From the Guidelines
C spine osteomyelitis requires prompt diagnosis and treatment with empiric intravenous antibiotics, such as vancomycin and ceftriaxone, and adjustment based on culture results, with a recommended duration of 6-8 weeks total. The diagnostic criteria for C spine osteomyelitis include recalcitrant back pain unresponsive to conservative measures, elevated inflammatory markers, and imaging (MRI preferred) to confirm diagnosis 1.
Diagnostic Approach
- Obtain blood cultures and imaging (MRI preferred) to confirm diagnosis
- Consider image-guided or intraoperative aspiration or biopsy of a disc space or vertebral endplate sample for microbiologic and pathologic examination 1
Treatment Options
- Start empiric intravenous antibiotics immediately:
- Vancomycin 15-20 mg/kg IV every 8-12 hours PLUS
- Ceftriaxone 2g IV daily
- Adjust antibiotics based on culture results and continue for 6-8 weeks total
- Provide pain management and consider cervical spine immobilization
- Consult neurosurgery for potential surgical debridement if there's neurological compromise, spinal instability, or abscess formation
Monitoring and Follow-up
- Monitor with repeat imaging and inflammatory markers (ESR, CRP) to assess treatment response
- Consider the addition of rifampin 600 mg daily or 300–450 mg PO twice daily to the antibiotic chosen above, especially for patients with concurrent bacteremia 1
- The optimal duration of therapy for C spine osteomyelitis is unknown, but a minimum 6-8 week course is recommended, with some experts suggesting an additional 1–3 months of oral rifampin-based combination therapy 1
The most recent and highest quality study, published in 2024, suggests that oral antibiotic therapy may be adequate for the treatment of osteomyelitis in a subset of patients, and that a shorter duration of therapy (2–4 weeks) may be appropriate following bone debridement and flap reconstruction 1. However, additional high-quality data are required before implementing shorter treatment courses.
From the Research
Diagnostic Criteria
- Cervical spine osteomyelitis is a rare disease, representing only 3% to 6% of all cases of vertebral osteomyelitis 2
- The disease can be diagnosed using plain cervical spine films, polytomography, computerized tomography, and magnetic resonance imaging (MRI) to detect bone involvement and the presence of epidural extension associated with cervical osteomyelitis 3
- Laboratory tests such as blood culture and needle aspiration can be used to identify the causative microorganisms 4, 3
Treatment Options
- Surgical treatment options include:
- Radical debridement of the infected bone and either immediate bone grafting and stabilization as a one-step procedure or interval antibiotic treatment before bone grafting and surgical stabilization as a second procedure 2
- Anterior cervical debridement and strut-grafting 3
- Anterior debridement and fusion, irrigation and debridement, simultaneous cervical anterior interbody and transthoracic thoracic interbody fusion 4
- Antibiotic treatment is also crucial, with patients typically receiving intravenous antibiotics for several weeks, followed by oral antibiotics for several months 4, 5
- Internal fixation devices may be used to stabilize the spine, but there is a risk of persistence of culture-positive infection around the implants, and removal of the implants may be necessary 5
Outcomes
- Early and aggressive surgical intervention can lead to a favorable outcome, including complete resolution of neurologic deficits in more than 50% of patients and complete bony fusion in all but one patient 2
- Patients with cervical osteomyelitis can experience significant long-term sequelae, including ankylosis of the affected joints, but can still achieve successful return to work and normal activities 6