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Native vertebral osteomyelitis (NVO) is a dangerous form of blood-born bone infection that can be difficult to diagnose. The IDSA has recently issued guidelines for diagnosis of NVO.
1. NVO Diagnosis
Native vertebral osteomyelitis (NVO), or spondylodiscitis, is a complex infection of the spine resulting in varying degrees of morbidity and mortality. A high index of suspicion combined with a multidisciplinary approach to NVO diagnosis can lead to optimal treatment outcomes, including long-term remission. However, diagnosing these patients remains challenging despite the availability of various imaging techniques and blood culture-based identification of causative organisms.
Optimal management of bacterial NVO depends on accurate identification of the infecting organism and its antimicrobial resistance patterns. The IDSA recommends that patients with suspected NVO undergo a bacteriological examination, including two sets of bacterial blood cultures at the time of presentation. northern voices online obviate the need for biopsy, but may be complicated by prior antibiotic therapy.
The current study was a retrospective, multicentre observational cohort of adults with bacterial NVO in the UK. Patients were identified from a variety of sources, including hospital patient lists, outpatient parenteral antibiotic therapy databases and infection team databases; radiology departments; and ICD-10 discharge diagnoses/procedures codes.
A combination of clinical and laboratory investigations was used to establish the diagnosis of bacterial NVO, in particular, the presence of Modic type I changes on MRI and raised inflammatory markers such as ESR and CRP. Other diagnostic tools include a CT scan, which is superior to MRI in evaluating cortical bone damage and depicting the disc space vacuum phenomenon; a combined nuclear medicine test (galium and technetium) that can identify gas accumulation within the spine by measuring a discordant uptake of these tracer agents on the MRI (Diehn, 2012); and a positron emission tomography-computed tomography (PET/CT) technique that has demonstrated a high degree of sensitivity in identifying NVO (Mavrogenis et al, 2008).
Image-guided aspiration biopsy can be performed under computed tomographic (CT) or fluoroscopic guidance to confirm the presence of a bacterial infective process and to guide antimicrobial therapy. However, this technique is prone to error and requires an experienced operator. Moreover, the IDSA guidelines advise against image-guided biopsies in patients with sub-acute NVO and strongly positive Brucella serology or in patients with Staphylococcus aureus or S. lugdunensis isolated in their blood cultures as these circumstances obviate the need for biopsy.
2. NVO Treatment
Despite the fact that NVO is a potentially fatal infection, it is not always diagnosed early enough to decrease complications and neurologic deficits. Symptoms of vertebral osteomyelitis, such as pain, may not present in the first phase of disease (Diehn, 2012). The diagnosis is made through a compatible clinical picture and suggestive imaging and laboratory findings. The presence of NVO is generally confirmed by MRI or CT scan in most patients, although plain radiography can also be helpful in the earlier stages of the disease, especially to identify other causes of back pain and to establish spinal enumeration (Gupta et al., 2014).
Blood and bone marrow cultures are obtained in most patients with suspected NVO. Identification of the causative organism is important in order to guide antibiotic therapy (Sheikh et al., 2017). In cases where microbiological cultures are non-diagnostic, a biopsy of the affected region may be necessary to identify the infecting organism and determine antimicrobial susceptibility. Novel molecular diagnostic techniques such as 16S ribosomal RNA polymerase chain reaction (PCR) and the GeneXpert system have also gained interest due to their ability to rapidly identify mycobacteria and differentiate them from non-mycobacteria strains, including multidrug resistant tuberculosis (Held et al., 2004).
Other diagnostic tools include scintigraphy with single-photon emission computed tomography (SPECT) using Technetium-99m or Gallium-67 (67 Ga) tracers. The sensitivity of this technique is low, but it can be used in conjunction with other diagnostic methods to increase the likelihood of diagnosis. Alternatively, a magnetic resonance angiography (MRA) scan can be performed to detect epidural abscesses and demonstrate the location of an active infection. CRP or ESR monitoring is routinely used in most centres to identify inflammatory markers of inflammation and monitor treatment response (Clintsworth et al., 2017). The study authors recommend that the UK NVO bacterial guidelines be updated to reflect the current aetiology of NVO and that a formal registry be established. The authors also call for a mandatory reporting of antibiotic use in NVO patients to ensure compliance with the relevant guidance. This should include recording the antibiotic and doses prescribed, as well as any complications and/or death.