type of vertebral osteomyelitis

VERTEBRAL OSTEOMYELITIS 22nd ECCMID, April 1, 2012, LONDON

Werner Zimmerli, Basel University Medical Clinic Liestal

• Classification of vertebral osteomyelitis • Epidemiology, microorganisms • Clinical characteristics • Diagnostic work-up • Differential diagnosis of MRI • Treatment • Conclusions

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TYPE OF VERTEBRAL OSTEOMYELITIS

• Acute haematogenous vertebral osteomyelitis: < 30 days of duration (pyogenic)

• Subacute or chronic haematogenous VO: >30 days of duration (tb, brucellosis)

• Exogenous VO without implant: mainly after disk surgery (rare)

• Exogenous implant-associated VO: mainly after internal stabilisation for scoliosis

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EPIDEMIOLOGY

[Grammatico L et al. Epidemiol Infect 136:653-660, 2008]

Incidence: 2.4 cases per 100,000 population Clear age-dependence, i.e. infection of the elderly: - 0.3 cases/100,000 <20 years of age - 2.4 cases/100,000 >70 years of age

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VERTEBRAL OSTEOMYELITIS CAUSED BY S. AUREUS: AGE DEPENDENCE

[Jensen et al. Arch Intern Med 1998]

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MICROORGANISMS IN 255 EPISODES

Number of Microorganism episodes

S. aureus 123 (48.3 %) Coagulase-neg. staphylococci 17 (6.7 %) Gram-negative bacilli 59 (23.1%) Streptococci 24 (9.4 %) Polymicrobial 20 (7.8 %) Micellaneous 12 (4.7 %)

[M.C. McHenry et al. Clin Infect Dis 2002]

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LOCALISATION

• Cervical 10.6 % • Cervico-thoracal 0.4 % • Thoracal 23.9 % • Thoracolumbal 6.3 % • Lumbal 43.1 % • Lumbosacral 15.3 % • Sacral 0.4%

[M.C. McHenry et al. Clin Infect Dis 24:1342, 2002]

Data from 255 episodes of vertebral osteomyelitis in the USA from 1950-94

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CLINICAL CHARACTERISTICS

SYMPTOMS: Back pain 86% (528/608) Fever 60% (481/800) CLINICAL SIGNS: Neurologic impairment* 34% (310/901)

(*Sensory loss, weakness, radiculopathy)

Tenderness on percussion 17.5% (7/40) Paraspinal muscle spasm 7.5% (3/40)

[Mylona E et al.: Semin Arthritis Rheum 39:10-7,2009 Priest&Peacock: South Med J 98:854-62,2005]

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LABORATORY WORK-UP

• Leukocytosis and neutrophilia have a low sensitivity (65% and 40%, respectively)

• Increased ESR and CRP have a high sensitivity (98% and 100%, respectively)

• Blood cultures: 58% positive (30-78%)

• CT-guided or open biopsy: 77% (535/693) positive (47-100%)

[Zimmerli W, NEJM 2010 and Mylona E, Sem Arthritis Rheum 2009]

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IMAGING WORK-UP

• Technetium-99 methylene diphosphonate → positive within a few days: non-specific

• Anti-granulocyte antibodies and labeled leukocyte scan → difficult interpretation

• CT-scan → useful for CT-guided biopsy

• MRI: early positive (bone marrow edema): 90% accuracy (gold standard)

• PET-scanning with 18-fluoro-deoxyglucose, similar to MRI, may be better in case of metallic implants

[Palestro CJ et al., Best Pract Res Clin Rheumatol 2006]

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3-PHASE TECHNETIUM AND ANTI-GRANULOCYTE SCAN

99mTc-MDP 99mTc-anti-NCA-90Fab

Vertebral osteomyelitis Th6/7 in a man with growth of Streptococcus bovis in blood cultures

Hot spot Cold spot

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MRI in a 62-y-old woman with group B Streptococcus vertebral osteomyelitis Th10/11

T1 w/o gadolinium T1 with gadolinium T2

Edema in vertebrae, disk and prevertebral

Gadolinium enhancement in vertebrae,disk and prevertebral

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MRI - DIFFERENTIAL DIAGNOSIS

• Case 1: 71-y-old woman with increasing lumbar pain and high CRP

• Case 2: 85-y-old man with lumbar back and flank pain and arthritis

• Case 3: 84-y-old man with lumbar pain and high CRP

• Case 4: 20-y-old man returning from a trip to Ecuador with back pain and remitting fever

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DIFFERENTIAL DIAGNOSIS: Case 1 71-y-old woman R.V-A.,25.03.1937,f

Signs and symptoms Temp. 36.9°C, lumbosacral pain since many

years, however increasing since a couple of days.

Lab work-up Hb 143 g/L, Lc 14’000/µl with 8% band forms,

Tc 391‘000/µl, CRP 132 mg/L, 2 x 2 blood cultures without growth.

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MRI: 71-y-old woman (case 1)

T2 29/9/08 T1 29/9/08 T1fs 29/9/08 gadolinium

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T1/GAD Sept 2007 T1/Gad Sept 2008

No change during 1 year

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T1/GAD Sept 2007 T1/Gad Sept 2008

Erosive osteochondrosis


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DIFFERENTIAL DIAGNOSIS: Case 2 85-y-old man

Case history:

Chronic back pain, chronic renal insufficiency, gouty arthritis.

Clinical findings:

Intense tender lumbar back pain and pain in right flank, swelling and redness of the right index

Lab work-up:

Leukocytes 25.3G/L, CRP 349 mg/L, uric acid 513 µmol/L [Rufener J. et al. Lancet in press]

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MRI: 85-y-old man (case 2)

Erosion L1/L2 Gadolinium enhancement M. psoas

Courtesy: Parham Sendi Lancet in press 2012

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Work-up: 85-y-old man (case 2)

Microbiology:

• Blood cultures: No growth

• CT-guided biopsy of vertebra and psoas abscess: No growth in cultures, eubacterial PCR (16-S-RNA): negative

Which laboratory exam revealed the diagnosis?

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Work-up: 85-y-old man (case 2)

Polarized light microscopy showed needle-shaped uric acid cristals in the specimen of the psoas muscle:

Gouty tophus involving the spine and mimicking spondylodiscitis with psoas abscess

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DIFFERENTIAL DIAGNOSIS: Case 3 84-y-old man h. hermann,17.12.1926

Case history: Lumbar pain since 4 days before hospitalisation. Pain only during mobilisation, not in horizontal position. Steroid therapy for chronic obstructive lung disease since several years. Clinical findings: Tenderness on percussion in the lumbar spine Lab work-up: CRP 75 mg/L, Leukocytes 12‘000/µl

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1.4.10 T1 14.4.10 T1 14.4.10 T1 Gad

Low signal intensity = „fluid sign“ in L4

Air in L4 Prevertebral mass

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1.4.10 T1 14.4.10 T1 14.4.10 T1 Gad

Fluid in L4 Air in L4 Prevertebral mass (bleeding?)

Intravertebral fluid in conjunction with air is typical for osteonecrosis (M. Calvé = aseptic bone necrosis) [Yu CW et al., Am J Neuroradiol 28:42-7,2007]

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DIFFERENTIAL DIAGNOSIS: Case 4 20-y-old man s. luzius,6.7.91

Case history: 05.1.12: Trip to Ecuador. 15.1.12: 1-day episode of diarrhea. 31.1.12: rapidly progressing back pain. 4.2.12 remitting fever responding to ibuprofen. Early flight back to Switzerland because of severe back pain and fever. Clinical findings (16.2.12): 20-y-old man with 37.8°C, BP 120/78 mm Hg, HF 88/min, Lumbar paraspinal muscle spasm on the right side. Lab work-up: Lc 10‘400/ul, Hb 142 g/L, SR 39 mm, CRP 61 mg/L MRI and blood cultures performed.

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16.2.12 T2 16.2.12 T1 Gad

Minimal edema in Th12/L1 Gadolinium enhancement

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Blood cultures: In 4/4 blood cultures growth of Salmonella enterica subsp. enterica Tennessee Final diagnosis: Spondylitis due to Salmonella enterica Comment: No gadolinium enhancement in the discus. Nevertheless, clear vertebral osteomyelitis

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PRINCIPLES OF ANTIMICROBIAL THERAPY OF VERTEBRAL OSTEOMYELITIS

• Start antibiotics only when the infecting agent is known (positive blood cultures or positive biopsy).

• Most patients need 6 weeks of therapy, longer is not better. [Roblot et al. Semin Arthritis Rheum 2007]

• Longer treatment in case of undrained abscesses or implants. [Kowalski et al. CID 2007]

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PRINCIPLES OF SURGICAL THERAPY OF VERTEBRAL OSTEOMYELITIS

• Acute haematogenous osteomyelitis does not require surgery, except for diagnosis (biopsy).

• Most abscesses can be drained with the use of a CT-guided catheter, except for large epidural abscesses with neurologic deficit.

• A minority with large defects needs stabilisation

• Early (<30d) implant-associated infection can be treated with débridement and retention. Late infection requires removal or suppressive therapy. [Zimmerli, NEJM 2010, Kowalski et al. CID 2007]

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IS FOLLOW-UP MRI NEEDED IN ORDER TO DEFINE THE DURATION OF THERAPY?

49-y-old man with GBS-vertebral osteomyelitis.

T 0 (at dg) T 12 days T 52 days Would you stop therapy at day 52 based

on the MRI control?

Courtesy: Univ Hosp Geneva

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Study with 79 patients having 2 MRI at diagnosis and 4-8 weeks therapy

MRI follow-up Percentage without failure Better 100% (27/27) Equal 89% (34/38) Worse 56% (9/14) Clinical follow-up better at 2nd MRI: 94% (49/52)* * 2 with failure had still increased CRP and in one patient it has not been tested. [Kowalski TJ et al. CID 43:172-9, 2006]

IS CONTROL MRI NEEDED AND USEFUL?

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IN CASE OF EPIDURAL ABSCESS, MRI-CONTROL MAY BE USEFUL

57-y-old man with E. coli ESBL VO and epidural abscess

T1/GAD 21.7.09 T1/Gad 18.5.09

Based on the disapperance of the epidural abscess antibiotics could be stopped despite clear worsening of the bone deminera-lisation.

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COMPLICATONS AND OUTCOME

[Mylona et al. Semin Arthritis Rheum 39:10-7, 2009, Zimmerli W., N Engl J Med 362:1022-1029,2010]

Abscesses: paravertebral, epidural and M.psoas: • Paravertebral abscess: 26% • Disk abscess: 5% • Epidural abscess: 17%

Relapse: 8% (especially frequent with concomitant endocarditis)

Mortality: 6%

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VERTEBRAL OSTEOMYELITIS: CONCLUSIONS

• No specific signs or symptoms

• Only 40% have fever

• Nuclear medicine is not helpful

• MRI is gold standard, however differential diagnosis has to be considered

• No antibiotic treatment before culture result

• 6-week-therapy is enough

• Surgical therapy is almost never needed

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type of vertebral osteomyelitis

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