It has been recognized for decades in the pedi-atric population, with consistent dis-agreement as to the etiology and op-timal treatment.1-14 Diskitis is now generally accepted as a bact
Trang 1Sean D Early, MD, Robert M Kay, MD, and Vernon T Tolo, MD
Abstract
Childhood diskitis represents one end
of a continuum of spinal infections,
from diskitis to vertebral
osteomyeli-tis with soft-osteomyeli-tissue abscess It has been
recognized for decades in the
pedi-atric population, with consistent
dis-agreement as to the etiology and
op-timal treatment.1-14 Diskitis is now
generally accepted as a bacterial
in-fection involving the disk space and
adjacent vertebral end plates
Opti-mal management requires the use of
intravenous antibiotics Bracing does
not seem to improve the clinical
course but may be indicated with
ver-tebral involvement to decrease pain
and minimize deformity Biopsy is
not necessary for patients who
exhib-it all of the clinical characteristics, but
it is indicated for those whose
symp-toms do not resolve rapidly with
treatment or who have atypical
pre-sentation
The unique anatomy of the
pedi-atric spine has implications for the
etiology and pathophysiology of
dis-kitis To effectively diagnose and treat patients with diskitis, familiarity with its unique presentation is necessary
to differentiate it from classic osteo-myelitis and other entities with sim-ilar symptoms
Pathogenesis
As with other pediatric musculo-skeletal infections, the most common cause of diskitis is the hematogenous spread of infection Preceding or con-comitant infections, such as otitis me-dia, urinary tract infections, and re-spiratory infections, are common
Wiley and Trueta15showed that nu-trient arteries are a more direct route for the spread of disease to the ver-tebral column than is the paraverte-bral venous system They proposed that pyogenic infections of the spine result from septic emboli in the arte-rial system This is similar to the patho-physiologic development of
meta-physeal osteomyelitis in pediatric long bone infections Although rare, direct inoculation (after trauma or sur-gery) or contiguous spread from an adjacent infection can cause diskitis
in children
As in adults, the intervertebral disk
is avascular in children However, unique anatomic features of the de-veloping motion segment predispose the pediatric spine to disk space in-fections rather than to vertebral os-teomyelitis The disk is located be-tween the hyaline cartilage end plates covering the adjacent immature ver-tebral bodies The cartilaginous plates contain numerous canals that act as channels through which small vessels travel and terminate adjacent to the intervertebral disk.16-18These vascu-lar channels appear before the 16th week of gestation and persist until the ring apophyses fuse in the third
de-Dr Early is Assistant Professor, Division of Or-thopaedic Surgery, Childrens Hospital Los Ange-les and University of Southern California–Keck School of Medicine, Los Angeles, CA Dr Kay is Assistant Professor, Division of Orthopaedic Sur-gery, Childrens Hospital Los Angeles and Uni-versity of Southern California–Keck School of Medicine Dr Tolo is Professor and John C Wil-son Chair of Orthopaedic Surgery, Childrens Hos-pital Los Angeles and University of Southern Cal-ifornia–Keck School of Medicine.
None of the following authors or the departments with which they are affiliated has received anything
of value from or owns stock in a commercial com-pany or institution related directly or indirectly
to the subject of this article: Dr Early, Dr Kay, and Dr Tolo.
Copyright 2003 by the American Academy of Orthopaedic Surgeons.
Childhood diskitis may occur in the thoracic, lumbar, or sacral spine and can affect
children of all ages, but it is most common in the lumbar region in children younger
than 5 years Physical examination, laboratory tests, and radiologic studies all aid
in the diagnosis of this clinical syndrome, and proper use can prevent unnecessary
invasive intervention Presentation varies with age; the child may refuse to bear
weight on the lower extremities or may present with back pain, abdominal pain, a
limp, or, if an infant or toddler, with irritability The etiology appears to be a
bac-terial infection, usually caused by Staphylococcus aureus Most children improve
rapidly with a 4- to 6-week course of antibiotics Although not routinely necessary,
immobilization decreases symptoms and, in the case of osseous destruction, prevents
progression of spinal deformity Biopsy of the infected disk space is reserved for
chil-dren refractory to intravenous antibiotics Follow-up should include plain
radio-graphs at regular intervals for 12 to 18 months to ensure resolution of the
destruc-tive process.
J Am Acad Orthop Surg 2003;11:413-420
Trang 2cade of life The vascular channels
ap-pear to be an important source of
nu-trition for the developing disk but
also can deliver blood-borne bacteria
to the disk during periods of
bacter-emia.19Because of the relative
avas-cularity of the intervertebral disk,
bac-teria that reach the disk are relatively
free from the immune system and are
more likely to flourish
Differences in the vascular
anato-my of the vertebral bodies in children
and adults20result in differences in
spinal infections between pediatric
and adult populations Infants and
small children have widespread
anas-tomoses between intraosseous
arter-ies of the vertebral body; the
anasto-moses decrease notably by age 15
years and disappear by adulthood
These intraosseous anastomoses
de-crease the risk of vertebral body
in-farction and simultaneously enhance
the clearance of bacteria after a
sep-tic embolus in a pediatric
metaphys-eal artery This enhanced collateral
circulation in the young child
there-by decreases the risk of pyogenic
ver-tebral body infection
Bacteria that reach the immature
motion segment through
hematoge-nous spread can be deposited in the
vertebral body, hyaline cartilage
plate, or disk.19Because of the
redun-dant vascular supply in the childhood
vertebral body, infarction and
subse-quent vertebral osteomyelitis are less
likely than they would be in adults
Instead, bacteria are more likely to be
deposited at the superior or inferior
metaphyseal equivalent, which is
ad-jacent to the vertebral end plate.18
These bacteria then may travel
through the arterioles and sinusoidal
capillaries of the cartilage canals, to
be deposited at either the avascular
disk or the adjacent vertebral body
Should septic emboli result in
oc-clusion of these cartilage canals,
bac-teria may reside relatively free from
host defense mechanisms in the
avascular disk, and infection may
develop The adjacent vertebral
bod-ies often are spared because of their
hyaline cartilage–capped end plates and abundant intraosseous blood supply With infection of the disk space, the normal stiffness of the an-ulus fibrosus may be altered by deg-radation from bacterial and host de-fense enzymes, resulting in the characteristic disk space narrowing seen on plain radiographs (Fig 1)
As the infection progresses over a period of weeks, the hyaline carti-lage covering the end plates may be eroded, thus allowing the infection
to reach the bony vertebral end plates A sawtooth pattern of end plate destruction is then evident on radiographs (Fig 2) At this point, greater blood flow reaches the site of infection through the redundant in-traosseous network of the vertebral body, resulting in either resolution
of the infection by the body’s de-fense mechanisms or progression to classic vertebral osteomyelitis and possibly soft-tissue abscess
Evaluation History
The history and clinical presenta-tion of childhood diskitis are variable Frequently, the family reports an an-tecedent or concurrent illness (viral
or bacterial) and a confounding his-tory of trauma The duration of symp-toms is quite variable, from hours to weeks Although involvement of the lumbar spine is the most common clinical scenario in children younger than 5 years, back pain is a present-ing complaint in only 50% of children with diskitis.6Children younger than
3 years often present acutely with a limp or refusal to bear weight on the lower extremities.6 If diskitis is not promptly recognized and treated, it may progress to the point that the child is uncomfortable in all positions except when lying supine The child between the ages of 3 and 8 years also frequently avoids activity but
com-Figure 1 Posteroanterior (A) and lateral (B) radiographs of a 3-year-old girl with a 2-week
history of irritability and refusal to walk for 2 days The disk space narrowing at L3-4 is con-sistent with diskitis.
Trang 3plains of vague abdominal or back
pain more often than would a
young-er child Although oldyoung-er children and
teenagers occasionally present with
diskitis, vertebral osteomyelitis is
more common This age group also
may complain of abdominal
symp-toms but usually can localize the pain
to the thoracolumbar or lumbar spine
They may complain of buttock and
leg pain as a result of nerve root
ir-ritation
Physical Examination
Low-grade fever may be present;
however, most children with diskitis
do not appear to be acutely ill
Young-er children may refuse to ambulate
and may demonstrate irritability of
the hip, but not to the degree that
would be compatible with septic
ar-thritis Assessment of all limping
chil-dren must include spinal
examina-tion Local tenderness is common,
and the thoracic, lumbar, and sacral
regions must be palpated
Paraverte-bral muscle spasm, decreased range
of motion of the spine, and hamstring tightness are common A positive straight leg raise may be seen; how-ever, most children do not have find-ings on neurologic examination Chil-dren who will walk may show loss
of normal, fluid spinal motion and may keep the back stiff and rigid
When asked to pick up an object from the floor, the young child may bend the knees and squat while keeping the back straight
Laboratory Tests
In cases of suspected diskitis, as with other pediatric musculoskeletal infections, laboratory examination should include a complete blood count with differential blood cell count, blood cultures, erythrocyte sedimentation rate (ESR), and C-reactive protein level (if avail-able).21The white blood cell count is often in the high normal range, al-though the child may have a left shift
and/or mild leukocytosis.11 Blood cultures should be obtained, partic-ularly if the child is febrile.8The ESR will be elevated in nearly all patients, consistent with a chronic inflamma-tory or infectious process.7,8,22 The C-reactive protein level is helpful, es-pecially in early infections, and can
be used to follow the effect of initial antibiotic therapy The purified pro-tein derivative skin test for tubercu-losis also should be done with con-trols, especially for children with disk space narrowing or vertebral end plate erosions on plain radio-graphs.23,24
Radiography
The initial radiologic workup should consist of plain radiographs
In the patient with acute onset of dis-kitis, initial radiographs will not dem-onstrate osseous changes, although there may be a loss of normal lum-bar lordosis When symptoms have been present for 1 week or more, plain radiographs also may reveal isolated intervertebral disk space narrowing, and by 3 to 4 weeks may show saw-tooth erosion of adjacent vertebral end plates.25,26Scalloping of the su-perior and inferior vertebral body may be seen with long-standing in-fections Vertebra magna with resul-tant canal narrowing, permanent loss
of disk height, or block vertebra caused by spontaneous disk space fu-sion may be noted in patients with re-solved infections (Fig 3)
For continued clinical suspicion in the absence of changes on plain ra-diographs, technetium Tc 99m (99mTc)– labeled bone scan can isolate the area
of pathology to a specific motion seg-ment and help confirm the diagno-sis This is especially useful for young children in whom localization of the involved area can be extremely dif-ficult by physical examination alone Scintigraphic changes may appear as early as 3 to 5 days after the onset of clinical symptoms, well before any changes would be seen on plain ra-diographs No additional radiologic
Figure 2 Posteroanterior (A) and lateral (B) radiographs of a 19-month-old boy with a 4-week
history of refusal to walk Note the L4-5 end plate erosion (arrow), early vertebral body
scal-loping (arrowheads), and disk space narrowing.
Trang 4studies except plain radiographs are
necessary in patients with
character-istic bone scan findings.23,27
In patients whose symptoms and
findings clearly localize to a specific
area of the spine, bone scan can be
omitted in favor of more advanced
imaging Computed tomography
(CT) scans may show bony end plate
erosion but otherwise do not add
much value to management
deci-sions.14Magnetic resonance imaging
(MRI) (Fig 4) is more useful because
it allows excellent visualization of
the disk, neural tissues, surrounding
soft tissues, and pathophysiologic
changes in the vertebral body.25,28-34
MRI is more sensitive than nuclear
studies or CT scan in detecting
dis-kitis, helps differentiate diskitis from
classic vertebral osteomyelitis, and
can detect paraspinal or epidural
ab-scesses This may help reduce
diag-nostic delay while also guiding the
extent and duration of treatment18,24
(Fig 5) Fernandez et al13studied 50
patients with spinal infection, 36 of whom had diskitis Of the 33 patients with diskitis who had radiographs of the spine, 25 (76%) had plain radio-graphic abnormalities at initial eval-uation Of the 30 children who un-derwent 99mTc bone scan, 27 (90%) demonstrated increased marker up-take at the affected area Nine of 10 children also showed MRI abnormal-ities consistent with diskitis The au-thors recommended nuclear bone scanning in very young children in whom localization of the inflamma-tory process is uncertain by physical examination and MRI in children with suspected diskitis who do not display characteristic radiographic changes
Although MRI is more sensitive than other radiologic modalities at detecting diskitis, its use rarely alters treatment MRI is used to evaluate children who present with either a sagittal or coronal spinal deformity, who have no plain radiographic or
bone scan abnormality, or who do not improve after 2 to 3 days of
parenter-al antibiotic therapy In such patients, MRI allows detection of conditions that may require surgical interven-tion, such as soft-tissue abscess, bone destruction, and involvement of neu-rologic elements MRI also can be use-ful in the thoracic spine, where inter-pretation of plain radiographs may prove to be difficult
Differential Diagnosis
The differential diagnosis of a child with irritability and back pain in-cludes a number of noninfectious eti-ologies Scheuermann’s kyphosis may manifest as back pain in adoles-cents Schmorl’s nodes are often present on plain radiographs, espe-cially in children with lumbar spine involvement Patients with metastatic tumor and leukemia tend to have ver-tebral body involvement rather than end plate erosion on plain radio-graphs These changes often occur at multiple levels throughout the spine Vertebra plana, secondary to eosino-philic granuloma, is characteristic on radiographs Osteoid osteoma and osteoblastoma most commonly in-volve the posterior elements of the spine
In a child with fever and elevated laboratory test results, other etiologies
of infection must be considered Sep-tic arthritis of the sacroiliac joint may clinically mimic diskitis It can be dif-ferentiated with careful palpation, use
of the flexion, abduction, and exter-nal rotation (FABER) maneuver, and characteristic bone scan findings Destructive pyogenic osteomyelitis, which may be the sequela of long-standing untreated diskitis, may lead
to vertebral body destruction and seg-mental collapse In acutely ill chil-dren, or those with neurologic or meningeal signs, paraspinal or epidu-ral abscess must be ruled out by MRI evaluation Infections secondary to brucellosis, fungal species, or tuber-culosis are indolent and rarely cause acute symptoms Steplike vertebral
Figure 3 Posteroanterior (A) and lateral (B) radiographs of the patient in Figure 2, 5 years
after presentation Note the extreme narrowing of the disk space with near formation of a
block vertebra The patient was asymptomatic.
Trang 5body erosions and elevated Brucella
titers (>1:80) are characteristic of
bru-cellosis Fungal infections secondary
to species of Aspergillus or
Cryptococ-cus generally affect
immunocompro-mised patients Tuberculosis more
commonly affects the thoracic and
lumbar spine and is usually
accom-panied by slowly progressive
consti-tutional symptoms The infection
characteristically tunnels below the
anterior and posterior longitudinal
ligaments, initially sparing the disk
spaces Apositive purified protein
de-rivative skin test or characteristic
chest radiograph findings may be
seen early in the disease process
be-fore spinal deformity occurs Back
pain usually occurs late in
tubercu-lous infections, after bony collapse
be-comes evident on plain radiographs
(Fig 6)
Biopsy
Positive cultures have been
report-ed in approximately 60% of patients
undergoing biopsy for suspected
dis-kitis, with Staphylococcus aureus the
most commonly isolated organ-ism.2,4,6,7,14,29 These low yields are compatible with biopsy results in pe-diatric acute hematogenous osteomy-elitis and septic arthritis They are most likely the result of confounding factors, such as inadequate sampling, culture technique, previous
antibiot-ic treatment, or brisk host response
to a pathogen of low virulence,
rath-er than a noninfectious
etiolo-gy.19,24,35,36Chew and Kline37
report-ed positive cultures in 39 of 43 patients who underwent CT-guided percutaneous disk space aspiration
However, the mean age of their pa-tients was 57 years, with no papa-tients younger than 13 years In five recent reports of pediatric disk space infec-tions, biopsy was not done in most patients, and only 37% (29/79) of the children who underwent biopsy had positive culture results.10,11,13,14,24 Because of the low yield, potential morbidity, and need for conscious se-dation or general anesthesia in the
young child, biopsy is not routinely recommended for the evaluation of the child with diskitis.12,19,21,24
Biop-sy should be reserved for patients who do not respond to empiric intra-venous antistaphylococcal antibiotics because an unusual or highly virulent organism may be present.8,19,24In such patients, CT-guided aspiration or core needle biopsy under general anesthe-sia with immediate Gram stain and frozen section analysis is preferred
If the specimen is nondiagnostic, open surgical biopsy is indicated to rule out neoplasm, fungal infection, brucellosis, tuberculosis, and non-staphylococcal pyogenic infections
Treatment
The goals of treatment are eradication
of infection and minimization of mor-bidity The variable responses to a myriad of treatment protocols in pre-vious studies of diskitis in the pedi-atric population have resulted in con-tinued confusion and discussion as to
Figure 4 A,Sagittal postcontrast T1-weighted MRI scan of the patient in Figure 1 Note the
increased uptake of contrast at the L3-4 disk space and adjacent vertebral bodies There is
no evidence of soft-tissue abscess or canal impingement B, Sagittal T2-weighted MRI scan.
Note the loss of normal signal intensity at the L3-4 disk and mild signal increase at the
ad-jacent vertebral bodies These findings are consistent with diskitis.
Figure 5 Sagittal T2-weighted MRI scan of the patient in Figure 2, 4 months after pre-sentation Note the decreased signal inten-sity at the L4-5 disk, consistent with resolved diskitis The child now walks normally.
Trang 6its underlying etiology Bed rest or
various modes of immobilization
have been almost universally
recom-mended, but debate existed
regard-ing the need for antibiotic therapy In
some series, no difference was found
between patients who received
anti-biotics and those treated with only
rest and immobilization.1,2,4,5,8,10,26
However, those series had few
pa-tients and sometimes followed
incon-sistent treatment algorithms Most
patients who did not improve after
weeks of rest and immobilization
were started on antistaphylococcal
antibiotics, at which time there was
often rapid clinical resolution
Al-though antibiotic therapy was
neces-sary for improvement in some
chil-dren, authors often concluded that no
apparent difference was seen between
patients who received antibiotics and
those who did not In other series,
nearly all patients were treated with
antibiotic therapy in addition to rest and immobilization because the au-thors believed diskitis to be of an in-fectious etiology.3,6,7,9,14,18,24,38 Diskitis is now accepted to be
a bacterial infection of the disk space and adjacent vertebral end plates.12,21The severity of the infec-tion likely depends on a dynamic in-terplay between the virulence of the infecting organism and the patient’s immunologic defenses.23,24 Relative rest or immobilization without anti-biotic therapy may be sufficient for se-lect immunocompetent children without virulent infection However,
in other children a delay in antibiotic therapy may lead to prolonged hos-pitalization, recurrent symptoms, and worsening infections Boston et al4 recommended antibiotics for any pa-tient with pain, compensatory scoli-osis, or persistently elevated ESR
Scoles and Quinn7recommended 7 to
10 days of intravenous antibiotics for all patients with high fever, extreme pain, or positive blood, sputum, throat, or urine cultures In most re-cently published reports, intravenous antibiotics are recommended as ini-tial management.11,14,18,23,24,36 Ring et al11analyzed a series of 47 patients Of the 38 nonimmobilized patients, 22 were treated with intra-venous antibiotics, 10 received oral antibiotics, and 6 received no antibi-otics Prolonged or recurrent symp-toms occurred in 9 of the 16 patients who did not receive intravenous an-tibiotics but in only 4 of the 22 patients treated with intravenous antibiotics
Seven patients were treated with im-mobilization Only one of five pa-tients treated with immobilization and intravenous antibiotics had a re-currence Both patients treated with immobilization alone developed re-current symptoms after immobiliza-tion was removed Thus, intravenous antibiotics were believed more likely
to lead to rapid resolution of symp-toms over 2 to 4 days without recur-rence than were oral antibiotics or no antibiotic therapy (The remaining 2
of the 47 patients required surgical drainage of paraspinal abscesses.)
It is difficult to initially separate children infected with organisms of low virulence from those infected with highly virulent bacteria The pre-sentation of disk space infection of-ten is benign and does not allow differentiation based on clinical char-acteristics The need for general an-esthesia, the low incidence of positive cultures from obtained specimens, and the potential risks of biopsy pre-clude the use of direct biopsy in ev-ery patient.11,14,24Thus, to allow
rap-id healing and prevent complications from worsening infection, all patients should receive intravenous antibiot-ics once the diagnosis of diskitis is es-tablished Empiric coverage is
direct-ed against S aureus because it has been
the most common organism isolated from culture-positive biopsy speci-mens
There are no absolute recommen-dations to guide duration of antibi-otic treatment Initial treatment is with parenteral antibiotics, with a change
to oral antibiotics when there is clin-ical and laboratory evidence of patient response to antibiotic therapy The rec-ommended duration of parenteral an-tibiotics ranges from 1 to 8 weeks, while oral antibiotics may be continued for
as long as 3 to 6 months.11,13,18,19,24The C-reactive protein level improves more rapidly than the ESR in response to appropriate initial antibiotic therapy and can help guide the duration of antibiotic treatment Typical duration
of antibiotic therapy should be between
4 and 6 weeks, with parenteral anti-biotics administered for 1 to 2 weeks, followed by oral antibiotics for a to-tal course of 4 to 6 weeks If compli-ance with oral antibiotics is unlikely, parenteral antibiotics may need to be administered for the duration of an-tibiotic treatment
Relative rest and immobilization with a lumbosacral corset or thora-columbosacral orthosis may be used
in conjunction with antibiotics to im-prove comfort A thoracolumbosacral
Figure 6 Lateral radiograph of a 15-year-old
girl with a 2-year history of tuberculous
in-fection of the spine and progressive kyphotic
deformity She had no pain despite near
com-plete destruction of the L1 vertebral body and
76° of focal kyphosis.
Trang 7orthosis is recommended if, on
imag-ing studies, sagittal or coronal
defor-mity of the spine exists or if extensive
bony destruction and soft-tissue
in-volvement are evident
Surgical débridement should be
considered only in the rare patient
with a documented abscess who is
systemically ill or has an evolving
neurologic deficit In light of clinical
improvement with antibiotic therapy,
MRI findings of paraspinal fluid
col-lection do not necessitate surgical
débridement However, drainage
may be necessary if clinical
improve-ment does not occur.14,24
Follow-up
After resolution of symptoms with
antibiotic treatment, patients are
fol-lowed for 12 to 18 months
Recur-rence of symptoms, although rare
af-ter a 4- to 6-week course of antibiotics,
should prompt the treating physician
to obtain new radiographs, a
com-plete blood count, C-reactive protein
level, and ESR In general, C-reactive
protein level and ESR should
grad-ually return to normal predisease
lev-els; a rise in these levels may indicate
recurrent infection
Periodic plain radiographs will
show continued residual disk space
narrowing.18With disease resolution,
partial reconstitution of the disk
height may gradually occur, but
reconstitution is rarely complete18
(Fig 7) Vertebra magna, with
resul-tant canal narrowing, or block
verte-bra, from spontaneous fusion, also
may be seen.9
MRI is rarely needed but can be done if extensive bony destruction or soft-tissue involvement occurred in conjunction with the disk space infec-tion MRI findings are not acutely af-fected by antibiotic therapy
Howev-er, after complete resolution, there is
a return to normal signal with a de-creased disk width on T1-weighted images Anormal vertebral body with low disk signal will be seen with T2-weighted imaging.28,29
Summary
Despite previous controversy regard-ing etiology and treatment, childhood diskitis is now accepted to be a pyo-genic infection of the disk space and
bony vertebral end plates Clinical presentation varies depending on the age of the child, but characteristic findings on physical examination, laboratory studies, plain radiographs, and bone scan make early diagnosis possible Early diagnosis can prevent unnecessary testing and invasive in-tervention Intravenous antibiotic therapy, empirically directed against
S aureus, is the mainstay of treatment.
With clinical resolution, a switch to oral antibiotics is appropriate, for a total antibiotic course of 4 to 6 weeks Immobilization and rest may be
add-ed for symptomatic relief Follow-up should continue for 12 to 18 months after healing Biopsy and surgery are reserved for patients refractory to in-travenous antibiotic therapy
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