Recommendations for diagnosis and treatment of spondylodiscitis

Spondylodiscitis, also known as vertebral osteomyelitis, is a destructive disease with high morbidity and mortality. Diagnosis is often delayed because of the rarity of the disease and the fact that early symptoms are often non-specific. There are currently no national guidelines on the diagnosis and treatment of spondylodiscitis in the Netherlands. We performed a single-centre retrospective cohort study examining 49 patients over 18 years of age treated for spondylodiscitis in a six-year time period. Mean age of patients was 69 years (range 40-89). Most patients underwent an MRI scan to confirm diagnosis (n=30). In 39 patients a microorganism was found, most commonly Staphylococcus aureus (n=14), Streptococcus species (n=11) and Gram-negative bacteria (n=11). All patients were treated with antibiotics. Thirty-seven patients received antibiotic treatment for at least six weeks, while 17 patients were treated for 90 days or longer. In 13 patients no adequate treatment was started until culture results were available. Eleven patients underwent surgery after their diagnosis. Two patients had a recurrence. We recommend that, when considering spondylodiscitis as a possible diagnosis, all patients should undergo thorough physical examination, neurological screening, blood tests for infection and blood cultures. An MRI scan should be performed, followed by a PET-CT scan when results are inconclusive. Ideally a CT-guided biopsy is performed before treatment is started. Awaiting culture results all patients should receive broad-spectrum antibiotics. Targeting only Gram-positive microorganisms in empiric treatment will lead to a delay in adequate treatment in a substantial group of patients. A multidisciplinary approach is advocated.