What is the treatment for an adult with spinal bone and nerve inflammation?

Treatment for Spinal Bone and Nerve Inflammation in Adults

Immediate Diagnostic Priority: Determine the Underlying Etiology

The treatment approach depends entirely on whether the inflammation is infectious (vertebral osteomyelitis/spondylodiscitis), autoimmune/inflammatory (chronic non-bacterial osteitis, ankylosing spondylitis), or neurologic (transverse myelitis). You must first obtain tissue diagnosis through image-guided aspiration biopsy or surgical sampling to guide definitive therapy, as infectious causes require antimicrobial therapy while non-infectious causes require immunomodulatory treatment 1.

Critical First Steps

• Obtain MRI of the spine immediately to assess for epidural abscess, paraspinal soft tissue involvement, spinal cord signal abnormality, and nerve root enhancement 1, 2
• Check inflammatory markers (ESR and CRP) to establish baseline and guide treatment monitoring 1
• Perform tissue sampling (image-guided aspiration biopsy or surgical biopsy) for microbiologic cultures (bacterial, fungal, mycobacterial) and histopathology before starting antimicrobials if infection is suspected 1
• Assess for neurologic deficits including motor weakness, sensory changes, and bowel/bladder dysfunction, as these indicate need for urgent surgical consultation 1, 2

Treatment Algorithm Based on Etiology

If Infectious Etiology (Vertebral Osteomyelitis/Spondylodiscitis)

Start pathogen-directed antimicrobial therapy for 6 weeks minimum after obtaining tissue diagnosis 1. The IDSA guidelines emphasize that antimicrobial selection must be based on culture results, not empiric therapy alone 1.

Indications for Surgical Intervention:

• Progressive neurologic deficits despite appropriate antimicrobial therapy 1
• Spinal instability or deformity 1
• Large epidural or paraspinal abscess causing mass effect 1
• Worsening pain despite appropriate medical therapy 1

Monitoring Treatment Response:

• Recheck ESR/CRP at 4 weeks: A 25-33% reduction indicates adequate response; unchanged or increasing values suggest treatment failure 1
• Obtain follow-up MRI only if clinical deterioration occurs, focusing on paraspinal and epidural soft tissue changes (not bone changes, which paradoxically worsen despite successful treatment) 1
• Consult infectious disease and spine surgery if treatment failure is suspected 1

If Non-Infectious Inflammatory Etiology (Chronic Non-Bacterial Osteitis)

For spinal bone lesions with risk of vertebral collapse, start intravenous bisphosphonates immediately without NSAID trial 1. This is critical because extensive bone marrow edema in vertebral bodies can lead to catastrophic collapse 1.

First-Line Treatment for CNO:

• Intravenous pamidronate 30 mg on 3 consecutive days, repeated every 3 months (preferred over zoledronate for pain reduction) 1
• Add TNF inhibitor (infliximab 3-5 mg/kg IV at weeks 0,2,6, then every 6-8 weeks; or adalimumab 40 mg subcutaneously every 2 weeks) if significant accumulated skeletal damage or extensive disease 1

For Less Severe CNO Without Vertebral Collapse Risk:

• Start NSAIDs at maximum tolerated dose for 2-4 weeks (naproxen 375-1100 mg/day, diclofenac 150 mg/day, or indomethacin 150 mg/day) 1
• Add proton pump inhibitor for gastroprotection when using oral NSAIDs 1
• Evaluate response at 2-4 weeks: If insufficient, advance to intravenous bisphosphonates or TNF inhibitors 1
• Short courses of oral prednisolone or intra-articular glucocorticoid injections may be used as bridging therapy, but avoid long-term systemic glucocorticoids 1

If Inflammatory Spondyloarthritis (Ankylosing Spondylitis)

Start continuous daily NSAIDs at full therapeutic doses combined with physical therapy 1. This is the cornerstone before considering biologic therapy 1.

NSAID Regimen:

• Use continuous daily dosing, not on-demand dosing, as this provides better symptom control and may reduce radiographic progression 1
• Trial 2-3 different NSAIDs at optimal doses before concluding NSAID failure 1
• No specific NSAID is preferred, but ibuprofen 1800 mg/day, naproxen 1000 mg/day, or indomethacin 150 mg/day are commonly used 1

Physical Therapy (Mandatory):

• Strongly recommend active supervised exercise programs over passive modalities 1
• Prefer land-based exercises over aquatic therapy 1

Biologic Therapy:

• If disease remains active despite adequate NSAID trial, strongly recommend TNF inhibitor therapy 1
• For concomitant inflammatory bowel disease or recurrent uveitis, use monoclonal antibody TNF inhibitors (infliximab, adalimumab, golimumab, certolizumab) rather than etanercept 1
• Alternatively, use IL-17 inhibitors (secukinumab or ixekizumab) if TNF inhibitors are contraindicated 1

Critical Contraindications:

• Never use systemic glucocorticoids for axial spondylitis, as they provide no proven benefit 1, 3
• Avoid spinal manipulation in patients with advanced spinal osteoporosis or spinal fusion due to fracture risk 1

If Transverse Myelitis (Spinal Cord Inflammation)

Rapid initiation of treatment is critical, as early therapy portends more favorable outcomes 2. The specific treatment depends on the suspected etiology (autoimmune vs. infectious vs. demyelinating) 2, 4.

Immediate Management:

• Rule out compressive myelopathy first, as this requires emergent surgical intervention and is clinically indistinguishable from transverse myelitis 2
• Obtain CSF studies and serological tests to differentiate autoimmune, inflammatory, and infectious etiologies 2, 4
• For autoimmune/idiopathic myelitis: High-dose intravenous methylprednisolone followed by plasma exchange if no response 2
• For infectious myelitis: Pathogen-specific antimicrobial therapy 2, 4

Common Pitfalls to Avoid

• Do not start antimicrobials before obtaining tissue diagnosis in suspected vertebral osteomyelitis, as this reduces culture yield 1
• Do not use routine follow-up MRI in patients responding well to treatment, as bone changes paradoxically worsen despite clinical improvement 1
• Do not interpret persistent pain alone as treatment failure, as many successfully treated patients report residual pain 1
• Do not use systemic glucocorticoids for axial inflammatory conditions, as they are ineffective and cause harm 1, 3
• Do not delay surgical consultation if neurologic deficits are present or worsening 1, 2