Diskitis, Pediatric

Basics

Description

Often benign, self-limited inflammatory process of an intervertebral disk

Epidemiology

>50% of the cases occur in children <4 years of age.
Incidence

Peak incidence is between 0 and 2 years of age.
Second peak: >10 years

Prevalence
Rare

Pathophysiology

Probably of infectious etiology by an indolent organism
Usually none identified; occasionally, Staphylococcus aureus, Moraxella, or the Enterobacteriaceae are cultured.

Etiology

Idiopathic, infectious, or traumatic

Diagnosis

History

Uncomfortable, irritable child
Refusal to walk
Fever
Back or abdominal pain
Symptoms of short duration prior to presentation

Physical Exam

Usually, rigid posture and pain elicited on movement (sits in tripod position)
Loss of lumbar lordosis
Focal tenderness to palpation
Most common locations: L4-L5 and L3-L4

Diagnostic Tests & Interpretation

Lab
Initial Lab Tests

Purified protein derivative (PPD)
WBC count
Erythrocyte sedimentation rate (ESR)
C-reactive protein (CRP)
Blood cultures

Imaging

Plain radiographic studies
- Usually normal, although may demonstrate disk narrowing as illness progresses
MRI
- Useful to confirm diagnosis and location of pathology
- Demonstrates disk edema
Bone scan
- Demonstrates increased uptake at affected area
- May be used to screen for other sites of infection

Differential Diagnosis

Infection
- Vertebral osteomyelitis (e.g., Staphylococcus, Salmonella)
- Pott disease (tuberculous spondylitis)
- Pyelonephritis
- Retrocecal appendicitis
- Psoas or epidural abscess
Trauma
- Fracture
- Disk herniation
Tumors
- Osteoid osteoma
- Langerhans cell granulomatosis of the spine
Vascular: avascular necrosis of vertebral body
Congenital: spondylolisthesis
Immunologic
- Ankylosing spondylitis
- Nonbacterial osteitis
Miscellaneous: Scheuermann disease (osteochondritis of the vertebral bodies)

Alert
There is difficulty distinguishing early vertebral body osteomyelitis from diskitis.

Treatment

Medication

Usually quite responsive to NSAIDs
Toddlers are usually treated with anti-staphylococcal antibiotics.

Complementary & Alternative Therapies

Physical therapy
- Patient should be immobilized during acute period.
- Casting may be required.

Inpatient Considerations

Initial Stabilization
Duration

Follow CBC, CRP, and ESR.
Continue treatment until child is asymptomatic.

Ongoing Care

Follow-up Recommendations

Patient Monitoring

When to expect improvement: Most patients are asymptomatic in 6-8 weeks.
Signs to watch for:
- Recurrence of symptoms due to reactivation of the disease
- Progressive loss of disk height
- Destruction of adjacent vertebral bodies

Prognosis

Usually excellent
Scoliosis may occur.
Radiologic disk space narrowing almost always occurs.

Complications

Occasionally, scoliosis or kyphosis
Ankylosis of adjacent vertebrae may occur.

Additional Reading

Arthurs OJ, Gomez AC, Heinz P, et al. The toddler refusing to weight-bear: a revised imaging guide from a case series. Emerg Med J. 2009;26(11):797-801. [View Abstract]
Chandrasenan J, Klezl Z, Bommireddy R, et al. Spondylodiscitis in children. J Bone Joint Surg Br. 2011;93(8):1122-1125. [View Abstract]
Early SD, Kay RM, Tolo VT. Childhood diskitis. J Am Acad Orthop Surg. 2003;11(6):413-420. [View Abstract]
Fernandez M, Carrol CL, Baker CJ. Discitis and vertebral osteomyelitis in children: an 18-year review. Pediatrics. 2000;105(6):1299-1304. [View Abstract]
Garron E, Viehweger E, Launay F, et al. Nontuberculous spondylodiscitis in children. J Pediatr Orthop. 2002;22(3):321-328. [View Abstract]
Karabouta Z, Bisbinas I, Davidson A, et al. Discitis in toddlers: a case series and review. Acta Paeditr. 2005;94(10):1516-1518. [View Abstract]
Kayser R, Mahlfeld K, Greulich M, et al. Spondylodiscitis in childhood: results of a long-term study. Spine. 2005;30(3):318-323. [View Abstract]
Marin C, Sanchez-Alegre ML, Gallego C, et al. Magnetic resonance imaging of osteoarticular infections in children. Curr Probl Diagn Radiol. 2004;33(2):43-59. [View Abstract]
McCarthy JJ, Dormans JP, Kozin SH, et al. Musculoskeletal infections in children: basic treatment principles and recent advancements. Instr Course Lect. 2005;54:515-528. [View Abstract]

Codes

ICD09

722.90 Other and unspecified disc disorder, unspecified region
722.93 Other and unspecified disc disorder, lumbar region
722.91 Other and unspecified disc disorder, cervical region
722.92 Other and unspecified disc disorder, thoracic region

ICD10

M46.40 Discitis, unspecified, site unspecified
M46.46 Discitis, unspecified, lumbar region
M46.42 Discitis, unspecified, cervical region
M46.44 Discitis, unspecified, thoracic region
M46.49 Discitis, unspecified, multiple sites in spine
M46.36 Infection of intervertebral disc (pyogenic), lumbar region
M46.32 Infection of intervertebral disc (pyogenic), cervical region
M46.45 Discitis, unspecified, thoracolumbar region
M46.31 Infection of intvrt disc (pyogenic), occipt-atlan-ax region
M46.48 Discitis, unspecified, sacral and sacrococcygeal region
M46.35 Infection of intvrt disc (pyogenic), thoracolumbar region
M46.34 Infection of intervertebral disc (pyogenic), thoracic region
M46.38 Infection of intvrt disc (pyogenic), sacr/sacrocygl region
M46.41 Discitis, unspecified, occipito-atlanto-axial region
M46.30 Infection of intervertebral disc (pyogenic), site unsp
M46.33 Infection of intvrt disc (pyogenic), cervicothor region
M46.37 Infection of intvrt disc (pyogenic), lumbosacral region
M46.39 Infection of intvrt disc (pyogenic), multiple sites in spine
M46.43 Discitis, unspecified, cervicothoracic region

SNOMED

2304001 Discitis (disorder)
202752002 Lumbar discitis (disorder)
202744000 Cervical discitis (disorder)
202748002 Thoracic discitis (disorder)
302935008 Infective discitis (disorder)

FAQ

Q: When are a biopsy and tissue culture indicated?
A: If there is bony destruction of adjacent vertebral bodies or if clinical course is prolonged or recurrent
Q: When are antibiotics indicated?
A: Obviously, in situations with positive cultures or clear infective focus, or if course is atypical or prolonged

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