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http://upload.orthobullets.com/topic/2028/images/lateralxrdiskitis.jpg
http://upload.orthobullets.com/topic/2028/images/pediatric diskitis t2 mri.jpg
Introduction
  • Epidemiology
    • demographics
      • more common in pediatric patients relative to adults
      • more common in males 
      • usually affects patients less than 5 years old
    • location
      • most common in lumbar spine (50-60%)
  • Pathophysiology
    • pathoanatomy
      • in children blood vessels extend from the cartilaginous end plate into the nucleus pulposus
        • this allows direct inoculation of the disc
        • infection may spread from the end plate to the disc space and vertebral body
      • in adult patients, blood vessels extend only to the annulus fibrosis
        • this limits the incidence of isolated disc space infections in adults 
    • microbiology
      • staphylococcus aureus
        • is most common causative organism (>80%)
      • tuberculosis
        • always consider as organism, especially if patient is not improving with first line antibiotics
      • salmonella
        • in sickle cell anemia patients, salmonella may be the causative organism
Anatomy
  • Disc anatomy
    • in pediatric patients, blood vessels extend from the cartilaginous end plate into the nucleus pulposus
    • in adult patients, blood vessels extend only to the annulus fibrosis
Presentation
  • Symptoms depend on age of child
    • toddler
      • refusal to sit or walk, or painful limping
      • loss of appetite
      • fever (only 25% of patients will be febrile)
      • abdominal pain
    • older children
      • back pain with point tenderness
  • Physical exam
    • tender to palpation over involved level
    • limited range of motion
Imaging
  • Radiographs
    • radiographic findings are unreliable
    • earliest manifestation is at 1 week
    • findings
      • usually normal radiographs early in process
      • loss of lumbar lordosis may be earliest radiographic sign 
      • disc space narrowing (10-21 days after infection begins) 
      • endplate erosion (10-21 days after infection begins)
  • MRI
    • diagnostic test of choice 
Studies
  • Serum Labs
    • ESR
      • high normal or mildly elevated
    • C-reactive protein
      • high normal or mildly elevated
    • WBC
      • high normal or mildly elevated
  • Blood Cultures
    • blood cultures should be obtained to identify organism
Treatment
  • Nonoperative
    • bedrest, immobilization, and antibiotics for 4-6 weeks
      • indications
        • early infection with no abscess or displacement of thecal sac
      • modalities
        • initial treatment is with parenteral antibiotics directed at Staph aureus for 7-10 days
      • followup
        • watch serial labs to monitor efficacy of antibiotic treatment
        • obtain CT-guided biopsy if no response (rule out TB)
  • Operative
    • surgical debridement followed by antibiotic treatment
      • indications
        • late infection 
        • paraspinal abscess in the presence of neurologic deficits
        • limited responsiveness to nonoperative measures
      • technique
        • important to obtain cultures 
        • followed with antibiotics and bracing
Complications
  • Long term narrowing of disk space
  • Fusion between vertebra
  • Back pain
 

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