DÄ internationalArchive51-52/2017Spondylodiscitis: Diagnosis and Treatment Options

Original article

Spondylodiscitis: Diagnosis and Treatment Options

A Systematic Review

Dtsch Arztebl Int 2017; 114(51-52): 875-82; DOI: 10.3238/arztebl.2017.0875

Herren, C; Jung, N; Pishnamaz, M; Breuninger, M; Siewe, J; Sobottke, R

Background: A recent population-based study from Denmark showed that the incidence of spondylodiscitis rose from 2.2 to 5.8 per 100 000 persons per year over the period 1995–2008; the age-standardized incidence in Germany has been estimated at 30 per 250 000 per year on the basis of data from the Federal Statistical Office (2015). The early diagnosis and treatment of this condition are essential to give the patient the best chance of a good outcome, but these are often delayed because it tends to present with nonspecific manifestations, and fever is often absent.

Methods: This article is based on a systematic search of Medline and the Cochrane Library for the period January 2009 to March 2017. Of the 788 articles identified, 30 publications were considered.

Results: The goals of treatment for spondylodiscitis are to eliminate infection, restore functionality of the spine, and relieve pain. Magnetic resonance imaging (MRI) remains the gold standard for the radiological demonstration of this condition, with 92% sensitivity and 96% specificity. It also enables visualization of the spatial extent of the infection and of abscess formation (if present). The most common bacterial cause of spondylodiscitis in Europe is Staphylococcus aureus, but tuberculous spondylodiscitis is the most common type worldwide. Antibiotic therapy is a pillar of treatment for spondylodiscitis and should be a part of the treatment in all cases. Neurologic deficits, sepsis, an intraspinal empyema, the failure of conservative treatment, and spinal instability are all indications for surgical treatment.

Conclusion: The quality of life of patients who have been appropriately treated for spondylodiscitis has been found to be highly satisfactory in general, although back pain often persists. The risk of recurrence increases in the presence of accompanying illnesses such as diabetes mellitus, renal failure, or undrained epidural abscesses.

LNSLNS

Although vertebral osteomyelitis is rare at a rate of 3%–5%, it is the third most common form of osteomyelitis (e1) at >50 years of age. Spondylodiscitis is characterized by marked heterogeneity, which limits its scientific evaluation and recommendations on its treatment. Differential diagnoses include polymyalgia rheumatica, activated osteochondrosis, vertebral hemangioma, destruction of the spinal column by tumors, fractures, and ankylosing spondyloarthritis.

Propagation and spectrum of pathogens: Three infection pathways are described from a pathogenetic perspective: endogenous, exogenous, and per continuitatem. The hematogenic form is the most common and can be differentiated on the basis of its arterial or venous etiology. Spondylodiscitis is usually a monobacterial infection and more than 50% of cases in Europe are caused by Staphylococcus aureus, followed by gram-negative pathogens such as Escherichia coli (11%–25%) (1, e2, e3). The most common pathogen worldwide is Mycobacterium tuberculosis. Brucellosis should be included in pathogen identification in patients from Mediterranean countries and the Middle East (e4).

Incidence and risk factors: Although the literature reports a low incidence of approximately 5–6/100 000 patient years, data from the German Federal Statistical Office (2015) are clearly higher at an age-standardized rate of approximately 30/250 000 (2, e2). Due to improved diagnostic methods, a growing incidence of cases has been seen (2, e5). Moreover, the rate of surgical procedures in older, polymorbid patients is rising—patients aged over 65 years are affected up to 3.5 times more frequently, while women are affected 0.82 times less frequently (2). Other risk factors include diabetes mellitus, immunosuppression, a history of infections, i.v. drug abuse, and HIV (3).

Diagnosis is based not only on radiological findings, but also on clinical, laboratory, and microbiological findings. It is not uncommon for this to cause a delay of 2–12 weeks between diagnosis and treatment initiation (4). The prognosis of spondylodiscitis without accompanying neurological deficits is good if antibiotic therapy and surgical management, if necessary, are initiated promptly (5). Nevertheless, the overall mortality rate in the case of inadequate treatment is given as up to 20% in the literature (6, 7).

Methods

Based on the article Aktuelle Diagnostik und Therapie der Spondylodiszitis (Current Diagnosis and Therapy of Spondylodiscitis) published by Sobottke et al. in 2008 (3), a systematic review of the English literature (Medline, Cochrane Library; 2009–2017) was performed using the following search terms: “vertebral osteomyelitis,” “spinal infection,” “discitis,” “spondylodiscitis,” “pyogenic osteomyelitis,” AND “spine,” “diagnosis,” and “therapy.”

Titles and abstracts were reviewed and included on the basis of diagnostic/therapeutic recommendations. Case reports and all articles containing the term “ankylosing spondylitis” were excluded. Of the 788 articles identified, 30 publications were considered (Figure 1) and summarized in two overview tables according to the Oxford evidence grading system (Table 1 and eTable) (e6).

Flowchart showing the publications included
Flowchart showing the publications included
Figure 1
Flowchart showing the publications included
Treatment of spondylodiscitis: overview of study outcomes
Treatment of spondylodiscitis: overview of study outcomes
Table 1
Treatment of spondylodiscitis: overview of study outcomes
Treatment of spondylodiscitis: overview of the literature on diagnostic methods
Treatment of spondylodiscitis: overview of the literature on diagnostic methods
eTable
Treatment of spondylodiscitis: overview of the literature on diagnostic methods

Results

Patient history and symptoms

There is a direct association between the occurrence of post-invasive spondylodiscitis and prolonged surgical time and dorsal instrumentation (e5, e10e12). According to Sobottke et al., spondylodiscitis occurs in 22.2% of conservatively treated and 50.4% of invasively treated (e.g., catheterization, fine-needle aspiration) patients. Other aspects to be considered are summarized in Table 2.

Important aspects of patient history and clinical examination
Important aspects of patient history and clinical examination
Table 2
Important aspects of patient history and clinical examination

Laboratory and microbiological tests

Blood testing includes leukocyte and C-reactive protein (CRP) counts. Although blood sedimentation rate (BSG) is often cited as an easy parameter to determine, it is non-specific (e13, e14). However, response to antibiotic therapy can be effectively followed-up using CRP/BSG (10). An acute disease course is characterized by increased inflammatory markers (75%–98%), whereas these can be virtually normal in the chronic course. Leukocytosis is not necessarily present, whereas increased CRP is seen in 90%–98% of cases (4, e15). Jean et al. showed that an increased CRP can shorten the time to diagnosis compared with other laboratory parameters (9). The procalcitonin (PCT) level plays a minor role as a parameter of sepsis in the primary diagnosis of spondylodiscitis, is more cost-intensive than CRP determination, and is not suitable as a follow-up parameter (11).

In addition, at least two blood culture pairs (aerobic/anaerobic) are obtained. The pathogen can be identified in 25%–59% of blood cultures (4), whereas a pathogen detection rate of as much as 70% is described in patients not previously treated with antibiotics (e12). Since a focus of infection, such as in the case of bacterial endocarditis, requires targeted therapy, the search for the focus is an important part of the diagnostic work-up. In addition, the primary source of infection can be found in approximately 50% of infections.

Material can be obtained for further histopathological investigation by means of computed tomography (CT)–guided fine-needle biopsy or removed surgically. The presence of granulomas can point to specific pathogens. Pathogen detection is 19%–30% when using CT-guided fine-needle biopsy due to the small amount of tissue available, whereas detection can be achieved in 41% using histopathological methods (13, e16). More recent literature shows that pathogen detection can be improved using a combined magnetic resonance imaging (MRI)/CT investigation involving superimposition of the respective image data prior to fine-needle biopsy (14, 15). According to Kim et al., the pathogen detection rate is 2.28 times higher following soft tissue investigation compared with bone tissue (16), whereas in their retrospective analysis (126 tissue biopsies), Chang et al. demonstrated that there is an approximately significant difference in specificity/sensitivity in relation to the type of biopsy tissue (sensitivity/specificity end plate vs. paravertebral soft tissue: 38%/86% vs. 68%/92%, p = 0.09; disc vs. endplate: 57%/89% vs. 38%/86%; p = 0.05) (16, 17).

The most reliable method remains surgical biopsy (e12, e17), with a pathogen detection rate of up to 68%–93%. Molecular biological investigations (polymerase chain reaction [PCR]) can be used to further identify the pathogen in the case of negative cultures after 48-h incubation, especially in patients pre-treated with antibiotics. Species-specific PCR (e.g., for S. aureus and M. tuberculosis) can further increase sensitivity (12, e1). Using species-specific PCR, Choi et al. were able to detect 46,7% of spondylodiscitis cases overall, whereas only 26,7% could be detected using conventional PCR (12). This was also demonstrated in a retrospective study in which 275 of 427 diagnoses (62.9%) could only be made using species-specific rather than conventional PCR (e18). In contrast to culture results with additional antimicrobial resistance testing, however, PCR does not provide any information on pathogen sensitivity to antibiotics.

Diagnostic imaging

Conventional radiological imaging of the relevant spinal segment is the first-line imaging investigation in patients with unclear spinal symptoms; sensitivity and specificity are low at 82% and 57%, respectively (e19). Erosion of the base and upper plates or increasingly destructive kyphosis can manifest after days or weeks depending on the virulence of the pathogen, the patient’s immune status, or the clinical course of the disease (33, e7). Therefore, a negative native X-ray does not exclude spondylodiscitis, but is nevertheless important to evaluate disease progression.

CT is often used as an alternative in the case of contraindications to MRI (non–MRI-compatible pacemakers, other patient-specific factors). Paravertebral abscesses can be better diagnosed with contrast-enhanced CT; moreover, CT simplifies fine-needle biopsy or abscess drain placement (e20e22). CT is also useful in the preoperative planning of spinal procedures and, depending on the system used, is a prerequisite to computer-assisted spine surgery (e23).

MRI is the gold standard in imaging studies to detect spondylodiscitis, whereby adding a contrast agent also enables a distinction to be made between findings suspicious for spondylodiscitis, degeneration (Modic type I), or neoplasia (e8, e24). Specificity and sensitivity are extremely high at 96% and 92%, respectively (33, e8, e25). Gadolinium-enhanced MRI can increase sensitivity to as much as 95.4% (e26). Table 3 summarizes radiological signs.

Radiological changes on MRI (e26)
Radiological changes on MRI (e26)
Table 3
Radiological changes on MRI (e26)

Fluorine-18 fluorodeoxyglucose positron emission tomography/CT (18F-FDG-PET-CT) is a procedure well known in oncology and infectious diseases and appears to be playing an increasingly important role in the diagnosis of spondylodiscitis (18, 19, 34). PET-CT represents a good alternative particularly in the case of contraindications to contrast-enhanced MRI/CT (e.g., kidney failure). However, on the whole, it remains an expensive procedure that is only available in specialized centers. Physiologically, the correspondingly labeled glucose does not accumulate in the bone marrow and spine, such that inflammatory processes with increased glucose activity appear as “hot spots” on PET-CT. Ioannou et al. and Skanjeti et al. consider MRI to be equivalent to PET-CT with minor advantages for PET-CT in the first 2 weeks following disease onset (35, 36). Recent studies have shown that PET-CT has clear advantages in the differentiation between degenerative (Modic type I) and inflammatory changes (19, 20, 37, e27) compared with MRI. However, PET-CT’s lack of specificity to differentiate between neoplasia, spondylodiscitis, and post-traumatic bone marrow edema represents a drawback (e28, e29). Thus, its combination with MRI is recommended. On the other hand, PET-CT offers the advantage that it can be performed in all patients irrespective of metal implants and non–MRI-compatible pacemakers.

Multiphase bone scintigraphy can be performed with 99technetium (TM)-labeled leukocytes in combination with 67gallium (Ga) citrate, thereby increasing sensitivity to 86%. To this end, radioactively labeled antigranulocyte antibodies, which accumulate in the case of an inflammatory reaction, are used. However, specificity is low, since remodeling processes such as osteochondrosis (e30) are also visualized. The advantage of this technique is its potential to detect further sources of infection. Figure 2 shows the three-step diagnostic algorithm for the detection of spondylodiscitis.

Three-step diagnostic algorithm to detect spondylodiscitis PCR, polymerase chain reaction; PET, positron emission tomography
Three-step diagnostic algorithm to detect spondylodiscitis PCR, polymerase chain reaction; PET, positron emission tomography
Figure 2
Three-step diagnostic algorithm to detect spondylodiscitis PCR, polymerase chain reaction; PET, positron emission tomography

Treatment

Spondylodiscitis is highly heterogeneous in terms of severity, which depends, e.g., on patients’ health condition and pathogen spectrum. The formulation of a standard treatment consensus is hampered by the varying study results (level I–IV) and expert opinions (level V). Therefore, Pola et al. proposed a treatment algorithm on the basis of a retrospective analysis in which clinical radiological findings were taken into account (30).

In this context, it is important to mention the risk of bias. With the exception of the recommendations on antibiotic therapy, the studies presented in the present review differ greatly in terms of evidence level and should primarily be considered level III/IV studies. Given that it is impossible to establish uniformity in terms of the statistics used, the follow-up period, or the number of patients investigated, there is also a publication bias.

The aim of spondylodiscitis treatment is to eliminate the focus of infection, restore spinal functionality, and reduce pain. Microbiological pathogen detection forms the basis for the initiation of specific antibiotic therapy. There is consensus that empirical antibiotic therapy should only be initiated once the pathogen has been identified (38, e31). No consensus has been reached as yet on the period of targeted antibiotic therapy; there are a number of retrospective studies and the recommendations equate to an expert opinion; the study by Bernard et al. was the first randomized study to be published on the duration of treatment. Based on an analysis of 359 patients, it was shown that a 6-week course is not inferior to a 12-week course of treatment in terms of cure rate at 1 year (90.9% of the patients in each group; group difference: 0.05%; 95% confidence interval (CI): [–6.2;6.3]) (21). It was not possible to establish which subgroups might have required longer therapy. However, there was evidence that advanced age (≥ 75 years) and S. aureus are risk factors for the failure of antibiotic therapy. Another retrospective study (n = 314) identified risk factors for recurrence, classified patients into high-risk and low-risk groups, and correlated treatment success with treatment duration (39). The mean time to relapse was given as 5 weeks (1.5 weeks−30 months), and infections with methicillin-resistant S. aureus (MRSA), undrained paravertebral and psoas abscesses, as well as severe kidney failure were identified as independent risk factors.

The guidelines of the Infectious Diseases Society of America (IDSA) deem 6-week therapy to be adequate in most patients with non-specific spondylodiscitis (38). It remains unclear at what point oral administration is possible. In the above-mentioned study by Bernard et al., treatment was administered intravenously for a short period of time [median 14 days (interquartile range 7–27)]. The IDSA guidelines propose oral therapy in the case of good oral bioavailability as a possible alternative to i.v. therapy. Quinolones, clindamycin, and cotrimoxazole are suitable for this purpose, whereby β-lactams have poor bioavailability. The OVIVA (oral versus intravenous antibiotics for bone and joint infections) study is currently investigating the possibility of oral administration in bone infections, including spondylodiscitis; the results of this study are still pending. In the case of culture-negative spondylodiscitis, antibiotics that cover the most common pathogens (especially S. aureus, streptococci, and E. coli) should be administered (6). When deciding on antibiotics and oral administration, one also needs to take bioavailability and bone penetration into consideration in the course of treatment. Table 4 summarizes further recommendations for targeted therapy.

Recommendations on antibiotic treatment (according to IDSA guidelines [38])
Recommendations on antibiotic treatment (according to IDSA guidelines [38])
Table 4
Recommendations on antibiotic treatment (according to IDSA guidelines [38])

In addition to antibiotic therapy, conservative treatment comprises an analgesic component as well as relief of the affected spinal segment by means of, e.g., reclining orthosis. The former practice of long-term bed rest is now obsolete (e32). A conservative approach is justified if symptoms and spread of infection are mild. In their retrospective analysis of 45 geriatric patients with neurological symptoms, Yashiomoto et al. showed that neurological symptoms decreased within a minimum follow-up period of 10 months in 72,7% (8 of 11 patients) under antibiotic therapy alone (22). De Graeff et al. pointed out that the risk of treatment failure is increased in the presence of concomitant epidural abscess, further osteomyelitis, or diabetes (23). Therefore, inflammatory parameters and clinical findings should be checked at least once a week in order to promptly identify treatment response or failure (38). One can assume treatment failure if symptoms remain unchanged or worsened after a period of 4 weeks. Repeat MRI is only useful if there is no clinical improvement or if conventional radiological imaging shows signs of deterioration (e25).

In the case of spondylodiscitis with psoas abscesses, percutaneous abscess drainage is an adjunct to conservative treatment, since drainage placement relieves the focus of infection. Success rates of up to 87.5% are described for ultrasound-guided percutaneous drainage placement or CT-guided drainage placement (25, 26).

In addition to the elimination of infection, the primary aim of surgical therapy is segmental stabilization (Box).

Criteria for surgical treatment*
Criteria for surgical treatment*
Box
Criteria for surgical treatment*

There are recommendations on anterior, posterior, or combination procedures (24, 33, e7). Si et al. showed that a single anterior procedure results in a better outcome at 2 years (Oswestry Disability Index [ODI]: 25 versus 29), whereas, according Nasto et al., minimally invasive transpedicular stabilization combined with debridement leads to faster recovery (32, 40). Vcelak et al. showed that a single posterior procedure causes a significant loss of sagittal balance (preoperative 1.75) over 6 weeks (−3.73) and 12 months (−0.79), but that this has no effect on outcome compared with an anteroposterior procedure (27). Minimally invasive procedures, such as the retroperitoneal transpsoas approach (XLIF), permit removal of the site of infection, good restoration of the lumbar lordosis (from 23.1° preoperatively to 34.0° postoperatively), and additional percutaneous posterior instrumentation (31). There is also no common consensus on the timing of the treatment plan (single-/two-stage).

Conclusion

Ascione et al. showed that conservative treatment leads to good results after 2.5 years in terms of quality of life parameters (ODI: 26, SF-36 Health Questionnaire: 40.6) (28). MRSA-positive spondylodiscitis and delayed diagnosis can worsen the outcome. Gupta et al. showed that surgical treatment often fails within the first 6 months, whereas the failure rate at 2 years is similarly high to that at 5 and 10 years (5). Rossbach et al. demonstrated that the prognosis of neurological deficits, independent of the surgical approach used, is improved by 1 or 2 Frankel scores (measurement of spinal cord function) if decompression of the causal epidural abscess is achieved (29). On the whole, back pain often persists irrespective of the selected treatment approach.

Conflict of interest statement

Dr. Jung received lecture fees and travel expenses from Novartis and Gilead, as well as lecture fees from Labor Stein GmbH and travel expenses from Basilea. She received fees for carrying out a clinical study commissioned by InfectoPharm Arzneimittel.

The remaining authors state that they have no conflict of interests.

Manuscript received on 19 May 2017, revised version accepted on
16 October 2017

Translated from the original German by Christine Schaefer-Tsorpatzidis

Corresponding author
Dr. med. Christian Herren
Klinik für Unfall- und Wiederherstellungschirurgie
Uniklinik RWTH Aachen
Pauwelsstr. 30
52074 Aachen, Germany
cherren@ukaachen.de

Supplementary material
For eReferences please refer to:
www.aerzteblatt-international.de/ref5117

eTable:
www.aerzteblatt-international.de/17m0875

1.
Doutchi M, Seng P, Menard A, et al.: Changing trends in the epidemiology of vertebral osteomyelitis in Marseille, France. New Microbes New Infect 2015; 7: 1–7 CrossRef MEDLINE PubMed Central
2.
Statistisches Bundesamt: Diagnosedaten der Krankenhäuser ab 2000 (Eckdaten der vollstationären Patienten und Patientinnen). Gliederungsmerkmale: Jahre, Behandlungs-/Wohnort, ICD10. Statistisches Bundesamt 2017.
3.
Sobottke R, Seifert H, Fätkenheuer G, Schmidt M, Goßmann A, Eysel P: Current diagnosis and treatment of spondylodiscitis. Dtsch Arztebl Int 2008; 105: 181–7 VOLLTEXT
4.
Cheung WY, Luk KDK: Pyogenic spondylitis. Int Orthop 2012; 36: 397–404 CrossRef MEDLINE PubMed Central
5.
Gupta A, Kowalski TJ, Osmon DR, et al.: Long-term outcome of pyogenic vertebral osteomyelitis: a cohort study of 260 patients. Open Forum Infect Dis 2014; 1: ofu107 CrossRef CrossRef
6.
Kehrer M, Pedersen C, Jensen TG, Hallas J, Lassen AT: Increased short- and long-term mortality among patients with infectious spondylodiscitis compared with a reference population. Spine J 2015; 15: 1233–40 CrossRef MEDLINE
7.
Sobottke R, Rollinghoff M, Zarghooni K, et al.: Spondylodiscitis in the elderly patient: clinical mid-term results and quality of life. Arch Orthop Trauma Surg 2010; 130: 1083–91 CrossRef MEDLINE
8.
Kim CJ, Song KH, Jeon JH, et al.: A comparative study of pyogenic and tuberculous spondylodiscitis. Spine 2010; 35: E1096–100 CrossRef MEDLINE
9.
Jean M, Irisson JO, Gras G, et al.: Diagnostic delay of pyogenic vertebral osteomyelitis and its associated factors. Scand J Rheumatol 2017; 46: 64–8 CrossRef MEDLINE
10.
Kapsalaki E, Gatselis N, Stefos A, et al.: Spontaneous spondylodiscitis: presentation, risk factors, diagnosis, management, and outcome. Int J Infect Dis 2009; 13: 564–9 CrossRef MEDLINE
11.
Maus U, Andereya S, Gravius S, Ohnsorge JA, Miltner O, Niedhart C: Procalcitonin (PCT) as diagnostic tool for the monitoring of spondylodiscitis. Z Orthop Unfall 2009; 147: 59–64 CrossRef MEDLINE
12.
Choi SH, Sung H, Kim SH, et al.: Usefulness of a direct 16S rRNA gene PCR assay of percutaneous biopsies or aspirates for etiological diagnosis of vertebral osteomyelitis. Diagn Microbiol Infect Dis 2014; 78: 75–8 CrossRef MEDLINE
13.
Sehn JK, Gilula LA: Percutaneous needle biopsy in diagnosis and identification of causative organisms in cases of suspected vertebral osteomyelitis. Eur J Radiol 2012; 81: 940–6 CrossRef MEDLINE
14.
Foreman SC, Schwaiger BJ, Gempt J, et al.: MR and CT Imaging to optimize CT-guided biopsies in suspected spondylodiscitis. World Neurosurg 2017; 99: 726–34 CrossRef MEDLINE
15.
Spira D, Germann T, Lehner B, et al.: CT-guided biopsy in suspected spondylodiscitis—the association of paravertebral inflammation with microbial pathogen detection. PloS one 2016; 11: e0146399 CrossRef MEDLINE PubMed Central
16.
Kim CJ, Kang SJ, Choe PG, et al.: Which tissues are best for microbiological diagnosis in patients with pyogenic vertebral osteomyelitis undergoing needle biopsy? Clin Microbiol Infect 2015; 21: 931–5 CrossRef MEDLINE
17.
Chang CY, Simeone FJ, Nelson SB, Taneja AK, Huang AJ: Is biopsying the paravertebral soft tissue as effective as biopsying the disk or vertebral endplate? 10-year retrospective review of CT-guided biopsy of diskitis-osteomyelitis. Am J Roentgenol 2015; 205: 123–9 CrossRef MEDLINE
18.
Prodromou ML, Ziakas PD, Poulou LS, Karsaliakos P, Thanos L, Mylonakis E: FDG PET is a robust tool for the diagnosis of spondylodiscitis: a meta-analysis of diagnostic data. Cloin Nucl Med 2014; 39: 330–5 CrossRef MEDLINE
19.
Rensi M, Giacomuzzi F, Geatti O: FDG PET-CT (PET), in the diagnosis of spondylodiscitis (SPD): experience in 146 patients (pts). J Nucl Med 2014; 55: 93.
20.
Ohtori S, Suzuki M, Koshi T, et al.: 18F-fluorodeoxyglucose-PET for patients with suspected spondylitis showing Modic change. Spine (Phila Pa 1976) 2010; 35: E1599–603 CrossRef MEDLINE
21.
Bernard L, Dinh A, Ghout I, et al.: Antibiotic treatment for 6 weeks versus 12 weeks in patients with pyogenic vertebral osteomyelitis: an open-label, non-inferiority, randomised, controlled trial. Lancet 2015; 385: 875–82 CrossRef
22.
Yoshimoto M, Takebayashi T, Kawaguchi S, et al.: Pyogenic spondylitis in the elderly: a report from Japan with the most aging society. Eur Spine J 2011; 20: 649–54 CrossRef MEDLINE PubMed Central
23.
de Graeff JJ, Pereira NR, van Wulfften Palthe OD, Nelson SB, Schwab JH: Prognostic factors for failure of antibiotic treatment in patients with osteomyelitis of the spine. Spine (Phila Pa 1976) 2017; 42: 1339–46 CrossRef MEDLINE
24.
Menon VK, Kumar KM, Al Ghafri K: One-stage biopsy, debridement, reconstruction, and stabilization of pyogenic vertebral osteomyelitis. Global Spine J 2014; 4: 93–100 CrossRef MEDLINE PubMed Central
25.
Aboobakar R, Cheddie S, Singh B: Surgical management of psoas abscess in the Human Immunodeficiency Virus era. Asian J Surg 2016; DOI: 10.1016/j.asjsur.
2016.10.003 [Epub ahead of print] CrossRef
26.
Matsumoto T, Yamagami T, Morishita H, et al.: CT-guided percutaneous drainage within intervertebral space for pyogenic spondylodiscitis with psoas abscess. Acta radiologica 2012; 53: 76–80 CrossRef MEDLINE
27.
Vcelak J, Chomiak J, Toth L: Surgical treatment of lumbar spondylodiscitis: a comparison of two methods. Int Orthop 2014; 38: 1425–34 CrossRef MEDLINE PubMed Central
28.
Ascione T, Balato G, Di Donato SL, et al.: Clinical and microbiological outcomes in haematogenous spondylodiscitis treated conservatively. Eur Spine J 2017; 26 (Suppl 4): 489–95 CrossRef MEDLINE
29.
Rossbach BP, Niethammer TR, Paulus AC, et al.: Surgical treatment of patients with spondylodiscitis and neurological deficits caused by spinal epidural abscess (SEA) is a predictor of clinical outcome. J Spinal Disord Tech 2014; 27: 395–400 CrossRef MEDLINE
30.
Pola E, Autore G, Formica VM, et al.: New classification for the treatment of pyogenic spondylodiscitis: validation study on a population of 250 patients with a follow-up of 2 years. Eur Spine J 2017; 26 (Suppl 4): 479–88 CrossRef MEDLINE
31.
Blizzard DJ, Hills CP, Isaacs RE, Brown CR: Extreme lateral interbody fusion with posterior instrumentation for spondylodiscitis. J Clin Neurosci 2015; 22: 1758–61 CrossRef MEDLINE
32.
Nasto LA, Colangelo D, Mazzotta V, et al.: Is posterior percutaneous screw-rod instrumentation a safe and effective alternative approach to TLSO rigid bracing for single-level pyogenic spondylodiscitis? Results of a retrospective cohort analysis. Spine J 2014; 14: 1139–46 CrossRef MEDLINE
33.
Cornett CA, Vincent SA, Crow J, Hewlett A: Bacterial spine infections in adults: evaluation and management. J Am Acad Orthop Surg 2016; 24: 11–8 CrossRef MEDLINE
34.
Smids C, Kouijzer IJ, Vos FJ, et al.: A comparison of the diagnostic value of MRI and 18F-FDG-PET/CT in suspected spondylodiscitis. Infection 2017; 45: 41–9 CrossRef MEDLINE PubMed Central
35.
Ioannou S, Chatziioannou S, Pneumaticos SG, Zormpala A, Sipsas NV: Fluorine-18 fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography scan contributes to the diagnosis and management of brucellar spondylodiskitis. BMC Infect Dis 2013; 7: 73 CrossRef MEDLINE PubMed Central
36.
Skanjeti A, Penna D, Douroukas A, et al.: PET in the clinical work-up of patients with spondylodiscitis: a new tool for the clinician? J Nucl Med Mol Imaging 2012; 56: 569–76.
37.
Fuster D, Tomas X, Mayoral M, et al.: Prospective comparison of whole-body (18)F-FDG PET/CT and MRI of the spine in the diagnosis of haematogenous spondylodiscitis. Eur J Nucl Med Mol Imaging 2015; 42: 264–71 CrossRef CrossRef
38.
Berbari EF, Kanj SS, Kowalski TJ, et al.: Infectious Diseases Society of America (IDSA): clinical practice for the diagnosis and therapy of native vertebral osteomyelitis in adults. Clin Infect Dis 2015; 61: 26–46 CrossRef MEDLINE
39.
Park KH, Cho OH, Lee JH, et al.: Optimal duration of antibiotic therapy in patients with hematogenous vertebral osteomyelitis at low risk and high risk of recurrence. Clin Infect Dis 2016; 62: 1262–9 CrossRef MEDLINE
40.
Si M, Yang ZP, Li ZF, Yang Q, Li JM: Anterior versus posterior fixation for the treatment of lumbar pyogenic vertebral osteomyelitis. Orthopedics 2013; 36: 831–6 CrossRef MEDLINE
e1.
Gouliouris T, Aliyu SH, Brown NM: Spondylodiscitis: update on diagnosis and management. J Antimicrob Chemother 2010;
65 (Suppl 3): iii11–24 MEDLINE
e2.
Kehrer M, Pedersen C, Jensen TG, Lassen AT: Increasing incidence of pyogenic spondylodiscitis: a 14-year population-based study. J Infect 2014; 68: 313–20 CrossRef MEDLINE
e3.
Fantoni M, Trecarichi EM, Rossi B, et al.: Epidemiological and clinical features of pyogenic spondylodiscitis. Eur Rev Med Pharmacol Sci 2012; 16 (Suppl 2): 2–7.
e4.
Eren Gok S, Kaptanoglu E, Celikbas A, et al.: Vertebral osteomyelitis: clinical features and diagnosis. Clinical microbiology and infection: the official publication of the European Society of Clinical Microbiology and Infectious Diseases 2014; 20: 1055–60 CrossRef MEDLINE
e5.
Cottle L, Riordan T: Infectious spondylodiscitis. J Infect 2008; 56: 401–12 CrossRef MEDLINE
e6.
Oxford: Centre for Evidence-based Medicine: Levels of evidence. www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/ (last accessed on 30 November 2017).
e7.
Boody BS, Jenkins TJ, Maslak J, Hsu WK, Patel AA: Vertebral osteomyelitis and spinal epidural abscess: an evidence-based review. J Spinal Disord Tech 2015; 28: E316–27 CrossRef MEDLINE
e8.
Diehn FE: Imaging of spine infection. Radiol Clin North Am 2012; 50: 777–98 CrossRef MEDLINE
e9.
Guerado E, Cervan AM: Surgical treatment of spondylodiscitis. An update. Int Orthop 2012; 36: 413–20 CrossRef MEDLINE PubMed Central
e10.
Legrand E, Flipo RM, Guggenbuhl P: Management of nontuberculous infectious discitis. Treatments used in 110 patients admitted to 12 teaching hospitals in France. Joint Bone Spine 2001; 68: 504–9 CrossRef
e11.
McHenry MC, Easley KA, Locker GA: Vertebral osteomyelitis: long-term outcome for 253 patients from 7 Cleveland-area hospitals. Clin Infect Dis 2002; 34: 1342–50 CrossRef MEDLINE
e12.
Nolla JM, Ariza J, Gomez-Vaquero C, Fiter J: Spontaneous pyogenic vertebral osteomyelitis in non-drug-users. Semin Arthritis Rheum 2002; 31: 271–8 CrossRef
e13.
Yoon SH, Chung SK, Kim KJ, Kim HJ, Jin YJ, Kim HB: Pyogenic vertebral osteomyelitis: identification of microorganism and laboratory markers used to predict clinical outcome. Eur Spine J 2010; 19: 575–82 CrossRef MEDLINE PubMed Central
e14.
Carragee EJ, Kim D, van der Vlugt T, Vittum D: The clinical use of erythrocyte sedimentation rate in pyogenic vertebral osteomyelitis. Spine 1997; 22: 2089–93 CrossRef
e15.
Cramer J, Haase N, Behre I, Ostermann PAW: Spondylitis und Spondylodiszitis. Trauma und Berufskrankheit 2003; 5: 336–41 CrossRef
e16.
Garg V, Kosmas C, Young PC, Togaru UK, Robbin MR: Computed tomography-guided percutaneous biopsy for vertebral osteomyelitis: a department‘s experience. Neurosurg Focus 2014; 37: E10 CrossRef
e17.
Fleege C, Wichelhaus TA, Rauschmann MA: Systemic and local antibiotic therapy of conservative and operative treatment of spondylodiscitis. Orthopäde 2012; 41: 727–35 MEDLINE
e18.
Morel AS, Dubourg G, Prudent E, et al.: Complementarity between targeted real-time specific PCR and conventional broad-range 16S rDNA PCR in the syndrome-driven diagnosis of infectious diseases. Eur J Clin Microbio Infect Dis 2015; 34: 561–70 CrossRef MEDLINE
e19.
Grados F, Lescure FX, Senneville E, Flipo RM, Schmit JL, Fardellone P: Suggestions for managing pyogenic (non-tuberculous) discitis in adults. Joint Bone Spine 2007; 74: 133–9 CrossRef MEDLINE
e20.
Enoch DA, Cargill JS, Laing R: Value of CT-guided biopsy in the diagnosis of septic discitis. J Clin Pathol 2008; 61: 750–3 MEDLINE
e21.
Chew FS, Kline MJ: Diagnostic yield of CT-guided percutaneous aspiration procedures in suspected spontaneous infectious diskitis. Radiology 2001; 218: 211–4 CrossRef MEDLINE
e22.
Gasbarrini A, Boriani L, Salvadori C, et al.: Biopsy for suspected spondylodiscitis. Eur Rev Med Pharmacol Sci 2012; 16: 26–34.
e23.
Lund T, Laine T, Österman H, Yrjönen T, Schlenzka D: Computer-aided spine surgery. In: Bentley G (ed.): European surgical orthopaedics and traumatology. Berlin, Heidelberg, New York: Springer 2014; 677–95 CrossRef
e24.
Sharif HS: Role of MR imaging in the management of spinal infections. Am J Roentgenol 1992; 158: 1333–45 CrossRef MEDLINE
e25.
Zimmerli W: Clinical practice. Vertebral osteomyelitis. N Engl J Med 2010; 362: 1022–9 CrossRef MEDLINE
e26.
Ledermann HP, Schweitzer ME, Morrison WB: MR imaging findings in spinal infections: rules or myths? Radiology 2003: 506–14 MEDLINE
e27.
Hungenbach S, Delank KS, Dietlein M, Eysel P, Drzezga A, Schmidt MC: 18F-fluorodeoxyglucose uptake pattern in patients with suspected spondylodiscitis. Nuc Med Commun 2013; 34: 1068–74 CrossRef MEDLINE
e28.
Schmitz A, Risse JH, Grunwald F: Fluorine-18 fluorodeoxyglucose positron emission tomography findings in spondylodiscitis: preliminary results. Eur Spine J 2001; 10: 534–9 CrossRef PubMed Central
e29.
Zhuang H, Sam JW, Chacko TK, et al.: Rapid normalization of osseous FDG uptake following traumatic or surgical fractures. Eur J Nucl Med Mol Imaging 2003; 30: 1096–103 CrossRef MEDLINE
e30.
Treglia G, Focacci C, Caldarella C, et al.: The role of nuclear medicine in the diagnosis of spondylodiscitis. Eur Rev Med Pharmacol Sci 2012; 16 (Suppl 2): 20–5.
e31.
Jung N, Seifert H, Siewe J, Fätkenheuer G: [Vertebral osteomyelitis]. Der Internist 2013; 54: 945–53 MEDLINE
e32.
Zarghooni K, Rollinghoff M, Sobottke R, Eysel P: Treatment of spondylodiscitis. Int Orthop 2012; 36: 405–11 CrossRef MEDLINE PubMed Central
e33.
Dietze DD, Fessler RG, Jacob RP: Primary reconstruction for spinal infections. J Neurosurg 1997; 86: 981–9 CrossRef MEDLINE
Department for Trauma and Reconstructive Surgery, University Hospital RWTH Aachen:
Dr. med. Herren, Dr. med. Pishnamaz
Department I for Internal Medicine, University Hospital Cologne: PD Dr. med. Dipl. chem. Jung,
Dr. med. Breuninger
Center of Orthopedic and Trauma Surgery, University Hospital Cologne: PD Dr. med. Siewe,
Prof. Dr. med. Sobottke
Center for Orthopaedics and Trauma Surgery, Rhein-Maas Klinikum GmbH, Würselen:
Prof. Dr. med. Sobottke
Criteria for surgical treatment*
Criteria for surgical treatment*
Box
Criteria for surgical treatment*
Flowchart showing the publications included
Flowchart showing the publications included
Figure 1
Flowchart showing the publications included
Three-step diagnostic algorithm to detect spondylodiscitis PCR, polymerase chain reaction; PET, positron emission tomography
Three-step diagnostic algorithm to detect spondylodiscitis PCR, polymerase chain reaction; PET, positron emission tomography
Figure 2
Three-step diagnostic algorithm to detect spondylodiscitis PCR, polymerase chain reaction; PET, positron emission tomography
Key messages
Treatment of spondylodiscitis: overview of study outcomes
Treatment of spondylodiscitis: overview of study outcomes
Table 1
Treatment of spondylodiscitis: overview of study outcomes
Important aspects of patient history and clinical examination
Important aspects of patient history and clinical examination
Table 2
Important aspects of patient history and clinical examination
Radiological changes on MRI (e26)
Radiological changes on MRI (e26)
Table 3
Radiological changes on MRI (e26)
Recommendations on antibiotic treatment (according to IDSA guidelines [38])
Recommendations on antibiotic treatment (according to IDSA guidelines [38])
Table 4
Recommendations on antibiotic treatment (according to IDSA guidelines [38])
Treatment of spondylodiscitis: overview of the literature on diagnostic methods
Treatment of spondylodiscitis: overview of the literature on diagnostic methods
eTable
Treatment of spondylodiscitis: overview of the literature on diagnostic methods
1.Doutchi M, Seng P, Menard A, et al.: Changing trends in the epidemiology of vertebral osteomyelitis in Marseille, France. New Microbes New Infect 2015; 7: 1–7 CrossRef MEDLINE PubMed Central
2. Statistisches Bundesamt: Diagnosedaten der Krankenhäuser ab 2000 (Eckdaten der vollstationären Patienten und Patientinnen). Gliederungsmerkmale: Jahre, Behandlungs-/Wohnort, ICD10. Statistisches Bundesamt 2017.
3. Sobottke R, Seifert H, Fätkenheuer G, Schmidt M, Goßmann A, Eysel P: Current diagnosis and treatment of spondylodiscitis. Dtsch Arztebl Int 2008; 105: 181–7 VOLLTEXT
4.Cheung WY, Luk KDK: Pyogenic spondylitis. Int Orthop 2012; 36: 397–404 CrossRef MEDLINE PubMed Central
5.Gupta A, Kowalski TJ, Osmon DR, et al.: Long-term outcome of pyogenic vertebral osteomyelitis: a cohort study of 260 patients. Open Forum Infect Dis 2014; 1: ofu107 CrossRef CrossRef
6.Kehrer M, Pedersen C, Jensen TG, Hallas J, Lassen AT: Increased short- and long-term mortality among patients with infectious spondylodiscitis compared with a reference population. Spine J 2015; 15: 1233–40 CrossRef MEDLINE
7. Sobottke R, Rollinghoff M, Zarghooni K, et al.: Spondylodiscitis in the elderly patient: clinical mid-term results and quality of life. Arch Orthop Trauma Surg 2010; 130: 1083–91 CrossRef MEDLINE
8.Kim CJ, Song KH, Jeon JH, et al.: A comparative study of pyogenic and tuberculous spondylodiscitis. Spine 2010; 35: E1096–100 CrossRef MEDLINE
9.Jean M, Irisson JO, Gras G, et al.: Diagnostic delay of pyogenic vertebral osteomyelitis and its associated factors. Scand J Rheumatol 2017; 46: 64–8 CrossRef MEDLINE
10.Kapsalaki E, Gatselis N, Stefos A, et al.: Spontaneous spondylodiscitis: presentation, risk factors, diagnosis, management, and outcome. Int J Infect Dis 2009; 13: 564–9 CrossRef MEDLINE
11.Maus U, Andereya S, Gravius S, Ohnsorge JA, Miltner O, Niedhart C: Procalcitonin (PCT) as diagnostic tool for the monitoring of spondylodiscitis. Z Orthop Unfall 2009; 147: 59–64 CrossRef MEDLINE
12. Choi SH, Sung H, Kim SH, et al.: Usefulness of a direct 16S rRNA gene PCR assay of percutaneous biopsies or aspirates for etiological diagnosis of vertebral osteomyelitis. Diagn Microbiol Infect Dis 2014; 78: 75–8 CrossRef MEDLINE
13. Sehn JK, Gilula LA: Percutaneous needle biopsy in diagnosis and identification of causative organisms in cases of suspected vertebral osteomyelitis. Eur J Radiol 2012; 81: 940–6 CrossRef MEDLINE
14. Foreman SC, Schwaiger BJ, Gempt J, et al.: MR and CT Imaging to optimize CT-guided biopsies in suspected spondylodiscitis. World Neurosurg 2017; 99: 726–34 CrossRef MEDLINE
15.Spira D, Germann T, Lehner B, et al.: CT-guided biopsy in suspected spondylodiscitis—the association of paravertebral inflammation with microbial pathogen detection. PloS one 2016; 11: e0146399 CrossRef MEDLINE PubMed Central
16. Kim CJ, Kang SJ, Choe PG, et al.: Which tissues are best for microbiological diagnosis in patients with pyogenic vertebral osteomyelitis undergoing needle biopsy? Clin Microbiol Infect 2015; 21: 931–5 CrossRef MEDLINE
17.Chang CY, Simeone FJ, Nelson SB, Taneja AK, Huang AJ: Is biopsying the paravertebral soft tissue as effective as biopsying the disk or vertebral endplate? 10-year retrospective review of CT-guided biopsy of diskitis-osteomyelitis. Am J Roentgenol 2015; 205: 123–9 CrossRef MEDLINE
18. Prodromou ML, Ziakas PD, Poulou LS, Karsaliakos P, Thanos L, Mylonakis E: FDG PET is a robust tool for the diagnosis of spondylodiscitis: a meta-analysis of diagnostic data. Cloin Nucl Med 2014; 39: 330–5 CrossRef MEDLINE
19. Rensi M, Giacomuzzi F, Geatti O: FDG PET-CT (PET), in the diagnosis of spondylodiscitis (SPD): experience in 146 patients (pts). J Nucl Med 2014; 55: 93.
20. Ohtori S, Suzuki M, Koshi T, et al.: 18F-fluorodeoxyglucose-PET for patients with suspected spondylitis showing Modic change. Spine (Phila Pa 1976) 2010; 35: E1599–603 CrossRef MEDLINE
21. Bernard L, Dinh A, Ghout I, et al.: Antibiotic treatment for 6 weeks versus 12 weeks in patients with pyogenic vertebral osteomyelitis: an open-label, non-inferiority, randomised, controlled trial. Lancet 2015; 385: 875–82 CrossRef
22. Yoshimoto M, Takebayashi T, Kawaguchi S, et al.: Pyogenic spondylitis in the elderly: a report from Japan with the most aging society. Eur Spine J 2011; 20: 649–54 CrossRef MEDLINE PubMed Central
23. de Graeff JJ, Pereira NR, van Wulfften Palthe OD, Nelson SB, Schwab JH: Prognostic factors for failure of antibiotic treatment in patients with osteomyelitis of the spine. Spine (Phila Pa 1976) 2017; 42: 1339–46 CrossRef MEDLINE
24. Menon VK, Kumar KM, Al Ghafri K: One-stage biopsy, debridement, reconstruction, and stabilization of pyogenic vertebral osteomyelitis. Global Spine J 2014; 4: 93–100 CrossRef MEDLINE PubMed Central
25. Aboobakar R, Cheddie S, Singh B: Surgical management of psoas abscess in the Human Immunodeficiency Virus era. Asian J Surg 2016; DOI: 10.1016/j.asjsur.
2016.10.003 [Epub ahead of print] CrossRef
26. Matsumoto T, Yamagami T, Morishita H, et al.: CT-guided percutaneous drainage within intervertebral space for pyogenic spondylodiscitis with psoas abscess. Acta radiologica 2012; 53: 76–80 CrossRef MEDLINE
27. Vcelak J, Chomiak J, Toth L: Surgical treatment of lumbar spondylodiscitis: a comparison of two methods. Int Orthop 2014; 38: 1425–34 CrossRef MEDLINE PubMed Central
28. Ascione T, Balato G, Di Donato SL, et al.: Clinical and microbiological outcomes in haematogenous spondylodiscitis treated conservatively. Eur Spine J 2017; 26 (Suppl 4): 489–95 CrossRef MEDLINE
29. Rossbach BP, Niethammer TR, Paulus AC, et al.: Surgical treatment of patients with spondylodiscitis and neurological deficits caused by spinal epidural abscess (SEA) is a predictor of clinical outcome. J Spinal Disord Tech 2014; 27: 395–400 CrossRef MEDLINE
30. Pola E, Autore G, Formica VM, et al.: New classification for the treatment of pyogenic spondylodiscitis: validation study on a population of 250 patients with a follow-up of 2 years. Eur Spine J 2017; 26 (Suppl 4): 479–88 CrossRef MEDLINE
31. Blizzard DJ, Hills CP, Isaacs RE, Brown CR: Extreme lateral interbody fusion with posterior instrumentation for spondylodiscitis. J Clin Neurosci 2015; 22: 1758–61 CrossRef MEDLINE
32. Nasto LA, Colangelo D, Mazzotta V, et al.: Is posterior percutaneous screw-rod instrumentation a safe and effective alternative approach to TLSO rigid bracing for single-level pyogenic spondylodiscitis? Results of a retrospective cohort analysis. Spine J 2014; 14: 1139–46 CrossRef MEDLINE
33. Cornett CA, Vincent SA, Crow J, Hewlett A: Bacterial spine infections in adults: evaluation and management. J Am Acad Orthop Surg 2016; 24: 11–8 CrossRef MEDLINE
34. Smids C, Kouijzer IJ, Vos FJ, et al.: A comparison of the diagnostic value of MRI and 18F-FDG-PET/CT in suspected spondylodiscitis. Infection 2017; 45: 41–9 CrossRef MEDLINE PubMed Central
35. Ioannou S, Chatziioannou S, Pneumaticos SG, Zormpala A, Sipsas NV: Fluorine-18 fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography scan contributes to the diagnosis and management of brucellar spondylodiskitis. BMC Infect Dis 2013; 7: 73 CrossRef MEDLINE PubMed Central
36. Skanjeti A, Penna D, Douroukas A, et al.: PET in the clinical work-up of patients with spondylodiscitis: a new tool for the clinician? J Nucl Med Mol Imaging 2012; 56: 569–76.
37. Fuster D, Tomas X, Mayoral M, et al.: Prospective comparison of whole-body (18)F-FDG PET/CT and MRI of the spine in the diagnosis of haematogenous spondylodiscitis. Eur J Nucl Med Mol Imaging 2015; 42: 264–71 CrossRef CrossRef
38. Berbari EF, Kanj SS, Kowalski TJ, et al.: Infectious Diseases Society of America (IDSA): clinical practice for the diagnosis and therapy of native vertebral osteomyelitis in adults. Clin Infect Dis 2015; 61: 26–46 CrossRef MEDLINE
39. Park KH, Cho OH, Lee JH, et al.: Optimal duration of antibiotic therapy in patients with hematogenous vertebral osteomyelitis at low risk and high risk of recurrence. Clin Infect Dis 2016; 62: 1262–9 CrossRef MEDLINE
40.Si M, Yang ZP, Li ZF, Yang Q, Li JM: Anterior versus posterior fixation for the treatment of lumbar pyogenic vertebral osteomyelitis. Orthopedics 2013; 36: 831–6 CrossRef MEDLINE
e1. Gouliouris T, Aliyu SH, Brown NM: Spondylodiscitis: update on diagnosis and management. J Antimicrob Chemother 2010;
65 (Suppl 3): iii11–24 MEDLINE
e2. Kehrer M, Pedersen C, Jensen TG, Lassen AT: Increasing incidence of pyogenic spondylodiscitis: a 14-year population-based study. J Infect 2014; 68: 313–20 CrossRef MEDLINE
e3. Fantoni M, Trecarichi EM, Rossi B, et al.: Epidemiological and clinical features of pyogenic spondylodiscitis. Eur Rev Med Pharmacol Sci 2012; 16 (Suppl 2): 2–7.
e4. Eren Gok S, Kaptanoglu E, Celikbas A, et al.: Vertebral osteomyelitis: clinical features and diagnosis. Clinical microbiology and infection: the official publication of the European Society of Clinical Microbiology and Infectious Diseases 2014; 20: 1055–60 CrossRef MEDLINE
e5. Cottle L, Riordan T: Infectious spondylodiscitis. J Infect 2008; 56: 401–12 CrossRef MEDLINE
e6. Oxford: Centre for Evidence-based Medicine: Levels of evidence. www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/ (last accessed on 30 November 2017).
e7. Boody BS, Jenkins TJ, Maslak J, Hsu WK, Patel AA: Vertebral osteomyelitis and spinal epidural abscess: an evidence-based review. J Spinal Disord Tech 2015; 28: E316–27 CrossRef MEDLINE
e8. Diehn FE: Imaging of spine infection. Radiol Clin North Am 2012; 50: 777–98 CrossRef MEDLINE
e9. Guerado E, Cervan AM: Surgical treatment of spondylodiscitis. An update. Int Orthop 2012; 36: 413–20 CrossRef MEDLINE PubMed Central
e10. Legrand E, Flipo RM, Guggenbuhl P: Management of nontuberculous infectious discitis. Treatments used in 110 patients admitted to 12 teaching hospitals in France. Joint Bone Spine 2001; 68: 504–9 CrossRef
e11. McHenry MC, Easley KA, Locker GA: Vertebral osteomyelitis: long-term outcome for 253 patients from 7 Cleveland-area hospitals. Clin Infect Dis 2002; 34: 1342–50 CrossRef MEDLINE
e12. Nolla JM, Ariza J, Gomez-Vaquero C, Fiter J: Spontaneous pyogenic vertebral osteomyelitis in non-drug-users. Semin Arthritis Rheum 2002; 31: 271–8 CrossRef
e13. Yoon SH, Chung SK, Kim KJ, Kim HJ, Jin YJ, Kim HB: Pyogenic vertebral osteomyelitis: identification of microorganism and laboratory markers used to predict clinical outcome. Eur Spine J 2010; 19: 575–82 CrossRef MEDLINE PubMed Central
e14. Carragee EJ, Kim D, van der Vlugt T, Vittum D: The clinical use of erythrocyte sedimentation rate in pyogenic vertebral osteomyelitis. Spine 1997; 22: 2089–93 CrossRef
e15. Cramer J, Haase N, Behre I, Ostermann PAW: Spondylitis und Spondylodiszitis. Trauma und Berufskrankheit 2003; 5: 336–41 CrossRef
e16. Garg V, Kosmas C, Young PC, Togaru UK, Robbin MR: Computed tomography-guided percutaneous biopsy for vertebral osteomyelitis: a department‘s experience. Neurosurg Focus 2014; 37: E10 CrossRef
e17. Fleege C, Wichelhaus TA, Rauschmann MA: Systemic and local antibiotic therapy of conservative and operative treatment of spondylodiscitis. Orthopäde 2012; 41: 727–35 MEDLINE
e18. Morel AS, Dubourg G, Prudent E, et al.: Complementarity between targeted real-time specific PCR and conventional broad-range 16S rDNA PCR in the syndrome-driven diagnosis of infectious diseases. Eur J Clin Microbio Infect Dis 2015; 34: 561–70 CrossRef MEDLINE
e19. Grados F, Lescure FX, Senneville E, Flipo RM, Schmit JL, Fardellone P: Suggestions for managing pyogenic (non-tuberculous) discitis in adults. Joint Bone Spine 2007; 74: 133–9 CrossRef MEDLINE
e20. Enoch DA, Cargill JS, Laing R: Value of CT-guided biopsy in the diagnosis of septic discitis. J Clin Pathol 2008; 61: 750–3 MEDLINE
e21. Chew FS, Kline MJ: Diagnostic yield of CT-guided percutaneous aspiration procedures in suspected spontaneous infectious diskitis. Radiology 2001; 218: 211–4 CrossRef MEDLINE
e22. Gasbarrini A, Boriani L, Salvadori C, et al.: Biopsy for suspected spondylodiscitis. Eur Rev Med Pharmacol Sci 2012; 16: 26–34.
e23. Lund T, Laine T, Österman H, Yrjönen T, Schlenzka D: Computer-aided spine surgery. In: Bentley G (ed.): European surgical orthopaedics and traumatology. Berlin, Heidelberg, New York: Springer 2014; 677–95 CrossRef
e24. Sharif HS: Role of MR imaging in the management of spinal infections. Am J Roentgenol 1992; 158: 1333–45 CrossRef MEDLINE
e25. Zimmerli W: Clinical practice. Vertebral osteomyelitis. N Engl J Med 2010; 362: 1022–9 CrossRef MEDLINE
e26. Ledermann HP, Schweitzer ME, Morrison WB: MR imaging findings in spinal infections: rules or myths? Radiology 2003: 506–14 MEDLINE
e27. Hungenbach S, Delank KS, Dietlein M, Eysel P, Drzezga A, Schmidt MC: 18F-fluorodeoxyglucose uptake pattern in patients with suspected spondylodiscitis. Nuc Med Commun 2013; 34: 1068–74 CrossRef MEDLINE
e28. Schmitz A, Risse JH, Grunwald F: Fluorine-18 fluorodeoxyglucose positron emission tomography findings in spondylodiscitis: preliminary results. Eur Spine J 2001; 10: 534–9 CrossRef PubMed Central
e29.Zhuang H, Sam JW, Chacko TK, et al.: Rapid normalization of osseous FDG uptake following traumatic or surgical fractures. Eur J Nucl Med Mol Imaging 2003; 30: 1096–103 CrossRef MEDLINE
e30. Treglia G, Focacci C, Caldarella C, et al.: The role of nuclear medicine in the diagnosis of spondylodiscitis. Eur Rev Med Pharmacol Sci 2012; 16 (Suppl 2): 20–5.
e31. Jung N, Seifert H, Siewe J, Fätkenheuer G: [Vertebral osteomyelitis]. Der Internist 2013; 54: 945–53 MEDLINE
e32. Zarghooni K, Rollinghoff M, Sobottke R, Eysel P: Treatment of spondylodiscitis. Int Orthop 2012; 36: 405–11 CrossRef MEDLINE PubMed Central
e33. Dietze DD, Fessler RG, Jacob RP: Primary reconstruction for spinal infections. J Neurosurg 1997; 86: 981–9 CrossRef MEDLINE