With an incidence of 1:250,000, spondylodiscitis is a rare inflammatory infection of the intervertebral disc involving the adjacent vertebral bodies. Men are more commonly affected by spondylodiscitis than women, with an average ratio of 3:1, and the peak age is generally between 50 and 70 years of age.
What is spondylodiscitis?
Spondylodiscitis is the name given to a rare inflammation of the intervertebral disc space and adjacent vertebral bodies, most often due to a bacterial infection. The disease is assigned to the spectrum of osteomyelitides (bone or bone marrow inflammations). Spondylodiscitis is often characterized by an initial non-specific symptomatology, which is why in many cases the disease is only diagnosed after two to six months. In general, a distinction is made between endogenous and exogenous spondylodiscitis depending on the underlying cause. In endogenous spondylodiscitis, the triggering site of infection is located in structures remote from the vertebral body, from which the pathogens colonize one or more vertebral bodies via hematogenous spread (via the bloodstream), often affecting the ventral spinal segments. In contrast, exogenous spondylodiscitis is caused by injections near the vertebral body or surgical procedures, among other causes.
Causes
In most cases, spondylodiscitis can be attributed to a primary infection of the intervertebral disc by bacteria, fungi, or, in rare cases, parasites, although bacterial colonization is most commonly present. The most common bacterial pathogens are Staphylococcus aureus (30 to 80 percent) and Escherichia coli. In addition, spondylodiscitis is associated with inflammatory rheumatic diseases such as rheumatoid arthritis or ankylosing spondylitis, exposure to chemical noxae, for example in the course of enzymatic chemonucleolysis, and in rare cases with lumbar disc surgery (between 0.1 and 3 %). The pathogens endogenously or exogenously infect the intervertebral disc and spread to the adjacent vertebral bodies, where they cause destructive processes to the bone tissue. Endogenous spondylodiscitis is caused in many cases by tuberculosis, which also manifests itself later in the skeleton or spine (tuberculous spondylodiscitis).
Symptoms, complaints, and signs
Spondylodiscitis, or inflammation of the intervertebral discs, is manifested by very different symptoms and courses. Decisive for the symptomatology is the location and cause of the inflammation. Thus, in addition to completely inconspicuous courses, there are also life-threatening septic courses of the disease. In the beginning, there are generally hardly any symptoms, so that spondylodiscitis usually remains undetected at first. This may be followed by a phase in which rapidly worsening pain develops. The pain is usually local to the affected area. These are pressure or tapping pains that intensify with exertion. Pain in the cervical spine often radiates into the neck and arms. When there is inflammation in the lumbar spine, the pain often radiates to the legs. The mobility of the spine is severely limited. If the inflammation extends, the pain is no longer localized but affects the entire back. The most common form of spondylodiscitis is caused by a bacterial infection. In the context of bacterial spondylodiscitis, in addition to the typical pain, there is also fever, fatigue and pain in the limbs, i.e. signs of a general infection. In rare cases, neurological deficits, paralysis and severe irritation of the nerve roots are also possible in spondylodiscitis. The nerve root irritations aggravate the overall pain situation in the body. They cause the pain to be felt even more acutely outside the actual source of pain in other areas of the body.
Diagnosis and course
Suspicion of the presence of spondylodiscitis results from characteristic clinical symptoms, such as tapping, heel drop, and compression pain with little to no pressure pain, relieving posture, and pain during uprighting and during inclination (bending forward). The diagnosis is confirmed by imaging techniques (X-ray, CT, MRI), which also allow an evaluation of the spinal changes as well as the inflammatory processes.In addition, the inflammatory markers in the serum (including CRP, leukocytes) and the erythrocyte sedimentation rate (ESR) are elevated, especially in acute courses. The differential diagnosis of spondylodiscitis should be differentiated from erosive osteochondrosis, tumor-related destruction, ankylosing spondylarthritis, and Scheuermann’s disease, among others. If left untreated, spondylodiscitis can present with severe symptoms and a vital threatening course (about 70 percent). If left untreated, spondylodiscitis can also lead to immobility, pseudarthrosis, deformity and a chronic pain syndrome. The prognosis for spondylodiscitis depends on the severity of the disease. Thus, in many cases, especially with progressive destruction of the vertebral bodies, posttherapeutic complaints (including motor deficits, hypesthesias) can be observed.
Complications
Spondylodiscitis primarily causes severe pain in the affected person. In most cases, these occur in the form of pressure pain. However, they can also occur in the form of pain at rest, negatively affecting the affected person’s sleep. Patients may suffer from sleep disturbances and thus possibly from depression or other psychological upsets. Similarly, spondylodiscitis may cause fever and general fatigue and exhaustion in the patient. Some sufferers also lose weight and may suffer from night sweats. The patient’s quality of life is honestly limited and reduced by spondylodiscitis. Treatment of this disease is usually without complications. With the help of medications, the discomfort can be very well limited and the infection can be alleviated. However, painkillers should not be taken for a long period of time, as they can damage the stomach. In severe cases, spondylodiscitis can also lead to blood poisoning, which can result in the death of the affected person. However, successful treatment will not negatively limit or reduce the patient’s life expectancy.
When should you see a doctor?
A doctor is needed if there are limitations in movement, pain in the limbs, or signs of paralysis. Pain, disturbances in sensitivity, fever, as well as fatigue are other complaints that need to be examined and treated. General malaise, a decrease in physical as well as mental performance and irritability are indications of spondylodiscitis. A doctor must be consulted to establish the diagnosis. Subsequently, an individual treatment plan is drawn up based on the existing complaints. If pain is present, a painkilling medication should not be taken on one’s own responsibility under any circumstances. To avoid risks and side effects, consultation with a medical professional should be sought beforehand. If light tapping or pressing on the affected area leads to a significant increase in discomfort, further investigations are necessary to clarify the cause. Gait unsteadiness, an increased risk of accidents, and avoidance of movement indicate a disease. If behavioral abnormalities or emotional irregularities also occur, the observations should be discussed with a physician. Since spondylodiscitis can lead to blood poisoning in severe cases, there is a potential danger to life. Any internal heat sensation or spread of existing abnormalities should be presented to a physician as soon as possible. Sweating or sleep disturbances are common symptoms of the disease, as are mood swings or faintness. It is advisable to consult a physician immediately.
Treatment and therapy
Therapeutic measures for spondylodiscitis primarily include sufficient immobilization (including orthoses and/or bed rest) and sparing of the specifically affected spinal segment, as well as antibiotic, antifungal, or antiparasitic therapy. The basis for the treatment of bacterial spondylodiscitis is the detection of the specific pathogen, which can be done by blood culture or (intraoperative) biopsy, and the resistogram or antibiogram.In the case of pronounced acute spondylodiscitis, broad-spectrum antibiotic therapy can be started even before the resistogram is available, although this should take into account the most likely pathogens (Staphylococcus aureus, Escherichia coli). In this case, antibiotics are applied intravenously or parenterally (bypassing the intestine) for the first two to four weeks. If the inflammation parameters have normalized and the patient’s general condition has improved, it is usually possible to switch to oral administration. In high-risk groups, prolongation of antibiotic therapy is recommended. If the spondylodiscitis is caused by a mycotic or parasitic infection, antifungal or antiparasitic therapy is used analogously. In parallel, pain symptoms should be treated with analgesics (painkillers). If sepsis, neurologic deficits, instabilities, and/or potential deformities can be detected in the affected spinal segments or if the therapeutic success of conservative measures remains unsuccessful, surgical intervention to remove the focus of infection causing the spondylodiscitis (debridement) and stabilization of the affected spinal segment (span interposition) may be indicated.
Prevention
Spondylodiscitis can be prevented by adequate therapy of infectious diseases. Diabetes mellitus, renal insufficiency, obesity, tumors, tuberculosis, systemic diseases, drug abuse, cardiovascular diseases, and HIV are considered predisposing factors and should be treated accordingly at an early stage and consistently to prevent spondylodiscitis.
Follow-up
Since spondylodiscitis cannot heal on its own, the affected person should primarily see a doctor early on to prevent the occurrence of other complaints and complications. In many cases, aftercare measures are significantly limited or are not even available to those affected. In most cases, spondylodiscitis requires the use of various medications to limit and completely alleviate the symptoms. The affected person should always pay attention to a correct dosage and also to a regular intake in order to properly counteract the symptoms. If there are any uncertainties or questions, a doctor should always be consulted first. The doctor should also be consulted in the event of severe side effects. When taking antibiotics, it should be noted that they should not be taken together with alcohol, so as not to impair the effect. Furthermore, regular check-ups by a doctor are very important even after successful treatment. Spondylodiscitis does not usually reduce the life expectancy of the affected person.
What you can do yourself
The acute phase often exceeds a period of 8 weeks, regardless of whether conservative or surgical treatment is sought. During this time, absolute bed rest must be maintained. The patient should therefore learn to use a stabilizing trunk orthosis as soon as possible in order to be able to change position in bed autonomously. Furthermore, the use of a bedpan and eating in the lateral position should be learned, because prolonged sitting and bent postures are absolutely contraindicated. Positioning pillows for spinal relief must be tucked under the legs at regular intervals in the supine position. In addition, daily control of the skin for pressure points and developing decubital ulcers on the part of the patient or the nursing staff is obligatory. After the acute phase, a permanent adaptation to the changed physiological movements and restrictions begins for most people. For this purpose, it is necessary to strive for optimal pain management with medication, physiotherapy and physical measures. If necessary, an adaptation of the workplace is necessary, for example by changing the desk to a standing-sitting desk. In addition to weight adjustment, pain- and phase-adapted exercise to build muscle in the back and abdomen should be focused on. A back-friendly redesign of everyday life means, for example, that no loads over 5 kg should be lifted, no shoes with heels should be worn and no mattress with a raised headboard should be chosen.
