J Korean Neurosurg Soc.  2018 Jan;61(1):81-88. 10.3340/jkns.2016.1212.005.

Comparative Analysis of Spontaneous Infectious Spondylitis : Pyogenic versus Tuberculous

Affiliations
  • 1Department of Neurosurgery, Korea University Ansan Hospital, Ansan, Korea. nsbjkim@gmail.com

Abstract


OBJECTIVE
Spondylitis is often chemotherapy resistant and requires long-term treatment. Without adequate chemotherapy, the outcome can be fatal or result in severe neurologic damage. Therefore, differentiating the etiology of spondylitis is very important, particularly in spontaneous cases. As the prevalence of tuberculosis in Korea has decreased in recent years, updated clinical research about spondylitis is warranted.
METHODS
From April 2010 to March 2016, data from spondylitis patients were collected retrospectively. In total, 69 patients (51 with pyogenic spondylitis and 18 with tuberculous spondylitis) were included. Clinical data, laboratory findings including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level, measurements of Cobb angles at the initial and final follow-up, and radiologic features on magnetic resonance imaging (MRI) scans were evaluated. To test differences between the pyogenic and tuberculous groups, numerical data were compared using the student's t-test and Mann-Whitney U test, and categorical data were compared using the chi-square test and Fisher's exact test.
RESULTS
The patients' mean age was 60.0 years. Male sex was slightly predominant (56.5%). There was no difference in mean age and sex between the two groups. The pyogenic group had a relatively higher proportion of immunocompromised patients. The peak CRP value was higher in the pyogenic group than in the tuberculous group (14.08 mg/dL and 8.50 mg/dL, respectively, p=0.009), whereas the ESR was not significantly different between the groups (81.5 mm/h and 75.6 mm/h, respectively, p=0.442). Radiologically, the presence of disc space sparing and vertebral body collapse differed between the groups. In the tuberculous group, the disc was more commonly preserved on contrast-enhanced MRI (50% and 23.5%, respectively, p=0.044), and vertebral body collapse was more common (66.6% and 15.7%, respectively, p < 0.001). The mean length of hospitalization was longer in the pyogenic group (56.5 days and 41.2 days, respectively, p=0.001). Four mortality cases were observed only in the pyogenic group. The most commonly isolated microorganism in the pyogenic group was Staphylococcus aureus (S. aureus) (methicillin susceptible S. aureus and methicillin resistant S. aureus [MRSA] in 8 and 4 cases, respectively).
CONCLUSION
The clinical and radiological manifestations of spontaneous spondylitis differ based on the causative organism. Pyogenic spondylitis patients tend to have a higher CRP level and a more severe clinical course, whereas tuberculous spondylitis patients present with destruction of the vertebral body with disc sparing more frequently. The presence of MRSA is increasing in community-acquired spondylitis cases.

Keyword

Spondylitis; Osteomyelitis; Bone diseases, Infectious; Bacterial infection; Spondylodiscitis; Tuberculosis

MeSH Terms

Bacterial Infections
Blood Sedimentation
Bone Diseases, Infectious
C-Reactive Protein
Discitis
Drug Therapy
Follow-Up Studies
Hospitalization
Humans
Immunocompromised Host
Korea
Magnetic Resonance Imaging
Male
Methicillin Resistance
Methicillin-Resistant Staphylococcus aureus
Mortality
Osteomyelitis
Prevalence
Retrospective Studies
Spondylitis*
Staphylococcus aureus
Tuberculosis
C-Reactive Protein

Figure

  • Fig. 1 Representative magnetic resonance imaging (MRI) scans of patients with methicillin resistant Staphylococcus aureus (MRSA) spondylitis. On the initial MRI scan of a 60-year-old woman who was diagnosed as having MRSA spondylitis, the L1 vertebral body was hypointense on a T2 weighted image and showed a bursting fracture with an epidural abscess compressing the conus medullaris (A). On a T1 image with contrast enhancement, the posterior wall of the L1 vertebra and upper endplate of the L2 vertebra showed strong enhancement, and the epidural abscess showed a rim-enhancing pattern (B). Despite abscess removal and vancomycin use, the follow-up MRI scan reveals that the L1 vertebral body had totally disappeared after 2 weeks, communicating with the paraspinal abscesses on both sides (C). Two 4.5×4.0 cm sized abscess pockets were occupying the whole psoas muscles (D), which were removed by image-guided percutaneous drain insertion.

  • Fig. 2 Representative magnetic resonance images of tuberculous spondylitis. A 57-year old woman presented with hoarseness. A : A T2 sagittal image showed a destructive lesion at the C3 vertebral body compressing the spinal cord and a huge cystic lesion at the retropharyngeal space. Both the destroyed C3 vertebra and cyst were hypointense on T1 (B) and showed strong rim enhancement, whereas the disc spaces were relatively spared (C). On the axial image, the rim enhancing lesion of the vertebral body, epidural, and retropharyngeal space were communicating and severely encroaching the spinal canal (D).


Reference

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