Management of Spondylodiscitis
The management of spondylodiscitis requires a combination of appropriate antimicrobial therapy, possible surgical intervention, and regular monitoring with both clinical and imaging parameters to ensure optimal outcomes and prevent complications. 1, 2, 3
Diagnostic Approach
- MRI with and without contrast is the primary diagnostic modality for spinal infections, with 96% sensitivity, 94% specificity, and 92% accuracy 2, 3
- [18F]FDG PET/CT could be the preferred modality for detection of spondylodiscitis within 14 days of symptom onset 1
- Blood cultures should be obtained before starting antibiotics to identify the causative organism 4, 5
- CT-guided biopsy is recommended when blood cultures are negative to establish microbiological diagnosis 3, 5
- Monitor inflammatory markers (CRP and ESR) to assess disease activity and treatment response 1, 4
Antimicrobial Therapy
- Empirical antibiotic therapy should be initiated after obtaining blood cultures and tissue samples in patients with severe or progressive neurological deficits or hemodynamic instability 5, 6
- Initial empirical therapy should cover both Gram-positive and Gram-negative organisms, as targeting only Gram-positive bacteria may lead to treatment delays in a substantial number of patients 5, 6
- Staphylococcus aureus is the most common pathogen (up to 80% of cases), but coverage for other organisms including tuberculosis should be considered based on epidemiological factors 4, 6
- A combination of a glycopeptide (vancomycin or teicoplanin) with a broad-spectrum β-lactam antibiotic shows the highest potential susceptibility rates (>90%) 6
- Intravenous antibiotics should be administered for 2-4 weeks, followed by oral therapy for 6-12 weeks 4
Surgical Management
- Surgical intervention is indicated in the following scenarios: 4, 7
- Neurological deficits with spinal cord compression
- Progressive spinal deformity or instability
- Failure of conservative therapy with insufficient pain relief
- Large anterior abscesses requiring drainage
- Need for bacterial isolate when other methods have failed
- The anterior approach provides direct access to the most commonly affected parts of the spine 7
- Thorough debridement of infected tissue combined with spinal stabilization is essential 7
- Spinal instrumentation can be performed in the same setting as debridement without increased risk of persistent infection 7
Monitoring and Follow-up
- Regular monitoring of inflammatory markers (CRP and ESR) is essential to assess treatment response 1, 4
- Follow-up MRI is recommended to evaluate treatment response, though imaging findings may normalize more slowly than clinical and laboratory parameters 3
- CT is useful for follow-up in patients with spinal instrumentation 2, 3
- Approximately 10% of cases may have non-contiguous multilevel infections, which should be considered during follow-up 1
Special Considerations
- Mycobacterium tuberculosis should be considered as a potential pathogen, especially in patients with low socioeconomic status or limited access to healthcare 7, 8
- For patients with spinal hardware, [18F]FDG PET/CT is recommended, preferably performed 3-4 months after surgery 1
- A multidisciplinary approach involving infectious disease specialists, spine surgeons, and radiologists is crucial for optimal management 5, 8
Prognosis
- The prognosis is generally good with appropriate treatment, with mortality rates around 2-3% 4
- Favorable outcomes are associated with a clear reduction in CRP and ESR in the first few weeks of treatment 4
- Neurological recovery is possible in patients with preoperative deficits following appropriate surgical intervention 7