What is the treatment for aseptic discitis?

Treatment of Aseptic Discitis

The treatment of aseptic discitis primarily consists of immobilization, anti-inflammatory medications, and close monitoring, with antibiotics generally not indicated unless infection cannot be ruled out. 1

Definition and Clinical Presentation

Aseptic discitis is an inflammation of the intervertebral disc without identifiable infectious etiology. It presents with:

• Back pain of inflammatory nature (worse at night, improved with activity) 2
• Possible low-grade fever and elevated inflammatory markers 2
• In children: irritability, decreased appetite, refusal to walk or sit, and sometimes abdominal or hip pain 1, 3
• Radiological findings showing decreased disc space and irregularity of vertebral endplates 2

Diagnostic Approach

• MRI is the gold standard for diagnosis, showing inflammation of the disc space without abscess formation 1, 4
• Blood tests may show elevated inflammatory markers (ESR, CRP) but can sometimes be normal 1
• Blood cultures are typically negative 1
• FDG PET/CT can be useful in cases with inconclusive MRI findings or to differentiate from infectious discitis 4

Treatment Algorithm

First-Line Treatment:

1. Immobilization of the affected spinal segment 1, 4

   • External brace immobilization with cervical collar for neck involvement
   • Thoracolumbosacral orthosis brace for thoracolumbar spine involvement

2. Anti-inflammatory medications 1, 4

   • NSAIDs are typically effective for symptom control
   • Caution: NSAIDs themselves can rarely cause aseptic meningitis, particularly in patients with underlying autoimmune conditions 5

3. Rest and activity modification 1, 3

   • Bed rest during acute phase
   • Gradual return to activities as symptoms improve

Monitoring:

• Regular clinical assessment for symptom improvement 4
• Serial imaging (MRI) to monitor resolution of inflammation 4
• Follow inflammatory markers (ESR, CRP) to track response 6

When to Consider Antibiotics:

• If infectious etiology cannot be definitively ruled out 7
• When clinical deterioration occurs despite conservative management 6
• In immunocompromised patients where infection risk is higher 6

Special Considerations

• Children vs. Adults: Children typically have better outcomes with conservative management alone 3
• Underlying Conditions: Patients with rheumatic diseases may be more prone to aseptic discitis and may require more aggressive anti-inflammatory treatment 2
• Differential Diagnosis: Important to distinguish from infectious discitis, which requires targeted antibiotic therapy 6

Potential Complications

• Nerve damage if inflammation extends to neural structures 1
• Spinal fusion as a long-term complication 1
• Chronic pain if inadequately treated 2

Follow-up

• Regular clinical assessment until symptoms resolve 3
• Follow-up imaging to confirm resolution of inflammation 4
• Long-term follow-up (2-10 years) shows generally good outcomes with appropriate management 3

Pitfalls to Avoid

• Misdiagnosing as infectious discitis and unnecessarily treating with prolonged antibiotics 6
• Failing to rule out infection before concluding aseptic etiology 7
• Overlooking underlying rheumatic conditions that may predispose to aseptic discitis 2
• Delaying diagnosis due to non-specific symptoms, particularly in children 1