostic sensitivity of these three procedures and assessed how it is influenced by antibiotics. METHODS we retrospectively analyzed data from patients with SD and ISEE treated surgically at a neurosurgery university center in Germany between 2002 and 2021. RESULTS we included 208 patients (68 [23-90] years, 34.6% females, 68% SD). Pathogens were identified in 192 cases (92.3%), including 187 (97.4%) pyogenic and five (2.6%) non-pyogenic infections, with Gram-positive bacteria accounting for 86.6% (162 cases) and Gram-negative for 13.4% (25 cases) of the pyogenic infections. The diagnostic sensitivity was highest for intraoperative specimens at 77.9% (162/208, p = 0.012) and lowest for blood cultures at 57.2% (119/208) and computed tomography (CT)-guided biopsies at 55.7% (39/70). Blood cultures displayed the highest sensitivity in SD patients (SD: 91/142, 64.1% vs. ISEE: 28/66, 42.4%, p = 0.004), while intraoperative specimens were the most sensitive procedure in ISEE (SD: 102/142, 71.8% vs. ISEE: 59/66, 89.4%, p = 0.007). The diagnostic sensitivity was lower in SD patients with ongoing empiric antibiotic therapy (EAT) than in patients treated postoperatively with targeted antibiotic therapy (TAT) (EAT: 77/89, 86.5% vs. TAT: 53/53, 100%, p = 0.004), whereas no effect was observed in patients with ISEE (EAT: 47/51, 92.2% vs. TAT: 15/15, 100%, p = 0.567). CONCLUSIONS in our cohort, intraoperative specimens displayed the highest diagnostic sensitivity especially for ISEE, whereas blood cultures appear to be the most sensitive for SD. The sensitivity of these tests seems modifiable by preoperative EAT in patients with SD, but not in those with ISEE, underscoring the distinct differences between both pathologies.
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Affiliation(s)
- Mido Max Hijazi
- Department of Neurosurgery, Division of Spine Surgery, Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Timo Siepmann
- Department of Neurology, Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Alexander Carl Disch
- Department of Orthopedics and Traumatology, Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Uwe Platz
- Department of Orthopedics and Traumatology, Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Tareq A Juratli
- Department of Neurosurgery, Division of Spine Surgery, Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Ilker Y Eyüpoglu
- Department of Neurosurgery, Division of Spine Surgery, Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Dino Podlesek
- Department of Neurosurgery, Division of Spine Surgery, Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany
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Chang CY, Pelzl C, Jesse MK, Habibollahi S, Habib U, Gyftopoulos S. Image-Guided Biopsy in Acute Diskitis-Osteomyelitis: A Systematic Review and Meta-Analysis. AJR Am J Roentgenol 2023; 220:499-511. [PMID: 36222488 DOI: 10.2214/ajr.22.28423] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND. The reported sensitivity and yield of image-guided biopsies for diskitis-osteomyelitis vary widely. OBJECTIVE. The purpose of this study was to perform a systematic review of the literature and meta-analysis of pooled sensitivity data to elucidate strategies for optimal image-guided biopsies among patients suspected to have diskitis-osteomyelitis. EVIDENCE ACQUISITION. A comprehensive literature search was performed for studies of patient populations with proven or suspected diskitis-osteomyelitis that included percutaneous image-guided biopsy as part of the workup algorithm. Type of pathogens, imaging modality used for biopsy guidance, tissue targeted, antibiotic administration at the time of biopsy, true microbiology positives, true microbiology negatives, false microbiology positives, false microbiology negatives, disease (i.e., diskitis-osteomyelitis) positives as determined by reference standard, true infection positives (i.e., positive microbiology or pathology results), and total number of biopsies performed were extracted from the studies. Microbiology sensitivity, microbiology biopsy yield, and infection sensitivity were calculated from the pooled data. These terms and the data required to calculate them were also defined in detail. EVIDENCE SYNTHESIS. Thirty-six articles satisfied inclusion criteria and were used for analysis. The pooled microbiology sensitivity, infection sensitivity, and microbiology biopsy yields were 46.6%, 70.0%, and 26.7%, respectively. Mycobacterium tuberculosis-only microbiology sensitivity was significantly higher than both pyogenic bacteria and mixed-organism microbiology sensitivity (p < .001). Staphylococcus aureus was the most common causative organism (28.6%). Pooled microbiology sensitivity was not significantly different for CT guidance and fluoroscopy guidance (p = .16). There was a statistically significant difference between pooled microbiology sensitivity of bone/end plate (45.5%) and disk/paravertebral soft-tissue (64.8%) image-guided biopsies (p < .001). There was no statistically significant difference in pooled microbiology sensitivities for patients who received antibiotics before the procedure (46.2%) and those who did not (44.6%) (p = .70). CONCLUSION. Image guidance by CT or fluoroscopy does not affect microbiology yield, disk and paravertebral soft-tissue biopsies should be considered over bone and end plate biopsies, and preprocedural antibiotic administration does not appear to impact biopsy results. CLINICAL IMPACT. Understanding and correctly applying reported statistics contribute to appropriate interpretation of the abundant literature on this topic and optimization of care for patients with diskitis-osteomyelitis.
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Affiliation(s)
- Connie Y Chang
- Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Yawkey 6E, Boston, MA 02114
| | - Casey Pelzl
- Harvey L. Neiman Health Policy Institute, Reston, VA
| | | | - Sina Habibollahi
- Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Yawkey 6E, Boston, MA 02114
| | - Ukasha Habib
- Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Yawkey 6E, Boston, MA 02114
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New Concepts in Diagnosis, Risk Factors and Work Ability in Patients with Hematogenous Spinal Infection. J Clin Med 2022; 11:jcm11185470. [PMID: 36143117 PMCID: PMC9504885 DOI: 10.3390/jcm11185470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 09/16/2022] [Indexed: 11/23/2022] Open
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Weber MA, Bazzocchi A, Nöbauer-Huhmann IM. Tumors of the Spine: When Can Biopsy Be Avoided? Semin Musculoskelet Radiol 2022; 26:453-468. [PMID: 36103887 DOI: 10.1055/s-0042-1753506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Regarding osseous tumors of the spine, characteristic morphology is encountered in hemangioma of the vertebral body, osteoid osteoma (OO), osteochondroma, Paget's disease, and bone islands. In these cases, radiologic imaging can make a specific diagnosis and thereby avoid biopsy, especially when the radiologist has chosen the correct imaging modality to establish the diagnosis, such as thin-slice computed tomography in suspected OO. A benign lesion is suggested by a high amount of fat within the lesion, the lack of uptake of the contrast agent, and a homogeneous aspect without solid parts in a cystic tumor. Suspicion of malignancy should be raised in spinal lesions with a heterogeneous disordered matrix, distinct signal decrease in T1-weighted magnetic resonance imaging, blurred border, perilesional edema, cortex erosion, and a large soft tissue component. Biopsy is mandatory in presumed malignancy, such as any Lodwick grade II or III osteolytic lesion in the vertebral column. The radiologist plays a crucial role in determining the clinical pathway by choosing the imaging approach wisely, by narrowing the differential diagnosis list, and, when characteristic morphology is encountered, by avoiding unnecessary biopsies.
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Affiliation(s)
- Marc-André Weber
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Center Rostock, Rostock, Germany
| | - Alberto Bazzocchi
- Diagnostic and Interventional Radiology, The Rizzoli Orthopedic Institute, Bologna, Italy
| | - Iris-M Nöbauer-Huhmann
- Department of Biomedical Imaging and Image Guided Therapy, Division of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna, Vienna, Austria
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Skusa C, Skusa R, Wohlfarth M, Warnke P, Podbielski A, Bath K, Groß J, Schafmayer C, Frickmann H, Weber MA, Hahn A, Meinel FG. Imaging and Clinical Parameters for Distinction between Infected and Non-Infected Fluid Collections in CT: Prospective Study Using Extended Microbiological Approach. Diagnostics (Basel) 2022; 12:diagnostics12020493. [PMID: 35204585 PMCID: PMC8870876 DOI: 10.3390/diagnostics12020493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/05/2022] [Accepted: 02/08/2022] [Indexed: 12/14/2022] Open
Abstract
The aim of this investigation was to evaluate predictive CT imaging features and clinical parameters to distinguish infected from sterile fluid collections. Detection of infectious agents by advanced microbiological analysis was used as the reference standard. From April 2018 to October 2019, all patients undergoing CT-guided drainages were prospectively enrolled, if drainage material volume was at least 5 mL. Univariate analysis revealed attenuation (p = 0.001), entrapped gas (p < 0.001), fat stranding (p < 0.001), wall thickness (p < 0.001) and enhancement (p < 0.001) as imaging biomarkers and procalcitonin (p = 0.003) as clinical predictive parameters for infected fluid collections. On multivariate analysis, attenuation > 10 HU (p = 0.038), presence of entrapped gas (p = 0.027) and wall enhancement (p = 0.028) were independent parameters for distinguishing between infected and non-infected fluids. Gas entrapment had high specificity (93%) but low sensitivity (48%), while wall enhancement had high sensitivity (91%) but low specificity (50%). CT attenuation > 10 HU showed intermediate sensitivity (74%) and specificity (70%). Evaluation of the published proposed scoring systems did not improve diagnostic accuracy over independent predictors in our study. In conclusion, this prospective study confirmed that CT attenuation > 10 HU, entrapped gas and wall enhancement are the key imaging features to distinguish infected from sterile fluid collections on CT.
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Affiliation(s)
- Christopher Skusa
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, Rostock University Medical Center, 18057 Rostock, Germany; (M.W.); (K.B.); (M.-A.W.); (F.G.M.)
- Correspondence: ; Tel.: +49-381-4949201
| | - Romy Skusa
- Institute of Medical Microbiology, Virology and Hygiene, Rostock University Medical Center, 18057 Rostock, Germany; (R.S.); (P.W.); (A.P.); (H.F.); (A.H.)
| | - Moritz Wohlfarth
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, Rostock University Medical Center, 18057 Rostock, Germany; (M.W.); (K.B.); (M.-A.W.); (F.G.M.)
| | - Philipp Warnke
- Institute of Medical Microbiology, Virology and Hygiene, Rostock University Medical Center, 18057 Rostock, Germany; (R.S.); (P.W.); (A.P.); (H.F.); (A.H.)
| | - Andreas Podbielski
- Institute of Medical Microbiology, Virology and Hygiene, Rostock University Medical Center, 18057 Rostock, Germany; (R.S.); (P.W.); (A.P.); (H.F.); (A.H.)
| | - Kristina Bath
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, Rostock University Medical Center, 18057 Rostock, Germany; (M.W.); (K.B.); (M.-A.W.); (F.G.M.)
| | - Justus Groß
- Department of General, Visceral, Vascular, Thoracic and Transplantation Surgery, Rostock University Medical Center, 18057 Rostock, Germany; (J.G.); (C.S.)
| | - Clemens Schafmayer
- Department of General, Visceral, Vascular, Thoracic and Transplantation Surgery, Rostock University Medical Center, 18057 Rostock, Germany; (J.G.); (C.S.)
| | - Hagen Frickmann
- Institute of Medical Microbiology, Virology and Hygiene, Rostock University Medical Center, 18057 Rostock, Germany; (R.S.); (P.W.); (A.P.); (H.F.); (A.H.)
- Department of Microbiology and Hospital Hygiene, Bundeswehr Hospital Hamburg, 20359 Hamburg, Germany
| | - Marc-André Weber
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, Rostock University Medical Center, 18057 Rostock, Germany; (M.W.); (K.B.); (M.-A.W.); (F.G.M.)
| | - Andreas Hahn
- Institute of Medical Microbiology, Virology and Hygiene, Rostock University Medical Center, 18057 Rostock, Germany; (R.S.); (P.W.); (A.P.); (H.F.); (A.H.)
| | - Felix G. Meinel
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, Rostock University Medical Center, 18057 Rostock, Germany; (M.W.); (K.B.); (M.-A.W.); (F.G.M.)
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Boudabbous S, Paulin EN, Delattre BMA, Hamard M, Vargas MI. Spinal disorders mimicking infection. Insights Imaging 2021; 12:176. [PMID: 34862958 PMCID: PMC8643376 DOI: 10.1186/s13244-021-01103-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/03/2021] [Indexed: 12/23/2022] Open
Abstract
Spinal infections are very commonly encountered by radiologists in their routine clinical practice. In case of typical MRI features, the diagnosis is relatively easy to interpret, all the more so if the clinical and laboratory findings are in agreement with the radiological findings. In many cases, the radiologist is able to make the right diagnosis, thereby avoiding a disco-vertebral biopsy, which is technically challenging and associated with a risk of negative results. However, several diseases mimic similar patterns, such as degenerative changes (Modic) and crystal-induced discopathy. Differentiation between these diagnoses relies on imaging changes in endplate contours as well as in disc signal. This review sought to illustrate the imaging pattern of spinal diseases mimicking an infection and to define characteristic MRI and CT patterns allowing to distinguish between these different disco-vertebral disorders. The contribution of advanced techniques, such as DWI and dual-energy CT (DECT) is also discussed.
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Affiliation(s)
- Sana Boudabbous
- Division of Radiology, Department of Diagnosis, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland. .,Faculty of Medicine of the Geneva University, Geneva, Switzerland.
| | - Emilie Nicodème Paulin
- Division of Radiology, Medical Imaging Department, Hospital of Neuchatel, Neuchâtel, Switzerland
| | - Bénédicte Marie Anne Delattre
- Division of Radiology, Department of Diagnosis, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland.,Faculty of Medicine of the Geneva University, Geneva, Switzerland
| | - Marion Hamard
- Division of Radiology, Department of Diagnosis, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
| | - Maria Isabel Vargas
- Faculty of Medicine of the Geneva University, Geneva, Switzerland.,Division of Neuroradiology, Diagnostic Department, University Hospitals of Geneva, Geneva, Switzerland
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Review article: the current status of CT-guided needle biopsy of the spine. Skeletal Radiol 2021; 50:281-299. [PMID: 32815040 DOI: 10.1007/s00256-020-03584-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/12/2020] [Accepted: 08/12/2020] [Indexed: 02/02/2023]
Abstract
CT-guided percutaneous needle biopsy of the spine is a well-described technique for determining the nature of indeterminate vertebral lesions or establishing a diagnosis of spinal infection, the high diagnostic accuracy and the safety of the procedure having been extensively documented. The purpose of the current article is to review the literature to date on CT-guided spinal biopsy. Specifically, indications for spinal biopsy, techniques for optimising yield, detail of the approaches for various spinal levels which is dependent upon both the region within the spinal column and lesion location within the vertebra (body vs. neural arch), determinants of biopsy outcome and complications are covered. It is hoped that the review will be of particular benefit to junior radiologists who are required to perform this procedure.
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Schwarz-Nemec U, Friedrich KM, Stihsen C, Schwarz FK, Trattnig S, Weber M, Grohs JG, Nemec SF. Vertebral Bone Marrow and Endplate Assessment on MR Imaging for the Differentiation of Modic Type 1 Endplate Changes and Infectious Spondylodiscitis. J Clin Med 2020; 9:jcm9030826. [PMID: 32197459 PMCID: PMC7141365 DOI: 10.3390/jcm9030826] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 03/16/2020] [Indexed: 12/11/2022] Open
Abstract
On magnetic resonance (MR) imaging, Modic type 1 (MT1) endplate changes and infectious spondylodiscitis share similar findings. Therefore, this study investigated vertebral bone marrow and endplate changes to enable their differentiation. The lumbar spine MR examinations of 91 adult patients were retrospectively included: 39 with MT1; 19 with early spondylodiscitis without abscess; and 33 with advanced spondylodiscitis with abscess. The assessment included percentage of bone marrow edema on sagittal short tau inversion recovery images, and the signal ratio of edema to unaffected bone and endplate contour (normal; irregular, yet intact; blurred; destructive) on sagittal unenhanced T1-weighted images. Differences were tested for statistical significance by Chi-square test and mixed model analysis of variance. The MR diagnostic accuracy in differentiating MT1 and spondylodiscitis was assessed by cross-tabulation and receiver-operating characteristic analysis. The endplate contours, edema extents, and T1-signal ratios of MT1 (extent, 31.96%; ratio, 0.83) were significantly different (p < 0.001) from early spondylodiscitis (56.42%; 0.60), and advanced spondylodiscitis (91.84%; 0.61). The highest diagnostic accuracy (sensitivity, 94.87%; specificity, 94.23%; accuracy, 94.51%) in identifying MT1 was provided by an irregular, yet intact endplate contour. This may be a useful MR feature for the differentiation between MT1 and spondylodiscitis, particularly in its early stage.
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Affiliation(s)
- Ursula Schwarz-Nemec
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, A-1090 Vienna, Austria; (U.S.-N.); (F.K.S.); (M.W.); (S.F.N.)
| | - Klaus M. Friedrich
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, A-1090 Vienna, Austria; (U.S.-N.); (F.K.S.); (M.W.); (S.F.N.)
- Correspondence: ; +43-140400-48950
| | - Christoph Stihsen
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, A-1090 Vienna, Austria; (C.S.); (J.G.G.)
| | - Felix K. Schwarz
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, A-1090 Vienna, Austria; (U.S.-N.); (F.K.S.); (M.W.); (S.F.N.)
| | - Siegfried Trattnig
- MR Center of Excellence, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, A-1090 Vienna, Austria;
| | - Michael Weber
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, A-1090 Vienna, Austria; (U.S.-N.); (F.K.S.); (M.W.); (S.F.N.)
| | - Josef G. Grohs
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, A-1090 Vienna, Austria; (C.S.); (J.G.G.)
| | - Stefan F. Nemec
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, A-1090 Vienna, Austria; (U.S.-N.); (F.K.S.); (M.W.); (S.F.N.)
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