CASE HISTORY – July 2007

Nonspecific pyogenic spondylitis


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Pyogenic spinal infections are relatively rare with an incidence of 2.2 cases per 100 000 habitants per year. During the last twenty years there has been a fivehold increase in the incidence. This is due to the ageing of  the population as well as to an increased number of diabetics, drug users and patients with immunosupressive diseases or treatments. Spinal infections can be classified according to the  anatomical localisation: vertebral osteomyelitis, discitis – spondylodiscitis, spinal canal infections (epidural and subdural abscesses), adjacent soft tissue infections.
The infections are usually hematogenous but may also have an invasive (spinal procedure, operation, trauma) or a contiguous source. In two thirds of cases the infection is caused by gram–positive bacteria (staphylococcus aureus, streptococcus pneumonia). Staphylococcus aureus should always be taken into account when choosing empirical antibiotic treatment.
• Pain is the most frequent complaint, but neurological complications may also dominate the clinical picture. Due to the complexity of symptoms diagnostic delay is common.
• MRI is the diagnostic tool of choice. Early diagnosis and treatment are the most important prognostic factors. Adequate antibiotic medication must be based on accurate microbiological diagnosis. If blood cultures are negative an attempt should be made to obtain biopsy material from the affected vertebral and intervertebral disks.
Treatment of spondylitis is in most cases nonsurgical. Surgical indication includes spinal compression, vertebral instability and medically intractable pain. Antibacterial treatment is usually given for a period of 3-6 months. The key to successful management of spinal infection is the multidisciplinary approach involving specialists of infectious diseases, radiologist and neurosurgeon.