Spondylodiscitis

Welcome to Vrije Universiteit Brussel's Evidence-based Practice project. This space was created by and for the students in the Rehabilitation Sciences and Physiotherapy program of the Vrije Universiteit Brussel, Brussels, Belgium. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors - Lynn Leemans

Top Contributors - Ine Wittevrongel, Bo Hellinckx and Claire Knott  

Search Strategy

Keywords: Spondylodiscitis + Diagnosis / Therapy / Epidemiology / Rehabilitation / Rehabilitation / Examination / Symptoms / Characteristics / Clinical

Search engines: Pubmed Web of knowledge PEDro

Definition/Description

Spondylodiscitis can be defined as a primary infection (accompanied by destruction) of the intervertebral disc (discitis), with secondary infections of the vertebrae (spondylitis), starting at the endplates.[1][2][2][2][3] It can lead to osteomyelitis of the spinal column.[4][2] It has a high morbidity and mortality and is a rare but serious infection.[1][2][4][3][5]

Pathogens causing spondylodiscitis are staphylococci, Escheria coli and mycobacterium tuberculosis.[1][2][6][3][2][6][7]
Spinal infections can be described aetiologically as pyogenic, granulomatous (tuberculous, brucellar, fungal) and parasitic. Pyogenic spinal infections include: spondylodiscitis, a term encompassing vertebral osteomyelitis, spondylitis and discitis. [1][7]

 Clinically Relevant Anatomy

The intervertebral disc is located between adjacent superior and inferior vertebral bodies and links them together. The function of the disc is particularly mechanical, namely transmitting loads arising from body weight and muscle through the spinal column. [1] It has a central nucleus pulposus, which surrounds the annulus fibrosis and cartilaginous endplates. When the intervertebral disc is axially loaded, most of the weight will be absorbed by the nucleus pulposus while the annulus assists in diffusing compression forces, carried out on the nucleus. The cartilaginous endplates are located along the central osseous endplates of adjacent vertebral bodies, and overlie the superior and inferior margins of the nucleus pulposus.[7]
A typical vertebra (vertebral body) is composed by the following parts:

  • Body, the weight bearing part.
  • Vertebral arch, which protects the spinal cord.
  • Process spinosus
  • Processes transverse, left and right. Articular processes, two superior and two inferior, that help to restrict the movements.[5]

In the beginning of pyogenic spondylodiscitis the anterior aspect of the vertebral end plate will abrade. Also loss of disc height, gradual development of osteolysis and further destruction of the subchondral plate will manage. Later on there will be more destruction of the vertebral body, new bone formation and kyphotic deformity. Because of the erosion of the vertebral end plates, the vertebra can collapse.[8][9] Tuberculous spondylodiscitis is also identified by the loss of the anterior subchondral part of the vertebral body. The difference between the two types, is that the intervertebral disc and the joint space are preserved longer in the tuberculous spondylodiscitis.[8]

Epidemiology /Etiology

According to scarce researches, the incidence of spondylodiscitis is 2.4/100,000 inhabitants. In England and Wales there is a 150% increase from the incidence between 1995-1999 and 2008-2011.[6] All ages can be affected, but the appearance mostly increases with the age.[2][6][1] Men are up to three times more often affected than women, this is probably because of a higher frequency of comorbidities in men.[10][2][4]
The predisposing factors are:

  • Diabetes mellitus[5][7]
  • Age [5]
  • Cardiovascular diseases or high blood pressure [10][7]
  • Obestity [2][7]
  • Drug abuse [2][5][7] or chronic steroid intake [2][7]
  • Chronic alcoholism and nicotine abuse [2][5]
  • HIV infection [2][7]
  • A spinal abnormality or intervention [10] (catheter-associated infections [5], surgical interventions [5], prior visceral operations [2][7])
  • Infection: endocarditis [2][7], urinary tract infection [2][7], previous infection loci
  • Multimorbidity [2][7]
  • Serious traumas [10]
  • Impaired immunocompetence (chemotherapy, human immunodeficiency virus infections, or chronic alcoholism) [2][5][7]
  • Cancer [2][10][3][7]
  • Sickle cell anemia [2][4]
  • Renal failure [2][10][7]
  • Liver failure: chronic hepatitis or lever cirrhosis [2][10][7]
  • Rheumatic diseases  [7]


The causes of spondylodiscitis are assigned to a large number of bacteria, fungi, which is to be taken into consideration in diagnostic treatment of patients. The main causative organisms are staphylococci [1][6][10] and mycobacterium tuberculosis. [6][3] Especially the lumbar spine (55%) and the thoracic spine (34%) suffer from spondylodiscitis. [1] Pyogenic spondylodiscitis, which expanded the last years because of the higher life expectancy of older patients with chronic debilitating diseases, is frequently caused by the staphylococcus. This type of spondylodiscitis represents 2-5% of all cases of osteomyelitis, and is more prevalent in patients older than 50 years.[4]

Another frequent form of spondylodiscitis is tuberculous spondylodiscitis. The causative microorganism in this case is the mycobacterium tuberculosis. This kind of spondylodiscitis is most common in patients aged between 30 to 40 years.[6]

Characteristics/Clinical Presentation

The symptoms are non-specific, diffuse [2] and treacherous [10].

  • Back or neck pain [1][10]
  • Constant pain, more worse at night [2][6][11]
  • Radicular pain radiating to the chest or abdomen
  • Fever (less common in patients with tuberculous spondylodiscitis, 1/2 of the cases)[1][10][4]
  • Spinal deformities, predominantly kyphosis and gibbus formation (commoner in tuberculous spondylodiscitis)[1]
  • Neurological deficits: leg weakness, paralysis, sensory deficit, radiculopathy and sphincter loss (1/3 of the cases)[1][10][4]
  • Cervical lesion [1]
  • Spinal tenderness
  • restricted range of movement[1]
  • paravertebral muscle spasm[1]
  • Local tenderness[5]
  • Motor deficits: limb weakness, para- or tetraplegia, para- or tetraparesis[7]
  • Epidural abcess formation (cervical: severe cervical rigidity, dysphagia or torticollis; thoracal: symptoms are localized at the legs; lumbar: spread through the ischiatic foramen and involve gluteus muscles; lumbosacral: cauda equine syndrome)[4]
  • Weight loss (when the delay in diagnosis is long)[4]
  • Mortality 2-17% [2] in children (symptoms are non-specific)
  • Irritability
  • Limping
  • Refusal to crawl, sit or walk
  • Hip pain or even abdominal pain
  • Incontinence may be a presenting feature
  • Loss of lumbar lordosis and lower back movement
  • Compared with adults, children are less likely to have comorbidities and neurological deficits are uncommon [1]


The severity of the infection does not always correspond with the severity symptoms of pain. According to N. Bettini et al, an increase in the pain symptoms is observed when digital pressure was applied to the vertebral area and the pain also irradiated to the homolateral periumbilical area. Also patients suffered radicular irradiation in the sciatica or crural fascia area. Untreated chronic infections can progress to sinus formation. Also secondary instability can occur towards kyphosis deformity with paraplegia or tetraplegia. Cervical spondylodiscitis may manifest with dysphagia or torticollis. [10] Spontaneous pyogenic spondylodiscitis usually spreads hematogenously from infections of the skin, subcutaneous tissues, and urinary tract. [5]

Differential Diagnosis

Differential diagnoses include:

  • Erosive osteochondrosis [10]
  • Osteoporotic and pathological fracture
  • Cancer related destruction
  • Ankylosing spondylarthritis
  • Scheuermann's kyphosis [1][2]
  • Charcot joint
  • Modic type I degenerative change
  • Schmorl nodes
  • Langerhans cell histiocytosis (LCH) [1][2]
  • Disc herniation
  • Metastatic seeding
  • Inflammatory or degenerative spinal disease [4]

Spondylodiscitis is an important differential diagnosis of lower back, flank, groin, and buttock pain. [7]

Diagnostic Procedures

It is important to identify and treat spondylodiscitis as early as possible.

The clinical presentation of spondylodiscitis are manifold. This commonly leads to a several months from initial symptoms to final diagnosis. [8]

A high index of suspicion is needed for prompt diagnosis to ensure improved long-term outcomes. A microbiological diagnosis is essential to enable appropriate choice of therapeutic agents. [9]

Diagnosis is difficult and often delayed or missed due to the rarity of the disease and the high frequency of low back pain in the general population. [1] The basic diagnostic examinations to establish spondylodiscitis are:


  • Magnetic Resonance Imaging (MRI) [2][10][3][7][9][7]
    - Golden standard. Detects any spread of the inflammation.
    - Contrast-enhanced images improve the sensitivity and specificity of
    detection and differentiation of tubercular and pyogenic spondylodiscitis.[30]When the MRI shows a high suspicion of spondylodiscitis, there is a high chance that it is actually there (tested via biopt). As the correlation is high, we find MRI to be a better detection method as it is less invasive and thus represents less risk for the patient. [3]
  • Computed tomography (CT):
    - Inferior to MRI, gives a more detailed image of bone destruction (second choice)
  • PET and PET/CT [4][6][10]
    - Due to its high specificity, [2] F-FDG PET/CT should be considered as a first-line imaging procedure in the diagnosis of spondylodiscitis. [4]
  • Conventional x-ray [2]
    - Acute phase: unreliable
    - Chronic phase: difficult to distinguish from other degenerative diseases of the spinal column (Only use for distinguish other pathologies)
  • Biopsy
    - Pathogens are only successfully detected in about half of the patients. To obtain a definite diagnosis: Necessary in the acute phase
  • Blood Culture [8][9]
    - Acute Phase
    > inflammatory markers [4]
  • Leukocyte count
  • C-reactive protein [4][7]
  • erythrocyte sedimentation rate [4][7]
    - Chronic phase
    > increase C-reactive protein: Easiest and most successful procedure, min. 3 times. When blood cultures are negative, CT-guided or surgical biopsy is recommended [4]
  • Microbiological tests [6][10]
  • PCR method
    - This method proves more and more the infection causes [6]
  • Bony Fusion Rate [4][6]
    - using spine X-ray
  • Cobb modified angle [3]
    - to evaluate the sagittal balance restoration
  • Haematochemical tests and inflammation indicators must be taken on weekly basis, then monthly until normal values. [10][7]
  • Multiple phase scintigraphy
    - No good diagnostic method. Provides a reliable evidence for the absence of osseous inflammation [10]

Outcome Measures

  • Visual Analogue Scale (VAS): [2][4][6][3]
    - to evaluate therapeutic effects
    -  for assessment of pain.
  • Oswestry disability index (ODI): [2][4][6]
    - to evaluate therapeutic effects
    - assessment of quality of life
  • Japanese Orthopaedic Association Back pain evaluation Questionnaire (JOA)
    - surgeon based evaluation tools [4][3]
    - Only the Japanese version is valide
  • Lumbar function score [4]
  • Kirkaldy-Willis functional criteria [3]

Examination

It is important to identify and treat spondylodiscitis as early as possible. Diagnosis by means of blood culture and MRI and treatment of the infection with antibiotics and possibly surgical interventions seem be very suitable, but need to be individualized to each and every patient.[8] (level of evidence 2B)

Diagnosis is based on clinical, laboratory and radiological features and can be difficult. It is often delayed or missed due to the rarity of the disease, the insidious onset of symptoms and the high frequency of low back pain in the general population.[6][7][3] (level of evidence 2A)


1.Anamnesis:[5][10] (level of evidence 1B)

  • Gender, age
  • Risk factors (see clinical presentation)
    o diabetes mellitus
    o advanced aged
    o steroid use
  • Comorbidity
  • Clinical symptomatology (see clinical presentation)
    o Constant pain, more worse at night [1]
    o Radicular pain radiating to the chest or abdomen
    o Fever
    o Screening red flags [10]
    o Thoracic pain
    o Widespread neurological deficit, vertebral level involved
    o Lower limb weakness
    o Drug abuse/human immunodeficiency virus
    o Age <20 or >55 years
    o Weight loss
    o Persistent severe restriction of lumbar flexion
    o Constant progressive, mechanical pain
    o Positive cough/sneeze
    o Previous history of cancer
    o Recent history of a trauma


2. Clinical examination [2] (level of evidence 2A)
Inspection concentrating on local changes and taking a detailed neurological status

  • Spinal tenderness [1]
  • Loss of lumbar lordosis and lower back movement [1]
  • Inspection on local changes and neurological status (parese, paralyse,..)
  • Pain on heelstrike, impactation and percussion
  • Relieving posture (avoid stressing the ventral sections of the spinal column
  • Inclination and re-erection are painful
  • Reduction of mobility
  • Paravertebral muscle spasm [1]

3. Basic objective tools [2]

  • See diagnostic procedures.

Medical Management

There are several treatments for spondylodiscitis, par example: surgical and conservative treatment. Surgical and conservative treatment for postoperative lumbar spondylodiscitis is effective. Surgical treatment is superior to conservative treatment in a short time, while conservative treatment can achieve long-term satisfactory curative effects. [LoE: 2B] [2]
Randomized trials are needed to assess the optimal treatment duration, route of administration, and the role of combination therapy and newer agents.
[LoE: 2A] [1]


1. Conservative treatment:

This treatment is based on antibiotics and immobilization of the spine.[4] It can be considered when the clinical symptoms and destruction are relatively mild or the risk of operation is too great. The main problem in conservative treatment is to achieve adequate fixation of the affected section of the spinal column. Reclining orthosis distribute the stress over the unaffected spinal column joints, thus decreasing stress in the infected ventral area. The mobilization of the patient is only recommended once osseous infiltration becomes visible. Aside from the risk of immobilization, there is a high rate of pseudoarthroses (16% to 50%), which may eventually lead to kyphotic malposition and chronic pain syndrome. If there is no fusion reaction, continuing destruction, when the symptoms persist or worsen [10], or there’s no clinical improvement, it is not promising to continue conservative treatment beyond four to six weeks.[2] Although protracted bed rest used to be prescribed, this practice is now being abandoned. There’s also a correlation between early diagnosis and successful results obtained with suitable conservative treatment.[2]
A review of case series has demonstrated the effectiveness of intravenous antibiotic therapy. While no official guidance exists for when to switch from intravenous to oral antibiotics, our study shows that CRP at 1 month is >30mg/l and we recommend 6 weeks of intravenous therapy, followed by 6 further weeks of oral therapy.[LoE: 2B] [6]
Treatment of spondylodiscitis at children should be conservative with antibiotics only. [9]

2. Surgery

Surgery has an important role in alleviating pain, correcting deformities and neural compromise and restoring function.[LoE: 2B][8]

  • Indications for surgical intervention:
    o compression of neural elements
    o spinal instability due extensive bony destruction
    o severe kyphosis
    o failure of conservative management
    o (sometimes) inatractable pain
    o (sometimes) epidural abscess even in the absence of neurogical deficits
  • Indications for surgical emergency
    o spinal cord compression
    o outcomes are worse if paralysis has been present over 24-36h (there are also investigators who improve improvement with prolonged paralysis) [LoE: 2B] [9]
  • Methodes
    o While radical surgical debridement, stable reconstruction together with antibiotic therapy remained a reliable approach to achieve complete healing of the inflammation, anterior alone surgery became more applicable. [2B][7][5]

A debridement and fixation with anterior column support in combination with an antibiotic therapy appear to be the key points for successful treatment of pyogenic spondylodiscitis. [2B][10]

Physical Therapy Management

Spondylodiscitis has several clinical symptoms, a severe one is low back pain. This can be treated with exercises. (LOE 3B) [2] Prognosis seems to be good with conservative treatment including NSAID’S, physiotherapy (exercises), and a corset. Wearing the corset for a period of 6–10 weeks is instead confirmed by most authors. (LOE 5) [10][9][1]Several exercises can be done with the emphasis on extension exercises and exercises for trunk balance. This is important to maintain a good posture. (LOE 5, 3B, 3A, 1A) [8][1][2][10][9][1][9][1]


Thoracic.jpgThoracic extension 2.jpg

Thoracal extension exercises

Early mobilization is important. (LOE 3A) [10] But also limb exercises are considered to be good for the therapy.(LOE 3B) [10] These exercises should be done daily at home. Also general fitness, like swimming, should be encouraged. This therapy can lead to a decrease in pain and the ability to accomplish activities of daily living. (LOE 5, 3B) [9][1]In a severe disease TNF therapy can be done. (LOE 5) [1] Lung re-expansion exercises (breathing exercises) are taken into the physical therapy. These exercises help the stability in the lower back. (LOE 3B, 3A) [10][5]


Resp.jpg

Respiratory exercises


Low back pain is strongly related with tight and strained hamstrings. Patients should do flexibility exercises for the hamstrings, maintain a good position while sitting and move enough to help this. Keeping the hamstrings flexible is important for pain control as well as in prevention of spinal pain flare-ups. (LOE 5) [8]

Hamstr.png

  Flexibility exercises


In general the rehabilitation program will improve the patient’s sensory and motor skills, develop the balance and proprioception and will help the patient’s to do their daily living activities. During the total program the onset and increase of pain should be evaluated. Pain intensity increases or exercises that provoke too much pain or exhaust the patient should not be in the rehabilitation program and there has to be enough rest after the exercises. It is important that when there is a resting period, this one has to be kept minimal. Immobilization lead to weakness of the trunk and lower extremity muscles and will contribute to complications. Secondary problems because of immobilization and musculoskeletal problems should be looked after and prevented. The patient also gets a home exercise program that is based on the patient’s capacity. (LOE 5) [1]


Back school is less effective compared to the active programme. (LOE 1A) [4] Exercises were significantly better than no intervention and reduced back pain experience and work absenteeism. Exercises may be effective in prevention of back pain (LOE 1A) [4]

Key Research

add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)

Resources

  • Pubmed (VUB BIBLIO)
  • Web of Knowledge  
  • Pedro
  • Google Scholar

Clinical Bottom Line

Spondylodiscitis can be defined as a primary infection of the intervertebral disc (discitis), with secondary infections of the vertebrae (spondylitis). It can lead to osteomyelitis of the spinal column. Pyogenic spondylodiscitis is frequently caused by the staphylococcus. Tuberculous spondylodiscitis is caused by the mycobacterium tuberculosis. The symptoms are non-specific, diffuse and treacherous. Diagnosis is difficult and often delayed or missed due to the rarity of the disease. The basic diagnostic examination to establish spondylodiscitis is MRI. Surgical and conservative treatment for postoperative lumbar spondylodiscitis is effective. Prognosis seems to be good with conservative treatment including NSAID’S, physiotherapy (exercises), and a corset.

Recent Related Research (from Pubmed)

see tutorial on Adding PubMed Feed

Extension:RSS -- Error: Not a valid URL: Feed goes here!!

References

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 1.27 1.28 1.29 1.30 R. Sobottke et al., Current Diagnosis and Treatment of Spondylodiscitis. Deutsches ärzteblatt International, 2008. (Level of evidence 2A)
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 2.21 2.22 2.23 2.24 2.25 2.26 2.27 2.28 2.29 2.30 2.31 2.32 2.33 2.34 2.35 2.36 2.37 2.38 2.39 F. Postacchini, 1999, Lumbar disc herniation, Springer, 481p. (Level of evidence 5)
  3. 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 Enrique G. et al., Surgical treatment of spondylodiscitis. An update, International Orthopaedics 2012. (level of evidence 5)
  4. 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 4.15 4.16 4.17 4.18 4.19 4.20 4.21 4.22 4.23 M. Titlic et al., Spondylodiscitis, Journal Citation/ Science Edition, 2008; 109(8) 345-347. (Level of evidence 2A)
  5. 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 5.12 5.13 Sans N. et al., Infections of the spinal column — Spondylodiscitis, Diagnostic and Interventional Imaging 2012. (level of evidence 5)
  6. 6.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 6.11 6.12 6.13 6.14 6.15 M. Hasenbring et al., Intervertebral disk diseases, Thieme, 2008, 236p. (Level of evidence 5)
  7. 7.00 7.01 7.02 7.03 7.04 7.05 7.06 7.07 7.08 7.09 7.10 7.11 7.12 7.13 7.14 7.15 7.16 7.17 7.18 7.19 7.20 7.21 7.22 7.23 7.24 7.25 7.26 Kapsalaki E. et al., Spontaneous spondylodiscitis: presentation, risk factors, diagnosis, management, and outcomes, International Journal of Infectious Diseases 2009. (level of evidence 1B)
  8. 8.0 8.1 8.2 8.3 8.4 8.5 8.6 8.7 A. Hegde, et al., Infections of the deep neck spaces, Singapore Med J. 2012 May;53(5):305-312 (level of evidence 5)
  9. 9.0 9.1 9.2 9.3 9.4 9.5 9.6 9.7 9.8 9.9 P. Prithvi, et al., Intervertebral Disc: Anatomy-Physiology-Pathophysiology-Treatment, Department of Anesthesiology and Pain Management, World Institute of Pain, 2008 (level of evidence 2A)
  10. 10.00 10.01 10.02 10.03 10.04 10.05 10.06 10.07 10.08 10.09 10.10 10.11 10.12 10.13 10.14 10.15 10.16 10.17 10.18 10.19 10.20 10.21 10.22 10.23 10.24 10.25 10.26 10.27 Erhard R, Relative Effectiveness of an Extension Program and a Combined Program of Manipulation and Flexion and Extension Exercises in Patients With Acute Low Back Syndrome, Journal of The American Physical Therapy Association 1994. (level of evidence 1A)
  11. 23