Haematogenous vertebral osteomyelitis (HVO) is a relatively rare disorder which accounts for 2–4% of all cases of infectious bone disease. In recent years, the incidence of spinal infections seems to have increased according to the growing number of intravenous drug users in young people and with the use of intravenous access devices, genitourinary surgery and manipulation in the elderly. Men are more frequently affected than women, with an average age of onset in the fifth and sixth decade of life. The onset of symptoms is typically insidious, with neck or back pain often underestimated by the patient. The early diagnosis is also difficult due to the non-specific nature of laboratory and radiographic findings. The frequent observation of back pain also makes the diagnosis a challenge in most cases. Several studies in the literature report an average delay in the diagnosis of HVO from 2 to 6 months after the beginning of the symptoms. In this article we review the clinical features and the diagnostic approach to HVO in order to optimise treatment strategies and follow-up assessment.

From 1997 to 2003 we treated 153 patients affected by vertebral osteomyelitis. The localisation was cervical in 11.5% of the cases, thoracic in 31% and lumbar in 57.5% cases. In all, 92 CT needle biopsies were performed without any complications. We were able to identify the microbiological pattern in 57% of cases (the most represented bacteria were Staphylococcus aureus and Mycobaterium tuberculosis) whereas in 47% of cases we could not identify any micro-organismus. Treatment was conservative in 112 cases and surgical in 41 cases.

Most of the studies in the literature consider HVO as a challenge for the physician: symptoms are not specific and sub-acute or chronic presentation is most common. In general, a delay in diagnosis is the rule rather than the exception. This is an easily missed infectious process, particularly in the elderly, in whom degenerative radiographic changes and conditions resulting in back pain, such as osteoporotic fractures or spinal metastases, are common and signs of sepsis may not become manifest. However, persisting localised back pain and tenderness with elevated ESR should prompt the physician to also consider HVO, although fever and leucocytosis may often not be present.

Once HVO is suspected, a long series of imaging and laboratory tests, and if necessary surgical procedures, must be initiated. The purpose of this study is to formulate a systematic, comprehensive and simple approach to the management of this disease following the diagnostic algorithm suggested.