Discitis and vertebral osteomyelitis

Discitis and vertebral osteomyelitis form an infection spectrum involving the disc-endplate unit and adjacent vertebrae. Ask about pain onset, nocturnal and mechanical components, fever, recent bacteraemia, skin or urinary infection, vascular access, spinal procedure, injecting drug use, tuberculosis contact and travel. Record all antibiotics because culture suppression matters. Diabetes, renal replacement therapy, immune suppression, cancer and frailty increase risk. Children may refuse to sit, crawl or walk and can present with abdominal pain rather than localised spinal symptoms.

ABCDE assessment comes first. Then perform and document a complete neurological examination: limb power and sensation, reflexes, upper motor-neuron signs, gait when safe, saddle sensation, anal tone and bladder function. Examine the whole spine for focal percussion tenderness and deformity and the abdomen, flank and hip for psoas irritation. Search skin, lines, heart, urine and other bones or joints for source and spread. Repeat the neurological record after analgesia, imaging, transfer and any deterioration.

Obtain FBC, CRP, ESR, renal and liver profiles and two sets of blood cultures before treatment when feasible. Blood cultures can establish microbiology and sometimes avoid biopsy, especially with a convincing MRI and a typical organism. Persistent S. aureus bacteraemia requires repeat cultures, endocarditis assessment and a search for other metastatic sites. Normal white count or absent fever does not exclude disease. Tuberculosis, Brucella or fungal tests are selected from exposure and immune status rather than sent indiscriminately.

MRI is the preferred study because it shows disc and endplate inflammation, epidural disease, neural compression and paraspinal collections. Use contrast when renal function and the diagnostic question permit. Image the symptomatic region urgently and extend coverage when neurological findings, bacteraemia or multifocal pain suggest more levels. If MRI is contraindicated, spinal specialists and radiology combine CT, nuclear techniques or CT myelography for the safest answer. Plain radiographs provide alignment and collapse baseline but are insensitive early.

A stable, neurologically intact patient with negative blood cultures usually needs image-guided biopsy before antibiotics. Target disc, endplate or accessible paraspinal collection and send multiple samples for aerobic and anaerobic culture and histology, adding mycobacterial, fungal or molecular tests when indicated. If the first biopsy is non-diagnostic and suspicion remains high, review targeting, prior antibiotics and pathology, then repeat percutaneous or obtain open biopsy rather than declaring infection absent. Do not biopsy through a route that compromises later surgery.

Treatment urgency changes with physiology and neurology. Sepsis, instability or progressive deficit requires immediate antibiotics after rapidly obtainable blood cultures and urgent decompression or drainage; biopsy should be incorporated into surgery without delaying it. Stable disease waits for microbiological sampling, then receives organism-directed treatment through infection specialists. Many bacterial cases receive about six weeks of parenteral or highly bioavailable oral therapy, but organism, abscess drainage, implants and response determine the exact documented route and duration.

Spinal surgery addresses compression, instability, deformity and uncontrolled source rather than simply the MRI label. Drain epidural or large paraspinal collections, decompress threatened neural structures, debride non-viable tissue and stabilise when destruction makes the spine unsafe. Instrumentation may be necessary in an infected field to restore stability and is planned by specialist teams. Percutaneous drainage can control selected psoas or paraspinal collections. Persistent bacteraemia or pain despite susceptible drugs means reconsider source, abscess and diagnosis.

Monitor pain pattern, neurological function, mobility, fever and CRP. ESR may fall slowly. Clinical improvement and falling markers generally outweigh persistent MRI abnormalities, which can lag and even appear worse during healing; repeat MRI for new deficit, recurrent bacteraemia or poor response. Provide venous-thrombosis prevention, nutrition, pressure care, bowel and bladder support and early rehabilitation. At discharge, specify activity and brace advice, antimicrobial monitoring and emergency return for weakness, numbness, saddle change, bladder symptoms, fever or escalating pain.