Aims

Gram-negative infections are associated with comorbid patients, but outcomes are less well understood. This study reviewed diagnosis, management, and treatment for a cohort treated in a tertiary spinal centre.

Aims

The aim of this study was to determine the consensus best practice approach for the investigation and management of children (aged 0 to 15 years) in the UK with musculoskeletal infection (including septic arthritis, osteomyelitis, pyomyositis, tenosynovitis, fasciitis, and discitis). This consensus can then be used to ensure consistent, safe care for children in UK hospitals and those elsewhere with similar healthcare systems.

Aims

Early cases of cauda equina syndrome (CES) often present with nonspecific symptoms and signs, and it is recommended that patients undergo emergency MRI regardless of the time since presentation. This creates substantial pressure on resources, with many scans performed to rule out cauda equina rather than confirm it. We propose that compression of the cauda equina should be apparent with a limited sequence (LS) scan that takes significantly less time to perform.

Objectives

Although vertebroplasty is very effective for relieving acute pain from an osteoporotic vertebral compression fracture, not all patients who undergo vertebroplasty receive the same degree of benefit from the procedure. In order to identify the ideal candidate for vertebroplasty, pre-operative prognostic demographic or clinico-radiological factors need to be identified. The objective of this study was to identify the pre-operative prognostic factors related to the effect of vertebroplasty on acute pain control using a cohort of surgically and non-surgically managed patients.

Aim of the study was to define the role of surgical stabilization of the spine in treatment of pyogenic spondylitis/diskitis.

We restrospectively analyzed patients referred to our department for treatment of pyogenic infection of axial skeleton.

In three years period we treated 51 patients with pyogenic infection of axial skeleton, and 46 of them were surgically stabilized by means of posterior instrumentation with or without anterior column reconstruction. Reoperation rate was 7%, and was in all cases associated with failure in reconstruction of anterior column of the spine. This could be achieved either by posterior or by combined approach, and there was no significant difference in perioperative complications in either group of patients. 14 patients presented with initial neurological deficit, and that presented the indication for urgent surgical procedure.

We conclude that surgical stabilization of axial skeleton should be always performed in patients with destruction of bone structure. The procedure allows easy achievement of material for bacteriological culture, and precisely targeted antibiotic treatment, and at the same time results with a stable spine, therefore allowing early rehabilitation of these patients. Though neurological deficit presents the indication for urgent decompression of neural structures, we emphasize the importance of reconstruction of all three columns of the spine in all circumstances.

Back pain is a common symptom in children and adolescents. Here we review the important causes, of which defects and stress reactions of the pars interarticularis are the most common identifiable problems. More serious pathology, including malignancy and infection, needs to be excluded when there is associated systemic illness. Clinical evaluation and management may be difficult and always requires a thorough history and physical examination. Diagnostic imaging is obtained when symptoms are persistent or severe. Imaging is used to reassure the patient, relatives and carers, and to guide management.

Cite this article: Bone Joint J 2014;96-B:717–23.

Discitis in childhood is rare. It can be difficult to diagnose, particularly in the younger child, often leading to a delay in initiation of appropriate treatment. It is not known whether it represents an infective or an inflammatory process. Our aim was to review all cases treated at a regional children's hospital since the introduction of the departmental database. A retrospective review (64,058 cases), for the period 1990-2008 was performed. 12 cases were identified (3 male/9 female), with a biphasic age distribution; eight [mean 22 months old (12-32)] and four [mean 12 years old (11-13)]. Mean time to diagnosis from onset was 22 days, (5-49). Symptoms varied with age, no one less than 28 months complained of back pain, while all over 28 months did, to a varying degree. All the younger children presented primarily with a gait abnormality. 92% (11/12) were apyrexial on admission. WBC and CRP were normal in 83% (10/12). Venous blood cultures were negative in 89% (8/9). Only ESR was mildly raised, mean 30 (10-65). Radiographs showed loss of intervertebral disc height in 91% (10/11), earliest by 10 days following onset symptoms, mean 28 days. A technetium bone scan was performed in 42% (5/12) and an MRI of the lumbar spine, in 58% (7/12). All were positive for discitis. All occurred in the lumbar spine, 50% at L3/4. Antibiotics were used in 11/12 (92%), flucloxacillin alone in the majority 9/11. One had non-steroidal medication alone. No form of brace was used. Mean follow-up was 13.3 months (2-36). In all, symptoms had resolved by mean 6.5 weeks (2-12). No recurrence was noted. The common features of childhood discitis are presented; knowledge of these may aid the physician to come to a more rapid diagnosis of this uncommon paediatric condition

Spinal disc infection is associated with a significant morbidity and mortality in the acute setting. On long term review it leads to significant moribidity due to the deformity and secondary osteoarthritic changes in the surrounding vertebral segments.

Prospective collection of data of 21 patients suffering from discitis was collected over the span of last 10 years. The age group ranged between 21 -67 yrs. The male: female ratio was 1.2:1. The minimum delay in presentation since the onset of symptoms was 8 weeks. The detection of the micro-organism was either by needle/open biopsy or indirectly via blood cultures. Serial records were maintained of inflammatory markers. All patients received plain radiographs, gadolinium-enhanced magnetic resonance imaging scans, and bone/gallium radionuclide studies

Operative decompression was performed in 7 patients. Infection elsewhere was the most common predisposing factor. Leukocyte counts were elevated in 54% of spondylodiscitis cases. The erythrocyte sedimentation rate and CRP were elevated in all cases of epidural abscess. The most common organism was Staph Aureus. Antibiotics were administered for duration of at least 6 weeks. On long term, all patients developed deformity at the level of the infection, with half of them being symptomatic.

Spinal infections are extremely morbid conditions demanding prompt diagnosis and urgent treatment to prevent complications.

Ethics approval: Audit Committee Interest statement: No conflict of interest

Introduction: The best surgical technique for patients with bacterial spinal infections is still matter of debate. Recent publications suggest that titanium implants can be used safely in infectious sites in combination with debridement and antibiotic therapy. The aim of this study was to provide further evidence in support of debridement and instrumentation as a single-stage procedure for spinal osteomyelitis/discitis.

Methods: We retrospectively review patients with spontaneous spondylodiscitis in whom medical therapy failed, and consequently underwent instrumented fusion by the same surgeon (DD). We defined failed medical treatment as progression of the neurological deficit, lack of improvement of the inflamatory markers after 48 hours of an adequate antibiotic therapy or progression to spinal deformity in the follow-up x-rays. In all cases, the following variables were evaluated: sex, age, relevant medical history, neurological compromise measured by the Frankel scale, level operated and operation performed, source of infection, etiologic agent, antibiotic treatment, postoperative complications, inflammatory markers, length of hospitalization, fusion time. Quality of life was measured after at least 12 months of the operation with the EQ5D questionnaire.

Results: 12 patients (5 men and 7 women), ranging in age from 42 to 85 years, with a Frankel score of D in 10 cases, and of E in 2 cases, underwent a single stage debridement and posterior instrumented fusion with titanium pedicle screws and interbody autogenous bone. Preoperative neurological deficits improved in all cases and solid bone fusion was achieved in all 12 patients (100%) at 6 months. The indication for surgery was progressive neurological deficit in the lower limbs in 9 cases, lack of improvement after 48hrs of antibiotic therapy guided by blood culture results in 2 patients and progression to spinal deformity in the remaining one. The mean follow-up period was 60 months (range 12 to 100). In all patients the infection healed after surgery, not requiring a second operation to remove the metal implants. Quality of life assessed with the EQ5-questionnaire showed the following results: mobility (median 1, range 1 to 2), personal care (median 1, range 1 to 1), usual activities (median 1.5, range 1 to 2), pain/discomfort (median 1.5, range 1 to 2), anxiety/depression (median 1, range 1 to 2), visual analog scale for health state (median 67.5, range 30 to 80).

Discussion: These findings support that debridement and instrumented fusion can be performed as a single-stage procedure without an increase in the recurrence rate or morbidity. The outcome has been satisfactory in our patients in terms of rate of fusion and quality of life in the long term follow up.

Bertolotti’s syndrome is characterised by anomalous enlargement of the transverse process(es) of the most caudal lumbar vertebra which may articulate or fuse with the sacrum or ilium and cause isolated L4/5 disc disease.

We analysed the elective MR scans of the lumbosacral spine of 769 consecutive patients with low back pain taken between July 2003 and November 2004. Of these 568 showed disc degeneration. Bertolotti’s syndrome was present in 35 patients with a mean age of 32.7 years (15 to 60). This was a younger age than that of patients with multiple disc degeneration, single-level disease and isolated disc degeneration at the L4/5 level (p ≤ 0.05). The overall incidence of Bertolotti’s syndrome in our study was 4.6% (35 of 769). It was present in 11.4% (20 patients) of the under-30 age group.

Our findings suggest that Bertolotti’s syndrome must form part of a list of differential diagnoses in the investigation of low back pain in young people.

Introduction: Although prophylactic antibiotic administration is common in spinal surgery, the choice of drug, dose, and timing of administration often varies. Little is known about the activity of antibiotics in the spine and indeed if they are distributed throughout the disc and if the time intervals are optimal. Because infections that produce iatrogenic discitis generally arise within the disc, the antibiotic concentration of the disc is more relevant than serum concentrations. The aims of the study were to determine if a 2g dose of cephazolin was effective at preventing discitis over a four-hour period in immature ovine discs that were both non-degenerate and degenerate; and also to determine the concentration of cephazolin in serum and disc tissue. Methods: In 10 Merino wethers aged 12 weeks, three lumbar discs were “degenerated” by incising the posterolateral annulus with a scalpel blade and using ronguers, removing the bulk of the nucleus pulposus. After 12 weeks nine animals were anaesthetised and given a 2g dose of cephazolin (David Bull Laboratories, Australia) at predetermined time intervals over a four-hour period. The antibiotic was chosen for effectiveness against Staphylococcus aureus a common discitis-causing organism. One sheep (control) did not receive any antibiotics to follow the natural progression of infection. All animals had discography with radiographic contrast that contained S. aureus at two incised levels and at two non-incised levels. Lateral radiographs of the lumbar spine were taken at two, six and 12 weeks to monitor the bony changes. At 12 weeks all sheep were given a 2g intravenous dose of cephazolin at time intervals before being killed. The spines were removed and prepared for light microscopy to assess pathology of the discs and for biochemical analysis of antibiotic concentration. Success of treatment was judged using histologic and radiographic features. Results: The control sheep that did not receive any antibiotics developed discitis at four levels. Histology at 12 weeks confirmed discitis in 10/36 “prophylactic discs”. Of these “prophylactic discs” 7/10 had previously been “degenerated”. Discitis only developed in immature discs that were administered cephazolin two hours prior to inoculation. When antibiotic was administered after inoculation discitis was prevented. Biochemistry results confirmed that antibiotic diffused throughout the disc but was concentrated in the annulus more than the nucleus. Antibiotic levels in the disc peaked at 15 minutes (annulus mean concentration 15.5 mg/L, nucleus mean concentration 3.2 mg/L). Serum levels at 15 minutes were up to 50 times greater at this time (serum mean concentration 178 mg/L). Discussion: The discs that were “degenerate” had a higher incidence of discitis compared to “non-degenerate” discs. However the concentration of antibiotic in degenerate discs was not significantly different than in non-degenerate discs. A 2 gram dose of cephazolin is reasonably effective (approx 70% success rate) at preventing discitis over a four-hour period

Introduction: Treatment of discitis using conventional methods can be prolonged and unrewarding. Patients can have prolonged pain and persistently elevated Inflammatory markers. We propose a new method of treatment of severe cases, and present two cases where this method has successfully been used. Method: Once discitis has been diagnosed clinically and radiologically, a percutaneous discectomy of the infected level is performed. Matter is sent for microbiological analysis. An epidural catheter is then left in the infected disc space cavity. This is then used to administer appropriate antibiotics directly into the infected cavity. After one week the patient is converted on to intravenous antibiotics, for a further two weeks, then a prolonged course of oral antibiotics. Discussion: Discitis can be a difficult and unrewarding condition to treat. This novel method appears to be a new and effective mode of treatment, for both acute and chronic infections, although it does require further evaluation

Introduction: Infection can occur after any spinal procedure that involves entry into the disc and although it is not common, the potential consequences are serious. Treatment usually requires identification of the bacteria followed by a course of antibiotics. This treatment remains controversial since it is not clear whether antibiotics actually penetrate the disc and if so, whether they are effective, or even if the outcome would be the same without antibiotics. For an antibiotic to be effective against the infecting organism it must diffuse through the disc matrix. Blood vessels that surround the disc facilitate the diffusion process, but with age this vascularity decreases and may impede diffusion. The aims of the pilot study were to assess the effectiveness of antibiotic in treating infection in both normal and degenerate sheep discs and to measure the concentration of antibiotic in non-operated discs at varying ages. Methods: In each of six Merino wethers aged 12 weeks (n=3) and 24 months (n=3), two lumbar discs were “degenerated” by incising the posterolateral annulus with a scalpel blade. After four weeks all animals had discography with radiographic contrast that contained Staphylococcus aureus at the incised levels and at two non-incised levels. Seven days after infection four animals began IV antibiotic treatment with cephazolin sodium (David Bull Laboratories, Australia) for 21 days at a dose of 50mg/kg/day. The antibiotic was chosen for effectiveness against S. aureus. One control animal from each age group did not receive any antibiotics, to follow the natural progression of infection. Lateral radiographs of the lumbar spine were taken at two, six and 12 weeks. At 12 weeks all sheep were given a single intravenous dose of cephazolin sodium as either a 1, 2 or 3g dose. The sheep were then killed after 30 minutes. The spines were removed and prepared for light microscopy to assess pathology of the discs and for biochemical analysis of antibiotic concentration. Success of treatment was judged using histologic and radiographic features. Results: Discitis was evident radilogically as early as two weeks after inoculation in all animals. Histology at 12 weeks confirmed discitis in all discs regardless of treatment. Biochemistry results confirmed that antibiotic diffused throughout the disc but was more concentrated in the annulus than the nucleus. At all doses disc concentration of antibiotic was higher in lambs than sheep. Discussion: Treatment with cephazolin sodium at a dose of 50mg/kg/day for 21 days administered from seven days after inoculation, did not prevent discitis. This does not appear to be due to inability of antibiotic diffusion into the disc

INTRODUCTION: Treatment of discitis using conventional methods can be prolonged and unrewarding. Patients can have prolonged pain and persistently elevated Inflammatory markers. We propose a new method of treatment of severe cases, and present two cases where this method has successfully been used. METHOD: Once discitis has been diagnosed clinically and radiologically, a percutaneous discectomy of the infected level is performed. Matter is sent for microbiological analysis. An epidural catheter is then left in the infected disc space cavity. This is then used to administer appropriate antibiotics directly into the infected cavity. After one week the patient is converted on to intravenous antibiotics, for a further two weeks, then a prolonged course of oral antibiotics. DISCUSSION: Discitis can be a difficult and unrewarding condition to treat. This novel method appears to be a new and effective mode of treatment, for both acute and chronic infections, although it does require further evaluation

INTRODUCTION: Infection can occur after any spinal procedure that involves entry into the disc and although it is not common, the potential consequences are serious. Treatment usually requires identification of the bacteria followed by a course of antibiotics. This treatment remains controversial since it is not clear whether antibiotics actually penetrate the disc and if so, whether they are effective, or even if the outcome would be the same without antibiotics. For an antibiotic to be effective against the infecting organism it must diffuse through the disc matrix. Blood vessels that surround the disc facilitate the diffusion process, but with age this vascularity decreases and may impede diffusion. The aims of the pilot study were to assess the effectiveness of antibiotic in treating infection in both normal and degenerate sheep discs and to measure the concentration of antibiotic in non-operated discs at varying ages. METHODS: In each of six Merino wethers aged 12 weeks (n=3) and 24 months (n=3), two lumbar discs were “degenerated” by incising the posterolateral annulus with a scalpel blade. After four weeks all animals had discography with radiographic contrast that contained Staphylococcus aureus at the incised levels and at two non-incised levels. Seven days after infection four animals began IV antibiotic treatment with cephazolin sodium (David Bull Laboratories, Australia) for 21 days at a dose of 50 mg/kg/day. The antibiotic was chosen for effectiveness against S. aureus. One control animal from each age group did not receive any antibiotics, to follow the natural progression of infection. Lateral radiographs of the lumbar spine were taken at two, six and 12 weeks. At 12 weeks all sheep were given a single intravenous dose of cephazolin sodium as either a 1, 2 or 3 g dose. The sheep were then killed after 30 minutes. The spines were removed and prepared for light microscopy to assess pathology of the discs and for biochemical analysis of antibiotic concentration. Success of treatment was judged using histologic and radiographic features. RESULTS: Discitis was evident radiologically as early as two weeks after inoculation in all animals. Histology at 12 weeks confirmed discitis in all discs regardless of treatment. Biochemistry results confirmed that antibiotic diffused throughout the disc but was more concentrated in the annulus than the nucleus. At all doses disc concentration of antibiotic was higher in lambs than sheep. DISCUSSION: Treatment with cephazolin sodium at a dose of 50 mg/kg/day for 21 days administered from seven days after inoculation, did not prevent discitis. This does not appear to be due to inability of antibiotic diffusion into the disc

Diagnosis of infective discitis may be difficult as presentation is usually non-specific with little symptomatology and few signs in the early stages. This dilemma is further complicated by the fact there is a long latent period between the onset of symptoms and plain radiograph changes and a high index of suspicion must be maintained. We reviewed 30 cases referred to our unit for treatment between 1996 and 2001 with an emphasis on time to diagnosis. 90% of patients complained of some degree of back pain at initial presentation and 70% had symptoms of active infection. 60% had a history of recent sepsis and a further 23% had been extensively investigated for pyrexia of unknown origin (PUO). The mean time to diagnosis from first presentation to a member of the medical profession was 54 days (range 0–183 days). 35% of patients were diagnosed incidentally on a CT scan while investigating abdominal and chest symptoms or PUO so these diagnoses could potentially have been delayed further. 23% of patients required acute surgical treatment and in this sub-group the mean time to diagnosis was 61 days (range 14–91 days). 16% of patients died as a result of discitis. In this subgroup the mean time to diagnosis was 74 days (range 56–183 days). Many patients were extensively investigated for PUO or sepsis of unknown cause despite having persistent back pain. Although a small sample, delay in diagnosis seems to increase death rates. Many of these patients had first presented to their general practitioner or a physician for investigation, however discitis is rarely cited as a differential diagnosis of PUO in medical textbooks. A high index of suspicion must be maintained in patients with back pain, especially that of a non-mechanical nature. Discitis should be considered early in such patients especially those with evidence of infection. Discitis must always be included in the differential diagnosis of pyrexia of unknown origin

Aim: To effect a retrospective review of all patients who presented with discitis at Auckland Hospital between 1990 and 1998 for the purpose of delineating the indications for surgery and to establish guidelines for treatment of those patients where a pathogen was not isolated.

Method: The clinical, laboratory and radiological findings were reviewed. Where possible, patients underwent telephone interviews.

Results: Thirty-one patients were reviewed. Two patients had died. The clinical picture was characterised by back pain, point tenderness, spasm, radiculopathy, fevers and chills. The average time between clinical presentation and diagnosis was 11 weeks. The ESR was consistently elevated at the time of presentation and it was indicative of disease activity. A causative pathogen was isolated in 28 patients. Mixed pathogens were uncommon. Seven patients required operative debridement and five needed orthotic supports. A spectrum of imaging modalities was used. Particular attention to MRI in support of the diagnosis was critically reviewed.

Conclusions: Non operative management along with chemotherapy specific to the pathogen remains the main stay of treatment for patients with discitis. An algorithm for treatment is recommended including indications for surgery and guidelines for empirical treatment where a causative pathogen is not isolated.

Objectives: To assess the early diagnostic procedures and results of treatment for pyogenic discitis and to propose the ideal method of treatment for it.

Materal and Methods: 35 patients underwent open discectomies : 24 males and 11 females. 34 had single level and one had two-level discectomies. Blood were analysed on pre- and postop 3rd, 7th, 14th days, and 6 weeks. MRI exam in 6 patients and bone scintigraphy in 3 were done. Clinical symptoms of infection was observed on the postop 7 day on average. The characteristic features were back pain with muscle spasm, muscle cramping in legs, malaise, mild fever. 32 had conservative treatment and two had anterior radical surgery. Tobramycin, cloxacillin, and clindamycin were used for 4–6 weeks.

Results: WBC, ESR, CRP and body temperatures (BT) at postop 3rd, 7th and 14 days, and 6 weeks were checked; WBC were 11,500, 13,000, 9,300, 6,300 respectively: ESRs at one hour were 39, 50, 46, and 26mm : CRPs were 16.8, 23.5, 8.1 and 2.5. BT on average at postop 3rd, 7th and 14th days were 37.6, 37.4 and 37.2. Muscle spasm subsided together with cramping in legs 7–12 days after chemotherapy, but back pain persisted even after control of infection in most of the cases. MRI disclosed the infection in 5 of 6 cases, while in all 3 bone scans were positive. Infection was controlled in all. In 2 cases bony destruction advanced during chemotherapy, and in 2 other cases after anterior surgery infection exacerbated and spreaded to the neighbouring bone and joints.

Conclusion: Antibiotic therapy is found sufficient in controlling discitis, and surgery should be reserved for the patients without response to antibiotics.

Primary disc space infections are thought to occur in children because of the abundant vascularity of the disc prior to skeletal maturity, and while they generally resolve with treatment, little is known about the long-term consequences on the spine.

An ovine model of discitis was used to investigate the effects of discitis on spinal development in the growing sheep. Six-week-old lambs underwent lumbar discography at multiple spinal levels using either radiographic contrast inoculated with Staphylococcus epidermidis (inoculated group) or radiographic contrast only (control group). Plain x-rays of the spines were taken at intervals up to 18 months before the animals were killed and the spines removed for histologic and morphometric analysis.

Discs from animals in the control group were radiologically and histologically normal at all time points, and as expected there was a steady increase in vertebral body and disc dimensions. Although not all inoculated animals showed histologic evidence of discitis, disc abnormalities were evident from an early stage. In particular disc height was significantly reduced from 2 weeks after inoculation and vertebral body dimensions were significantly reduced from one year.

Infection of discs at a young age, whether or not it progresses to discitis, has a significant effect on spinal development.

The aim of the study was to review the role of Magnetic Resonance Imaging of the spine in discitis in the toddler age group (one to three years). Discitis presents differently in different age groups of children. It is most difficult to diagnose in the uncommunicative non-compliant toddler. The clinical features are often non-specific and laboratory and microbiological tests can be unhelpful. A highly sensitive test is required to aid in making the diagnosis. Although MR Imaging has been used in discitis for several years, we reviewed its actual effectiveness in this specific difficult age group. At a mean of 21 months at follow-up (range 10 to 40), MR imaging of the disc was variable, with partial recovery after 15 months and complete recovery after 34 months. Routine follow-up MR imaging was not recommended. We reviewed the role of Magnetic Resonance Imaging in eleven consecutive cases, both at presentation and at a follow-up clinic. MR imaging was diagnostic in all cases, reduced the diagnostic delay, and often avoided a disc biopsy. It demonstrated any paravertebral inflammatory collection, which helped in determining the duration of the oral therapy given after the initial intravenous antibiotics