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