European Review for Medical and Pharmacological Sciences 2005; 9: 53-66 Clinical features, diagnostic and therapeutic approaches to haematogenous vertebral osteomyelitis AL. GASBARRINI, E. BERTOLDI, M. MAZZETTI*, L. FINI***, S. TERZI, F. GONELLA, L. MIRABILE, G. BARBANTI BRÒDANO, A. FURNO**, A. GASBARRINI***, S. BORIANI* Department of Orthopaedics and Traumatology, Maggiore Hospital “C.A. Pizzardi” - Bologna (Italy) *Department of infections disease, Maggiore Hospital “C.A. Pizzardi” - Bologna (Italy) **Nuclear Medicine, Maggiore Hospital “C.A. Pizzardi” - Bologna (Italy) ***Internal Medicine, Catholic University - Rome (Italy) Abstract. – This article review the clinical Chronic ostemyelitis may require surgery in features and the diagnostic approach to case of a development of biomechanical insta- haematogenous vertebral osteomyelitis in order bility and/or a vertebral collapse with progres- to optimise treatment strategies and follow-up sive deformity. assessment. Haematogenous spread is consid- ered to be the most important route: the lumbar spine is the most common site of involvement Key words: for pyogenic infection and the thoracic spine for Vertebral osteomyelitis, Spondylodiscitis, Pyogenic os- tuberculosis infection. The risk factors for devel- teomyelitis, Skeletal tuberculosis. oping haematogenous vertebral osteomyelitis are different among old people, adults and chil- dren: the literature reports that the incidence seems to be increasing in older patients. The Introduction source of infection in the elderly has been relat- ed to the use of intravenous access devices and Haematogenous vertebral osteomyelitis the asymptomatic urinary infections. In young (HVO) is a relatively rare disorder which ac- patients the increase has been correlated with counts for 2-4% of all cases of infectious bone the growing number of intravenous drug 1 abusers, with endocarditis and with immigrants disease . In recent years, the incidence of spinal from areas where tuberculosis is still endemic. infections has seemed to increase according to The onset of symptoms is typically insidious the growing number of intravenous drug users with neck or back pain often underestimated by in young people and in the elderly with the use the patient. Fever is present in 10-45% of pa- of intravenous access devices, genitourinary tients. Spinal infections may cause severe neu- surgery and manipulation. Males are more fre- rological compromise in few cases, but mild neurological deficit, limited to one or two nerve quently affected than females with an average roots, was detected in 28-35% of patients. The age of onset in the fifth and sixth decade. The diagnosis of haematogenous vertebral os- onset of symptoms is typically insidious with teomyelitis may be very difficult, as the symp- neck or back pain often underestimated by the toms can be sometimes not specific, vague or patient. The early diagnosis is also difficult due almost absent. The usual delay in diagnosis has to the non-specific nature of laboratory and ra- been reported to be two to four months, despite diographic findings. The frequent observation the use of imaging techniques: in the early diag- nosis of vertebral ostemyelitis is important the of back pain also makes the diagnosis a chal- role of bone scintigraphy. The general principles lenge in most cases. Several studies in the liter- for the management of spine infections are non ature report an average delay in the diagnosis operative, consisting of external immobilization of haematogenous vertebral osteomyelitis from and intravenous antibiotics, followed by oral an- 2 to 6 months after the beginning of the symp- tibiotics. Indications for surgery should be given toms2,3,4. In this article we review the clinical in case of absence of clinical improvement after 2-3 weeks of intravenous antibiotics, persistent features and the diagnostic approach to back pain and systemic effects of chronic infec- haematogenous vertebral osteomyelitis in or- tion and with presence or progression of neuro- der to optimise treatment strategies and fol- logical deficit in elderly or in cervical infection. low-up assessment. 53 Al. Gasbarrini, E. Bertoldi, M. Mazzetti, L. Fini, S. Terzi, F. Gonella, L. Mirabile, et al Etiopathogenesis ple level involvement in pyogenic infection in 5 to 18% of patients7,11-13. Spinal infections may affect the vertebral The commonest cause of osteomyelitis is body, the intervertebral disc, the neural arch Staphilococcus Aureus. In adults enteric or the posterior elements but most commonly Gram negative organism are second cause, they involve the anterior and middle while H. Influenzae is more frequent in columns1. The infection can involve and cross young infants14 and Group B Streptococci in cortical bone and longitudinal ligaments, neonates15. In a retrospective analysis16 in a leading to soft tissue abscesses. Epidural ab- population of 72 patients, the organism more scesses may arise adjacent to the area of os- frequently isolated were Staphilococcus Au- teomyelitis or, less commonly, occur de novo. reus and Epidermidis, Brucella Melitensis, E. Haematogenous spread by means of the Coli, Mycobacterium Tuberculosis. Strepto- arterial system is considered to be the most coccus pneumoniae, S. agalactiae, S. viridans, important route, because the vertebral body S. faecalis, Proteus mirabilis, Pseudomonas is richly supplied by an arterial network, es- Aeruginosa, Candida Glabrata were uncom- pecially in the anterior subchondral region mon. Hidatidosis, actinomicosis, aspergillosis near the anterior longitudinal ligament5. Disc and fungal infections rarely cause os- space infections that occurs in adults are usu- teomyelitis, while only one case of ally associated with prior surgical disruption Haemophilus paraphrophilus15 and Pastourel- of the disc, while the most common site of de la dogmatis17 vertebral osteomyelitis have novo infection in children is within the disc. been reported. Serratia marcenscens and Indeed, histological analyses have confirmed Pseudomonas Aeruginosa can be responsible that an endarteriolar supply to the disc is pre- of osteomyelitis in intravenous drug sent until childhood but is then slowly oblit- abusers18. erated in the first three decades of life. Thus, The risk factors for developing HVO are adult intervertebral disc is usually not primar- different among old people, adults and chil- ily involved, since it is avascular1. dren18. The literature reports that the inci- As a result of haematogenous spread, mul- dence of HVO seems to be increasing in old- tiple foci of infection can occur. A complex er patients. This may be related to the greater valveless venous drainage, known as Batson’s longevity of the general population as well as paravertebral venous plexus, may also act as to the more intensive treatment of serious ill- a potential route of infection, particularly for nesses and the use of chemotherapy to treat spread from the pelvic organs especially in in- cancer and immunological disorders. stances of sepsis originating in the urinary Carrage7 reviewed 111 patients: sixty-one bladder, bowel and female pelvic organs5. (55%) were sixty years old or more and forty- The lumbar spine is the most common site four patients (40%) had an impaired immune of involvement for pyogenic infection fol- system. In a multicenter study, which includ- lowed by the thoracic, cervical and sacral re- ed 219 adult patients, Colmenero et al.19 re- gions1,5-7. The thoracic spine is the most com- ported similar figures concerning age and as- monly affected site in tuberculosis infection8, sociated disease. which may be explained by the frequent in- The source of infection in the elderly has volvement of mediastinal lymphnodes and been related to the use of intravenous access pleura in pulmonary tuberculosis, from where devices, with resultant nosocomial bacter- microorganism can reach the vertebral bone aemia20. Others source were respiratory or through the limphatic route8. oral infection, skin ulceration, genitourinary Matsui et al.9 noted that the degree of de- surgery, placement of indwelling bladder struction may depend on the patients’s bio- catheters or ureteral stents, or both. Typical- logical reaction relating to their physical con- ly, HVO caused by Gram-negative dition or age. Buchelt et al.10, instead, sug- pathogens (mainly Escherichia coli and Pro- gested that it was influenced by the species of teus Mirabilis) derive from the urinary tract pathogen, reporting that more than two seg- and it should be considered when elderly pa- ments were involved in 23% of patients with tients complain of back pain. In fact, asymp- tuberculous and 9% of patients with pyogenic tomatic urinary infections are very common infection. Others studies have reported multi- in old people21 due to urinary incontinence, 54 Haematogenous vertebral osteomyelitis use of catheters, comorbid illness such as di- or incomplete paraplegia5,7. Neurological abetes or neoplasms, vaginal bacterial colo- deficit (in particular, paralysis) are frequent- nization in postmenopausal period16. Renal ly associated with epidural abscesses. Hadji- insufficiency, chronic hepatic disease, alco- pavlou et al6 reported 33 cases of epidural holism, recent surgery, haemodialisis are abscesses as a complication of spondy- other recognised risk factor in the elderly. lodiscitis in study of 101 cases of pyogenic Recent studies demonstrated a relationship spinal infection. Out of this group of pa- between surgical procedure, ageing and im- tients 15