Clinical profile, diagnosis, treatment, and outcome of patients with tubercular versus nontubercular causes of spine involvement: A retrospective cohort study from India.

Background: In tuberculosis (TB) endemic areas, other pyogenic causes of spine involvement may be missed. The study aimed to describe TB and non-TB causes of spine involvement and identify features that can help in differentiating them. Methods: A retrospective cohort study was conducted to screen the clinical records of all admitted patients (Kasturba Hospital, Manipal) in 2018-20 for a diagnosis of spondylitis and/or sacroiliitis. The clinical features, radiological findings, laboratory parameters, treatment details, and outcomes were compared among those diagnosed with confirmed TB, confirmed brucellosis, or confirmed pyogenic infection. A scoring system was also developed to differentiate spondylodiscitis due to tuberculous and pyogenic causes. The qualitative variables were compared using the Chi-square test, while quantitative variables were compared using the one-way analysis of variance test. Results: Of 120 patients with spine infections, a total of 85 patients were confirmed with the microbiological diagnosis of interest. Involvement of the thoracic spine, longer duration of illness, and caseous granulomatous reaction on histopathology was more common in TB patients. Male gender, involvement of lumbar vertebra, and neutrophilic infiltrate on histopathology were more common in brucellosis patients. Male gender, diabetes mellitus, involvement of lumbar vertebra, neutrophilic infiltrate on histopathology, leukocytosis, and increased C-reactive protein were more commonly seen in patients with pyogenic infection. The scoring system had a sensitivity and specificity of 75% and 91%, respectively, when used to differentiate TB from pyogenic infection. Conclusions: In resource-limited settings, suggestive findings can be used to decide empiric therapy.

Espondilodiscite em idade pediátrica ­ uma doença rara, um diagnóstico difícil / Spondylodiscitis in pediatric age ­ a rare disease, a difficult diagnosis

Introdução e objetivo: a espondilodiscite é a infeção que atinge o disco intervertebral e as vértebras contíguas e representa dois a quatro % do total das infeções osteoarticulares em idade pediátrica. O agente patogénico é identificado em cerca de metade dos casos, sendo o Staphylococcus aureus o mais frequentemente isolado. Estudos recentes demonstram que entre os seis meses e os quatro anos a Kingella kingae tem um papel etiológico importante. O objetivo da exposição deste caso clínico foi chamar atenção para esta patologia rara cujo diagnóstico é difícil e exige um elevado nível de suspeição. Descrição do caso: criança de 16 meses, sexo masculino, com antecedentes de obstipação, é trazida múltiplas vezes à Urgência Pediátrica por quadro com mais de um mês de evolução de irritabilidade persistente, dor abdominal e recusa da marcha de agravamento progressivo. Na segunda vinda à Urgência Pediátrica apresentava dorsolombalgia à palpação da coluna dorsolombar e diminuição da lordose lombar, o que motivou a realização de avaliação analítica, sumária de urina, ecografia renal e vesical e radiografia dorsolombar sem alterações. Na terceira vinda à Urgência Pediátrica foi decidido internamento e solicitada ressonância magnética nuclear dorsolombar e cintigrafia óssea que revelaram espondilodiscite em D7-D8. Parâmetros analíticos sem alterações valorizáveis, exceto discreta elevação da velocidade de sedimentação. Hemoculturas e restante estudo etiológico negativo. Iniciou terapêutica endovenosa com cefu-roxime e flucloxacilina, com melhoria progressiva das queixas álgicas. Aquando da alta, assintomático, mantendo flucloxacilina oral até completar seis semanas de tratamento. Reavaliado posteriormente, encontrando-se assintomático, com um exame físico, reavaliação analítica e radiografia dorsolombar sem alterações. Conclusões: a espondilodiscite é uma identidade de difícil diagnóstico, especialmente na criança, devido à sua raridade, clínica inespecífica, impossibilidade de as crianças verbalizarem os seus sintomas e aos sinais radiológicos tardios, requerendo um alto índice de suspeição. O intervalo médio de tempo entre o início dos sintomas e o diagnóstico é de três semanas a três meses. A ressonância magnética é o exame de escolha. As hemoculturas são, muitas vezes, negativas. O pilar do tratamento é a antibioterapia por várias semanas, mas a sua escolha e duração são controversas. O tratamento inadequado pode originar dor crônica, sequelas ortopédicas graves e complicações neurológicas devastadoras. Quando atempada e adequadamente tratada, a maioria dos casos apresenta uma evolução clínica benigna e autolimitada.

Introduction and objective: spondylodiscitis is an infection that affects the intervertebral disc and the contiguous vertebrae. It represents two to four % of all osteoarticular infections in pediatric age. The pathogen is identified in about half of the cases, with Staphylococcus aureus being the most frequently isolated. Recent studies show that between six months and four years, Kingella kingaehas an important etiological role. The purpose of the presentation of this clinical case was to draw attention to this rare pathology whose diagnosis is difficult and requires a high level of suspicion. Clinical case description: a sixteen-month-old male, with a history of constipation, is brought multiple times to the Pediatric Emergency Department for a clinical picture with more than a month of evolution of persistent irritability, abdominal pain and refusal to walk, with progressive worsening. On the second visit to the Pediatric Emergency Department, he presented dorsolombalgia on palpation of the dorsolumbar spine and decreased lumbar lordosis, which led to the performance of analytical evaluation, urinalysis, renal and bladder ultrasound and dorsolumbar radiography, all without changes. On the third visit to the Pediatric Emergency Department, hospitalization was decided and dorsolumbar nuclear magnetic resonance and bone scintigraphy were requested, revealing spondylodiscitis in D7-D8. Analytical parameters had no changes, except for a slight increase in erythrocyte sedimentation rate. Blood cultures and remaining etiological study negatives. Intravenous therapy with cefuroxime and flucloxacillin was started with progressive improvement of pain. Upon discharge he was asymptomatic and maintained oral flucloxacillin until a total of six weeks of treatment. He was subsequently reassessed and remained asymptomatic, with a physical examination, analytical evaluation and dorsolumbar radiography without changes. Conclusions: spondylodiscitis is an identity that is difficult to diagnose, especially in children, due to its rarity, unspecific clinic, inability for children to verbalize their symptoms and late radiologic signs, requiring a high index of suspicion. The average time between the onset of symptoms and the diagnosis is three weeks to three months. Magnetic resonance imaging is the exam of choice. Blood cultures are often negative. The mainstay of treatment is antibiotic therapy for several weeks, but its choice and duration are controversial. Inappropriate treatment can lead to chronic pain, severe orthopaedic sequelae and devastating neurological complications. When timely and properly treated, most cases have a benign and self-limited clinical course.

Best Practices: CT-Guided Percutaneous Sampling of Vertebral Discitis-Osteomyelitis and Technical Factors Maximizing Biopsy Yield.

Vertebral discitis-osteomyelitis is an infection of the intervertebral disk and vertebral bodies that may extend to adjacent paraspinal and epidural soft tissues. Its incidence is increasing, likely because of improved treatments and increased life expectancy for patients with predisposing chronic disease and increased rates of IV drug use and intravascular intervention. Because blood cultures are frequently negative in patients with vertebral discitis-osteomyelitis, biopsy is often indicated to identify a causative microorganism for targeted antimicrobial therapy. The reported yield of CT-guided percutaneous sampling is 31-91%, which is lower than the reported yield of open biopsy of 76-91%. However, the less invasive approach may be favored given its relative safety and low cost. If paravertebral fluid collections are present, CT-guided aspiration should be performed. If aspiration is unsuccessful or no paravertebral fluid collections are present, CT-guided percutaneous biopsy should be performed, considering technical factors (e.g., anatomic approach, needle selection, and needle angulation) that may improve microbiologic yield. Although antimicrobial therapy should be withheld for 1-2 weeks before biopsy if clinically feasible, biopsy may still be performed without stopping antimicrobial therapy if needed. Because of the importance of targeted antimicrobial therapy, repeat biopsy should be considered after 72 hours if initial biopsy does not identify a pathogen.

Defining Disc Biopsy Timing in Relation to Blood Culture Results for Inpatients with Suspected Discitis-Osteomyelitis.

PURPOSE: To determine optimal timing of biopsy for suspected discitis-osteomyelitis (DOM) with respect to preliminary blood culture results and the effect of biopsy timing on hospital length of stay (LOS). MATERIALS AND METHODS: This retrospective study reviewed disc/vertebral biopsies for suspected DOM performed between 2010 and 2018. A total of 107 disc/vertebral biopsies were performed on 96 inpatients (mean ± SD age 57.9 ± 14.5 years, 68 men/28 women) for suspected DOM, and 100 cases of DOM were clinically confirmed and treated. Descriptive and regression statistics were performed with LOS as the primary outcome. RESULTS: Of disc biopsies in clinically confirmed cases, 68% were positive; 20% of all biopsies had preliminary positive blood cultures after 2 hospital days. There was no difference in LOS between cases with biopsy performed ≤ 2 days after blood culture and cases with biopsy performed > 2 days after blood culture (P = .40). Regression analysis showed no association between positive biopsy results and sepsis, white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), or C-reactive protein (CRP). Biopsy yield was not significantly decreased in patients previously taking antibiotics (P = .09). CONCLUSIONS: Waiting 2 days for preliminary blood culture results could avoid disc/vertebral biopsy in 20% of patients and does not significantly impact hospital LOS. Additionally, clinical factors (sepsis, WBC count, CRP, and ESR) do not have predictive value for positive disc biopsy results.

Is there a change in trend towards pyogenous spondylodiscitis compared to tubercular spondylodiscitis in India-A study of percutaneous biopsy evaluation in spondylodiscitis.

BACKGROUND: In Indian subcontinent where tuberculosis is endemic, the spinal infection was thought to be due to mycobacterium tuberculosis in most of the cases. Hence there is a practice of treating these patients with empirical antitubercular treatment. However, recent guidelines advice biopsy and tissue diagnosis before starting antibiotics. OBJECTIVE OF STUDY: Our retrospective study analyses the role of biopsy in establishing the microbiological diagnosis and thus identifying the incidence of pyogenic and tubercular spondylodiscitis presented to a tertiary care centre. MATERIALS AND METHODS: All patients who were diagnosed as spondylodiscitis by clinical and radiological criteria and who underwent biopsy were included in the study and data was retrieved from medical records and PACS. Criteria for tubercular spondylodiscitis included presence of mycobacterium tuberculosis either in smear/gene Xpert, or histopathological evidence of tuberculosis. Organism isolation other than MTB or absence of tubercular granuloma and response to antibiotics were considered as non-tubercular aetiology. RESULTS: Our study achieved 84% (n-63) accuracy for first biopsy and 34 patients (53.96%) were diagnosed as pyogenic spondylodiscitis. Organisms were isolated in 11 cases (32%) of pyogenic spondylodiscitis and tubercular bacilli in 17 cases (65%) of tubercular spondylodiscitis. Aspiration of pus yielded better isolation of organisms (P < 0.001) in pyogenic spondylodiscitis. 11% of cases showed drug resistant tuberculosis. CONCLUSION: We conclude that there is an increasing trend of pyogenous spondylodiscitis compared to tubercular spondylodiscitis in patients presenting to tertiary care centre, hence biopsy is essential to start antimicrobials.

Combination of Imaging Features and Clinical Biomarkers Predicts Positive Pathology and Microbiology Findings Suggestive of Spondylodiscitis in Patients Undergoing Image-Guided Percutaneous Biopsy.

BACKGROUND AND PURPOSE: Pathology and microbiology results for suspected spondylodiscitis on MR imaging are often negative in up to 70% of cases. We aimed to predict whether MR imaging features will add diagnostic value when combined with clinical biomarkers to predict positive findings of spondylodiscitis on pathology and/or microbiology from percutaneous biopsy. MATERIALS AND METHODS: In this retrospective single-center institutional review board-approved study, patients with radiologically suspected spondylodiscitis and having undergone percutaneous biopsies were assessed. Demographic characteristics, laboratory values, and tissue and blood cultures were collected. Pathology and microbiology results were used as end points. Three independent observers provided MR imaging-based scoring for typical MR imaging features for spondylodiscitis. Multivariate logistic regression and receiver operating characteristic analysis were performed to determine an optimal combination of imaging and clinical biomarkers in predicting positive findings on pathology and/or microbiology from percutaneous biopsy suggestive of spondylodiscitis. RESULTS: Our patient cohort consisted of 72 patients, of whom 33.3% (24/72) had spondylodiscitis. The mean age was 63 ± 16 years with a male/female ratio of 41:31. Logistic regression revealed a combination with an area under the curve of 0.72 for pathology and 0.68 for pathology and/or microbiology. Epidural enhancement on MR imaging improved predictive performance to 0.87 for pathology and 0.78 for pathology and/or microbiology. CONCLUSIONS: Our findings demonstrate that epidural enhancement on MR imaging added diagnostic value when combined with clinical biomarkers to help predict which patients undergoing percutaneous biopsy will have positive findings for spondylodiscitis on pathology and/or microbiology.

Brucellar spondylodiscitis: A case series with focus on histopathological features.

Brucellar spondylodiscitis (BS) is the most common form of musculoskeletal brucellosis. The isolation of Brucella spp from blood, other body fluids or tissue cultures is the gold standard for definitive diagnosis of BS. BS shows a large histopathological spectrum of lesions with non-specific and granulomatous forms, and its histopathological features are not widely reported. This case series study reported the histopathological features of a series of 21 BS. Ten cases revealed nonspecific forms of BS. Lymphocytes were the predominant inflammatory cells in this group. In one case neutrophils were predominant. The eleven remaining were granulomatous. The 11 exhibited histiocytic type granulomas. Ten were non-necrotizing. One case, taken from abscess wall, contained minimal deposition of caseous like necrotic material. This case and 2 others corresponding to abscess wall biopsies, showed histiocytic granulomas mixed with small aggregates of epithelioid cells without well-formed epithelioid granuloma nor giant cell. The histopathological diagnosis of BS is challenging. Nonspecific forms of BS, mimiking pyogenic spondylodiscitis, are observed in about half of the cases. Although nonspecific forms of BS are characterized by the predominance of lymphocytes and plasmocytes, BS forms with predominant neutrophil cell infiltration do exist. Histiocytic granuloma is highly suggestive of BS. Purely epithelioid forms of BS were not observed in the present series. Caseous like necrosis suggestive of tuberculosis is a possible feature of BS.

Non-infectious thoracic discitis: A diagnostic and management dilemma. A report of two cases with review of the literature.

Discitis/ Osteomyelitis is an inflammatory process involving an intervertebral disc and the adjacent vertebral bodies. Infection is the most common cause of discitis, which is often spontaneous and hematogenous in origin. However, many noninfectious processes affecting the spine such as pseudarthrosis in ankylosing spondylitis, amyloidosis, destructive spondyloarthropathy of hemodialysis, Modic changes type 1, neuropathic arthropathy, calcium pyrophosphate dehydrate (CPPD) spondyloarthropathy and gout can mimic infectious discitis/ osteomyelitis. To determine whether a particular patient's spinal process is due to an infectious versus non-infectious cause can be challenging. Although clinical findings and laboratory studies including erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) can be helpful in the diagnosis of bacterial discitis/osteomyelitis due to their high sensitivity; however, their specificity is low. Moreover, both the infectious and non-infectious discitis can appear quite similar on the imaging studies. We present two cases of thoracic discitis with adjacent vertebral osteomyelitis of probable non-infectious etiology. Both were managed with instrumented fusion for stabilization. We also discuss a range of noninfectious causes of discitis/spondylitis and their radiological features which can help differentiate from infectious processes.

CT-guided discitis-osteomyelitis biopsies with negative microbiology: how many days should we wait before repeating the biopsy?

PURPOSE: To determine the number of days to positive CT-guided biopsy sample culture in patients with discitis-osteomyelitis. METHODS: Our study was IRB approved and HIPAA compliant. All CT-guided biopsies performed for acute discitis-osteomyelitis with positive microbiology between 2002 and 2018 were reviewed. Microbiological organism and days to positive biopsy were documented. Mean, median, skew, and standard deviation were calculated. The proportion of positive cultures that become positive after each day has elapsed was also calculated. RESULTS: There were 96 true positive cultures, with 64 (67%) male and 32 (33%) female, ages 57 ± 18 (range 19-87) years. Overall, including all culture results, the mean number of days to positive culture was 2.9 ± 3.5 days. The median number of days was 2, with a positive skew of 2.9. At days 1, 2, 3, 4, and 5, 48%, 68%, 78%, 85%, and 89%, respectively, of biopsy samples had a positive microbiology culture. CONCLUSION: Approximately three-quarters of discitis-osteomyelitis pathogens will be identified by biopsy sample culture by 3 days after CT-guided biopsy. This finding should be considered if planning for a repeat biopsy in the setting of a negative microbiology culture.

Parvimonas micra spondylodiscitis with psoas abscess.

Parvimonas micra (P. micra) is a Gram-positive anaerobic cocci, normally found in the oral cavity and rarely causes severe infections. We describe a rare clinical presentation of P. micra as spondylodiscitis and psoas abscess with haematogenous spread in an adult patient. MRI lumbar spine detected L2 and L3 spondylodiscitis. Blood cultures were positive at 48 hours of incubation and P. micra was identified on anaerobic culture after 72 hours. Isolates from bone biopsy confirms P. micra She was successfully treated with ceftriaxone, followed by oral metronidzole for a total of 8 weeks. The suspected origin of her P. micra was a dental cavity. Anaerobic bacteria tend to be underestimated in spondylodiscitis. In cases of slow growing organisms, we emphasise the importance of performing accurate identification including anaerobic bacteria to guide management. P. micra should be considered in patients with spondylodiscitis who had recent dental intervention or perioral infection.

Outcomes and risk factors for spontaneous spondylodiscitis: Case series and meta-analysis of the literature.

Despite recent improvements in surgical and antimicrobial therapies, few generally applicable guidelines exist for spondylodiscitis management. We reviewed a consecutive series of patients as well as the past 18 years of the literature and analyzed outcomes for either conservative or surgical treatment. We analyzed a consecutive series of adults with spontaneous spondylodiscitis treated at our institution over the last 6 years. We analyzed predictors for neurological deficits, vertebral collapse, and surgical treatment. We also performed a meta-analysis of the literature between 2000 and 2018, stratifying the results between surgical and conservative treatment outcomes. A younger age at diagnosis, cervical location, tubercular infection, coexistence of morbidities, and vertebral collapse were predictors of surgical intervention. Cervical spondylodiscitis, vertebral collapse, and epidural collection were associated with a higher risk of developing neurological deficits, while tubercular spondylodiscitis was associated with a higher risk of vertebral collapse. Based on the current literature, conservative treatment has success rates similar to those of surgical treatment but lower complication and mortality rates. In cases without an absolute indication for surgery, a conservative approach should be considered as the first-line treatment. A closer diagnostic and clinical follow-up should be recommended in patients with cervical tract or tubercular spondylodiscitis because of the higher risk of developing bone collapse and neurological deficits.

A unilateral less invasive posterolateral approach for disc debridement and titanium cage insertion supplemented by contralateral transfascial screw fixation for high-morbidity patients suffering from septic thoracolumbosacral spondylodiscitis.

PURPOSE: This case series reports on the efficacy and safety of a less invasive posterolateral approach for septic thoracolumbosacral spondylodiscitis in high-morbidity patients. METHODS: Twenty consecutive severe sick (ASA > III) patients (14 men and 6 women), with an average age of 64 ± 14 years, suffering from septic subacute and chronic thoracolumbosacral spondylodiscitis were selected to undergo a one-stage less invasive unilateral posterolateral disc space debridement, supplemented by an ipsilateral titanium cage implantation and pedicle screw fixation plus a contralateral transfascial pedicle screw fixation. RESULTS: Two high-risk patients with severe comorbidities (ASA stage IV and V, respectively) died on days 1 and 8 postoperatively because of non-surgical complications such as massive lung embolism and acute myocardial infract, respectively. Three patients with incomplete paraplegia (ASIA C) preoperatively were improved after the surgery to ASIA D (two patients) and E (one patient), respectively, while there was no neurological deterioration in any patient postoperatively. From the 18 patients that survived, ten patients were available for the final follow-up 8.8 ± 2.7 years postoperatively. In two patients with spondylodiscitis caused by gram(-) bacteria, the posterior instrumentation was finally removed because of asymptomatic fistula emerging from posterior instrumentation solely, 15 and 19 months after surgery. The survivals at 2.5 and 10 years with revision as end point was 87.4% (95% CI 58.1-96.7); while in the "worst case scenario" the survivals at 2.5 and 10 years were: 66.7% (95% CI 40.4-83.4%); 47.7% (95% CI 23.2-68.8%) and 47.7% (95% CI 23.2-68.8%), respectively. CONCLUSIONS: The less invasive posterolateral approach for disc debridement and titanium cage insertion seems to be an alternative surgery for severe sick adult immunosuppressed patients with septic thoracolumbosacral spondylodiscitis that cannot tolerate traditional open transthoracic, thoracolumbar, retroperitoneal or combined approaches. The study has been registered in the Public Registry ClinicalTrials.gov PRS with the ID: NCT03472131.

The role of histology in the diagnosis of spondylodiscitis: correlation with clinical and microbiological findings.

AIMS: The aim of this study was to determine the diagnostic utility of histological analysis in spinal biopsies for spondylodiscitis (SD). PATIENTS AND METHODS: Clinical features, radiology, results of microbiology, histology, and laboratory investigations in 50 suspected SD patients were evaluated. In 29 patients, the final (i.e. treatment-based) diagnosis was pyogenic SD; in seven patients, the final diagnosis was mycobacterial SD. In pyogenic SD, the neutrophil polymorph (NP) infiltrate was scored semi-quantitatively by determining the mean number of NPs per (×400) high-power field (HPF). RESULTS: Of the 29 pyogenic SD patients, 17 had positive microbiology and 21 positive histology (i.e. one or more NPs per HPF on average). All non-SD patients showed less than one NP per HPF. The presence of one or more NPs per HPF had a diagnostic sensitivity of 72.4%, specificity 100%, accuracy 100%, positive predictive value (PPV) 81.0%, and negative predictive value (NPV) 61.9%. Sensitivity, specificity, and accuracy were greater using the criterion of positive histology and/or microbiology than positive histology or microbiology alone. Granulomas were identified histologically in seven mycobacterial SD patients, and positive microbiology was detected in four. CONCLUSION: The diagnosis of pyogenic SD was more often confirmed by positive histology (one or more NPs per HPF on average) than by microbiology, although diagnostic sensitivity was greater when both histology and microbiology were positive. Cite this article: Bone Joint J 2019;101-B:246-252.

The Efficacy of Computed Tomography-Guided Percutaneous Spine Biopsies in Determining a Causative Organism in Cases of Suspected Infection: A Systematic Review.

PURPOSE: In suspected spondylodiscitis and vertebral osteomyelitis, computed tomography (CT)-guided biopsies are often performed to determine a causative organism and guide antimicrobial therapy. The aim of this study is to determine the diagnostic culture yield of CT-guided biopsies performed in cases of suspected spinal infections. METHODS: A literature search of PubMed and MEDLINE up to April 2017 was performed for keywords "CT guided vertebral biopsy infection," "CT-guided spine biopsy infection," "CT guided spine biopsy yield," and "CT guided vertebral biopsy yield." Inclusion criteria primarily consisted of studies exclusively using CT-guided biopsies in cases of suspected infectious lesions only. After study selection, published articles were analysed to determine diagnostic culture yield. Descriptive statistics were applied. RESULTS: 220 search results were screened; 11 met our inclusion criteria and were reviewed. In total, 647 biopsies of suspected infectious spinal lesions were performed. Positive cultures were obtained in 241 cases. Upon excluding one paper's skewed results, the net pooled results culture yield was 33%. Several cultures grew multiple organisms, leading to a total of 244 species identified. Most common isolated organisms include Staphylococcus aureus (n = 83), coagulase-negative Staphylococcus (n = 45), and Mycobacteria (n = 38). CONCLUSIONS: The diagnostic culture yield of CT-guided biopsies in cases of suspected spinal infection is 33%. In the majority of cases, a causative organism is not identified. This suggests that improvements can be made in biopsy technique and specimen transfer to optimize culture yield and increase the clinical value of the procedure.

Lumbar intravertebral disc herniation secondary to idiopathic calcific discitis.

Calcific discitis is a well recognized entity in the paediatric population but more recently has been increasingly reported in adults. It typically involves the lower thoracic vertebrae and is of unknown aetiology. Herniation of the calcified fragment is rare but typically occurs out through the annulus fibrosus into the canal space. Herein we describe the first reported case of calcific discitis involving the lumbar vertebrae with subsequent herniation of the calcified disc into and through the anterior aspect of the L5 vertebra. The patient first presented with a history of right back pain and leg sciatica. Radiographic imaging demonstrated calcification within the L4/5 interspace, which was managed with simple analgesia. She subsequently re-presented 24-months later with worsening sciatica, right leg weakness and faecal incontinence. No evidence of cord or root compression was noted on MRI. However, an abnormality was noted at the anterior body of L5 with evidence of superior endplate depression and marrow signal change. Subsequent radionucleide bone studies confirmed a solitary focus of increased linear activity extending across the width of the L4-L5 interspace. Her symptoms were managed medically. Serial radiographic imaging demonstrated regression of the disc space calcification and healing of the L5 fracture. Despite its sinister presentation this condition was self-limiting. We describe the radiographic evolution of this pathology and postulate a putative hypothesis through which it may have arisen.

Spondylodiscitis in Paediatric Patients: The Importance of Early Diagnosis and Prolonged Therapy.

Background: Spondylodiscitis (SD), the concurrent infection of a vertebral disc and the adjacent vertebral bodies, is a very severe disease that can lead to death or cause spinal deformities, segmental instabilities, and chronic pain, which significantly reduces the quality of life for affected patients. Early diagnosis and treatment are essential in order to reduce the risk of negative outcomes. The two cases of SD that are described in this paper might be useful for informing paediatric approaches to children with SD. Case presentation: The cases that are reported here are about two children of approximately 2 and 3 years of age, in whom SD involving the L4⁻L5 and L3⁻L4 interspaces, had a subacute or chronic course. The clinical manifestations were mild, fever was absent, and the lumbar pain lasted for a long time and was the predominant symptom. Moreover, laboratory tests were in the normal range or only slightly abnormal, as were the standard radiographs of the lumbar spine. In both of the cases, SD confirmation was obtained through magnetic resonance imaging (MRI) and MRI was also used to evaluate the response to therapy. In both of our patients, tuberculosis was excluded based on tuberculin skin testing and the Quantiferon TBgold tests being negative. This finding led to the prescription of a broad-spectrum antibiotic therapy, including a drug that was potentially effective against Staphylococcus aureus (Sa). The strict monitoring of the spinal damage with MRI avoided the need for aspirations or biopsies; invasive procedures that are ethically acceptable in pediatric age only in a few selected cases, when the empirical antibiotic is associated with a worsening of spinal damage; or the vertebral osteomyelitis lesion mimics a tumoral lesion. Conclusions: Although rare, SD represents an important disease in children. In toddlers and preschool children, it can have a subacute or chronic course, in which only back pain, irritability, and walking difficulties are the signs and symptoms of the disease. MRI remains the best method for confirming the diagnosis and for evaluating therapy efficacy. Antibiotics are the drugs of choice. Although the duration has not been established, antibiotics should be administered for several weeks.

Culture yield of repeat percutaneous image-guided biopsy after a negative initial biopsy in suspected spondylodiscitis: a systematic review.

OBJECTIVE: To systematically review the published data on the culture yield of a repeat (second) percutaneous image-guided biopsy after negative initial biopsy in suspected spondylodiscitis. MATERIALS AND METHODS: A systematic search was performed of the PubMed/Medline and Embase databases. The methodological quality of the studies included was assessed. The proportions of positive cultures among all initial biopsies and second biopsies (after a negative initial biopsy) were calculated for each study and assessed for heterogeneity (defined as I2 > 50%). RESULTS: Eight studies, comprising a total of 107 patients who underwent a second percutaneous image-guided biopsy after a culture-negative initial biopsy in suspected spondylodiscitis, were included. All eight studies were at risk of bias and were concerning with regard to applicability, particularly patient selection, flow of patients through the study, and timing of the biopsy. The proportions of positive cultures among all initial biopsies ranged from 10.3 to 52.5%, and were subject to heterogeneity (I2 = 73.7%). The proportions of positive cultures among all second biopsies after negative initial biopsy ranged from 0 to 60.0%, and were not subject to heterogeneity (I2 = 38.7%). CONCLUSION: Although a second percutaneous image-guided biopsy may have some value in patients with suspected spondylodiscitis, its exact value remains unclear, given the available poor-quality evidence. Future well-designed studies are needed to determine the role of a second percutaneous image-guided biopsy in this setting. Such studies should clearly describe the spectrum of patients that was selected for a second percutaneous image-guided biopsy, the method of biopsy, and differences compared with the first biopsy, if any.

Retrospective review of CT-guided intervertebral disc biopsies performed at a tertiary referral centre for suspected osteodiscitis.

INTRODUCTION: Patients with osteodiscitis are often prescribed antibiotics prior to biopsy. There is controversy in the literature about whether antibiotic pre-treatment prior to CT-guided biopsy decreases the microbiological culture yield. Conclusions from previous studies are influenced by sample size error and selection bias. Our study, conducted in a large number of patients over a 10-year period, clarifies this issue so that best clinical practice is assured. METHODS: We performed a retrospective audit of the clinical, radiological and microbiological features of adult patients who underwent CT-guided biopsies for suspected osteodiscitis at a tertiary institution. Patients who had received intravenous antibiotic therapy in the month prior to biopsy or oral antibiotics 2 weeks prior to biopsy were considered as having had antecedent treatment. RESULTS: We initially found no significant difference in the likelihood of a positive culture between patients who had received antecedent treatment and those who had not. However, when we performed a subgroup analysis, we found that using multiple antibiotics influenced the likelihood of a positive culture. A second subgroup analysis demonstrated that pre-treatment reduced the likelihood of a positive culture. This discrepancy arose from the match between the antecedent antibiotics and the organisms' antibiotic sensitivity profile. CONCLUSION: Antibiotic treatment preceding CT-guided biopsy reduces the likelihood of a positive microbiological culture results. However, due to the often poor match, between the pre-treatment antibiotic and the organisms' antibiotic sensitivity profile, this is often not clinically apparent. Furthermore, positive cultures sensitive to the pre-treatment antibiotics can still be obtained.