summary Adult pyogenic vertebral osteomyelitis, also known as spondylodiscitis, represents a spectrum of spinal infections, including discitis, vertebral osteomyelitis, and epidural abscess Diagnosis is made with MRI with contrast Treatment may consist of long-term targeted antibiotics alone or surgical decompression and stabilization depending on the extent and chronicity of infection, location, and pathogen identification and susceptibility to antimicrobials Epidemiology Demographics usually seen in adults (median age for pyogenic osteomyelitis is 50-60 y/o) Anatomic location 50-60% of cases occur in the lumbar spine 30-40% of cases occur in the thoracic spine ~10% of cases occur in the cervical spine Risk factors include IV drug abuse diabetes recent systemic infection (UTI, pneumonia) malignancy immunodeficiency or immunosuppressive medications obesity malnutrition (serum albumin <3 g/dL is indicative of malnutrition) trauma smoking Etiology Pathophysiology pathogens bacterial login to view 6 more bullets pseudomonas login to view 1 more bullet salmonella login to view 1 more bullet fungal tuberculosis inoculation hematogenous seeding login to view 3 more bullets direct inoculation login to view 1 more bullet contiguous spread from local infection login to view 1 more bullet neurologic involvement neurologic deficits present in 10-20% results from login to view 3 more bullets Associated conditions epidural abscess defined as a collection of pus or inflammatory granulation tissue between the dura mater and surrounding adipose tissue epidemiology login to view 3 more bullets psoas abscess Presentation History history of UTI, pneumonia, skin infection, or organ transplant is common Symptoms fever is present in only 33% of patients pain pain is often severe and insidious in onset pain is usually worse with activity and unrelenting in nature pain that awakens patients at night should raise concern for malignancy and infection neurologic symptoms are present in 10-20% radiculopathy myelopathy Physical exam perform a careful neurological exam Imaging Radiographs findings are usually delayed by weeks findings include paraspinous soft tissue swelling (loss of psoas shadow) login to view 1 more bullet disc space narrowing and destruction login to view 2 more bullets endplate erosion or sclerosis is seen at 10-21 days local osteopenia CT useful to show bony abnormalities, abscess formation, and extent of bony involvement MRI MRI with gadolinium contrast indications login to view 1 more bullet sensitivity and specificity login to view 2 more bullets timing login to view 2 more bullets findings include login to view 4 more bullets Bone scan technetium Tc99m bone scans indications login to view 1 more bullet sensitivity and specificity login to view 2 more bullets indium 111-labeled scan not recommended due to poor sensitivity (17%) Studies Laboratory WBC elevated only in ~50% not a sensitive indicator for early infection ESR elevated in 90% of cases can be monitored serially to track success of treatment; however, is considered less reliable than CRP CRP elevated in 90% of cases can be monitored serially to track success of treatment and is considered more reliable than ESR blood cultures indications login to view 2 more bullets sensitivity & specificity login to view 4 more bullets CT-guided biopsy indications in patients who do not require immediate open surgery and whose blood cultures are negative sensitivity & specificity can provide diagnosis in 68-86% of patients technique can be guided by fluoroscopy or by CT scan cultures should be sent for: login to view 4 more bullets Open biopsy indications when tissue/organism diagnosis cannot be made with noninvasive techniques technique anterior, costotransversectomy, or transpedicular approaches are used Differential Spinal tumors MRI is the most specific imaging modality for differentiating infection from tumor features that favor infection include: login to view 3 more bullets Treatment Nonoperative immediate broad-spectrum antibiotics indications login to view 4 more bullets technique login to view 4 more bullets organism-specific antibiotics for 6-12 weeks +/- bracing indications login to view 3 more bullets bracing login to view 2 more bullets antibiotics login to view 12 more bullets outcomes login to view 1 more bullet Operative open biopsy alone indications login to view 2 more bullets technique login to view 1 more bullet neurologic decompression, surgical debridement, and spinal stabilization indications login to view 5 more bullets technique login to view 6 more bullets Techniques Anterior debridement and strut grafting +/- posterior instrumentation goals identify the organism eliminate infection prevent or improve neurologic deficits maintain spinal stability techniques strut graft selection login to view 3 more bullets instrumentation login to view 4 more bullets posterior instrumentation login to view 2 more bullets