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Diskitis, Pediatric

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Diskitis, Pediatric

Basics

Description

Epidemiology

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

Idiopathic, infectious, or traumatic

- Trauma - Tumors - Osteoid osteoma - Langerhans cell granulomatosis of the spine

There is difficulty distinguishing early vertebral body osteomyelitis from diskitis.

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

Pathophysiology

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

Etiology

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

  • Purified protein derivative (PPD)
  • WBC count
  • Erythrocyte sedimentation rate (ESR)
  • C-reactive protein (CRP)
  • Blood cultures
  • Plain radiographic studiesUsually normal, although may demonstrate disk narrowing as illness progresses
  • MRIUseful to confirm diagnosis and location of pathologyDemonstrates disk edema
  • Bone scanDemonstrates increased uptake at affected areaMay be used to screen for other sites of infection
  • Usually normal, although may demonstrate disk narrowing as illness progresses
  • Useful to confirm diagnosis and location of pathology
  • Demonstrates disk edema
  • Demonstrates increased uptake at affected area
  • May be used to screen for other sites of infection

Differential Diagnosis

  • InfectionVertebral osteomyelitis (e.g., Staphylococcus, Salmonella)Pott disease (tuberculous spondylitis)PyelonephritisRetrocecal appendicitisPsoas or epidural abscess
  • TraumaFractureDisk herniation
  • TumorsOsteoid osteomaLangerhans cell granulomatosis of the spine
  • Vascular: avascular necrosis of vertebral body
  • Congenital: spondylolisthesis
  • ImmunologicAnkylosing spondylitisNonbacterial osteitis
  • Miscellaneous: Scheuermann disease (osteochondritis of the vertebral bodies)
  • Vertebral osteomyelitis (e.g., Staphylococcus, Salmonella)
  • Pott disease (tuberculous spondylitis)
  • Pyelonephritis
  • Retrocecal appendicitis
  • Psoas or epidural abscess
  • Fracture
  • Disk herniation
  • Osteoid osteoma
  • Langerhans cell granulomatosis of the spine
  • Ankylosing spondylitis
  • Nonbacterial osteitis

Treatment

Medication

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

Complementary & Alternative Therapies

  • Physical therapyPatient should be immobilized during acute period.Casting may be required.
  • Patient should be immobilized during acute period.
  • Casting may be required.

Inpatient Considerations

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

Ongoing Care

Follow-up Recommendations

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