What is the presentation of vertebral diskitis in a 68-year-old man with back pain and tenderness of the thoracic (T) spine on examination?

From the Guidelines

Vertebral diskitis in a 68-year-old man with back pain and thoracic spine tenderness requires prompt evaluation and treatment with immediate MRI of the spine and empiric antibiotic therapy. The patient should undergo MRI of the spine, which is the gold standard imaging modality, along with blood cultures, complete blood count, erythrocyte sedimentation rate, and C-reactive protein to confirm infection 1. Empiric antibiotic therapy should be initiated after blood cultures are obtained, typically with vancomycin 15-20 mg/kg IV every 12 hours plus ceftriaxone 2g IV daily to cover common pathogens like Staphylococcus aureus and gram-negative organisms.

Key Considerations

• Consultation with infectious disease specialists is essential for tailoring antibiotic therapy once culture results are available 1.
• Treatment typically continues for 6-12 weeks, with transition to oral antibiotics when clinically improving.
• Pain management with appropriate analgesics and possible bracing for spinal stability are important adjunctive measures.
• Surgical intervention may be necessary if there is neurological compromise, spinal instability, or abscess formation.

Diagnostic Approach

• MRI without and with IV contrast is often utilized for the evaluation of patients with suspected spine infection, with a sensitivity, specificity, and accuracy of 96%, 94%, and 92%, respectively 1.
• The use of an IV contrast agent increases lesion conspicuity and helps to define the extent of the infectious process.
• The addition of a diffusion-weighted imaging sequence may assist in differentiating acute infectious spondylitis from reactive changes.

Clinical Context

• The patient's age and thoracic spine involvement raise concern for a potentially serious infection that could spread to adjacent structures 1.
• Thoracic myelopathy is most commonly due to compressive etiologies, including structural causes resulting in spinal canal stenosis, cord compression/deformity, or other inflammatory, infectious, vascular, or neoplastic etiologies.
• Symptomatic thoracic disc herniations are more common in patients in their third to fifth decades of life and, in more than one-third of patients, are associated with a history of trauma.

This condition requires urgent attention as delayed treatment can lead to irreversible neurological damage, sepsis, or chronic pain 1.

From the Research

Vertebral Diskitis Presentation

The presentation of vertebral diskitis in a 68-year-old man with back pain and tenderness of the T spine on exam can be evaluated using various laboratory markers and imaging studies.

• The patient's symptoms, such as back pain and tenderness, can be indicative of an inflammatory condition, and laboratory tests like erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) can be used to support the diagnosis 2, 3.
• ESR and CRP are markers of inflammatory conditions and can be used to monitor the patient's response to treatment 2, 3.
• However, it is essential to consider the limitations of these tests, as they lack sensitivity and specificity, and should be used in combination with clinical history and physical exam for diagnosis and monitoring of pathological conditions 3.
• In cases where infection is suspected, empiric antibiotic therapy may be necessary, and the choice of antibiotics should be guided by the suspected pathogens and their antimicrobial susceptibilities 4, 5, 6.
• The goal of empiric antibiotic therapy is to provide appropriate initial treatment while minimizing the emergence of antibiotic resistance, and antibacterial de-escalation can be an effective approach to achieve this goal 6.

Laboratory Markers

• ESR and CRP can be used to monitor the patient's inflammatory response and adjust treatment accordingly 2, 3.
• However, discrepancies between ESR and CRP measurements can occur, and proper utilization of these tests requires consideration of various physiological factors, including noninfectious conditions and resolution of inflammation 3.

Empiric Antibiotic Therapy

• Empiric antibiotic therapy should be guided by the suspected pathogens and their antimicrobial susceptibilities 4, 5, 6.
• The choice of antibiotics should balance the need to provide appropriate initial treatment while minimizing the emergence of antibiotic resistance 6.
• Antibacterial de-escalation can be an effective approach to achieve this goal, by narrowing the antibacterial regimen once the pathogens and their susceptibility profiles are determined, and by employing the shortest course of therapy clinically acceptable 6.