Vertebral Osteomyelitis, Discitis, and Spinal Epidural Abscess in Adults [2013 new]

Description: Vertebral osteomyelitis (VO) and spinal epidural abscess (SEA) are rare infections or inflammations of the bone, bone marrow of the spinal region, or epidural space. Although rare (2.4 cases per 100,000 persons annually), they are relatively easy to treat when recognized. However, failure to recognize, diagnose and treat it in a timely manner can lead to permanent paralysis. Unfortunately, diagnostic delays occur frequently, with reports of symptom onset to diagnosis ranging from 11 to 59 days.

Factors contributing to diagnostic delays include:

• The difficulty of the diagnosis. No "classic" history and physical exam findings easily and reliably identify VO/SEA. The primary symptom of back pain is a common complaint frequently associated with many less immediately serious conditions.
• Inconsistent approaches to diagnosis and treatment. Differing approaches to VO/SEA limit the development of standard, evidence-based procedures. For example, when should empiric antibiotics be started and which antibiotic combination should be used?
• Delays in performing needed studies and services. The risk of rapid progression of VO/SEA means that the processes of care such as imaging and consultations must be performed more rapidly than organizational infrastructures may allow. For example, imaging within a few hours is necessary to help confirm the diagnosis and initiate appropriate treatment. However, care systems are often not in place to assure that imaging can occur on evenings or weekends, resulting in delays of a day or longer in performing some "stat" imaging orders.

This CME activity addresses the diagnosis and initial treatment of vertebral osteomyelitis, discitis or paravertebral abscess with or without spinal epidural abscess in adult patients. The CME activity does not address antimicrobial adjustments once microorganisms have been identified, or indications for surgery.

Problem: While vertebral osteomyelitis (VO) and spinal epidural abscess (SEA) are rare, their diagnosis and treatment must be timely or permanent paralysis may result.

Diagnosis

• Evaluation should include a complete neurological exam and laboratory evaluation
• Prompt imaging: within 2 hours if neurological deficits, or 6 hours if without neurological deficits
• If imaging evidence of VO and negative blood culture: within 24 hours image-guided biopsy by Neuroradiology.

Treatment

• If abnormal neurological exam or imaging evidence of SEA: stat antibiotics, stat imaging within 2 hours (if not already imaged), and stat neurosurgical consult
• If imaging evidence of VO: if unstable, stat antibiotics; if stable, hold antibiotics until after blood culture results are returned; consider neurosurgery consult, neurological check every 4 hours.
• If stable, and no positive imaging findings, consider other diagnosis. If pain persists, repeat imaging in 2-3 weeks.
• Consult Infectious Disease Service to assist with antibiotic management and further evaluation.