299 ORIGINAL ARTICLE/ARTIGO ORIGINAL/ARTÍCULO ORIGINAL DIAGNOSTIC DIFFICULTIES IN BACTERIAL SPONDYLODISCITIS DIFICULDADES DIAGNÓSTICAS NA ESPONDILODISCITE BACTERIANA DIFICULTADES DE DIAGNÓSTICO EN ESPONDILODISCITIS BACTERIANA VINICIUS ORSO¹, AFRANE SERDEIRA1, MARCUS ZIEGLER1, ERASMO ZARDO2 ABSTRACT Objective: To analyze aspects related to the diagnostic difficulty in patients with bacterial spondylodiscitis. Methods: Cross-sectional obser- vational study with retrospective data collected in the period from March 2004 to January 2014.Twenty-one patients diagnosed with bacterial spondylodiscitis were analyzed. Results: Women were the most affected, as well as older individuals. Pain in the affected region was the initial symptom in 52% of patients, and 45.5% of the patients had low back pain, and those with dorsal discitis had back pain as the main complaint; the patients with thoracolumbar discitis had pain in that region, and only one patient had sacroiliac discitis. The average time between onset of symptoms and treatment was five months. The lumbar segment was the most affected with 11 cases (52%), followed by thoracolumbar in 24%, dorsal in 19% of cases and a case in the sacroiliac segment. Only seven patients had fever. Pain in the affected level was coincidentally the most common symptom. Conclusions: Early diagnosis of bacterial spondylodiscitis remains a challenge due to the nonspecific signs and symptoms reported by the patient and the wide variability of laboratory results and imaging. The basis for early diagnosis remains the clinical suspicion at the time of initial treatment. Keywords: Discitis; Spine; Intervertebral disc; Infection. RESUMO Objetivo: Analisar os aspectos relacionados com as dificuldades diagnósticas de pacientes portadores de espondilodiscite bacteriana. Métodos: Estudo observacional transversal com coleta retrospectiva de dados no período de março de 2004 a janeiro de 2014. Foram analisados 21 pacientes com diagnóstico de espondilodiscite bacteriana. Resultados: O sexo feminino foi o mais acometido, assim como indivíduos mais velhos. A dor na região comprometida foi o sintoma inicial em 52% dos pacientes, sendo que 45,5% dos pacientes apre- sentavam lombalgia, os pacientes com discite dorsal tiveram como queixa principal dorsalgia, e os com discite toracolombar apresentaram dor nessa região, sendo que apenas um paciente apresentou discite sacroilíaca. O tempo médio entre o início dos sintomas e o tratamento foi de cinco meses. O segmento lombar foi o mais acometido com 11 casos (52%), seguido pelo toracolombar 24%, pelo dorsal com 19% dos casos e um caso no segmento sacroilíaco. Apenas sete pacientes apresentaram febre. A dor no nível comprometido foi, coinciden- temente, o sintoma mais comum. Conclusões: O diagnóstico precoce da espondilodiscite bacteriana continua sendo um desafio devido à inespecificidade de sinais e sintomas referidos pelo paciente e à grande variabilidade dos resultados laboratoriais e de imagem. A base para o diagnóstico precoce continua sendo a suspeita clínica no momento do atendimento inicial. Descritores: Discite; Coluna vertebral; Disco intervertebral; Infecção. RESUMEN Objetivo: Analizar los aspectos relacionados con las dificultades de diagnóstico en pacientes con espondilodiscitis bacteriana. Métodos: Estudio observacional transversal con datos retrospectivos recopilados en el período comprendido entre marzo de 2004 y enero de 2014. Se analizaron 21 pacientes diagnosticados de espondilodiscitis bacteriana. Resultados: Las mujeres fueron las más afectadas, así como las personas de mayor edad. Dolor en la región afectada fue el síntoma inicial en el 52% de los pacientes, el 45,5% de los pacientes tenían dolor lumbar, los pacientes con discitis dorsal tenían dolor dorsal como la principal queja y las con discitis toracolumbar tenían dolor en esa zona, y sólo un paciente tuvo discitis sacroilíaca. El tiempo promedio entre el inicio de los síntomas y el tratamiento fue de cinco meses. El segmento lumbar fue lo más afectado, con 11 casos (52%), seguido por el 24% toracolumbar, dorsal con 19% de los casos y un caso en el segmento sacroilíaco. Sólo siete pacientes tenían fiebre. El dolor en el nivel afectado fue, por coincidencia, el síntoma más común. Conclusiones: El diagnóstico temprano de espondilodiscitis bacteriana sigue siendo un desafío debido a los signos y síntomas inespecíficos reportados por el paciente y la amplia variabilidad de los resul- tados de laboratorio y de imágenes. La base para el diagnóstico precoz sigue siendo la sospecha clínica en el momento del tratamiento inicial. Descriptores: Discitis; Columna vertebral; Disco intervertebral; Infección. INTRODUCTION as infectious disease of the spine or spondylodiscitis.¹ Infectious pathology of the spinal column is a challenge for the physician, Infectious diseases of the spine are conditions with high morbid- ity and, if the diagnosis is delayed, they can have a high number and consequently for its treatment. This pathology involves diffuse, of complications. Infectious or septic discitis is an infection of the vague, oligosymptomatic pain, usually without fever or indications intervertebral disc, and its physiopathology often compromises the of infection, making diagnosis difficult and increasing the number contiguous vertebral bodies, causing osteomyelitis, also known of comorbidities and complications.1,2 1. Orthopedics and Traumatology Service – SOT da Pontifícia Universidade Católica do Rio Grande do Sul, RS, Brazil. 2. Orthopedics and Traumatology Discipline at the Pontifícia Universidade Católica do Rio Grande do Sul, PUCRS-HSL, Porto Alegre, RS, Brazil. This study was conducted at the Orthopedics and Traumatology Service – SOT of Pontifícia Universidade Católica do Rio Grande do Sul, RS, Brazil. Correspondence: Avenida Ipiranga 6690, sala 208, Centro Clínico PUC, Porto Alegre, RS, BRAZIL. 90619900. [email protected] http://dx.doi.org/10.1590/S1808-185120151404132593 Received on 12/17/2014, accepted on 08/01/2015. Coluna/Columna. 2015;14(4):299-303 300 In most cases, spondylodiscitis is diagnosed in advanced Statistical analysis 1-3 phases because of the nonspecifity of its signs and symptoms. The data were analyzed in SPSS version 18. The quantitative Paradoxically, complementary research with laboratory tests is of data were described by their averages and standard deviation and little value, with the exception of the Erythrocyte Sedimentation the qualitative data by their frequencies. The difference of age be- Rate (ESR) and C-Reactive Protein (CRP) tests that can signal the tween the sexes was analyzed by the ANOVA test. The difference presence of this infection. Among the imaging exams, magnetic in the evolution time of symptoms between the sexes was analyzed resonance imaging (MRI) is the most sensitive for early detection. using the Mann-Whitney test. The presence of a difference in dis- Radiographic studies and even computed tomography do not tribution of the affected level between the sexes was analyzed by usually reveal the diagnosis in the first weeks of evolution of this the Gamma test. disease. An accurate early diagnosis and the early start of treat- ment are decisive factors for a favorable outcome and for warding RESULTS off surgical intervention and sequelae.3,4 The incidence of infectious spondylodiscitis has been growing, We reviewed the medical files of 66 patients with spondylodiscitis which could be a reflection of the increasing elderly immunocom- of various etiologies. Twenty-one patients met the inclusion criteria, promised population and of the increase in invasive spinal pro- having been diagnosed with bacterial spondylodiscitis and with cedures. In the urogynecological region, the venous return of the complete documentation. pelvis and retroperitoneum, through the valveless Batson venous The characteristics of the group studied are described in Ta- plexus5 that communicates with the venous return of the spine, ble 1. The average evolution time of the symptoms until diagnosis favors the spread of germ. The greater accessibility to the spine of was five months, with no statistical difference noted for symptom MRI, which is the most sensitive diagnostic method for this type of evolution time between the sexes (p=0.75). The average patient disorder, also has contributed to the increase in diagnoses.6 The age was 48±25.3 years (average ± standard deviation), males at main pathogens involved are Staphylococcus aureus, identified in 52.8±27.9 years of age and females at 40±26 years of age, also more than 50% of the cases, and also the enteric Gram-negative with no statistical difference found between the sexes (p=0.295). enteric bacilli, Candida spp, Pseudomonas aeruginosa, Streptoco- The distribution of the population studied by sex was equal, with cus Groups B and C, and Mycobacterium tuberculosis, the latter 52% females and 48% males. with high prevalence in our environment.7 Regarding the level of the spine affected, the lumbar segment The objective of this study was to analyze the factors that com- was the most commonly involved (52% of the cases), followed by plicate the diagnosis of bacterial spondylodiscitis. the thoracolumbar (24%), the dorsal (19%), with only one patient (5%) with sacroiliac involvement. There was a statistical difference MATERIAL AND METHODS between the sexes for the level affected, with the women having a greater preponderance in the thoracolumbar segment and the A cross-sectional observational study was conducted using men in the dorsal