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| {{SI}} | | '''For patient information, click [[Osteomyelitis (patient information)|here]]''' |
| | {{Vertebral osteomyelitis}} |
| {{CMG}} | | {{CMG}} |
| ==Overview==
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| The term ''[[osteomyelitis]]'' describes any new infection in the bone and bone marrow. '''Vertebral osteomyelitis''' is a specific type of this disease; the term describes a rare bone infection concentrated in the spinal region.<ref name="American Family Physician">{{cite journal|last=Carek, M.D.|first=Peter|coauthors=Lori Dickerson, Jonathan Sack, M.D.|title=Diagnosis and Management of Osteomyelitis|journal=American Family Physician|date=15|year=2001|month=June|volume=12|issue=63|pages=2413–2421|url=http://www.aafp.org/afp/2001/0615/p2413.html|accessdate=March 27, 2012}}</ref> Cases of vertebral osteomyelitis are so rare that only 2-4% of all bone infections are attributed to the disease.<ref name="miller">{{cite news|last=Miller|first=Janet|title=Vertebral Osteomyelitis|url=http://www.mghradrounds.org/clientuploads/nov_dec_2006/nov_dec_2006.pdf|accessdate=12 March 2012|newspaper=Radiology Rounds|date=November/December 2006|location=Massachusetts General Hospital}}</ref> The infection can be classified as acute or chronic depending on the severity of the onset of the case,<ref name="US Library">{{cite book|title=A.D.A.M Medical Encyclopedia: Osteomyelitis|year=2010|publisher=United States National Library of Medicine|location=Bethesda, MD|url=http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001473/|author=David Dugdale, III, M.D.|coauthors=Jatin Vyas, M.D.|accessdate=12 March 2012}}</ref> where acute patients often experience better outcomes than those living with the chronic symptoms that are characteristic of the disease. Although vertebral osteomyelitis is found in patients across a wide range of ages, the infection is commonly reported in young children and older adults. Vertebral osteomyelitis often attacks two vertebrae and the corresponding intervertebral disk, causing narrowing of the disc space between the vertebrae.<ref name="wheeless">{{cite book|last=Wheeless, III, M.D.|first=Clifford|title=Wheeless' Textbook of Orthopaedics|year=2011|publisher=Duke University Medical Center|location=Duke University|url=http://www.wheelessonline.com/ortho/vertebral_osteomyelitis}}</ref> The prognosis for the disease is dependent on where the infection is concentrated in the spine, the time between initial onset and treatment, and what approach is used to treat the disease.
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| Other names for vertebral osteomyelitis include spinal osteomyelitis, spondylodiskitis, or disk-space infection.<ref name=Zimmerli>{{cite journal|last=Zimmerli, M.D.|first=Werner|title=Vertebral Osteomyelitis|journal=The New England Journal of Medicine|date=18|year=2010|month=March|issue=362|pages=1022–1029|url=http://www.nejm.org/doi/full/10.1056/NEJMcp0910753|accessdate=March 27, 2012|doi=10.1056/NEJMcp0910753}}</ref>
| | {{SK}} Spinal osteomyelitis; disc space infection |
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| ==Pathogenic Causes== | | ==[[Vertebral osteomyelitis overview|Overview]]== |
| [[File:Staphylococcus aureus bacteria escape.jpg|thumb|Staphylococcus aureus, the most common microorganism associated with vertebral osteomyelitis]] | |
| [[File:MRSA7820.jpg|thumb|MRSA, a rare pathogen associated with some cases of vertebral osteomyelitis]]
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| A notable aspect of the disease is found in its ability to start anywhere in the body and spread to other regions through the bloodstream.<ref name="US Library" /> A number of bacterial strains can enter the body in this manner, making the origin of the infection hard to trace; thus, for many patients with the infection, this characteristic can delay an accurate diagnosis and prolong suffering. The most common microorganism associated with vertebral osteomyelitis is the bacteria ''[[staphylococcus aureus]]''. Another strain of ''staphylococcus aureus'', commonly known as ''[[methicillin-resistant staphylococcus aureus]]'' (MRSA), is a particularly harmful microorganism that is more difficult to treat than other related strains. ''Streptococcus equisimilis'' may also be responsible for the onset of vertebral osteomyelitis, though it is thought to be less virulent than ''staphylococcus aureus''.<ref name="kumar">{{cite journal|last=Kumar|first=Aravind|coauthors=Jonathan Sandoe, Naresh Kumar|title=Three cases of vertebral osteomyelitis caused by Streptococcus dysgalactiae subsp. equisimilis|journal=The Journal of Medical Microbiology|year=2005|month=November|volume=54|issue=11|pages=1103–1105|url=http://jmm.sgmjournals.org/content/54/11/1103.full|accessdate=14 Feb. 2012}}</ref>
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| ==Symptoms== | | ==[[Vertebral osteomyelitis historical perspective|Historical Perspective]]== |
| The disease is known for its subtle onset in patients, and few symptoms characterize vertebral osteomyelitis. Correct diagnosis of the disease is often delayed for an average of six to twelve weeks due to such vague, ambiguous symptoms.<ref name=wheeless />
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| ===General Cases=== | | ==[[Vertebral osteomyelitis classification|Classification]]== |
| General symptoms found in a cross-section of patients with vertebral osteomyelitis include fever, swelling at the infection site, weakness of the vertebral column and surrounding muscles, episodes of night sweats, and difficulty transitioning from a standing to a sitting position.<ref name="cedars">{{cite web|title=Health Conditions: Osteomyelitis|url=http://www.cedars-sinai.edu/Patients/Health-Conditions/Osteomyelitis.aspx|publisher=Cedars Sinai Medical Center|accessdate=12 March 2012}}</ref> Additionally, persistent back pain and muscle spasms may become so debilitating that they confine the patient to a sedentary state, where even slight movement or jolting of the body results in excruciating pain. In children, the presence of vertebral osteomyelitis can be signaled by these symptoms, along with high-grade fevers and an increase in the body's [[leukocyte]] count.<ref name=wheeless />
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| ===Advanced Cases=== | | ==[[Vertebral osteomyelitis pathophysiology|Pathophysiology]]== |
| Patients with an advanced case may present some or none of the symptoms associated with general cases of vertebral osteomyelitis. When the osteomyelitis is isolated in the back, as it is in vertebral osteomyelitis, the patient will report muscle spasms coming from the back, but may not report experiencing any fevers.<ref name=cedars /> Symptomatic signs vary in each patient and depend on the severity of the case. Neurologic deficiency characterizes advanced, threatening cases of the disease. On average, 40% of patients with an advanced case of vertebral osteomyelitis experience some type of neurological deficiency; this is a sign that the infection has been progressing for some time. In advanced cases, the untreated infection will attack the nervous system through the spinal cord which runs parallel to the vertebral column, placing the patient at risk for paralysis of the extremities. Additionally, loss of the ability to move is a trademark symptom of neurologic problems in advanced cases of vertebral osteomyelitis. Any further signs of [[neurological deficit]] signal an advanced case of vertebral osteomyelitis that requires immediate intervention to prevent further threat to the spinal cord.<ref name=wheeless />
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| ==Diagnosis== | | ==[[Vertebral osteomyelitis causes|Causes]]== |
| Diagnosis of vertebral osteomyelitis is often complicated due to the delay between the onset of the disease and the initial display of symptoms. Before pursuing radiological methods of testing, physicians often order a full blood test to see how the patient's levels compare to normal blood levels in a healthy body.<ref name="US Library" /> In a complete blood test, the [[C-reactive protein]] (CRP) is an indicator of infection levels, the [[complete blood count]] (CBC) evaluates the presence of white and red blood cells, and the [[erythrocyte sedimentation rate]] (ESR) tests for inflammation in the body. Anomalous values that lie outside the acceptable ranges in any of these subcategories confirm the presence of infection in the body and indicate that further diagnostic measures are necessary. Blood tests may prove inconclusive and may not serve as enough evidence to confirm the presence of vertebral osteomyelitis. Diagnosis can also be complicated due to the disease's similarity to [[discitis]], commonly known as an infection of the disc space. Both diseases are characterized by a patient's inability to walk and concentrated back pain; however, patients with vertebral osteomyelitis often appear more ill than those with discitis.<ref name="ADC: Discitis">{{cite journal|last=National Center for Biotechnology Information|title=Discitis versus Vertebral Osteomyelitis|journal=Archives of Disease in Childhood|year=2000|month=October|volume=4|issue=83|pages=368|accessdate=March 27, 2012|pmc=1718514|pmid=10999882}}</ref> Additional measures may be called upon to rule out the possibility of discitis; such approaches include diagnosing the disease through various medical imaging techniques.
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| ===Radiological Diagnosis=== | | ==[[Vertebral osteomyelitis differential diagnosis|Differentiating Vertebral osteomyelitis from other Diseases]]== |
| Radiological intervention is often necessary to confirm the presence of vertebral osteomyelitis in the body. Plain-film radiological orders are necessary for all patients displaying symptoms of the disease. This diagnostic approach is often preliminary to other radiological procedures, such as magnetic resonance imaging, or [[MRI]], [[computed tomography]] (CT) scan, [[fine-needle aspiration]] biopsy, and [[nuclear scintigraphy]]. The initial plain-film X-ray images are scanned for any indication of disc compression between two vertebrae or the degeneration of one or more vertebrae. Only when these findings are ambiguous is further testing necessary to diagnose the disease. Other radiological approaches offer more comprehensive imaging of the spinal area, but can often prove inconclusive. MRI scans do not expose the patient to radiation and are highly sensitive to changes in the size and appearance of the intervertebral discs; however, findings on the MRI scan may be confused with other conditions such as the presence of tumors or bone fractures. If MRI imaging is inconclusive, the high sensitivity to erosions in the vertebrae or intervertebral discs of CT scans may be preferred for their ability to indicate signs of the disease more clearly than MRI. Additional tests may be ordered if such preliminary tests cannot confirm a diagnosis; for example, needle biopsies may be needed to take samples of bone surrounding the disc space where the infection is thought to live, or nuclear bone scans may be used to contrast areas of healthy bone with areas of infection.<ref name=miller />
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| ==Treatment== | | ==[[Vertebral osteomyelitis epidemiology and demographics|Epidemiology and Demographics]]== |
| Treatment options for vertebral osteomyelitis depend on the severity of the infection. Since the use of intravenous antibiotics seems to eliminate the responsible pathogen in most cases of vertebral osteomyelitis, physicians often attempt nonsurgical intervention before considering surgical options of treatment.<ref name="musher">{{cite journal|last=Musher, M.D.|first=Daniel|coauthors=Sigurdur Thorsteinsson, M.D. John Minuth, M.D. Robert Luchi, M.D.|title=Vertebral Osteomyelitis: Still a Diagnostic Pitfall|journal=Archives of Internal Medicine|year=1976|month=January|volume=136|issue=1|pages=105–110|url=http://archinte.ama-assn.org/cgi/content/abstract/136/1/105|accessdate=13 March 2012}}</ref>
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| ===Nonsurgical Intervention=== | | ==[[Vertebral osteomyelitis risk factors|Risk Factors]]== |
| Nonsurgical intervention is often desired because it poses less risk to the body of further infection that can occur if the body is unnecessarily exposed to other outside pathogens during surgery. Intravaneous antibiotics may be prescribed to kill the microorganism causing the infection. Such antibiotics are administered at a continuous rate for a varying amount of time, lasting from four weeks to several months. The outcome for patients who undergo intravaneous infusion differs according to factors such as age, strength of the immune system, and erthyrocyte sedimentation rate (ESR).<ref name="carragee">{{cite journal|last=Carragee, M.D.|first=Eugene|title=Pyogenic Vertebral Osteomyelitis|journal=The Journal of Bone and Joint Surgery|date=1|year=1997|month=June|volume=79|issue=6|pages=874–880|url=http://www.jbjs.org/article.aspx?Volume=79&page=874|accessdate=13 March 2012}}</ref> If intervention through antibiotics fails, patients are directed toward surgical treatment options.
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| ===Surgical Intervention=== | | ==[[Vertebral osteomyelitis natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| Surgery may be required for patients with advanced cases of vertebral osteomyelitis. [[Spinal fusion]] is a common approach to destroying the microorganism causing the disease and rebuilding parts of the spine that were lost due to the infection. Fusions can be approached anteriorly or posteriorly, or both, depending on where the infection is located in the vertebral area. Spinal fusions involve cleaning the infected area of the spine and inserting instrumentation to stabilize the vertebrae and disc(s).<ref name=carragee /> Such instrumentation often includes bone grafts harvested from other areas of the body or from a bone bank, where bone fragments are harvested from deceased donors.<ref name="NIH Medline">{{cite web|title=Bone Graft|url=http://www.nlm.nih.gov/medlineplus/ency/article/002963.htm|publisher=National Institute of Health|accessdate=March 29, 2012}}</ref> The new bone graft is secured in the appropriate spinal region through the use of supporting rods and screws, most of which are made from titanium. Rods of this material promote healing and fusion of the bones more efficiently than stainless steel rods and are also more visible on MRI.<ref name=Bono>{{cite book|last=Bono|first=Christopher|title=Spine|year=2004|publisher=Lipincott, Williams, & Wilkins|pages=252|url=http://books.google.com/books?id=r3Zgl361w_cC&pg=PA252&lpg=PA252&dq=advantage+of+titanium+rods+spinal+fusion&source=bl&ots=2YxerByFhT&sig=hFuDM8TR92DiPCx2_5AbW0930WY&hl=en&sa=X&ei=vUR7T4--LIqQ9QSc6sWVBQ&ved=0CFwQ6AEwBQ#v=onepage&q=advantage%20of%20titanium%20rods%20spinal%20fusion&f=false}}</ref>
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| ==Prognosis== | | ==Diagnosis== |
| Mortality rates are noted to be higher in patients whose infection is due to the bacteria, ''staphylococcus aureus''. However, if diagnosed quickly and treated correctly, patients with ''staphylococcus aureus'' experience better outcomes than those with the disease caused by other microorganisms. The subtle progression of vertebral osteomyelitis places patients at risk for paralysis, especially if the infection is concentrated in the [[thoracic]] or [[cervical vertebrae]].<ref name=wheeless /> Research published in ''The Journal of Bone and Joint Surgery'' (1997) notes that most patients do not experience symptoms of the infection following surgical intervention;<ref name=carragee /> therefore, patients with an advanced case of vertebral osteomyelitis who undergo a surgical approach often experience better outcomes than those treated solely through intravaneous antibiotics.
| | [[Vertebral osteomyelitis history and symptoms|History and Symptoms]] | [[Vertebral osteomyelitis physical examination|Physical Examination]] | [[Vertebral osteomyelitis laboratory findings|Laboratory Findings]] | [[Vertebral osteomyelitis x ray|X Ray]] | [[Vertebral osteomyelitis CT|CT]] | [[Vertebral osteomyelitis MRI|MRI]] | [[Vertebral osteomyelitis other imaging findings|Other Imaging Findings]] | [[Vertebral osteomyelitis other diagnostic studies|Other Diagnostic Studies]] |
| | ==Treatment== |
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| | [[Vertebral osteomyelitis medical therapy|Medical Therapy]] | [[Vertebral osteomyelitis surgery|Surgery]] | [[Vertebral osteomyelitis primary prevention|Primary Prevention]] | [[Vertebral osteomyelitis secondary prevention|Secondary Prevention]] | [[Vertebral osteomyelitis cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Vertebral osteomyelitis future or investigational therapies|Future or Investigational Therapies]] |
| | ==Case Studies== |
| | [[Vertebral osteomyelitis case study one|Case #1]] |
| ==Related Chapters== | | ==Related Chapters== |
| * [[Osteomyelitis]] | | * [[Osteomyelitis]] |
| * [[Bone grafting]] | | * [[Bone grafting]] |
| * [[Allotransplantation]] | | * [[Allotransplantation]] |
| * [[X-ray computed tomography]]
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| * [[Fine-needle aspiration]] | | * [[Fine-needle aspiration]] |
| * [[Intravenous therapy]] | | * [[Intravenous therapy]] |
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| ==References==
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| {{reflist}}
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| {{Osteochondropathy}} | | {{Osteochondropathy}} |
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| [[Category:Bacterial diseases]] | | [[Category:Bacterial diseases]] |
| [[Category:Skeletal disorders]] | | [[Category:Skeletal disorders]] |
| [[Category:Infectious disease]]
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| [[Category:Disease]] | | [[Category:Disease]] |
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| {{WH}} | | {{WH}} |
| {{WS}} | | {{WS}} |