Updated: 6/24/2021

Disk Space Infection - Pediatric

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  • summary
    • Disk Space Infections in the pediatric population are a common source of fever and low back pain caused by systemic infections in young children.
    • Diagnosis is made with blood cultures and MRI studies. 
    • Treatment is bed rest, immobilization, and antibiotics for 4-6 weeks for early infection with no abscess. Surgical debridement followed by antibiotic treatment is indicated in the presence of an abscess and/or lack of improvement with nonoperative therapy.
  • Epidemiology
    • Demographics
      • more common in pediatric patients relative to adults
      • more common in males
      • usually affects patients less than 5 years old
    • Anatomic location
      • most common in lumbar spine (50-60%)
  • Etiology
    • 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
            • CRP is the most sensitive in monitoring this patient's response to antibiotic therapy
          • 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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(OBQ06.21) In pediatric discitis, which of the following is the most accurate description of the radiographic findings.

QID: 32
1

The earliest radiographic finding is loss of normal lumbar lordosis, followed by disc space narrowing and endplate erosion.

64%

(2418/3772)

2

The earliest radiographic finding is disc space narrowing, followed by endplate erosion and loss or normal lumbar lordosis.

16%

(611/3772)

3

The earliest radiographic finding is endplate erosion, followed by disc space narrowing and loss or normal lumbar lordosis.

8%

(291/3772)

4

The earliest radiographic finding is scalloping of the inferior endplate, followed by disc space narrowing and endplate erosion.

9%

(356/3772)

5

The earliest radiographic finding is vertebra magna, followed by disc space narrowing and endplate erosion.

2%

(77/3772)

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