Referral for Chronic Discitis
Patients with chronic discitis should be referred to a tertiary care center with a multidisciplinary team led by an infectious disease specialist or rheumatologist, with access to spine surgery, musculoskeletal radiology, and interventional capabilities, particularly for difficult-to-treat cases or those with neurological complications. 1, 2
Primary Referral Destination
Refer to an infectious disease specialist or rheumatologist at a tertiary care center with expertise in complex spinal infections, as chronic discitis requires prolonged antimicrobial therapy (minimum 6 weeks) and often involves resistant organisms requiring specialized management 3, 1, 4
Ensure access to a spine surgeon for consultation, as surgical intervention may be necessary for bony destruction, spinal instability, spinal cord or nerve root compression, or medically refractory disease 5, 1
Involve musculoskeletal imaging experts who can perform and interpret MRI (the most sensitive and specific modality for discitis) and guide percutaneous disc biopsy when needed for microbiological diagnosis 1, 4, 2
Multidisciplinary Team Components
The referral center should provide access to:
Infectious disease specialists for complex antibiotic regimens, particularly when healthcare-associated infections or resistant organisms are suspected 3, 1
Spine surgeons for periodic consultation during medical treatment and immediate availability for surgical debridement if conservative management fails 5, 1
Interventional radiologists for image-guided percutaneous disc biopsy (positive in 50% of cases) to obtain definitive microbiological diagnosis 2
Pain management specialists for patients with severe, refractory pain requiring multimodal analgesia 1
Urgent Surgical Referral Indications
Obtain immediate spine surgery consultation for any of the following:
Neurological deficits including radiculopathy, myelopathy, or evolving spinal cord compression 5, 6
Spinal instability from bony destruction requiring mechanical stabilization 5, 1
Paraplegia development (a recognized complication of discitis requiring emergency intervention) 6
Medically refractory disease with progressive bony destruction despite appropriate antibiotic therapy 5, 1
Epidural or paraspinal abscess formation requiring drainage 5, 1
When to Consider Expert Center Referral
Refer immediately if:
Healthcare-associated discitis is suspected, as these cases often involve resistant organisms (MRSA, VRE) requiring complex antibiotic regimens 3
Diagnostic uncertainty exists, particularly in elderly patients where discitis may present atypically with back pain, restricted spinal movements, and elevated inflammatory markers 6
Failed initial antibiotic therapy after 2-4 weeks of appropriate treatment 1, 2
Multiple comorbidities are present (diabetes mellitus, immunosuppression, advanced age) that complicate management 2
Hub-and-Spoke Model
Consider a hub-and-spoke care model with periodic assessments at the expert center while maintaining local follow-up, particularly for patients requiring prolonged antibiotic therapy (6-12 weeks or longer) 5, 1
Schedule follow-up visits at the expert center every 3-6 months initially, with longer intervals (12-24 months) after clinical stabilization and documented radiographic improvement 5, 1
Critical Pitfalls to Avoid
Never delay referral in patients with neurological symptoms, as paraplegia can develop rapidly and represents a surgical emergency 6
Do not rely solely on blood cultures, as 90% of patients with positive disc cultures have negative blood cultures; percutaneous disc biopsy is critical for identifying the causative organism 4
Avoid assuming a single organism type, as spontaneous discitis involves a wide variety of pathogens (Staphylococcus, Streptococcus, gram-negatives, tuberculosis, fungi), making culture-directed therapy essential 3, 4, 2
Do not underestimate treatment duration, as antibiotic therapy should never be less than 6 weeks and often requires 12 weeks or longer for chronic cases 1, 2