Discitis

Background

• An infection in the intervertebral disc space but also occurs post surgically in approximately 1-2 percent of patients after spinal surgery.
• Infection of nucleus pulposus due to infection of vertebral body end-plate cartilage
• Risk Factors: peds (age < 8yo), post-op, immunocompromised

Clinical Features

• >90% p/w unremitting back or neck pain which awakens them at night
• Fever (60-70%)
• Neuro deficits (10-50%)
• ESR elevation (>90%)
• Leukocytosis (<50%)

Differential Diagnosis

Spinal infection

• Epidural Abscess (Spinal)
• Discitis
• Vertebral osteomyelitis

Lower Back Pain

• Spine related
  • Acute ligamentous injury
  • Acute muscle strain
  • Disk herniation (Sciatica)
  • Degenerative joint disease
  • Spondylolithesis
  • Epidural compression syndromes
    • Spinal cord compression (non-traumatic)
    • Cauda equina syndrome
    • Conus medullaris syndrome
    • Epidural abscess (spinal)
    • Epidural hematoma (spinal)
  • Thoracic and lumbar fractures and dislocations
  • Cancer metastasis
  • Spinal stenosis
  • Transverse myelitis
  • Vertebral osteomyelitis
  • Ankylosing spondylitis
  • Spondylolisthesis
  • Discitis
  • Spinal Infarct
• Renal disease
  • Kidney stone
  • Pyelonephritis
  • Nephrolithiasis
• Intra-abdominal
  • Abdominal aortic aneurysm
  • Ulcer perforation
  • Retrocecal appendicitis
  • Large bowel obstruction
  • Pancreatitis
• Pelvic disease
  • PID
• Other
  • Retroperitoneal hemorrhage/mass
  • Meningitis

Diagnosis

CT of an infected disc at the level of C5-C6 causing neurological symptoms

MRI of discitis in a 2 year old child.

• Labs
  • ESR elevated
• Imaging
  • Plain films are rarely positive
  • MRI is gold standard

Management

IV Antibiotics

• Treatment targets S. aureus, Streptococcus, Pseudomonas, E. coli

Inpatient Therapy

• Vancomycin 15-20 mg/kg IV BID PLUS any of the following:
  • Ceftriaxone 2g IV daily
  • Cefepime 2g IV IV three times daily
  • Ceftazidime 2g IV three times daily
  • Ciprofloxacin 400mg IV three times daily

Use cefepime or ciprofloxacin if targeting Pseudomonas spp

Disposition

• Admit to spine service