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Updated: Jun 24 2021

Adult Pyogenic Vertebral Osteomyelitis

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Images
https://upload.orthobullets.com/topic/2025/images/1a_moved.jpg
https://upload.orthobullets.com/topic/2025/images/case a - xray-lumbar-lat - shows disc space narrowing - mgh.jpg
https://upload.orthobullets.com/topic/2025/images/case a - mri t2 and t1.jpg
https://upload.orthobullets.com/topic/2025/images/case a -  ct - axial- showing biopsy.jpg
  • summary
    • Adult Pyogenic Vertebral Osteomyelitis, also known as spondylodiskitis, represents a spectrum of spinal infections including discitis, vertebral osteomyelitis, and epidural abscess.
    • Diagnosis is made with MRI studies with contrast. 
    • Treatment may be long-term targeted antibiotics alone or surgical decompression and stabilization depending on the extent and chronicity of infection, location in the spine, and identification and succeptibility to antimicrobials of the pathogen.
  • Epidemiology
    • Demographics
      • usually seen in adults (median age for pyogenic osteomyelitis is 50 to 60 years)
    • Anatomic location
      • 50-60% of cases occur in lumbar spine
      • 30-40% in thoracic spine
      • ~10% in 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 indicative of malnutrition)
      • trauma
      • smoking
  • Etiology
    • Pathophysiology
      • pathogens
        • bacterial
          • staph aureus
            • most common (50-65%)
          • staph epidermidis
            • is second most common cause
          • gram negative infections
            • increasing over last decade and often associated with gram negative infections of the GU and respiratory tract
        • pseudomonas
          • seen in patients with IV drug use
        • salmonella
          • seen in patients with sickle cell disease
        • tuberculosis
      • inoculation
        • hematogenous seeding
          • generally agreed that inoculation likely occurs through hematogenous seeding (arterial or venous) of the endplates and intervertebral discs
            • endplates contain area of low-flow vascular anastomosis that may provide an environment suited for inoculation
            • involvement of one endplate leads to direct extension into intervertebral discs, followed by direct extension into the second endplate
        • direct inoculation
          • can occur after penetrating trauma, open fractures, and following surgical procedure
        • contiguous spread from local infection
          • most commonly associated with retropharyngeal and retroperitoneal abscesses
      • neurologic involvement
        • neurologic deficits present in 10-20%
        • results from
          • direct infectious involvement of neural elements
          • compression from an epidural abscess
          • compression from instability of the spine
    • Associated conditions
      • epidural abscess
        • defined as a collection of pus or inflammatory granulation tissue between dura mater and surrounding adipose tissue
        • epidemiology
          • usually associated with vertebral osteomyelitis
          • present in ~18% of patients with spondylodiskitis
          • 50% of patients with an epidural abscess will have neurologic symptoms
      • psoas abscess
  • Presentation
    • History
      • history of UTI, pneumonia, skin infection, of organ transplant are common
    • Symptoms
      • fever is only present in 1/3 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 present in 10-20%
        • radiculopathy
        • myelopathy
    • Physical exam
      • perform careful neurological exam
  • Imaging
    • Radiographs
      • findings are usually delayed by weeks
      • findings include
        • paraspinous soft tissue swelling (loss of psoas shadow)
          • seen if first few days
        • disc space narrowing and disc destruction
          • seen at 7-10 days
          • remember disc destruction is atypical of neoplasm
        • endplate erosion or sclerosis 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
          • gold standard for diagnosis and treatment
        • sensitivity and specificity
          • most sensitive (96%) and specific (93%) imaging modality for diagnosis of spinal osteomyelitis
          • also most specific imaging modality to differentiate from tumor
        • timing
          • if performed early, finding may be interpretted as degenerative changes
            • repeat MRI to see progression may be required
        • findings include
          • paraspinal and epidural inflammation
          • disc and endplate enhancement with gadolinium
          • T2-weighted hyperintensity of the disk and endplate
            • rim enhancing
    • Bone scan
      • Technetium Tc99m bone scans
        • indications
          • patients who can not obtain an MRI
        • sensitivity and specificity
          • 90% sensitive but lack specificity
          • combined Technetium Tc99m and gallium 67 scan is both more specific and more sensitive than Technetium Tc99m alone
      • 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
          • all patients prior to antibiotic administration if organism unknown
          • identification of organism is mandatory for treatment
        • sensitivity & specificity
          • least invasive method to determine a diagnosis
          • ~33% (reports show 25%-66%) of patients with spondylodiskitis have positive blood cultures
          • when positive 85% are accurate for isolating the correct organism
          • blood culture yield is improved by withholding antibiotic and obtaining cultures when patient is febrile
    • CT guided biopsy
      • indications
        • in patients who do not have indications for immediate open surgery and 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
          • aerobic
          • anaerobic
          • fungal
          • acid-fast cultures
    • Open biopsy
      • indications
        • when tissue/organism diagnosis can not be made with noninvasive techniques
      • technique
        • anterior, costotransversectomy, or transpedicular approach used
  • Differential
    • Spinal tumors
      • MRI is the most specific imaging modality to differentiate from tumor
        • features that weigh towards an infection include
          • disc space involvement
          • end-plate erosion
          • significant inflammation
  • Treatment
    • Nonoperative
      • immediate broad spectrum antibiotics
        • indications
          • critically ill patient who are septic
            • obtain gram stains and cultures first then start abx
              • consider immediate CT guided aspiration prior to administration of IV abx
          • will not be able to wait for culture results before starting broad spectrum abx
        • technique
          • vancomycin +
            • for pencicillin-resistant and gram-positive bacteria
          • third-generation cephalosporin
            • for gram-negative coverage
      • organism-specific antibiotic for 6-12 weeks +/- bracing
        • indications
          • lumbar vertebral osteomyelitis
          • organism must be identified and sensitive to antibiotics
          • controversial - some argue surgical debridement needed
        • bracing
          • helps improve pain and prevent deformity
          • rigid cervicothoracic orthosis or halo required for cervical osteomyelitis
        • antibiotics
          • indications
            • once organism has been identified via blood culture or biopsy
          • technique
            • usually treated with IV culture directed antibiotics until signs of improvement (~ 4-6 weeks) and then converted to PO antibiotics
          • resistant strains
            • new antibiotic-resistant strains of microorganisms are becoming more common and failure to diagnose can have negative consequences
            • organisms include
              • MRSA (methicillin-resistant Staph aureus)
              • VRSA (vancomycin resistant Staph aureus)
              • VRE (vancomycin resistant enterococcus)
            • treatment
              • newer generation antibiotics for antibiotic resistant organisms include linezolid and daptomycin
        • outcomes
          • successful in 80%
    • Operative
      • open biopsy alone
        • indications
          • cultures and CT guided biopsy fail to provide pathogen
          • lumbar disease without abcess formation in canal
        • technique
          • can use transpedicular (kyphoplasty-like) approach
      • neurologic decompression, surgical debridement, and spinal stabilization
        • indications
          • cervical vertebral osteomyelitis
          • progressive neurologic deficits
          • progressive deformity & gross spinal instability
          • refractory cases
          • large abscess formation
        • technique
          • dictated by characteristics of pathology
            • anterior debridement and strut grafting, +/- posterior instrumentation
              • considered to be gold standard
            • posterior debridement and decompression alone
              • usually ineffective for debridement
              • may be indicated in some cases
  • Techniques
    • Anterior debridement and strut grafting, +/- posterior instrumentation
      • goals
        • identify organism
        • eliminate infection
        • prevent or improve neurologic deficits
        • maintain spinal stability
      • techniques
        • strut graft selection
          • autogenous tricortical iliac crest, rib, or fibula strut grafts have proven safe and effective in presence of acute infection
          • allograft being used with good results, but autogenous sources theoretically have better incorporation
          • a recent study showed improved deformity correction with titanium mesh cages filled with autograft (followed by posterior instrumentation)
        • instrumentation
          • spinal instrumentation in presence of active infection is controversial
            • some advocate I&D followed by staged instrumentation
            • some advocate a single procedure with bone graft and instrumentation in the presence of an active infection
          • titanium is preferred over stainless steel
        • posterior instrumentation
          • posterior instrumentation indicated when severe kyphotic deformity or a multilevel anterior construct required
          • posterior instrumentation can be performed at same time or as a staged procedure
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