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Figures
- FIG 1.
Proposed diagnostic algorithm for (suspected) acute spondylodiscitis. Acute spondylodiscitis is defined as acute pain in back or neck, fever and/or increased C-reactive protein levels, and characteristic imaging findings of spondylodiscitis on MR imaging or FDG-PET/CT (FDG-PET/CT should be considered when MR imaging cannot be performed). Explanation of annotations in this figure: 1) Addition of tobramycin 7 mg/kg once daily in case of sepsis, adjustment according to cultures; 2) Empiric antibiotics should be aimed at both Gram-positive and Gram-negative bacteria, and the most common pathogens of spondylodiscitis, with the final choice based on local antibiotics resistance data (in countries with a high prevalence of methicillin-resistant S. aureus, cefuroxim is not sufficient); 3) If sufficient material can be obtained, then biopsy samples should be sent in for both microbiological and pathological examination; 4) Additional diagnostics for atypical pathogens should be performed when clinically indicated, in consultation with an infectious disease specialist or medical microbiologist.
- FIG 2.
Proposed diagnostic algorithm for (suspected) chronic spondylodiscitis. Chronic spondylodiscitis is defined as chronic pain (weeks to months) in back or neck, and characteristic imaging findings of spondylodiscitis on MR imaging or FDG-PET/CT (FDG-PET/CT should be considered when MR imaging cannot be performed). Explanation of annotations in this figure: 1) If there is a suspicion of tuberculous spondylodiscitis or doubt about the diagnosis of spondylodiscitis, image-guided biopsy is recommended; 2) If sufficient material can be obtained, then biopsy samples should be sent in for both microbiological and pathological examination; 3) Additional diagnostics for atypical pathogens should be performed when clinically indicated, in consultation with an infectious disease specialist or medical microbiologist.
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Key findings of main studies discussed in this article
Study and Year Key Findings McNamara et al, 20174 Meta-analysis that reported image-guided biopsy to have a positive culture yield of approximately 48% in patients with suspected spondylodiscitis Sertic et al, 20199 Meta-analysis that reported that CT-guided biopsy had a positive culture yield of 33% in patients with suspected spondylodiscitis Kasalak et al, 201810 Initial CT-guided biopsy was culture-positive in 31.3% of patients with suspected spondylodiscitis Repeat CT-guided biopsy (after initial negative biopsy findings) was culture-positive in 33.3% of patients with suspected spondylodiscitis 96.9% of 64 patients with suspected spondylodiscitis would have been adequately treated if a strategy was followed that would subject all patients without clinical findings suspicious for “atypical” micro-organisms and negative blood cultures to empiric antibiotics (ie, clindamycin for coverage of Gram-positive bacteria) without using biopsy results to determine the optimal antibiotic regimen Outcome within 6 months (development of neurologic or orthopedic complications, an operation, and/or death) was not significantly different between positive and negative findings on biopsy cultures in patients with suspected spondylodiscitis Özmen et al, 201911 CT-guided biopsy was culture-positive in 33.8% with suspected spondylodiscitis Kasalak et al, 201812 Systematic review of 8 studies that reported that repeat percutaneous image-guided biopsy (after an initial biopsy with negative findings on cultures) had a positive culture yield ranging between 0% and 60.0% in patients with suspected spondylodiscitis, based on poor-quality evidence Bae et al, 201813 The species of blood and biopsy isolates in patients with pyogenic spondylodiscitis were identical in 95.7% Excluding 4 anaerobic isolates, antibiotic susceptibility patterns were identical between blood and biopsy isolates in 97.7% Kim et al, 201416 There were no significant differences in treatment success (defined as survival and absence of signs of infection at the end of the therapy) between 75 patients with microbiologically confirmed pyogenic spondylodiscitis (whether by means of blood or biopsy cultures) and 76 patients with clinically diagnosed pyogenic spondylodiscitis without microbiologic confirmation
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