What is the best course of treatment for a patient with suspected thoracic discitis, a history of decubitus (pressure sore) ulcer, and previous esophagectomy (surgical removal of the esophagus)?

Management of Suspected Thoracic Discitis with History of Decubitus Ulcer and Esophagectomy

Obtain urgent MRI of the thoracic spine without and with IV contrast immediately, followed by CT-guided biopsy for tissue diagnosis, and initiate empiric broad-spectrum antibiotics while arranging urgent neurosurgical consultation. 1, 2

Immediate Diagnostic Imaging

MRI thoracic spine without and with IV contrast is the definitive diagnostic test and must be performed urgently. 1 This imaging modality has 96% sensitivity and 94% specificity for spine infection and is superior to all other modalities. 1 The ACR Appropriateness Criteria specifically address your clinical scenario—suspected spine infection with decubitus ulcer or wound overlying the spine—and designate MRI with and without contrast as the optimal initial study. 1

Why Both Pre- and Post-Contrast Sequences Are Essential:

• Pre-contrast images are required for comparison to confirm areas of suspected abnormality 1
• Post-contrast enhancement defines the extent of infectious process, identifies peripherally enhancing fluid collections, and distinguishes postoperative changes from active infection 1
• The combination detects marrow edema, paraspinal muscle edema, abnormal fluid collections, disc space abnormalities, and vertebral endplate involvement 1

Alternative if MRI Contraindicated:

If MRI cannot be performed, obtain CT thoracic spine with IV contrast, which has 79% sensitivity and 100% specificity for spine infection. 1 CT with contrast increases conspicuity of paraspinal soft tissue abnormalities and abscesses. 1

Urgent Tissue Diagnosis

CT-guided percutaneous biopsy of the affected disc space must be obtained for microbiologic and histopathologic diagnosis. 2 This is critical because:

• Blood cultures are frequently negative even when disc cultures are positive (9 of 10 patients with positive disc cultures had negative blood cultures in one series) 3
• Up to 30% of discitis cases have negative routine bacterial cultures, requiring evaluation for atypical organisms 2
• A wide variety of organisms can cause spontaneous discitis, making empiric therapy unreliable without culture data 3

Comprehensive Culture Protocol:

Send tissue specimens for: 2

• Routine bacterial cultures
• Mycobacterial cultures (AFB)
• Fungal cultures
• Brucella cultures if epidemiologically relevant

Immediate Neurosurgical Consultation Required

Arrange urgent neurosurgical consultation on the same day if any of the following are present: 2

• Any neurological deficit (radiculopathy, myelopathy, spinal cord compression)—this is a surgical emergency 2
• Bony destruction with spinal instability—mechanical failure placing neural elements at risk 2
• Epidural abscess with mass effect 2
• Progressive neurological deterioration despite medical therapy 2

Even without these red flags, obtain elective neurosurgical consultation within 48 hours given the thoracic location and history of decubitus ulcer, as these patients require periodic surgical evaluation during medical treatment. 1, 2

Empiric Antibiotic Therapy

Initiate broad-spectrum IV antibiotics immediately after obtaining blood cultures and before biopsy results return. The history of decubitus ulcer suggests possible polymicrobial infection including skin flora and anaerobes. 1

Common pitfall: Do not delay antibiotics waiting for biopsy if the patient is systemically ill, but always obtain cultures first. 3

Special Considerations for This Patient

Decubitus Ulcer as Source:

The presence of a decubitus ulcer significantly increases risk of contiguous spread to the spine. 1 Imaging must distinguish between: 1

• Superficial infection/cellulitis
• Deep osteomyelitis
• Paraspinal abscess
• Epidural abscess formation

Post-Esophagectomy Considerations:

The history of esophagectomy raises concern for:

• Potential mediastinal involvement if thoracic discitis extends anteriorly
• Altered anatomy that may complicate surgical approaches if needed
• Possible nutritional compromise affecting healing
• Need to assess for any retained hardware or surgical changes on imaging 1

MRI with contrast specifically helps distinguish expected postoperative changes from active infection. 1

Referral to Tertiary Center

Transfer to a tertiary neuroscience center is indicated if your facility lacks: 2

• Neurosurgical expertise in spinal infections
• Interventional radiology for CT-guided biopsy
• Advanced MRI capabilities with contrast
• Multidisciplinary team for complex spinal infections

Monitoring During Initial Management

While awaiting definitive diagnosis and treatment:

• Monitor neurological status every 4-6 hours for any deterioration 2
• Consider external immobilization with thoracolumbosacral orthosis (TLSO) brace for pain control and segment stabilization 1
• Serial inflammatory markers (ESR, CRP) to track response
• Repeat MRI weekly if managed conservatively to detect disease progression 1

Critical pitfall: Thoracic discitis can rapidly progress to epidural abscess and cord compression. Any new neurological symptoms require immediate repeat imaging and surgical re-evaluation. 2