What is the treatment for discitis?

Treatment of Discitis

The treatment of discitis requires a combination of appropriate antimicrobial therapy for 4-8 weeks and consideration of surgical intervention in cases with neurological deficits, spinal instability, or significant sequestered abscesses. 1, 2

Diagnostic Approach Before Treatment

• MRI is the imaging modality of choice for diagnosing discitis, with sensitivity of 97%, specificity of 93%, and accuracy of 94% 1
• Blood cultures should be obtained in all patients with suspected discitis 1
• Image-guided aspiration biopsy is recommended to establish microbiological diagnosis before starting antibiotics 1
• Staphylococcus aureus is the most common causative organism (57.6%), though anaerobic bacteria may also be responsible in some cases 1, 3, 2

Medical Treatment

• Empiric antibiotics should be withheld until microbiologic diagnosis is established, except in patients with hemodynamic instability, sepsis, or severe neurologic symptoms 1
• CT-guided sampling for culture before commencing antibiotics increases organism detection from 33% to 67% 4
• Definitive therapy should be based on culture results and susceptibility testing 1
• Antibiotic therapy for 4-8 weeks provides the optimal balance of efficacy and treatment duration for most patients 2
• For Staphylococcus aureus infections, intravenous flucloxacillin is commonly used 4
• For anaerobic infections, appropriate antibiotics should be selected based on susceptibility testing (e.g., penicillin for Peptostreptococcus magnus, clindamycin for beta-lactamase-producing Fusobacterium nucleatum) 3

Surgical Management

• Surgical intervention is indicated for 5, 1:

  • Progressive neurologic deficits
  • Spinal instability
  • Progressive deformity
  • Significant sequestered paraspinal abscess
  • Pain despite adequate antimicrobial therapy

• Surgical options include 5:

  • Immobilization with external bracing (for isolated discitis with pain only)
  • Minimally invasive needle aspiration of abscesses
  • Surgical debridement via anterior, lateral, or posterior approaches
  • Spinal fusion when necessary for stability

• The choice of surgical approach depends on 5:

  • The specific segment of the spine affected
  • The structures involved
  • The comfort level of the surgeon

Monitoring Response to Treatment

• Monitor systemic inflammatory markers (ESR, CRP) after approximately 4 weeks of antimicrobial therapy 1
• ESR values >50 mm/hour and CRP values >2.75 mg/dL after 4 weeks of treatment may indicate higher risk of treatment failure 1
• Routine follow-up MRI is not recommended in patients with favorable clinical and laboratory response 1
• Identification of the specific causative organism can reduce the average antibiotic course from 142 days to 77 days 4

Special Considerations

• Discontinue any unnecessary antibiotics that may have been prescribed for other conditions, as they can potentially worsen the clinical course 5
• For patients with severe pain, external brace immobilization with a cervical collar for the neck or a thoracolumbosacral orthosis brace for the thoracolumbar spine can help immobilize the involved segment during concurrent medical therapy 5
• Imaging surveillance and close clinical observation are necessary at frequent intervals to ensure that disease progression is detected early 5
• Surgical consultation should be obtained periodically during the course of medical treatment 5

Prognosis

• Mortality rates have improved from approximately 25% in the pre-antibiotic era to 0-11% in contemporary cohorts 1
• Factors associated with worse outcomes include multidisc disease, concomitant epidural abscess, lack of surgical therapy when indicated, infection with S. aureus, and significant comorbidities 1
• An increased number of significant co-morbid conditions are associated with worse outcomes 4