Infection of the intervertebral disk and the adjacent vertebrae, variably

referred to as spondylodiskitis, disk space infection, and vertebral

osteomyelitis,
all with or without associated epidural or psoas abscesses, is
hematogenous in origin in most cases. It is believed that the
hematogenous
infection of the vertebrae occurs via the segmental artery supplying
the vertebrae.47 Potential sources of hematogenous infection are
skin and soft tissue infection, genitourinary tract, infective
endocarditis,
infected IV sites, IV drug abuse, and respiratory tract infection.48
Infection of the disk space and contiguous vertebra also can occur
postoperatively.49 Several studies have established the efficacy of
antimicrobial
prophylaxis before spinal surgery in reducing the risk of
postoperative superficial or deep infection, including vertebral
osteomyelitis.
In one study by Schnoring and Brock,50 0.2% of patients
receiving antimicrobial prophylaxis developed a surgical site infection,
whereas 2.8% of patients developed surgical site infection when
antimicrobial
prophylaxis was withheld.
The clinical presentation of vertebral osteomyelitis includes localized
insidious pain and tenderness in the spine area in 90% of patients.
Fever is present in less than 50% of cases. Motor and sensory deficits,
owing to spinal cord or nerve root compression, are present in 15%
of patients.48,49,51-53
S. aureus and coagulase-negative staphylococci are the most
common microorganisms encountered in vertebral osteomyelitis.
Mycobacterium tuberculosis and Brucella spondylodiskitis are common
in endemic regions. Spine infections resulting from gram-negative
aerobic bacteria and Candida spp. are seen more commonly in IV drug
abusers, immunosuppressed patients, and postoperative patients.
The diagnosis of vertebral osteomyelitis requires a high index of
suspicion in at-risk patients presenting with compatible signs and
symptoms. The goal of the diagnostic evaluation is to identify the
organism and to determine the extent of infection. Neurologic function
and spinal stability always should be assessed carefully. An elevation
of the ESR is present in more than 90% of cases, whereas the white
blood cell count is elevated in less than 50% of patients. Blood cultures
may be positive, and if they are, infective endocarditis may be
present.54,55
Plain spinal radiographs are not sensitive in the diagnosis of disk
space infection. In one study, 32% of radiographs obtained suggested
diskitis.54 MRI has proved to be an invaluable tool in detecting disk
space infection and spinal cord compression (Fig. 103-3). Gallium-67

citrate scanning seems to be a sensitive and specific method used to

diagnose diskitis, but provides much less anatomic detail than MRI.
In a study of 41 patients with suspected spondylodiskitis, gallium
scanning
proved to be 100% sensitive, specific, and accurate.56 We use gallium
scanning when MRI cannot be performed and in cases in
which MRI is inconclusive.
CT-guided percutaneous biopsy has a sensitivity of 50%.57 If the
results of the first aspirate are inconclusive, a repeat aspirate should
be
performed if possible so that a microbiologic diagnosis can be obtained
and pathogen-specific antimicrobial therapy administered. Open
biopsy should be reserved for patients with a nondiagnostic
percutaneous
biopsy or in patients not responding to empirical antimicrobial
therapy.57
The goals of therapy should include eradicating the infection, relieving
pain, preserving or restoring neurologic function, and maintaining
spinal stability. Complete bed rest is often unnecessary. The spine
could be externally stabilized using a corset or a body brace. The
treatment
of vertebral osteomyelitis requires an initial 4- to 6-week course
of antimicrobial therapy (see Table 103-3). Parenteral antimicrobial
treatment may be extended in difficult cases or in cases in which
undrained
abscesses are being treated and do not resolve after 4 to 6
weeks.
Surgical therapy is unnecessary in most cases. Surgical dbridement
should be considered in patients with a large paravertebral abscess,
when an epidural abscess is compressing the spinal cord, when
medical
management fails, or when the spine is mechanically unstable. In
selected cases, percutaneous transpedicular dbridement and
diskectomy,
performed under fluoroscopic guidance, may prevent the progression
of bone destruction and deformity in the early stages of
vertebral osteomyelitis and spondylodiskitis.58 The neurologic status
of the patient must be monitored closely.
With effective antimicrobial medical therapy, spontaneous fusion
between adjacent infected vertebral bodies requires 12 to 24 months.
Carragee and associates59 examined the value of serial
measurements
of ESR. In their study, a rapid decline of ESR (50% in the first month)
after institution of effective antimicrobial therapy was rarely seen in
treatment failure. Follow-up MRI of patients with vertebral
osteomyelitis

has a limited role and may give the impression of clinical progression
even though there is otherwise clinical improvement.60 We
advocate the use of follow-up MRI in patients with persistent elevation
of inflammation markers, in patients with persistent pain, or in
patients who develop new neurologic signs or symptoms.60
Early postoperative hardware-associated spine infection is treated
initially with surgical dbridement and retention of the hardware.
Removal of spinal hardware in this situation would compromise the
stability of the spine and the spinal cord. In this setting, surgical
dbridement is followed by a course of parenteral antimicrobial
therapy (see Table 103-3).61 Although not recommended by all
experts,
parenteral antimicrobial therapy at our institution is typically followed
by the use of long-term oral antimicrobial suppression in this situation.
61 Long-term antimicrobial suppression should be continued until
there is radiologic evidence of bone vertebral fusion. This modality is
highly successful in our institution. Complete bone remodeling and
fusion typically are complete after 2 years. At that time, long-term oral
suppression may be discontinued, with a low risk of recurrence. If
there is recurrence, the spinal hardware can be removed without
compromising
the stability of the spine.61 Successful therapy of late postoperative
hardware-associated spine infection often involves removal
of the hardware followed by a course of antimicrobial therapy (