Vertebral Osteomyelitis

Infection of the vertebrae

Aetiology

  • Mostly haematogenous, most commoly staph. aureus
  • May be associated with abscess - epidural, psoas
  • As the vertebral end plates weaken, vertebrae may collapse leading to kyphosis or vertebra plana (flat vertebra) and disc space may reduce

Risk factors

  • PWID
  • Poorly controlled diabetes
  • IV site infections
  • GU infections
  • SSTI
  • Post operative
  • Primary bacteraemia in the elderly

Clinical presentation

Symptoms

  • Patients present with insidious onset of back pain (most commonly lumbar) which is constant and unremitting

Signs

  • Paraspinal muscle spasm
  • Spinal tenderness
  • May have fever and/or systemic upset
  • Severe cases may have an associated neurological deficit

Investigations

  • Bloods - raised CRP
  • MRI - extent of infection and any abscess formation, imaging psoas sign indicates spondylodiscitis
  • Blood cultures may indicate the causative organism (usually Staph. aureus including MRSA but atypical infections can occur in the immunocompromised)
  • Consider endocarditis - look for clubbing, splinter haemorrhages, murmur, consider ECHO

Management

  • High dose IV antibiotics after CT guided biopsy to obtain tissue culture
  • Antibiotics may be required for several months and response is assessed clinically and by serial CRP
  • Around half of all patients go on to spontaneous fusion and resolution

Surgery

  • Indications for surgery include inability to obtain cultures by needle biopsy, no response to antibiotic therapy, progressive vertebral collapse and progressive neurological deficit
  • Surgery involves debridement, stabilization and fusion of adjacent vertebrae