Synopsis
Recognise bone and spinal infection, obtain blood and deep microbiology before treatment when safe, use MRI appropriately and secure drainage, stabilisation or decompression for complications.
- Osteomyelitis is infection of bone; discitis and vertebral osteomyelitis commonly overlap across the disc and adjacent vertebral endplates.
- Blood cultures are essential before antibiotics in suspected haematogenous or vertebral disease and may establish the organism without biopsy.
- MRI with appropriate contrast is the preferred imaging test for vertebral infection, marrow involvement, epidural abscess and neural compression.
- In a stable patient with negative blood cultures, obtain image-guided or operative bone or disc tissue before antibiotics when the result will direct prolonged therapy.
- Do not delay antibiotics for biopsy in sepsis, neurological compromise or rapidly progressive infection; obtain cultures and treat immediately.
- Superficial wound swabs do not reliably identify the bone pathogen; deep bone tissue for histology and culture is the reference microbiological specimen.
- Management combines organism-active therapy with drainage of abscess, removal of devitalised bone, implant decisions, perfusion and mechanical stability.
- Staphylococcus aureus in blood with compatible spinal pain requires clearance cultures and assessment for endocarditis and other metastatic foci.
Key red flags
New limb weakness, sensory level, saddle sensory change or bladder and bowel dysfunction requires emergency spinal imaging.
Severe spinal pain with fever, bacteraemia or injection exposure suggests discitis, vertebral osteomyelitis or epidural abscess.
Haemodynamic instability or persistent Staphylococcus aureus bacteraemia indicates invasive infection and metastatic-focus risk.
Sinus, exposed bone, chronic ulcer or implant may represent contiguous polymicrobial bone infection.
Spinal deformity, mechanical instability or progressive pain despite therapy requires surgical reassessment.
Immune compromise, diabetes, vascular insufficiency and previous antimicrobial treatment can blunt presentation and reduce culture yield.
Constant focal spinal pain, night pain, painful movement and paraspinal spasm with inflammatory or bloodstream risk supports discitis or vertebral osteomyelitis.
Radicular pain, weakness, sensory loss, gait change, saddle symptoms or sphincter dysfunction suggests epidural abscess or vertebral collapse.
Current or recent Staphylococcus aureus bacteraemia, endocarditis, line infection, injection exposure or skin infection raises probability of metastatic bone seeding.
Investigation priorities
Identify haematogenous organisms before antimicrobial exposure and guide the need for biopsy.
Management branches
Spinal infection is possible and a neurological deficit, sphincter symptom, deformity or instability is present.
- Use ABCDE, document motor power, sensation, reflexes, gait if safe, perianal sensation and bladder findings and repeat after any change.
- Obtain blood cultures and urgent whole-region MRI with sequences adequate to detect epidural abscess and compression.
- Contact spinal surgery and infection specialists immediately and begin local intravenous treatment after cultures without waiting for biopsy.
- Arrange decompression, drainage and stabilisation according to neural compression, abscess, instability and operative risk.
Bone or disc infection is likely but the patient has no sepsis, neurological compromise or rapidly destructive progression.
- Take blood cultures, MRI the involved region and review prior antibiotics, procedures, ulcers, implants, exposures and endocarditis risk.
- If blood cultures do not establish a credible organism, arrange image-guided or operative tissue for culture and histology before antibiotics when feasible.
- Request bacterial culture and add mycobacterial, fungal or molecular testing only when host and epidemiology support it.