What is the management of lumbar spine osteomyelitis (infection of the bone) and discitis (infection of the intervertebral disc) with possible abscess formation and symptoms of urinary incontinence?

From the Guidelines

Management of lumbar spine osteomyelitis/discitis with possible abscess and urinary incontinence requires prompt, aggressive treatment, prioritizing the patient's morbidity, mortality, and quality of life. The most recent and highest quality study, 1, published in 2021, emphasizes the importance of MRI with contrast in diagnosing spine infections, with a sensitivity, specificity, and accuracy of 96%, 94%, and 92%, respectively.

Key Components of Management

• Immediate hospitalization for intravenous antibiotics and further evaluation
• Obtain blood cultures and imaging (MRI with contrast) before starting antibiotics if possible, but do not delay treatment if the patient is septic, as recommended by 1
• Start empiric broad-spectrum IV antibiotics:
  • Vancomycin 15-20 mg/kg IV q8-12h (adjusted based on levels)
  • PLUS Ceftriaxone 2g IV q24h, as suggested by the 2015 IDSA guidelines 1
• Consult neurosurgery or orthopedic spine surgery for possible surgical debridement, especially if there's an abscess or neurological deficits

Urinary Incontinence Management

• Assess for cauda equina syndrome
• Implement bladder management with intermittent catheterization, as recommended by 1, which suggests that clean intermittent catheterization is the preferred method for bladder management in individuals with spinal cord injuries
• Ensure proper catheter hygiene and hand washing techniques to minimize the risk of urinary tract infections, as emphasized by 1

Additional Considerations

• Pain management with appropriate analgesics
• Once culture results are available, narrow antibiotic therapy accordingly
• Continue IV antibiotics for 4-6 weeks, then transition to oral antibiotics for a total of 6-12 weeks of therapy, as recommended by 1
• Monitor with serial inflammatory markers (ESR, CRP) and repeat imaging, as suggested by 1
• Implement early physical therapy and rehabilitation to prevent deconditioning

This aggressive approach is necessary due to the potential for rapid neurological deterioration and the difficulty in eradicating bone infections, as highlighted by 1 and 1. The combination of antibiotics targets both gram-positive (including MRSA) and gram-negative organisms commonly involved in vertebral osteomyelitis, and surgical intervention may be crucial for source control and preventing neurological complications.

From the Research

Management of Lumbar Spine Osteomyelitis and Discitis

The management of lumbar spine osteomyelitis and discitis involves a combination of medical and surgical interventions. The goal of treatment is to eradicate the infection, relieve symptoms, and prevent long-term complications.

• Surgical Treatment: Surgical treatment is indicated in cases of failure of antibiotic therapy, neurological deficits, epidural abscess, or spinal instability/deformity 2. Historically, surgical treatment mandated aggressive debridement and spinal stabilization. However, there is growing evidence that direct debridement may not be necessary and may contribute to morbidity.
• Posterior Fixation Without Debridement: A study published in the International Journal of Spine Surgery found that posterior instrumentation without debridement is effective in treating spinal infections 2. The study included 27 patients treated with posterior-only long-segmented rigid fixation without formal debridement of infected material.
• Minimally Invasive Management: A case report published in the International Journal of Surgery Case Reports described a novel minimally invasive management of lumbar osteomyelitis using percutaneous endoscopic debridement and kyphoplasty needle 3. The patient experienced instant relief of pain and had no recurrent infection.
• Two-Stage Management: A technical note published in Neurosurgery described a two-stage management approach for vertebral osteomyelitis and epidural abscess 4. The first stage involved anterior debridement or drainage and application of an external orthosis, followed by a second stage of complete debridement and stable reconstruction with or without instrumentation.

Considerations for Urinary Incontinence

Urinary incontinence is a potential symptom of lumbar spine osteomyelitis and discitis. The management of urinary incontinence in these cases should be individualized and may involve a combination of medical and surgical interventions.

• Neurological Deficits: Neurological deficits, including urinary incontinence, can occur in cases of lumbar spine osteomyelitis and discitis 2. Surgical treatment may be necessary to relieve compression on the spinal cord and prevent long-term neurological damage.
• Spinal Instability: Spinal instability can also contribute to urinary incontinence in cases of lumbar spine osteomyelitis and discitis 2. Surgical stabilization may be necessary to prevent further instability and relieve symptoms.

Diagnostic Challenges

The diagnosis of lumbar spine osteomyelitis and discitis can be challenging, and non-infectious causes of discitis/osteomyelitis should be considered 5. Clinical findings and laboratory studies, including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), can be helpful in diagnosis, but their specificity is low. Imaging studies, including magnetic resonance imaging (MRI) and computed tomography (CT), can also be useful in diagnosis.