Spondylodiscitis is characterised by infection involving the intervertebral disc and adjacent vertebrae.
Spondylodiscitis has a bimodal age distribution, which many authors consider essentially as separate entities:
- older population ~50 years
The typical presentation is usually fever and back pain. Patients are often bacteraemic with sources such as endocarditis and intravenous drug use.
In the paediatric age group infection often starts in the intervertebral disc itself (direct blood supply still present) whereas in adults infection is thought to begin at the vertebral body endplate, extending into the intervertebral disc space and then into the adjacent vertebral body endplate.
- remote infection (present in ~25%)
- ascending infection, e.g. from urogenital tract instrumentation
- spinal instrumentation or trauma
- intravenous drug use
- long-term systemic administration of steroids
- advanced age
- diabetes mellitus
- organ transplantation
Elevated serum CRP and/or ESR.
- Staphylococcus aureus (most common; 60%)
- Streptococcus viridans (IVDU, immunocompromised)
- gram-negative organisms, e.g. Enterobacter spp, E. coli
- Mycobacterium tuberculosis (Pott's disease)
- less common agents
- Cryptococcus neoformans,
- candida species
- Histoplasma capsulatum
- Burkholderia pseudomallei (i.e. melioidosis): diabetic patients from northern Australia and parts of Southeast Asia
- Brucellae spp
- can occur anywhere in the vertebral column but more commonly involves lumbar spine
- single level involvement (65%)
- multiple contiguous levels (20%)
- multiple non-contiguous levels (10%)
Plain radiography is insensitive to the early changes of discitis/osteomyelitis, with normal appearances being maintained for up to 2-4 weeks. Thereafter disc space narrowing and irregularity or ill-definition of the vertebral endplates can be seen. In untreated cases, bony sclerosis may begin to appear in 10-12 weeks.
CT findings are similar to plain film, but more sensitive to earlier changes. Additionally surrounding soft tissue swelling, collections and even epidural abscesses may be evident.
MRI is the imaging modality of choice due to very high sensitivity and specificity. It is also useful in differentiating between pyogenic infection, tuberculous and fungal infections or a neoplastic process.
Signal characteristics include:
- low signal in disc space (fluid)
- low signal in adjacent endplates (bone marrow oedema)
T2: (fat sat or STIR especially useful)
- high signal in disc space (fluid)
- high signal in adjacent endplates (bone marrow oedema)
- loss of low signal cortex at endplates
- high signal in paravertebral soft tissues
T1 C+ (Gd)
- peripheral enhancement around fluid collection(s)
- enhancement of vertebral endplates
- enhancement of perivertebral soft tissues
- enhancement around low-density center indicates abscess formation (hard to distinguish inflammatory phlegmon from abscess without contrast)
- hyperintense in acute stage
- hypointense in chronic stage
DWI sequence can help to distinguish acute from chronic stage of the disease 7.
A bone scan and white cell scan (WBC) may be used to demonstrate increased uptake at the site of infection, and are more sensitive than plain film and CT, however lacks specificity. Not infrequently, WBC scan demonstrates cold spots, a nonspecific finding. The classic appearance on multiphase bone scans is increased blood flow and pool activity and associated increased uptake on the standard delayed static images 15. 67Ga-citrate has been used with some success, but is hampered by higher dosimetry and inferior imaging characteristics (high effective dose, long half-life time, poor spatial resolution) 14-15.
PET and PET/CT
18F-FDG PET has been demonstrated to possess high sensitivity in detecting spondylodiscitis. As such infectious spondylodiscitis can virtually be excluded in a negative scan. Dual imaging with PET/CT may thus become the imaging modality of choice, especially in patients with prior surgery and/or implants, where MR is contraindicated or hampered by artefact 8-11. Specificity is not as high 10,16, but monitoring of treatment results is possible 9.
Non-FDG PET/CT with 68Ga-citrate (an emerging, generator-based tracer) has shown promising results in pilot studies/small series 12-13.
Possible imaging differential considerations include:
- 1. Dagirmanjian A, Schils J, Mchenry M et-al. MR imaging of vertebral osteomyelitis revisited. AJR Am J Roentgenol. 1996;167 (6): 1539-43. AJR Am J Roentgenol (abstract) - Pubmed citation
- 2. Dunbar JA, Sandoe JA, Rao AS et-al. The MRI appearances of early vertebral osteomyelitis and discitis. Clin Radiol. 2010;65 (12): 974-81. doi:10.1016/j.crad.2010.03.015 - Pubmed citation
- 3. Falade OO, Antonarakis ES, Kaul DR et-al. Clinical problem-solving. Beware of first impressions. N. Engl. J. Med. 2008;359 (6): 628-34. doi:10.1056/NEJMcps0708803 - Pubmed citation
- 4. Ledermann HP, Schweitzer ME, Morrison WB et-al. MR imaging findings in spinal infections: rules or myths? Radiology. 2003;228 (2): 506-14. doi:10.1148/radiol.2282020752 - Pubmed citation
- 5. Ritchie DA. Commentary on the MRI appearances of early osteomyelitis and discitis. Clin Radiol. 2010;65 (12): 982-3. doi:10.1016/j.crad.2010.04.022 - Pubmed citation
- 6. Stäbler A, Reiser MF. Imaging of spinal infection. Radiol. Clin. North Am. 2001;39 (1): 115-35. - Pubmed citation
- 7. Oztekin O, Calli C, Adibelli Z et-al. Brucellar spondylodiscitis: magnetic resonance imaging features with conventional sequences and diffusion-weighted imaging. Radiol Med. 2010;115 (5): 794-803. doi:10.1007/s11547-010-0530-3 - Pubmed citation
- 8. Prodromou ML, Ziakas PD, Poulou LS et-al. FDG PET is a robust tool for the diagnosis of spondylodiscitis: a meta-analysis of diagnostic data. Clin Nucl Med. 2014;39 (4): 330-5. doi:10.1097/RLU.0000000000000336 - Pubmed citation
- 9. Glaudemans AW, de Vries EF, Galli F et-al. The use of (18)F-FDG-PET/CT for diagnosis and treatment monitoring of inflammatory and infectious diseases. Clin. Dev. Immunol. 2013;2013: 623036. doi:10.1155/2013/623036 - Free text at pubmed - Pubmed citation
- 10. Hungenbach S, Delank KS, Dietlein M et-al. 18F-fluorodeoxyglucose uptake pattern in patients with suspected spondylodiscitis. Nucl Med Commun. 2013;34 (11): 1068-74. doi:10.1097/MNM.0b013e328365abec - Pubmed citation
- 11. Gemmel F, Rijk PC, Collins JM et-al. Expanding role of 18F-fluoro-D-deoxyglucose PET and PET/CT in spinal infections. Eur Spine J. 2010;19 (4): 540-51. doi:10.1007/s00586-009-1251-y - Free text at pubmed - Pubmed citation
- 12. Nanni C, Errani C, Boriani L et-al. 68Ga-citrate PET/CT for evaluating patients with infections of the bone: preliminary results. J. Nucl. Med. 2010;51 (12): 1932-6. doi:10.2967/jnumed.110.080184 - Pubmed citation
- 13. Osmany, S, Zaheer, S, Thian, Y, Tan, A, Tan, B, Padhy, A, PET/CT Imaging of Osteomyelitis in Humans Using the Novel PET Tracer Gallium-68 Citrate: Results of a Pilot Project. Radiological Society of North America 2010 Scientific Assembly and Annual Meeting, November 28 - December 3, 2010 ,Chicago IL. http://archive.rsna.org/2010/9006643.html Accessed November 28, 2014
- 14. Hadjipavlou AG, Cesani-Vazquez F, Villaneuva-Meyer J et-al. The effectiveness of gallium citrate Ga 67 radionuclide imaging in vertebral osteomyelitis revisited. Am J. Orthop. 1998;27 (3): 179-83. Pubmed citation
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