SCIENCE AND INNOVATION IN THE
EDUCATION SYSTEM
International scientific-online conference
10
ADVANCEMENTS IN DIAGNOSIS AND SURGICAL MANAGEMENT OF
THORACIC AND LUMBAR SPONDYLODISCITIS: A COMPREHENSIVE
REVIEW
Mardonov J.J.
Gafarov J.S.
https://doi.org/10.5281/zenodo.11112592
Introduction.
Spondylodiscitis, a term encompassing vertebral
osteomyelitis and discitis, represents a challenging infectious condition affecting
the thoracic and lumbar spine. This pathology involves inflammation and
infection of the vertebral bodies and intervertebral discs, leading to significant
clinical implications. Understanding the impact of spondylodiscitis on the
thoracic and lumbar spine is essential for appreciating the importance of
improving its diagnosis and surgical treatment.
Spondylodiscitis poses substantial challenges due to its potential to cause severe
spinal deformity, neurological deficits, and systemic complications. The thoracic
and lumbar spine regions are particularly susceptible to spondylodiscitis, given
their weight-bearing function and vulnerability to mechanical stress.
Consequently, spondylodiscitis can result in debilitating symptoms such as
severe back pain, radiculopathy, spinal cord compression, and even paralysis if
left untreated.
Given the significant morbidity associated with spondylodiscitis, there is a
pressing need to enhance its diagnosis and surgical treatment to achieve better
patient outcomes. Timely and accurate diagnosis is crucial for initiating
appropriate management strategies and preventing long-term complications.
Similarly, surgical intervention plays a pivotal role in the management of severe
cases of spondylodiscitis, aiming to eradicate infection, restore spinal stability,
and alleviate symptoms.
Current State of Diagnosis and Surgical Treatment
The diagnosis of spondylodiscitis typically involves a combination of clinical
evaluation, imaging studies, and laboratory tests. However, accurate diagnosis
remains challenging due to nonspecific symptoms, variable imaging findings,
and the overlap with other spinal pathologies. Imaging modalities such as X-
rays, magnetic resonance imaging (MRI), computed tomography (CT), and
nuclear imaging techniques play essential roles in detecting characteristic
changes associated with spondylodiscitis, including vertebral bone destruction,
disc space narrowing, and paraspinal soft tissue involvement.
SCIENCE AND INNOVATION IN THE
EDUCATION SYSTEM
International scientific-online conference
11
Surgical treatment options for spondylodiscitis include debridement,
decompression, fusion, and instrumentation, aiming to eradicate infection,
restore spinal stability, and alleviate symptoms. While surgery is often indicated
for severe cases or those refractory to conservative management, it carries
inherent risks, including perioperative complications, hardware failure, and
recurrent infection.
Challenges and Limitations
Despite advancements in diagnostic imaging and surgical techniques, several
challenges and limitations persist in the management of spondylodiscitis. These
include:
Diagnostic Delays: Delayed diagnosis is common due to nonspecific symptoms
and the lack of specific biomarkers for spondylodiscitis. This delay can lead to
the progression of infection, increased morbidity, and treatment failure.
Inadequate Imaging Sensitivity: Conventional imaging modalities may lack
sensitivity in detecting early or subtle changes of spondylodiscitis, leading to
diagnostic uncertainty and delayed intervention.
Risk of Surgical Complications: Surgical treatment carries risks of perioperative
complications, including wound infection, neurologic injury, and implant failure.
In addition, the complexity of spinal anatomy and the proximity to vital
structures pose technical challenges during surgery.
Incomplete Infection Eradication: Despite surgical debridement and
antimicrobial therapy, achieving complete eradication of infection can be
challenging, leading to persistent or recurrent disease.
Need for Advancements in Diagnosis and Surgical Techniques
There is a pressing need for advancements in the diagnosis and surgical
treatment of spondylodiscitis to address these challenges and improve patient
care. This includes the development of more sensitive and specific diagnostic
tests, such as novel imaging techniques or biomarkers, to facilitate early and
accurate diagnosis. Additionally, advancements in minimally invasive surgical
techniques and targeted antimicrobial therapy may help minimize surgical
morbidity and optimize treatment outcomes.
Epidemiological Data:
Spondylodiscitis, though relatively uncommon compared to other infectious
diseases, poses significant morbidity and healthcare burden. While precise
epidemiological data may vary across regions and populations, spondylodiscitis
affects individuals of all ages, with a higher incidence reported in older adults
SCIENCE AND INNOVATION IN THE
EDUCATION SYSTEM
International scientific-online conference
12
and those with predisposing factors such as immunosuppression, diabetes
mellitus, intravenous drug use, or spinal instrumentation.
Incidence rates of spondylodiscitis vary widely, ranging from 2 to 7 cases per
100,000 person-years in the general population. However, certain
subpopulations, such as elderly individuals or patients with comorbidities, may
have higher incidence rates. Thoracic and lumbar spine involvement accounts
for the majority of spondylodiscitis cases, with the lumbar spine being the most
commonly affected region due to its increased mobility and mechanical stress.
Clinical Manifestations and Symptoms:
The clinical presentation of spondylodiscitis can vary widely and may mimic
other spinal pathologies, making diagnosis challenging. Common clinical
manifestations and symptoms of spondylodiscitis include:
Localized Back Pain: Persistent, insidious onset of back pain is the hallmark
symptom of spondylodiscitis. The pain is often localized to the affected spinal
segment and may worsen with movement or weight-bearing activities. Unlike
mechanical back pain, pain due to spondylodiscitis may not respond to rest or
conservative measures.
Fever and Systemic Symptoms: Patients with spondylodiscitis may present with
fever, chills, night sweats, and fatigue, particularly in cases of acute or systemic
infection. These systemic symptoms are more common in acute bacterial
spondylodiscitis and may be absent in chronic or indolent cases.
Neurological Deficits: Severe cases of spondylodiscitis can lead to spinal cord
compression or nerve root impingement, resulting in neurological deficits such
as weakness, sensory loss, or bladder/bowel dysfunction. Neurological
symptoms may indicate advanced disease and require urgent evaluation and
intervention.
Limited Spinal Mobility: Patients with spondylodiscitis may experience limited
range of motion of the spine, stiffness, or muscle spasms due to pain and
inflammation. Restricted spinal mobility may be more pronounced in acute
cases or those with significant vertebral involvement.
Localized Tenderness and Swelling: Upon physical examination, clinicians may
elicit localized tenderness over the affected spinal segment, along with signs of
inflammation such as erythema, warmth, or swelling. Paraspinal muscle spasm
and guarding may also be present.
Radicular Symptoms: In cases of nerve root compression, patients may
experience radicular symptoms such as shooting pain, numbness, or tingling
SCIENCE AND INNOVATION IN THE
EDUCATION SYSTEM
International scientific-online conference
13
radiating down the extremities, corresponding to the dermatomal distribution of
the affected nerve roots.
Overall, recognizing the typical clinical manifestations and symptoms of
spondylodiscitis is crucial for timely diagnosis and initiation of appropriate
management strategies. Early intervention can prevent complications, minimize
morbidity, and improve patient outcomes.
Diagnostic Modalities for Spondylodiscitis
Imaging Techniques:
X-ray (Radiography):
Strengths: X-rays provide a quick and cost-effective initial assessment of the
spine, allowing visualization of bony changes such as vertebral div destruction,
disc space narrowing, and bony sclerosis. They are readily available and useful
for serial monitoring.
Limitations: X-rays have limited sensitivity and specificity for detecting early or
subtle changes of spondylodiscitis, particularly in the early stages of the disease
or in cases with nonspecific radiographic findings. Soft tissue involvement and
early disc changes may not be adequately visualized.
Magnetic Resonance Imaging (MRI):
Strengths: MRI is the imaging modality of choice for diagnosing spondylodiscitis
due to its superior soft tissue contrast and multiplanar imaging capabilities. It
allows visualization of spinal cord, nerve roots, intervertebral discs, and
paraspinal soft tissues, facilitating early detection of infection and assessment of
disease extent.
Limitations: MRI may be contraindicated in certain patients (e.g., those with
metallic implants or severe claustrophobia) and is relatively expensive
compared to other imaging modalities. Additionally, MRI findings may not
always distinguish between infectious and non-infectious etiologies, requiring
correlation with clinical and laboratory findings.
Computed Tomography (CT) Scan:
Strengths: CT scan provides detailed visualization of bony structures and is
useful for assessing osseous changes such as vertebral div destruction, cortical
erosions, and spinal canal compromise. It can complement MRI findings and
provide additional information on bone density and cortical integrity.
Limitations: CT scan has limited soft tissue contrast compared to MRI, making it
less sensitive for detecting early soft tissue changes or subtle disc abnormalities.
It also involves ionizing radiation exposure, which may limit its use, especially in
pregnant patients or those requiring repeated imaging.
SCIENCE AND INNOVATION IN THE
EDUCATION SYSTEM
International scientific-online conference
14
Laboratory Tests:
C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR):
Strengths: CRP and ESR are acute-phase reactants that are commonly elevated
in cases of infection, including spondylodiscitis. They serve as sensitive markers
of inflammation and can aid in monitoring disease activity and response to
treatment.
Limitations: CRP and ESR are nonspecific markers and may be elevated in
various inflammatory and non-inflammatory conditions. Normal values do not
rule out spondylodiscitis, and false positives can occur in the presence of other
inflammatory disorders.
Blood Cultures:
Strengths: Blood cultures are essential for identifying the causative
microorganism in cases of bacterial spondylodiscitis, guiding antimicrobial
therapy selection. Positive blood cultures provide valuable diagnostic
information and may influence treatment decisions.
Limitations: Blood cultures have relatively low sensitivity in cases of chronic or
indolent spondylodiscitis, as the rate of bacteremia may be low. Negative blood
cultures do not exclude the diagnosis of spondylodiscitis, and cultures may be
negative in cases of culture-negative or fungal infections.
Conclusion.
Each diagnostic modality has its strengths and limitations in the
evaluation of spondylodiscitis. A multimodal approach combining clinical
assessment, imaging studies, and laboratory tests is often necessary for accurate
diagnosis and treatment planning. Imaging modalities such as MRI and CT scan
provide detailed anatomical information, while laboratory tests such as CRP,
ESR, and blood cultures offer supportive evidence of infection and inflammation.
Integration of findings from multiple diagnostic modalities allows for a
comprehensive evaluation of spondylodiscitis, facilitating timely and
appropriate management decisions.
References:
1.
Gouliouris, T., & Aliyu, S. H. (2010). Spondylodiscitis: update on diagnosis
and management. Journal of Antimicrobial Chemotherapy, 65(Suppl_3), iii11–
iii24. [doi: 10.1093/jac/dkq303]
2.
Akiyama, T., Chikuda, H., Yasunaga, H., Horiguchi, H., Fushimi, K., & Saita, K.
(2013). Incidence and risk factors for mortality of vertebral osteomyelitis: a
retrospective analysis using the Japanese diagnosis procedure combination
database. BMJ Open, 3(3), e002412. [doi: 10.1136/bmjopen-2012-002412]
3.
Kowalski, T. J., Berbari, E. F., Huddleston III, P. M., Steckelberg, J. M.,
Mandrekar, J. N., Osmon, D. R., & Wald, J. T. (2005). The management and
SCIENCE AND INNOVATION IN THE
EDUCATION SYSTEM
International scientific-online conference
15
outcome of spinal implant infections: contemporary retrospective cohort study.
Clinical Infectious Diseases, 15(40), 480-490. [doi: 10.1086/427524]
4.
Hu, B., Lin, T., Yan, S. G., Hu, Y. C., & Shi, J. G. (2019). Surgery versus non-
surgical treatment for thoracic and lumbar spine tuberculosis—a meta-analysis.
Acta Orthopaedica et Traumatologica Turcica, 53(6), 421-428. [doi:
10.1016/j.aott.2019.07.002]
5.
Schimmel, J. J., Horsting, P. P., de Kleuver, M., Wonders, G., van Limbeek, J.,
& Complications and recurrence after surgery for primary vertebral
osteomyelitis. European Spine Journal, 18(1), 100-105. [doi: 10.1007/s00586-
008-0863-4]
