Review Question - QID 4392

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Adult Pyogenic Vertebral Osteomyelitis Treatment Nonoperative QID: 4392 (OBQ12.32)

QID 4392 (Type "4392" in App Search)

A 69-year-old male presents to the emergency room with low back pain for 1 week duration. His past medical history is significant for diabetes and coronary artery disease that was treated with stenting 7 years prior. Recently he was hospitalized for a urinary tract infection which was treated with oral antibiotics. On physical exam he is afebrile and has no neurologic deficits in his lower extremity. Laboratory studies show a white blood cell count of 10,300/mm3, an erythrocyte sedimentation rate of 35 mm/h (reference range, 0-25 mm/h), and C-reactive protein of 13 mg/L (reference range, 0-5.0 mg/L). A radiograph and MRI are performed and shown in Figure A and B respectively. Repeat blood cultures x2 are performed and both show methicillin-sensitive Staphylococcus aureus. What is the most appropriate next step in treatment.

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CT guided biopsy

14%

755/5424

Referral to an orthopaedic pathologist

32/5424

Organism specific intravenous antibiotics

79%

4290/5424

Posterior lumbar debridement

68/5424

Anterior lumbar debridement

251/5424

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The clinical presentation is consistent with discitis and vertebral osteomyelitis in a patient without neurologic deficits and an identified organism. Organism specific intravenous antibiotics would be the most appropriate next step in treatment.

Adult discitis and vertebral osteomyelitis is usually seen in adults from 50-60 years of age. Diabetes and IV drug abuse are risk factors. Identifying an organism, either through blood cultures or a biopsy, is critical for successful treatment. The majority of patients can be treated nonoperatively with antibiotics. Surgery is indicated when there are progressive neurologic deficits with evidence of spinal canal compromise, spinal instability, or failure to respond to medical management.

Carragee et al. found that magnetic resonance imaging was able to give the correct diagnosis or suggest a possible diagnosis in 91% of vertebral osteomyelitis cases with less than 2 weeks of symptoms. They concluded that magnetic resonance imaging is valuable in suggesting the diagnosis early in the clinical course and can eliminate significant delays in diagnosis.

Dunbar et al. did a retrospective review of spinal infection database in an effort to identify cases with clinical features suggestive of spinal infection and an MRI that did not show features typical of vertebral osteomyelitis and discitis. They found several such cases and concluded that MRI is the imaging method of choice for vertebral osteomyelitis in the early stages. However, in some cases of vertebral osteomyelitis it can be non-specific and a repeat MRI may be required to show the typical features.

Figure A shows a lateral radiograph that shows loss of definition of the vertebral endplates and disc space narrowing. Figure B shows an MRI consistent with pyogenic vertebral osteomyelitis without evidence of spinal canal compromise.

Incorrect Answers:
Answer 1: A CT guided biopsy is not indicated as an organism has been identified by blood cultures.
Answer 2: The clinical presentation and imaging studies are consistent with osteomyelitis and not a tumor.
Answer 4: Because there are no neurologic deficits surgical debridement is not indicated.
Answer 5: Because there are no neurologic deficits surgical debridement is not indicated.