- Email: [email protected]
Infectious spondylodiscitis – A case series analysis
Advances in Medical Sciences 59 (2014) 57–60
Contents lists available at ScienceDirect
Advances in Medical Sciences journal homepage: www.elsevier.com/locate/advms
Original Research Article
Infectious spondylodiscitis – A case series analysis Adam Garkowski a,*, Agata Zajkowska a, Piotr Czupryna a, Wojciech Łebkowski b, Michał Letmanowski a, Paweł Gołe˛bicki a, Anna Moniuszko a, Andrzej Ustymowicz c, Sławomir Pancewicz a, Joanna Zajkowska a a b c
Department of Infectious Diseases and Neuroinfections, Medical University of Bialystok, Bialystok, Poland Department of Neurosurgery, Medical University of Bialystok, Bialystok, Poland Department of Radiology, Medical University of Bialystok, Bialystok, Poland
A R T I C L E I N F O
A B S T R A C T
Article history: Received 15 October 2012 Accepted 2 August 2013 Available online 19 March 2014
Purpose: We aimed to describe the clinical and laboratory features as well as diagnostic difficulties in the case series of spondylodiscitis. Materials/methods: We retrospectively reviewed 11 cases of spondylodiscitis. The diagnosis of spondylodiscitis was based on clinical, radiological and microbiological evidence and by the response to antimicrobial therapy. Results: There were 7 men and 4 women, and the age ranged from 21 to 74 years. Risk factors of spondylodiscitis were observed in 7 patients. The approximate time from onset of symptoms to diagnosis was from 2 to 7 months (median 45 days). Back pain was the most common symptom. The most frequent location of spondylodiscitis was lumbar spine. Pathogens were isolated in 6 cases and were as follows: Staphylococcus aureus (4 cases), Staphylococcus warneri (1 case) and Escherichia coli (1 case). After therapy, all patients had rapid regression of symptoms and no permanent neurological impairments and recurrence of infection were observed. Conclusions: Diagnosis of spondylodiscitis is frequently delayed. This disease should be taken into consideration in differential diagnosis in patients with root syndromes accompanied by back pain and usually fever as well as increased values of CRP and ESR. ß 2014 Medical University of Bialystok. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.
Keywords: Spondylodiscitis Vertebral osteomyelitis Back pain Spine Infection
1. Introduction Spondylodiscitis is quite a rare disease characterized by insidious onset and non-specific symptoms such as back pain and fever. Consequently, early diagnosis is difficult and is often missed despite repeated warnings in the medical journals and better access to imaging techniques such as magnetic resonance imaging (MRI) and computed tomography (CT). The term spondylodiscitis includes vertebral osteomyelitis and discitis. The term vertebral osteomyelitis means inflammation of the vertebral body and the term discitis indicates infection of the intervertebral disk space. Spondylodiscitis may take acute, subacute or chronic course [1–3]. The incidence of spondylodiscitis is about 2.4 cases per 100,000 annually, and it increases with age. The disease is diagnosed in males more often than in females [2,4]. Aging, multi-morbidity, changes in
* Corresponding author at: Department of Infectious Diseases and Neuroinfections, Medical University of Bialystok, Z˙urawia 14, 15-540 Bialystok, Poland. Tel.: +48 85 740 9514; fax: +48 85 740 9515. E-mail address: [email protected] (A. Garkowski).
lifestyle leading to spinal injury, drug abuse, and increasing number of patients with immunological deficits are important factors contributing to gradual increase of spondylodiscitis incidence [1,3,5,6]. 2. Material and methods The medical documentation of 11 patients with spondylodiscitis hospitalized at the Department of Infectious Diseases and Neuroinfections of Medical University in Bialystok (Poland), between March 2002 and December 2011 was reviewed. Before admission to our Department the majority of patients were treated at the Department of Neurosurgery. The parameters analyzed were as follows: demographic pattern, risk factors, clinical symptoms, localization of the infection, blood tests, bacterial cultures, MRI findings and outcome of the disease. The final diagnosis of spondylodiscitis was based on clinical, radiological and microbiological evidence, laboratory tests (acute phase parameters) and the response to antimicrobial therapy. In the differential diagnosis diseases such as: compression fracture, metastatic spinal lesions, erosive osteochondrosis, gout arthritis, aseptic bone necrosis were excluded.
http://dx.doi.org/10.1016/j.advms.2014.02.001 1896-1126/ß 2014 Medical University of Bialystok. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.
A. Garkowski et al. / Advances in Medical Sciences 59 (2014) 57–60
58 Table 1 Demographic data of analyzed patients. Patient no.
Gender
Age
Predisposing factors
1 2 3 4 5 6 7 8 9 10 11
Female Female Male Male Male Male Male Male Female Male Female
52 62 64 44 74 67 34 21 56 45 51
Not present Not present Spine surgery (L3-L4-L5). Diabetes. Chronic kidney failure Vascular prosthesis because of aortic aneurysm Not present Spine surgery (L4-L5) Not present Not present Spine surgery (L4-L5) Spine surgery (L5-S1)
3. Results The median age of the patients was 52 years and ranged from 21 to 74 years. The male to female ratio was 7:4. Risk factors for spondylodiscitis were observed in 6 patients. Four patients had a history of recent spine surgery (and one of them also had diabetes); one patient had vascular prosthesis; one patient suffered from chronic kidney disease and one patient had a history of gangrenous cholecystitis and pleural empyema. Five patients had no identifiable risk factors. One or more comorbidities were presented in 8 patients. Concomitant degenerative spinal disease was found in 6 cases. Tables 1 and 2 present demographic and clinical characteristics of the patients. In most cases diagnosis was delayed. The approximate time from onset of symptoms to diagnosis was from 2 to 7 months (median 45 days).
At admission to the Department all patients complained about localized back pain related to the sites of infection. Nine patients presented with pain in the lumbar spine region which radiated to one or both lower limbs; in 1 patient with infection of the lumbar spine pain radiated to the buttocks. In 1 case pain radiated to the right upper limb. Fever 38 8C was observed in 5 patients. One patient had urinary incontinence. Sepsis developed in 4 cases (in 1 case septic shock was present). The most frequent localization of spondylodiscitis was lumbar spine (in 10 cases). Four patients presented with infection of two adjacent vertebrae and intervening intervertebral disk space; in 2 cases infection involved >2 contiguous vertebrae and intervening intervertebral disk space (vertebral osteomyelitis). In 4 patients infection was limited to intervertebral disk space without adjacent vertebrae (discitis). In 2 patients with lumbar spine involvement the inflammatory process spread to the paravertebral tissues. C-reactive protein concentration (CRP) was measured in all patients before treatment and was elevated in 7 patients (>10.0 mg/L). The erythrocyte sedimentation rate (ESR) was increased in all patients (in all >30 mm/h). Leukocytosis (>10,000 WBCs/mm3) was present in 5 cases. Pathogens were isolated from repeated sets of blood cultures in 5 cases. Staphylococcus spp. was found in 4 cases. Escherichia coli was isolated in 1 patient. In 1 case histopathologic examination and culture of the material from intervertebral space was performed. Staphylococcus aureus was isolated; histopathologic examination revealed pyogenic inflammation. Initial MRI scan was performed in 10 patients. Typical changes were observed in 9 cases. Hypointensity of the vertebral bodies and intervertebral discs in T1-weighted images was observed and
Table 2 Clinical characteristics and laboratory test of analyzed patients. Patient no.
Diagnosis
Clinical symptoms
Body temperature (8C)
1
Vertebral osteomyelitis
36.6
34
0.3
2
Discitis
Pain of the cervical spine during movement with radiation to the right upper limb. Limb weakness. Pain on palpation of the cervical spine. Pain of the L-S spine region, radiating to right lower limb. Limb weakness. Pain on palpation of the spine L-S.
38.0
95
3
Vertebral osteomyelitis. Sepsis Vertebral osteomyelitis. Sepsis Vertebral osteomyelitis.
Pain of the L-S spine region, radiating to both lower limbs, escalating during movement. Limb weakness. Pain of the L-S spine region, radiating to both lower limbs. Limb weakness.
37.2
4
5
6
Vertebral osteomyelitis
7
Discitis
8
10
Vertebral osteomyelitis. Sepsis Vertebral osteomyelitis. Sepsis + septic shock Discitis
11
Discitis
9
Localization
Cultures
5.8
C6-C7
Blood – negative
19.3
10.04
L2-L3
62
85.7
13.32
L3-L4-L5
Material from intervertebral space – Staphylococcus aureus MSSA Blood – negative Blood – Staphylococcus warneri
38.0
100
353.7
12.25
L3-L4-L5
Blood – Staphylococcus aureus MSSA
Pain of the L-S spine region, radiating to both lower limbs. Limb weakness. Pain on palpation of the spine. Pain of the L-S spine, radiating to left lower limb. Limb weakness. Pain on palpation of the spine. Pain of the L-S spine region, radiating to both lower limbs, escalating during movement. Limb weakness. Pain of the L-S spine region, radiating to buttocks muscles, escalating during hips movements. Limb weakness. Pain of the L-S spine region, radiating to right lower limb. Limb weakness. Pain on palpation of the spine
36.8
98
64.6
10.4
L4-L5
Blood – Staphylococcus aureus MSSA (blood)
39.0
72
240.4
6.64
L4-L5
Blood – negative
36.6
37
0.8
5.04
L4-L5
Blood – negative
40.0
116
81
7.7
L4-L5
Blood – Staphylococcus aureus MSSA
39.0
76
204
10.8
L4-L5
Blood – Escherichia coli
Pain of the L-S spine region, escalating during movement. Pain on palpation of the L-S spine. Pain of the L-S spine region, radiating to both lower limbs. Limb weakness. Reduced mobility of the lumbar spine. Urinary incontinence.
36.6
46
9.0
9.4
L4-L5
Blood – negative
37.0
42
7.4
6.49
L5-S1
Blood – negative
ESR (mm/h)
CRP (mg/l)
WBCs count (103/mm3)
A. Garkowski et al. / Advances in Medical Sciences 59 (2014) 57–60
59
Fig. 1. MRI scan showing inflammatory infiltrates in the course of discitis (T1 weighted–gadolinium enhanced). (A) sagittal plane, (B) transverse plane.
Fig. 2. MRI scan showing inflammatory infiltrates in the course of discitis (T1 weighted–gadolinium enhanced). (A) sagittal plane, (B) transverse plane.
hyperintensity – in T2-weighted images. Representative MRI scans are shown in Figs. 1 and 2. In 1 patient the diagnosis of spondylodiscitis was made during neurosurgical operation. This patient had surgery due to the concomitant lumbar discopathy; and while previously performed MRI did not show any features of discitis; the diagnosis was based on positive cultures of an infected intervertebral space. In 1 patient MRI scan was not obtained. In this case the diagnosis of discitis was based on spine X-ray radiographs that showed narrowing of the intervertebral space L4-L5 without abnormalities in the vertebrae. Length of hospital stay in our Department ranged from 7 days to 34 days (median 19 days). The duration of antimicrobial treatment depended on the CRP and ESR levels. All the patients received parenteral antibiotics, and the duration of IV antimicrobial therapy in our Department ranged from 7 days to 31 days (median 18.5 days), and in some cases it was a continuation of treatment started in other Departments. It was followed by several weeks (up to 4 weeks) peroral treatment. The most frequent intravenously administered antibiotic was ceftriaxione. The most common oral regimen was a combination of rifampicin plus ciprofloxacin. Two patients underwent surgical decompression. All patients showed favorable response to treatment manifested by improvement in general condition and CRP and ESR normalization. No recurrence of infection was observed.
usually affected secondary to the inflammation in adjacent vertebrae. Infection limited to intervertebral space (discitis) may be a complication of deep wounds and surgical interventions [1,2,4]. The majority of patients with spondylodiscitis have at least one of the risk factors e.g. old age, diabetes, immunoincompetence, steroid therapy, infection in other foci, vascular prosthesis, history of spinal surgery or dialysotherapy [5–7]. Six of our 11 patients presented with identifiable risk factors, most often spine surgery. The most frequently isolated bacteria in spondylodiscitis are: S. aureus (accounting for half of non-tuberculous cases) followed by Enterobacteriaceae – about 30% (usually E. coli). Salmonella sp., Proteus sp., Klebsiella sp. and fungi are less often isolated. Mycobacterium tuberculosis accounts for 9–46% of cases of spondylodiscitis in developed countries [1,7,8]. In our study S. aureus was the most common pathogen. In 1 patient repeated sets of blood cultures revealed Staphylococcus warneri growth. This organism is a very rare cause of spondylodiscitis and so far only 4 cases of S. warneri spinal infections have been reported in the literature [9–12]. The clinical symptoms of spondylodiscitis are related to the affected region of the spine. The disease in most cases affects the lumbar region of the spine, followed by the thoracic and cervical region (tuberculous spondylodiscitis involves the thoracic spine more frequently than others) [5,6,8,13–16]. Similarly to other reports majority of spondylodiscitis in our case series affected lumbar spine. In two patients infection involved >2 contiguous vertebrae. As demonstrated in our patients, back pain is the earliest and the most common symptom. It increases during movements and at night followed by the sensation of stiffness and leads to limitation of activity. These symptoms are frequently mistaken for overload
4. Discussion Spondylodiscitis may be a result of sepsis, pathogen migration from the inflammation focus adjacent to the spine or may be a complication of neurosurgical operation [2]. Intervertebral space is
60
A. Garkowski et al. / Advances in Medical Sciences 59 (2014) 57–60
disorders of spine. In all our cases pain radiated from the spine. Tenderness on palpation over the involved region of the spine is common in spondylodiscitis but it may be present (although less frequently) in other spinal disorders – such as disk herniation. We observed pain on palpation of the spine in 6 cases. Symptoms increase gradually for several weeks or months [3–5,7]. In patients with post-operative spondylodiscitis, the pain symptoms appear just after a couple of days/weeks after the procedure. Patients in this group usually do not feel any pain just after the surgery but afterwards the pain increases as a result of intervertebral space infection. Patients complain about presurgery symptoms coming back, which can lead to incorrect diagnosis, other than spondylodiscitis [4,17]. Also, all our patients with post-operative spondylodiscitis had self-reported pain relief after the procedures. Then the pain returned after a short period. Spondylodiscitis of the thoracic or lumbar region can cause pain radiating to the thorax or abdomen, imitating cholecystitis, pancreatitis or appendicitis [1,14]. Fever occurs in about half of all patients [5]. Neurological deficits including muscle weakness, numbness, paralysis and loss of sphincters control are observed in one third of patients [3]. In the present study, we observed root syndrome in all patients and urinary incontinence in one case. If spondylodiscitis is a complication of a distant localized infection spreading hematogenously, the symptoms of primary infection may dominate in the early phase of spondylodiscitis for example bacterial endocarditis, urinary tract infection or abscesses. In case of strong spine tenderness after local or systemic infection, spondylodiscitis should be taken into consideration in differential diagnosis [2,5,8,15]. In the early stage of spondylodiscitis, the X-ray usually does not show any abnormalities. Pathological changes are rarely seen before 2–4 weeks. That is why the MRI is the imaging test of choice as it may reveal changes in the early phase of the disease (<14 days). Sensitivity and specificity of the test exceeds 90%. In T1weighted images reduction in signal intensity from the vertebral body and intervertebral space can be observed, while T2-weighted images demonstrate increased intensity in the vertebral body and disk space. Intervertebral space involvement gives an image of its narrowing [18,19]. Most of our patients had typical MRI findings. CT is an alternative diagnostic tool but it has lower sensitivity and specificity than MRI. CRP concentration and ESR are elevated in about 95% of patients (approximately 2–4 times above normal). Leukocytosis occurs in about 1/3 of patients and usually is mild [5,6,14]. In our series CRP was elevated in 7 patients and ESR was elevated in all of the patients. Antibiotics (administered initially intravenously for at least 2–4 weeks and subsequently orally) are the treatment of choice for spondylodiscitis [20]. Shorter parenteral therapy is associated with much higher risk of treatment failure. The optimal duration of parenteral and oral antibiotics therapy is 12 weeks (6 weeks IV therapy and 6 weeks oral therapy) [4,8,20]. The decision of treatment discontinuation should be dependent on patient improvement, CRP and ESR normalization. If 50% decrease in CRP and ESR values is observed oral therapy may be started [1,4,17]. As yet, there is no firm guidelines for the duration and selection of antibiotic therapy. Antibiotic treatment may be implemented after microbiological sampling (blood culture, CT-guided or open biopsy for culture and histology). If cultures are negative empirical antibiotic therapy should target the most common pathogens, including staphylococci (usually with vancomycin if MRSA is a possibility) and Gramnegative bacteria (II and III generation Cephalosporins) [1,3,4]. Bed rest and administration of low-molecular weight heparin for 2–4 weeks is recommended. Then patients should be mobilized with a brace, corset or lumbar support belt [4]. Surgical treatment is recommended when progression of the disease is not stopped despite the use of antibiotics. It consists of
spinal cord decompression or draining of epidural or paravertebral abscesses [1,15]. 5. Conclusions Diagnosis of spondylodiscitis is frequently delayed. This disease should be taken into consideration in differential diagnosis in patients with root syndromes accompanied by back pain and usually fever as well as increased values of CRP and ESR. However, as it was shown in 4 of our patients, pain may be the only present symptom, which makes the diagnostic process more complicated. Accurate diagnosis in the early stage of the disease prevents irreversible spinal cord damages and reduces the length of antibiotic therapy. Conflict of interests The authors declare no conflict of interests. Financial disclosure The authors have no financing to disclose. References [1] Gouliouris T, Aliyu SH, Brown NM. Spondylodiscitis: update on diagnosis and management. J Antimicrob Chemother 2010;65(November (Suppl 3)):iii11–24. [2] Zimmerli W. Clinical practice.Vertebral osteomyelitis. N Engl J Med 2010 Mar;362(11):1022–9. [3] Mylona E, Samarkos M, Kakalou E, Fanourgiakis P, Skoutelis A. Pyogenic vertebral osteomyelitis: a systematic review of clinical characteristics. Semin Arthritis Rheum 2009;39(August (1)):10–7. [4] Cottle L, Riordan T. Infectious spondylodiscitis. J Infect 2008;56(June (6)):401–12. [5] Bhavan KP, Marschall J, Olsen MA, Fraser VJ, Wright NM, Warren DK. The epidemiology of hematogenous vertebral osteomyelitis: a cohort study in a tertiary care hospital. BMC Infect Dis 2010;10(June):158. [6] Sobottke R, Ro¨llinghoff M, Zarghooni K, Zarghooni K, Schlu¨ter-Brust K, Delank KS, et al. Spondylodiscitis in the elderly patient: clinical mid-term results and quality of life. Arch Orthop Trauma Surg 2010;130(September (9)):1083–91. [7] Torda AJ, Gottlieb T, Bradbury R. Pyogenic vertebral osteomyelitis: analysis of 20 cases and review. Clin Infect Dis Feb 1995;20(2):320–8. [8] McHenry MC, Easley KA, Locker GA. Vertebral osteomyelitis: long-term outcome for 253 patients from 7 Cleveland-area hospitals. Clin Infect Dis 2002;34(May (10)):1342–50. [9] Announ N, Mattei JP, Jaoua S, Fenollar F, Sati H, Chagnaud C, et al. Multifocal discitis caused by Staphylococcus warneri. Joint Bone Spine 2004;71(May (3)):240–2. [10] Bryan CS, Parisi JT, Strike DG. Vertebral osteomyelitis due to Staphylococcus warneri attributed to a Hickman catheter. Diagn Microbiol Infect Dis 1987;8(September (1)):57–9. [11] Karthigasu KT, Bowman RA, Grove DI. Vertebral osteomyelitis due to Staphylococcus warneri. Ann Rheum Dis 1986;45(December (12)):1029–30. [12] Wood CA, Sewell DL, Strausbaugh LJ. Vertebral osteomyelitis and native valve endocarditis caused by Staphylococcus warneri. Diagn Microbiol Infect Dis 1989;12(May-June (3)):261–3. [13] Hopkinson N, Stevenson J, Benjamin S. A case ascertainment study of septic discitis: clinical, microbiological and radiological features. QJM 2001;94(September (9)):465–70. [14] Jensen AG, Espersen F, Skinhøj P, Frimodt-Møller N. Bacteremic Staphylococcus aureus spondylitis. Arch Intern Med 1998;158(March (5)):509–17. ˜ ez [15] Cebria´n Parra JL, Saez-Arenillas Martı´n A, Urda Martı´nez-Aedo AL, Soler Ivan I, Agreda E, Lopez-Duran Stern L. Management of infectious discitis. Outcome in one hundred and eight patients in a University Hospital. Int Orthop 2012;36(February (2)):239–44. [16] Wang D. Diagnosis of tuberculous vertebral osteomyelitis (TVO) in a developed country and literature review. Spinal Cord 2005;43(September (9)):531–42. [17] Silber JS, Anderson DG, Vaccaro AR, Anderson PA, McCormick P. NASS. Management of postprocedural discitis. Spine J 2002;2(July–August (4)):279–87. [18] Maiuri F, Iaconetta G, Gallicchio B, Manto A, Briganti F. Spondylodiscitis. Clinical and magnetic resonance diagnosis. Spine 1997;22(August (15)):1741–6. [19] Ledermann HP, Schweitzer ME, Morrison WB, Carrino JA. MR imaging findings in spinal infections: rules or myths? Radiology 2003;228(August (2)):506–14. [20] Zarghooni K, Ro¨llinghoff M, Sobottke R, Eysel P. Treatment of spondylodiscitis. Int Orthop 2012;36(February (2)):405–11.
Contents lists available at ScienceDirect
Advances in Medical Sciences journal homepage: www.elsevier.com/locate/advms
Original Research Article
Infectious spondylodiscitis – A case series analysis Adam Garkowski a,*, Agata Zajkowska a, Piotr Czupryna a, Wojciech Łebkowski b, Michał Letmanowski a, Paweł Gołe˛bicki a, Anna Moniuszko a, Andrzej Ustymowicz c, Sławomir Pancewicz a, Joanna Zajkowska a a b c
Department of Infectious Diseases and Neuroinfections, Medical University of Bialystok, Bialystok, Poland Department of Neurosurgery, Medical University of Bialystok, Bialystok, Poland Department of Radiology, Medical University of Bialystok, Bialystok, Poland
A R T I C L E I N F O
A B S T R A C T
Article history: Received 15 October 2012 Accepted 2 August 2013 Available online 19 March 2014
Purpose: We aimed to describe the clinical and laboratory features as well as diagnostic difficulties in the case series of spondylodiscitis. Materials/methods: We retrospectively reviewed 11 cases of spondylodiscitis. The diagnosis of spondylodiscitis was based on clinical, radiological and microbiological evidence and by the response to antimicrobial therapy. Results: There were 7 men and 4 women, and the age ranged from 21 to 74 years. Risk factors of spondylodiscitis were observed in 7 patients. The approximate time from onset of symptoms to diagnosis was from 2 to 7 months (median 45 days). Back pain was the most common symptom. The most frequent location of spondylodiscitis was lumbar spine. Pathogens were isolated in 6 cases and were as follows: Staphylococcus aureus (4 cases), Staphylococcus warneri (1 case) and Escherichia coli (1 case). After therapy, all patients had rapid regression of symptoms and no permanent neurological impairments and recurrence of infection were observed. Conclusions: Diagnosis of spondylodiscitis is frequently delayed. This disease should be taken into consideration in differential diagnosis in patients with root syndromes accompanied by back pain and usually fever as well as increased values of CRP and ESR. ß 2014 Medical University of Bialystok. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.
Keywords: Spondylodiscitis Vertebral osteomyelitis Back pain Spine Infection
1. Introduction Spondylodiscitis is quite a rare disease characterized by insidious onset and non-specific symptoms such as back pain and fever. Consequently, early diagnosis is difficult and is often missed despite repeated warnings in the medical journals and better access to imaging techniques such as magnetic resonance imaging (MRI) and computed tomography (CT). The term spondylodiscitis includes vertebral osteomyelitis and discitis. The term vertebral osteomyelitis means inflammation of the vertebral body and the term discitis indicates infection of the intervertebral disk space. Spondylodiscitis may take acute, subacute or chronic course [1–3]. The incidence of spondylodiscitis is about 2.4 cases per 100,000 annually, and it increases with age. The disease is diagnosed in males more often than in females [2,4]. Aging, multi-morbidity, changes in
* Corresponding author at: Department of Infectious Diseases and Neuroinfections, Medical University of Bialystok, Z˙urawia 14, 15-540 Bialystok, Poland. Tel.: +48 85 740 9514; fax: +48 85 740 9515. E-mail address: [email protected] (A. Garkowski).
lifestyle leading to spinal injury, drug abuse, and increasing number of patients with immunological deficits are important factors contributing to gradual increase of spondylodiscitis incidence [1,3,5,6]. 2. Material and methods The medical documentation of 11 patients with spondylodiscitis hospitalized at the Department of Infectious Diseases and Neuroinfections of Medical University in Bialystok (Poland), between March 2002 and December 2011 was reviewed. Before admission to our Department the majority of patients were treated at the Department of Neurosurgery. The parameters analyzed were as follows: demographic pattern, risk factors, clinical symptoms, localization of the infection, blood tests, bacterial cultures, MRI findings and outcome of the disease. The final diagnosis of spondylodiscitis was based on clinical, radiological and microbiological evidence, laboratory tests (acute phase parameters) and the response to antimicrobial therapy. In the differential diagnosis diseases such as: compression fracture, metastatic spinal lesions, erosive osteochondrosis, gout arthritis, aseptic bone necrosis were excluded.
http://dx.doi.org/10.1016/j.advms.2014.02.001 1896-1126/ß 2014 Medical University of Bialystok. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.
A. Garkowski et al. / Advances in Medical Sciences 59 (2014) 57–60
58 Table 1 Demographic data of analyzed patients. Patient no.
Gender
Age
Predisposing factors
1 2 3 4 5 6 7 8 9 10 11
Female Female Male Male Male Male Male Male Female Male Female
52 62 64 44 74 67 34 21 56 45 51
Not present Not present Spine surgery (L3-L4-L5). Diabetes. Chronic kidney failure Vascular prosthesis because of aortic aneurysm Not present Spine surgery (L4-L5) Not present Not present Spine surgery (L4-L5) Spine surgery (L5-S1)
3. Results The median age of the patients was 52 years and ranged from 21 to 74 years. The male to female ratio was 7:4. Risk factors for spondylodiscitis were observed in 6 patients. Four patients had a history of recent spine surgery (and one of them also had diabetes); one patient had vascular prosthesis; one patient suffered from chronic kidney disease and one patient had a history of gangrenous cholecystitis and pleural empyema. Five patients had no identifiable risk factors. One or more comorbidities were presented in 8 patients. Concomitant degenerative spinal disease was found in 6 cases. Tables 1 and 2 present demographic and clinical characteristics of the patients. In most cases diagnosis was delayed. The approximate time from onset of symptoms to diagnosis was from 2 to 7 months (median 45 days).
At admission to the Department all patients complained about localized back pain related to the sites of infection. Nine patients presented with pain in the lumbar spine region which radiated to one or both lower limbs; in 1 patient with infection of the lumbar spine pain radiated to the buttocks. In 1 case pain radiated to the right upper limb. Fever 38 8C was observed in 5 patients. One patient had urinary incontinence. Sepsis developed in 4 cases (in 1 case septic shock was present). The most frequent localization of spondylodiscitis was lumbar spine (in 10 cases). Four patients presented with infection of two adjacent vertebrae and intervening intervertebral disk space; in 2 cases infection involved >2 contiguous vertebrae and intervening intervertebral disk space (vertebral osteomyelitis). In 4 patients infection was limited to intervertebral disk space without adjacent vertebrae (discitis). In 2 patients with lumbar spine involvement the inflammatory process spread to the paravertebral tissues. C-reactive protein concentration (CRP) was measured in all patients before treatment and was elevated in 7 patients (>10.0 mg/L). The erythrocyte sedimentation rate (ESR) was increased in all patients (in all >30 mm/h). Leukocytosis (>10,000 WBCs/mm3) was present in 5 cases. Pathogens were isolated from repeated sets of blood cultures in 5 cases. Staphylococcus spp. was found in 4 cases. Escherichia coli was isolated in 1 patient. In 1 case histopathologic examination and culture of the material from intervertebral space was performed. Staphylococcus aureus was isolated; histopathologic examination revealed pyogenic inflammation. Initial MRI scan was performed in 10 patients. Typical changes were observed in 9 cases. Hypointensity of the vertebral bodies and intervertebral discs in T1-weighted images was observed and
Table 2 Clinical characteristics and laboratory test of analyzed patients. Patient no.
Diagnosis
Clinical symptoms
Body temperature (8C)
1
Vertebral osteomyelitis
36.6
34
0.3
2
Discitis
Pain of the cervical spine during movement with radiation to the right upper limb. Limb weakness. Pain on palpation of the cervical spine. Pain of the L-S spine region, radiating to right lower limb. Limb weakness. Pain on palpation of the spine L-S.
38.0
95
3
Vertebral osteomyelitis. Sepsis Vertebral osteomyelitis. Sepsis Vertebral osteomyelitis.
Pain of the L-S spine region, radiating to both lower limbs, escalating during movement. Limb weakness. Pain of the L-S spine region, radiating to both lower limbs. Limb weakness.
37.2
4
5
6
Vertebral osteomyelitis
7
Discitis
8
10
Vertebral osteomyelitis. Sepsis Vertebral osteomyelitis. Sepsis + septic shock Discitis
11
Discitis
9
Localization
Cultures
5.8
C6-C7
Blood – negative
19.3
10.04
L2-L3
62
85.7
13.32
L3-L4-L5
Material from intervertebral space – Staphylococcus aureus MSSA Blood – negative Blood – Staphylococcus warneri
38.0
100
353.7
12.25
L3-L4-L5
Blood – Staphylococcus aureus MSSA
Pain of the L-S spine region, radiating to both lower limbs. Limb weakness. Pain on palpation of the spine. Pain of the L-S spine, radiating to left lower limb. Limb weakness. Pain on palpation of the spine. Pain of the L-S spine region, radiating to both lower limbs, escalating during movement. Limb weakness. Pain of the L-S spine region, radiating to buttocks muscles, escalating during hips movements. Limb weakness. Pain of the L-S spine region, radiating to right lower limb. Limb weakness. Pain on palpation of the spine
36.8
98
64.6
10.4
L4-L5
Blood – Staphylococcus aureus MSSA (blood)
39.0
72
240.4
6.64
L4-L5
Blood – negative
36.6
37
0.8
5.04
L4-L5
Blood – negative
40.0
116
81
7.7
L4-L5
Blood – Staphylococcus aureus MSSA
39.0
76
204
10.8
L4-L5
Blood – Escherichia coli
Pain of the L-S spine region, escalating during movement. Pain on palpation of the L-S spine. Pain of the L-S spine region, radiating to both lower limbs. Limb weakness. Reduced mobility of the lumbar spine. Urinary incontinence.
36.6
46
9.0
9.4
L4-L5
Blood – negative
37.0
42
7.4
6.49
L5-S1
Blood – negative
ESR (mm/h)
CRP (mg/l)
WBCs count (103/mm3)
A. Garkowski et al. / Advances in Medical Sciences 59 (2014) 57–60
59
Fig. 1. MRI scan showing inflammatory infiltrates in the course of discitis (T1 weighted–gadolinium enhanced). (A) sagittal plane, (B) transverse plane.
Fig. 2. MRI scan showing inflammatory infiltrates in the course of discitis (T1 weighted–gadolinium enhanced). (A) sagittal plane, (B) transverse plane.
hyperintensity – in T2-weighted images. Representative MRI scans are shown in Figs. 1 and 2. In 1 patient the diagnosis of spondylodiscitis was made during neurosurgical operation. This patient had surgery due to the concomitant lumbar discopathy; and while previously performed MRI did not show any features of discitis; the diagnosis was based on positive cultures of an infected intervertebral space. In 1 patient MRI scan was not obtained. In this case the diagnosis of discitis was based on spine X-ray radiographs that showed narrowing of the intervertebral space L4-L5 without abnormalities in the vertebrae. Length of hospital stay in our Department ranged from 7 days to 34 days (median 19 days). The duration of antimicrobial treatment depended on the CRP and ESR levels. All the patients received parenteral antibiotics, and the duration of IV antimicrobial therapy in our Department ranged from 7 days to 31 days (median 18.5 days), and in some cases it was a continuation of treatment started in other Departments. It was followed by several weeks (up to 4 weeks) peroral treatment. The most frequent intravenously administered antibiotic was ceftriaxione. The most common oral regimen was a combination of rifampicin plus ciprofloxacin. Two patients underwent surgical decompression. All patients showed favorable response to treatment manifested by improvement in general condition and CRP and ESR normalization. No recurrence of infection was observed.
usually affected secondary to the inflammation in adjacent vertebrae. Infection limited to intervertebral space (discitis) may be a complication of deep wounds and surgical interventions [1,2,4]. The majority of patients with spondylodiscitis have at least one of the risk factors e.g. old age, diabetes, immunoincompetence, steroid therapy, infection in other foci, vascular prosthesis, history of spinal surgery or dialysotherapy [5–7]. Six of our 11 patients presented with identifiable risk factors, most often spine surgery. The most frequently isolated bacteria in spondylodiscitis are: S. aureus (accounting for half of non-tuberculous cases) followed by Enterobacteriaceae – about 30% (usually E. coli). Salmonella sp., Proteus sp., Klebsiella sp. and fungi are less often isolated. Mycobacterium tuberculosis accounts for 9–46% of cases of spondylodiscitis in developed countries [1,7,8]. In our study S. aureus was the most common pathogen. In 1 patient repeated sets of blood cultures revealed Staphylococcus warneri growth. This organism is a very rare cause of spondylodiscitis and so far only 4 cases of S. warneri spinal infections have been reported in the literature [9–12]. The clinical symptoms of spondylodiscitis are related to the affected region of the spine. The disease in most cases affects the lumbar region of the spine, followed by the thoracic and cervical region (tuberculous spondylodiscitis involves the thoracic spine more frequently than others) [5,6,8,13–16]. Similarly to other reports majority of spondylodiscitis in our case series affected lumbar spine. In two patients infection involved >2 contiguous vertebrae. As demonstrated in our patients, back pain is the earliest and the most common symptom. It increases during movements and at night followed by the sensation of stiffness and leads to limitation of activity. These symptoms are frequently mistaken for overload
4. Discussion Spondylodiscitis may be a result of sepsis, pathogen migration from the inflammation focus adjacent to the spine or may be a complication of neurosurgical operation [2]. Intervertebral space is
60
A. Garkowski et al. / Advances in Medical Sciences 59 (2014) 57–60
disorders of spine. In all our cases pain radiated from the spine. Tenderness on palpation over the involved region of the spine is common in spondylodiscitis but it may be present (although less frequently) in other spinal disorders – such as disk herniation. We observed pain on palpation of the spine in 6 cases. Symptoms increase gradually for several weeks or months [3–5,7]. In patients with post-operative spondylodiscitis, the pain symptoms appear just after a couple of days/weeks after the procedure. Patients in this group usually do not feel any pain just after the surgery but afterwards the pain increases as a result of intervertebral space infection. Patients complain about presurgery symptoms coming back, which can lead to incorrect diagnosis, other than spondylodiscitis [4,17]. Also, all our patients with post-operative spondylodiscitis had self-reported pain relief after the procedures. Then the pain returned after a short period. Spondylodiscitis of the thoracic or lumbar region can cause pain radiating to the thorax or abdomen, imitating cholecystitis, pancreatitis or appendicitis [1,14]. Fever occurs in about half of all patients [5]. Neurological deficits including muscle weakness, numbness, paralysis and loss of sphincters control are observed in one third of patients [3]. In the present study, we observed root syndrome in all patients and urinary incontinence in one case. If spondylodiscitis is a complication of a distant localized infection spreading hematogenously, the symptoms of primary infection may dominate in the early phase of spondylodiscitis for example bacterial endocarditis, urinary tract infection or abscesses. In case of strong spine tenderness after local or systemic infection, spondylodiscitis should be taken into consideration in differential diagnosis [2,5,8,15]. In the early stage of spondylodiscitis, the X-ray usually does not show any abnormalities. Pathological changes are rarely seen before 2–4 weeks. That is why the MRI is the imaging test of choice as it may reveal changes in the early phase of the disease (<14 days). Sensitivity and specificity of the test exceeds 90%. In T1weighted images reduction in signal intensity from the vertebral body and intervertebral space can be observed, while T2-weighted images demonstrate increased intensity in the vertebral body and disk space. Intervertebral space involvement gives an image of its narrowing [18,19]. Most of our patients had typical MRI findings. CT is an alternative diagnostic tool but it has lower sensitivity and specificity than MRI. CRP concentration and ESR are elevated in about 95% of patients (approximately 2–4 times above normal). Leukocytosis occurs in about 1/3 of patients and usually is mild [5,6,14]. In our series CRP was elevated in 7 patients and ESR was elevated in all of the patients. Antibiotics (administered initially intravenously for at least 2–4 weeks and subsequently orally) are the treatment of choice for spondylodiscitis [20]. Shorter parenteral therapy is associated with much higher risk of treatment failure. The optimal duration of parenteral and oral antibiotics therapy is 12 weeks (6 weeks IV therapy and 6 weeks oral therapy) [4,8,20]. The decision of treatment discontinuation should be dependent on patient improvement, CRP and ESR normalization. If 50% decrease in CRP and ESR values is observed oral therapy may be started [1,4,17]. As yet, there is no firm guidelines for the duration and selection of antibiotic therapy. Antibiotic treatment may be implemented after microbiological sampling (blood culture, CT-guided or open biopsy for culture and histology). If cultures are negative empirical antibiotic therapy should target the most common pathogens, including staphylococci (usually with vancomycin if MRSA is a possibility) and Gramnegative bacteria (II and III generation Cephalosporins) [1,3,4]. Bed rest and administration of low-molecular weight heparin for 2–4 weeks is recommended. Then patients should be mobilized with a brace, corset or lumbar support belt [4]. Surgical treatment is recommended when progression of the disease is not stopped despite the use of antibiotics. It consists of
spinal cord decompression or draining of epidural or paravertebral abscesses [1,15]. 5. Conclusions Diagnosis of spondylodiscitis is frequently delayed. This disease should be taken into consideration in differential diagnosis in patients with root syndromes accompanied by back pain and usually fever as well as increased values of CRP and ESR. However, as it was shown in 4 of our patients, pain may be the only present symptom, which makes the diagnostic process more complicated. Accurate diagnosis in the early stage of the disease prevents irreversible spinal cord damages and reduces the length of antibiotic therapy. Conflict of interests The authors declare no conflict of interests. Financial disclosure The authors have no financing to disclose. References [1] Gouliouris T, Aliyu SH, Brown NM. Spondylodiscitis: update on diagnosis and management. J Antimicrob Chemother 2010;65(November (Suppl 3)):iii11–24. [2] Zimmerli W. Clinical practice.Vertebral osteomyelitis. N Engl J Med 2010 Mar;362(11):1022–9. [3] Mylona E, Samarkos M, Kakalou E, Fanourgiakis P, Skoutelis A. Pyogenic vertebral osteomyelitis: a systematic review of clinical characteristics. Semin Arthritis Rheum 2009;39(August (1)):10–7. [4] Cottle L, Riordan T. Infectious spondylodiscitis. J Infect 2008;56(June (6)):401–12. [5] Bhavan KP, Marschall J, Olsen MA, Fraser VJ, Wright NM, Warren DK. The epidemiology of hematogenous vertebral osteomyelitis: a cohort study in a tertiary care hospital. BMC Infect Dis 2010;10(June):158. [6] Sobottke R, Ro¨llinghoff M, Zarghooni K, Zarghooni K, Schlu¨ter-Brust K, Delank KS, et al. Spondylodiscitis in the elderly patient: clinical mid-term results and quality of life. Arch Orthop Trauma Surg 2010;130(September (9)):1083–91. [7] Torda AJ, Gottlieb T, Bradbury R. Pyogenic vertebral osteomyelitis: analysis of 20 cases and review. Clin Infect Dis Feb 1995;20(2):320–8. [8] McHenry MC, Easley KA, Locker GA. Vertebral osteomyelitis: long-term outcome for 253 patients from 7 Cleveland-area hospitals. Clin Infect Dis 2002;34(May (10)):1342–50. [9] Announ N, Mattei JP, Jaoua S, Fenollar F, Sati H, Chagnaud C, et al. Multifocal discitis caused by Staphylococcus warneri. Joint Bone Spine 2004;71(May (3)):240–2. [10] Bryan CS, Parisi JT, Strike DG. Vertebral osteomyelitis due to Staphylococcus warneri attributed to a Hickman catheter. Diagn Microbiol Infect Dis 1987;8(September (1)):57–9. [11] Karthigasu KT, Bowman RA, Grove DI. Vertebral osteomyelitis due to Staphylococcus warneri. Ann Rheum Dis 1986;45(December (12)):1029–30. [12] Wood CA, Sewell DL, Strausbaugh LJ. Vertebral osteomyelitis and native valve endocarditis caused by Staphylococcus warneri. Diagn Microbiol Infect Dis 1989;12(May-June (3)):261–3. [13] Hopkinson N, Stevenson J, Benjamin S. A case ascertainment study of septic discitis: clinical, microbiological and radiological features. QJM 2001;94(September (9)):465–70. [14] Jensen AG, Espersen F, Skinhøj P, Frimodt-Møller N. Bacteremic Staphylococcus aureus spondylitis. Arch Intern Med 1998;158(March (5)):509–17. ˜ ez [15] Cebria´n Parra JL, Saez-Arenillas Martı´n A, Urda Martı´nez-Aedo AL, Soler Ivan I, Agreda E, Lopez-Duran Stern L. Management of infectious discitis. Outcome in one hundred and eight patients in a University Hospital. Int Orthop 2012;36(February (2)):239–44. [16] Wang D. Diagnosis of tuberculous vertebral osteomyelitis (TVO) in a developed country and literature review. Spinal Cord 2005;43(September (9)):531–42. [17] Silber JS, Anderson DG, Vaccaro AR, Anderson PA, McCormick P. NASS. Management of postprocedural discitis. Spine J 2002;2(July–August (4)):279–87. [18] Maiuri F, Iaconetta G, Gallicchio B, Manto A, Briganti F. Spondylodiscitis. Clinical and magnetic resonance diagnosis. Spine 1997;22(August (15)):1741–6. [19] Ledermann HP, Schweitzer ME, Morrison WB, Carrino JA. MR imaging findings in spinal infections: rules or myths? Radiology 2003;228(August (2)):506–14. [20] Zarghooni K, Ro¨llinghoff M, Sobottke R, Eysel P. Treatment of spondylodiscitis. Int Orthop 2012;36(February (2)):405–11.