What is the most appropriate next step in diagnosis for a 40-year-old man with a 1-month history of fever, night sweats, and severe mid and low back pain, poorly controlled type 2 diabetes mellitus (T2DM), and imaging findings suggestive of a spinal infection?

From the Guidelines

The most appropriate next step in diagnosis for this 40-year-old man with suspected spinal infection is to perform a percutaneous spinal biopsy, as this will provide a definitive diagnosis and guide targeted antibiotic therapy. The patient's clinical presentation, including fever, night sweats, and severe back pain, along with imaging findings suggestive of a spinal infection, necessitates tissue sampling to identify the causative organism 1.

The use of MRI with contrast has already provided valuable information about the extent of the infection, including the presence of an enhancing epidural mass between T12 and L1, but a microbiological diagnosis is crucial to determine the appropriate antibiotic regimen 1.

Key considerations in this case include:

• The patient's poorly controlled type 2 diabetes mellitus, which increases his risk for infections, particularly those caused by Staphylococcus aureus
• The need for blood cultures and laboratory tests, such as complete blood count, C-reactive protein, and erythrocyte sedimentation rate, to assess infection severity and guide management
• The importance of obtaining tissue samples before initiating antimicrobial therapy to maximize the likelihood of identifying the causative organism

Given the patient's clinical presentation and imaging findings, a percutaneous spinal biopsy is the most appropriate next step in diagnosis, as it will provide a definitive diagnosis and guide targeted therapy to improve outcomes 1.

From the Research

Diagnosis of Spinal Infection

The patient's symptoms, including fever, night sweats, and severe mid and low back pain, along with imaging findings suggestive of a spinal infection, require a definitive diagnosis to guide appropriate treatment.

• The patient's history of poorly controlled type 2 diabetes mellitus (T2DM) increases the risk of infection, making it essential to identify the underlying cause of the spinal infection.
• Imaging findings, such as narrowing of the disc space and vertebral bony destruction, are consistent with a spinal infection, but a definitive diagnosis requires microbiological and/or histological confirmation.

Next Steps in Diagnosis

Considering the patient's symptoms and imaging findings, the most appropriate next step in diagnosis is:

• Percutaneous spinal biopsy 2, 3, 4, 5, 6, which is a safe and effective procedure for obtaining a tissue sample for microbiological and histological analysis.
• This procedure can help identify the underlying cause of the spinal infection, including bacterial, fungal, or tubercular infections, and guide appropriate treatment.

Rationale for Percutaneous Spinal Biopsy

• Studies have shown that percutaneous spinal biopsy is a reliable and accurate diagnostic procedure for spinal lesions of unknown etiology 2, 3, 4, 5, 6.
• The procedure has a high diagnostic yield, with accuracy rates ranging from 94.4% to 97.7% for histopathological and microbiological analysis, respectively 2.
• Percutaneous spinal biopsy can also help identify the underlying pathogen, which is essential for guiding appropriate antibiotic therapy 3, 6.