Paediatric Discitis

Aetiology

 

1.  Infection

- usually haematogenous 

- some direct spread from vertebral osteomyelitis

- usually frankly infective with marked vertebral body end plate changes

- elevated temperature & ESR

 

2.  Inflammatory 

- probable auto-immune picture with minimal bone changes

- no need for antibiotics

 

Anatomy 

 

Blood supply

- nucleus pulposis never has blood supply

- annulus fibrosis has blood supply until age 20

- primary infection possible in infants

 

Natural History

 

60% resolve

20% auto-fuse

20% chronic pain

 

Presentation

 

1-12 years / symptoms age dependent

 

0 - 3

- refusal to walk / weight bear / limp

- irritability

 

3 - 9

- abdominal pain

 

> 9

- back pain

 

Also

- stiff flexed spine 

- tight hamstrings & decreased SLR

- scoliosis

 

Microbiology

 

50% positive blood culture

66% positive CT guided biopsy

- usually not required

 

Types

- Staph 60-70%

- Streptococcus

- Gonococcus > 12 years

- E Coli in neonates

- Atypicals (TB, Brucellosis)

 

X-ray

 

Initial xray normal

 

Later

- loss of disc height

- end plate irregularity & sclerosis

- disc can regain height, but endplate changes remain

 

MRI

 

Child may need sedation / GA

 

DDx

 

Tumour

- leukaemia, metastasis (vertebral)

- EG (vertebra planar)

- OO, OB

 

Epidural abscess

Paraspinal abscess

SI joint septic arthritis

 

Management

 

Antibiotics

 

Controversial as whether to treat with antibiotics or not

- most authors agree that there is a bacterial component to the process

- most recover with or without antibiotics

 

Appropriate ABx (broad spectrum)

- bed rest

- brace

 

Usually rapid response

- CT guided biopsy if fails to resolve with above 

 

Results

 

Kayser et al Spine 2005

- 25 patients with spondylodiscitis

- most had long delays to treatment due to non specific symptoms

- inflammatory markers usually only mildly elevated

- 48% had evidence of vertebral body destruction

- 60% healed with disc narrowing, 40% with fusion

 

Garron et al J Paediatr Orthop 2002

- 35 needle aspirations of the disc

- 55% Staph

- 27% Kingella Kingae