Is a diagnosis of possible discitis on MRI (Magnetic Resonance Imaging) without contrast concerning in a patient with no signs of fever or sepsis?

From the Guidelines

An MRI finding of possible discitis is concerning even without fever or sepsis, and further evaluation is necessary to confirm the diagnosis and guide treatment. Discitis, an infection of the intervertebral disc space, can sometimes present with subtle or atypical symptoms, particularly in elderly patients, immunocompromised individuals, or those on antibiotics 1. While fever and signs of sepsis are common with discitis, their absence doesn't rule out the condition.

Key Considerations

• The absence of fever or sepsis does not exclude the diagnosis of discitis, and a high index of clinical suspicion is required to initiate the clinical workup 2.
• MRI without and with IV contrast has a sensitivity of 96% and a specificity of 94% for the evaluation of patients with suspected spine infection, and can help distinguish expected postoperative changes from infection 1.
• Blood tests like complete blood count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) are often elevated in discitis, and blood cultures should be obtained before starting antibiotics 3.

Recommended Course of Action

• Further evaluation is necessary, including blood tests and a follow-up MRI with contrast to confirm the diagnosis and guide treatment 1.
• If discitis is confirmed, treatment typically involves 6-12 weeks of antibiotics, initially intravenous then oral, targeted to the identified pathogen 2.
• Consultation with infectious disease specialists is recommended for antibiotic selection and duration, and pain management and possibly spinal bracing may be needed 3.
• Early diagnosis and treatment are crucial to prevent complications like vertebral destruction, spinal instability, or abscess formation 1.

From the Research

MRI without Contrast and Possible Discitis

• The patient's MRI without contrast suggests possible discitis, but they do not have fever or sepsis, which is a common presentation of septic discitis 4.
• Septic discitis is a rare but important cause of spinal pain caused by intervertebral disc infection, and patients typically present with spinal pain, fever, and raised inflammatory markers 4.
• The absence of fever or sepsis in this patient may indicate a non-septic or early septic discitis, and further evaluation is needed to determine the cause of the discitis.

Clinical Features and Management

• The clinical features of septic discitis include spinal pain, fever, and raised inflammatory markers, and the management of septic discitis typically involves intravenous antibiotics and possibly surgical intervention 4, 5.
• The choice of antibiotic therapy depends on the causative organism, and Staphylococcus aureus is a common cause of septic discitis 4, 5.
• The use of MRI and CT scanning has improved the diagnosis and management of septic discitis, and CT-guided biopsies can increase the yield of organism detection 4.

Treatment Options

• The treatment of septic discitis typically involves intravenous antibiotics, and the choice of antibiotic therapy depends on the causative organism 4, 5.
• Ceftaroline, an advanced-generation cephalosporin, has been shown to be effective in treating spine infections, including those caused by MRSA 6.
• The use of vancomycin, a glycopeptide antibiotic, is also common in the treatment of septic discitis, but it has been associated with poor outcomes such as nephrotoxicity and treatment failure 7.

Importance of Early Diagnosis and Management

• Early diagnosis and effective management of sepsis, including septic discitis, are critical to optimizing patient outcomes and reducing morbidity and mortality 8.
• Nurses play a vital role in the early identification of patients with or at risk of developing sepsis, and prompt treatment using care bundles such as the "sepsis six" can improve patient outcomes 8.