What important history should be obtained in a suspected case of spondylodiscitis in an adult patient with no significant medical history presenting with radiculopathy at the level C5-C7?

Critical Historical Elements in Suspected Spondylodiscitis

When evaluating a patient with suspected spondylodiscitis presenting with C5-C7 radiculopathy, you must systematically inquire about bacteremia risk factors, temporal symptom progression, and red flag features that indicate epidural extension or multilevel disease.

Essential Risk Factor Assessment

Bacteremia and Endocarditis History

• Bacteremia and endocarditis represent the most significant risk factors for spondylodiscitis, as hematogenous spread via septic emboli to vertebral endplate vasculature is the primary pathogenic mechanism in adults 1.
• Specifically ask about:
  • Recent or current endocarditis (documented or suspected) 1
  • Any recent episodes of documented bacteremia or sepsis 1
  • Intravenous drug use, which dramatically increases bacteremia risk 2
  • Recent invasive procedures or indwelling vascular catheters 2

Immunocompromised States

• Diabetes mellitus status, as this increases susceptibility to infection 3
• HIV status and CD4 count if known 3
• Current immunosuppressive medications (corticosteroids, biologics, chemotherapy) 2
• History of organ transplantation 2

Temporal Symptom Progression

Duration and Evolution

• Symptoms typically develop over 14-90 days before diagnosis, reflecting the insidious nature of the infection 1.
• Document the exact timeline of:
  • When back/neck pain first began 2
  • When radicular symptoms started and their progression pattern 4
  • Whether symptoms have been progressively worsening or fluctuating 5

Early vs. Late Presentation

• Patients presenting within 14 days of symptom onset require different diagnostic considerations, as early disease may lack radiographic changes despite active infection 3, 1.

Neurological Red Flags

Progressive Neurological Deficits

• Any motor weakness in the upper extremities must be documented, as this indicates potential spinal cord compression requiring urgent surgical evaluation 6, 7.
• Specifically assess for:
  • Progressive weakness in C5-C7 distribution (deltoid, biceps, triceps, wrist extensors) 4
  • Bowel or bladder dysfunction suggesting myelopathy 5
  • Gait disturbances or lower extremity symptoms suggesting cord compression 6

Pattern of Radiculopathy

• Determine if radiculopathy involves single or multiple contiguous levels, as multilevel radiculopathy suggests epidural extension or paravertebral abscess formation 7.
• Document whether symptoms are:
  • Confined to C5-C7 distribution only 7
  • Involving non-contiguous levels (suggesting multiple septic emboli) 7, 1

Infection Source and Recent Procedures

Direct Inoculation Risk

• Recent spinal procedures, injections, or surgery (within past 3-4 months) 3
• History of penetrating trauma to the spine 3
• Recent epidural anesthesia or spinal tap 5

Remote Infection Sources

• Recent or current infections elsewhere:
  • Urinary tract infections 2
  • Skin and soft tissue infections 2
  • Dental procedures or oral infections 2
  • Respiratory tract infections 2

Constitutional Symptoms

Fever Pattern

• Fever is a typical presenting feature but may be absent, particularly in immunocompromised patients or those with indolent organisms 1, 2.
• Document:
  • Presence, duration, and pattern of fever 2
  • Night sweats or chills 2
  • Unintentional weight loss 2

Tuberculosis Risk Assessment

TB-Specific History

• Tuberculous spondylodiscitis can present with radiculopathy and may be managed conservatively, but requires specific diagnostic and treatment approaches 4.
• Inquire about:
  • Country of origin or travel to TB-endemic areas 4
  • Known TB exposure or previous TB infection 4
  • HIV status (increases TB risk) 4
  • Previous positive TB skin test or interferon-gamma release assay 4

Pain Characteristics

Pain Quality and Severity

• Back or neck pain is the cardinal symptom, often described as severe, progressive, and unrelieved by rest 2, 8.
• Document:
  • Pain severity and whether it is worsening 5
  • Whether pain is worse at night (typical of infection) 2
  • Response to analgesics and anti-inflammatory medications 5
  • Mechanical vs. inflammatory pain pattern 5

Multilevel Disease Indicators

Non-Contiguous Symptoms

• Approximately 10% of cases present with non-contiguous multilevel infections from multiple septic emboli, requiring full spinal evaluation 6, 7, 1.
• Ask about:
  • Pain or neurological symptoms at distant spinal levels 7
  • Multiple areas of back pain separated by normal segments 7

Common Pitfalls to Avoid

• Do not dismiss the diagnosis in patients without fever, as constitutional symptoms may be absent, especially in the elderly or immunocompromised 2, 9.
• Do not assume single-level disease based on focal symptoms, as 20% have contiguous multilevel involvement and 10% have non-contiguous disease requiring full spine imaging 7, 1.
• Do not delay evaluation in patients with progressive neurological deficits, as epidural abscess with cord compression requires urgent surgical intervention 6, 7.
• Early in the disease course (within 14 days), radiographic changes may be absent despite active infection, so clinical suspicion based on history is paramount 3, 1.