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Vertebral osteomyelitis

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Updated 2023 SPLIF and 2021 ACR guidelines for the diagnosis and management of discovertebral infection.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of vertebral osteomyelitis are prepared by our editorial team based on guidelines from the European Society of Cardiology (ESC 2023), the French Society of Infectious Diseases (SPLIF 2023), the American College of Radiology (ACR 2021), the Infectious Diseases Society of America (IDSA/PIDS 2021), the European Association of Nuclear Medicine (EANM/ESNR/ESCMID 2019), ...
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Screening and diagnosis

Diagnosis: as per SPLIF 2023 guidelines, suspect discovertebral infection in patients with any of the following:
recent or worsening fever and spinal pain
spinal pain associated with bacteremia and/or elevated CRP levels
spinal pain associated with fever and/or elevated CRP levels
fever and/or spinal pain and/or an elevated CRP level and/or a scarring disorder following a percutaneous spinal or peri-spinal procedure.
E
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Diagnostic investigations

History and physical examination: as per IDSA 2015 guidelines, perform a pertinent medical and motor/sensory neurologic examination in patients with suspected native vertebral osteomyelitis.
B

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  • Inflammatory markers

  • Blood culture

  • Spinal imaging

  • Evaluation for endocarditis

  • Evaluation for tuberculosis

  • Evaluation for brucellosis

Diagnostic procedures

Biopsy and culture: as per SPLIF 2023 guidelines, perform a discovertebral biopsy to search for an infectious organism in patients with suspected discovertebral infection with sterile blood cultures.
E
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Medical management

Antimicrobial therapy, indications: as per SPLIF 2023 guidelines, evaluate for and treat an infectious source guided by the nature of the microorganism in case of a confirmed diagnosis of discovertebral infection.
E

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  • Antimicrobial therapy (regimens)

  • Antimicrobial therapy (duration)

  • Corticosteroids

Nonpharmacologic interventions

Patient positioning: as per SPLIF 2023 guidelines, do not offer strict dorsal decubitus in the initial phase of discovertebral infection if there are no clinical or radiological signs of spinal instability and the pain is under control.
D

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  • Immobilization

Surgical interventions

Indications for surgery: as per SPLIF 2023 guidelines, perform surgical decompression urgently in case of neurological deficiency (motor deficit or spinal cord compression).
E

Specific circumstances

Pediatric patients, evaluation: as per IDSA/PIDS 2021 guidelines, consider obtaining serum CRP in the initial evaluation of patients with suspected acute hematogenous osteomyelitis.
C
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  • Pediatric patients (management)

  • Pediatric patients (follow-up)

  • Patients with postoperative osteomyelitis (evaluation)

  • Patients with postoperative osteomyelitis (management)

  • Patients with MRSA osteomyelitis (evaluation)

  • Patients with MRSA osteomyelitis (management)

  • Patients with Candida osteomyelitis

  • Patients with Aspergillus osteomyelitis

Follow-up and surveillance

Indications for specialist referral
As per SPLIF 2023 guidelines:
Consult a spine specialist to evaluate spinal stability in the initial phase of discovertebral infection.
E
Obtain an emergency medical-surgical consultation for any radicular pain in patients with discovertebral Infection.
E

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  • Serial clinical assessment

  • Serial laboratory assessment

  • Serial imaging assessment

  • Management of treatment failure