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Guidelines
Vertebral OM / Discitis

Vertebral OM / Discitis

Background

Epidural abscess should be considered an emergency

Hematogenous seeding is the most common route of infection

Can also occur after surgery, injection of the disc space, or contiguous spread from adjacent soft tissue infection

Lumbar spine most common site

Staphylococcus aureus most common pathogen

  • MRSA: If previous MRSA infection or colonization

  • Streptococci, Enterococci, Gram-negative bacilli, and anaerobes are less common

Presentation

  • New or worsening back pain, often severe, with

    • elevated inflammatory markers,
    • fever (only ~50%),
    • current or recent bloodstream infection/infective endocarditis

  • Fever with new neurological symptoms

Diagnosis

MRI is preferred imaging
  • Early destructive changes can be missed with CT and is not sensitive for epidural abscess

2 sets of blood cultures

Note: positive in only ~50% of cases

Biopsy via interventional radiology or by surgical intervention
  • Concomitant presence of S. aureus bloodstream infection within the preceding 3 months and compatible spine MRI changes preclude the need for a disc space aspiration, as the etiology can be assumed to be S. aureus

Management

Delay empiric antibiotics until microbiologic diagnosis unless septic or neurologic compromise (perform a thorough neurological history and physical exam)

Assess for extension of infection

  • e.g. psoas abscess, epidural abscess, empyema

Assess for other sites of metastatic infection

  • e.g. endocarditis, septic joint, hardware infection

Regularly assess condition since neurological status can change quickly, urgent neurosurgery consultation if neurological symptoms or signs are present

Consult Neurosurgery if epidural abscess and closely monitor neurological status

Infectious diseases consult

Antimicrobials

Cefazolin is usual empiric drug of choice

Target antibiotics based on culture results

Usually 6 weeks of intravenous therapy and then reassessment