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Background and Objectives : Differentiation between brucella spondylodiscitis and Modic type I changes (MC1) includes difficulties. Hematological inflammatory indices (HII) such as neutrophil to lymphocyte ratio (NLR) and aggregate index of systemic inflammation (AISI) are suggested as indicators of inflammation and infection and have diagnostic, prognostic, and predictive roles in various diseases. This study aimed to evaluate differences between brucella spondylodiscitis and MC1 in terms of HII. Materials and Methods : Thirty-five patients with brucella spondylodiscitis and thirty-seven with MC1 were enrolled in the study. Brucella spondylodiscitis and MC1 were diagnosed by microbiological, serological, and radiological diagnostic tools. HII (NLR, MLR, PLR, NLPR, SII, SIRI, AISI) were derived from baseline complete blood count. Results : The two groups were similar for age ( p = 0.579) and gender ( p = 0.092), leukocyte ( p = 0.127), neutrophil ( p = 0.366), lymphocyte ( p = 0.090), and monocyte ( p = 0.756) scores. The Brucella spondylodiscitis group had significantly lower pain duration ( p < 0.001), higher CRP and ESR levels ( p < 0.001), and lower platelet count ( p = 0.047) than the MC1 group. The two groups had similarity in terms of HII: NLR ( p = 0.553), MLR ( p = 0.294), PLR ( p = 0.772), NLPR ( p = 0.115), SII ( p = 0.798), SIRI ( p = 0.447), and AISI ( p = 0.248). Conclusions : Increased HII can be used to differentiate infectious and non-infectious conditions, but this may be invalid in brucellosis. However, pain duration, CRP and ESR levels, and platelet count may be useful to distinguish brucella spondylodiscitis from MC1.

Purpose: C-reactive protein (CRP) and white blood cell (WBC) count are routine blood chemistry parameters in monitoring infection. Little is known about the natural history of their serum levels in conservative and operative spondylodiscitis treatment., Methods: Pre- and postoperative serum levels of CRP and WBC count in 145 patients with spondylodiscitis were retrospectively assessed. One hundred and four patients were treated by debridement, spondylodesis, and an antibiotic regime, 41 only with a brace and antibiotics. The results of the surgical group were compared to 156 patients fused for degenerative disc disease (DDD)., Results: Surgery had a significant effect on peak postoperative CRP levels. In surgically managed patients, CRP peaked at 2-3 days after surgery (spondylodiscitis: pre-OP: 90 mg/dl vs. post-OP days 2-3: 146 mg/dl; DDD: 9 mg/dl vs. 141 mg/dl; p < 0.001), followed by a sharp decline. Although values were higher for spondylodiscitis patients, dynamics of CRP values were similar in both groups. Nonoperative treatment showed a slower decline. Surgically managed spondylodiscitis showed a higher success rate in identifying bacteria. Specific antibiotic treatment led to a more predictable decline of CRP values. WBC did not show an interpretable profile., Conclusion: CRP is a predictable serum parameter in patients with spondylodiscitis. WBC count is unspecific. Initial CRP increase after surgery is of little value in monitoring infection. A preoperative CRP value, and control once during the first 3 days after surgery is sufficient. Closer monitoring should then be continued. Should a decline not be observed, therapy needs to be scrutinized, antibiotic treatment reassessed, and concomitant infection contemplated.

A 44-year-old male person with tetraplegia (C-5 AIS-A (American Spinal Cord Injury Association Standard Neurological Classification of Spinal Cord Injury Impairment Scale)) developed urinary tract infection and received appropriate antibiotic. Subsequently, he started sweating and shivering when he was sitting up; these symptoms resolved while lying on his back. Autonomic dysreflexia triggered by truncal movements continued to occur for 3 months. CT of the spine showed L5-S1 discitis. MRI of the spine showed diffuse marrow oedema in L5 and S1 vertebrae and a large abscess at L5/S1 level. Blood culture yielded Serratia marcescens sensitive to meropenem. Meropenem followed by ertapenem was given for 12 weeks. After 11 months, MRI showed resolution of discitis and epidural collection. The patient was able to sit up for 9 hours without developing autonomic dysreflexia. If a person with cervical spinal cord injury develops posture-related autonomic dysreflexia (eg, in sitting position, lying on sides or while hoisted), disco-vertebral pathology should be suspected., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Study Design: Case-control study., Objective: The objective of this study was to identify the best laboratory and imaging factors to predict bone biopsy culture positivity in the setting of vertebral discitis/osteomyelitis (VDO)., Summary of Background Data: Good predictors of bone biopsy culture positivity in the setting of VDO are unknown., Methods: Retrospective review was performed for 46 patients who underwent CT-guided bone biopsy for the evaluation of clinically confirmed VDO. Erythrocyte sedimentation rate, C-reactive protein (CRP), mean CT attenuation of the biopsied bone, and the change in the CT attenuation of the bone compared to unaffected vertebral bone (delta CT attenuation) were measured. Receiver-operator characteristic curve analyses were performed to identify the optimal threshold value for each variable. A multivariable logistic regression model was used to predict the probability of a positive bone culture using delta CT attenuation and CRPx100% fold above normal., Results: For one of the 46 VDO patients, bone cultures were not obtained. Approximately 35.6% (16/45) of bone cultures were positive. The most significant predictors of bone culture positivity were CRP x100% fold above normal (P = 0.011) and delta CT attenuation (P = <0.001). Optimized predictive thresholds were calculated to be CRP 4-fold above normal reference value (90.9% sensitivity, 73.7% specificity), or if the CT attenuation of the affected vertebral body was >25.9 HU lower relative to unaffected bone (93.8% sensitivity, 75.0% specificity)., Conclusion: Delta CT attenuation, as well as CRP level over four times the upper limits of normal, were the strongest predictors for bone culture positivity in patients with VDO., Level of Evidence: 3.

Aim: To investigate the efficacy of empirical antibiotic treatment in culture-negative pyogenic vertebral osteomyelitis (PVO) cases., Material and Methods: The records of patients with culture-negative PVO who were treated at infectious diseases and neurosurgery outpatient clinics in the past four years were examined retrospectively. The control group comprised healthy subjects with similar age, gender, and body mass index but without pathology. The comparison of the groups was performed by analysis of variance. Statistical significance was accepted as p < 0.05., Results: No statistically significant difference in the white blood cell count and erythrocyte sedimentation rate was found between the spondylodiscitis and the healthy subject groups when the blood parameters obtained before and after the treatment (p > 0.05). However, a statistical significance was assessed in the results of the comparison for C-reactive protein (p < 0.05)., Conclusion: In the context of evidence-based medicine and the rational use of antibiotics, it is clear that antibiotics should be preferred according to the culture antibiogram results in the treatment of infectious diseases.

Acute infectious spondylodiscitis (AIS) is a serious infection of the spine with rising incidence and a mortality of 3-6%. The role of the immune system in AIS is largely unknown. We performed extensive B and T-lymphocyte phenotyping in patients with AIS at diagnosis and after treatment cessation. In this prospective multicentre study, flow cytometric analysis of T and B-lymphocyte subsets was performed in 35 patients at diagnosis and 3 months after treatment cessation. We additionally analysed levels of immunoglobulins and IgG subclasses, serum level and genetic variants of mannose-binding lectin, and somatic hypermutation. A total of 22 (61%) patients had B-lymphocytes below reference limit at baseline, persisting in 7 (30%) patients at follow-up. We found a lower proportion of CD19 + CD27 + IgD+ marginal zone B-lymphocytes and a higher proportion of γδ+ T-lymphocyte receptors compared with controls at both time points. Immunoglobulin levels were elevated at baseline compared to follow-up, and not associated with absolute B-lymphocyte count. In conclusion, a large proportion of AIS patients presented with profound B-lymphocyte deficiency, only partly reversible at follow-up. Identification of immune dysfunction related to AIS may allow for future targeted therapeutic interventions to restore host immunity.

Aggregatibacter actinomycetemcomitans is well-known as the pathogen of gingivitis or periodontitis, and discitis or vertebral osteomyelitis cases caused by this organism have rarely been reported. Ampicillin or amoxicillin has been used in the previously reported discitis cases; however, no cases have been reported that is treated with levofloxacin. We report the first published case we chose levofloxacin to treat. We failed to perform the susceptibility testing because of the poor growth and fastidious nature of the organism, and the result of susceptibility of amoxicillin was unclear. Levofloxacin, which A. actinomycetemcomitans is usually susceptible to, can be an effective alternative oral antimicrobial agent in such cases., (Copyright © 2018 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Aim: Despite different surgical treatment protocols at different centers for spondylodiscitis due to lumbar surgery, there is no consensus on its surgical indications. In this study, we aimed to clarify the steps to be followed in the management and treatment of postoperative spondylodiscitis., Material and Methods: The data of 20 cases with postoperative spondylodiscitis were evaluated. C-reactive protein (CRP) was used for diagnosis and follow-up. According to culture results of the infected material obtained from the operated cases, appropriate antibiotic treatment was initiated. In non-operated cases, parenteral empirical antibiotic treatment was implemented. Surgical treatment was planned for cases with clinical and radiological instability, abscess on imaging and those who were nonrespondent to empirical antibiotic treatment. For the cases that clinically recovered and had normal CRP levels, oral antibiotic treatment was continued after parenteral antibiotic treatment., Results: Of the cases; 13 were male (65%) and 7 were femals (35%). The mean age was 56.3 years (32-74). The most prevalent complaints in referral were waist and leg pain. Except one, all cases had increased CRP levels. All patients had spondylodiscitis on magnetic resonance imaging. Seven had radiological and clinical instability and 3 had epidural abscess. The most commonly growing microorganism in culture was Staphylococcus aureus. Surgical treatment was applied to seven cases and medical treatment to 13 cases., Conclusion: In cases with waist pain in the postoperative period, the first potential diagnosis to be considered is spondylodiscitis. Surgical treatment should be implemented for cases resistant to empirical antibiotic treatment, with abscess on imaging, or with lumbar instability.

We observed a 69-year old man suffering from HLA B27 ankylosing spondylitis with persistent night back pain. 18F-FDG-PET/CT showed an increased metabolism at the level of the spinal space of L2-L3, L3-L4 with increased uptake compatible with spondylodiscitis. He started therapy with etanercept 50 mg/week. After six months of treatment repeated testing showed no uptake of the discs and vertebral bodies.

Background: C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) not only are useful in the diagnosis but also are reliable parameters in evaluating the response to treatment and prognosis of tuberculous spondylodiscitis., Objective: To analyze the correlation between neurological recovery and declination of CRP or ESR after two different posterior spinal procedures., Material and Method: The patients who had neurological deficit due to spinal tuberculosis and undergone spinal surgery between January 2009 and June 2013 were analyzed retrospectively. Posterior transforaminal decompression and interbody fusion were done in group I, whereas posterior transpedicular decompression and posterolateralfusion were performed on group II. Both groups were stabilized with pedicle screw instrumentation. Rapid recovery represented by improvement of at least one Frankel grade within 6 weeks after operation, otherwise it was slow recovery. Inflammatory markers were evaluated at initial diagnosis and at 6-week, 3-month, 6-month, and 1-year post-operation., Results: There were 31 patients. Group I included 14 cases and group II consisted of 17 cases. The median CRP and ESR at diagnosis were 80.4 mg/L and 78.0 mm/hour respectively. Rapid neurological recovery significantly related to the earlier declination of CRP within the first 6 weeks (p < 0.001). Considering the type of spinal procedures especially at thoracic and thoracolumbar level, neurological recovery in group I was significantly faster than in group II (p = 0.02; relative risk, 2.67; 95% confidence interval, 1.02 to 6.91)., Conclusion: Earlier declination of CRP within six weeks post-operation could determine rapid neurological recovery. Posterior transforaminal decompression and interbody fusion with instrumentation may be a suitable optionfor thoracic and thoracolumbar lesions.

Background Context: Although tuberculous and pyogenic spondylodiscitis are common causes of spinal infections, their protean manifestation complicates differential diagnosis., Purpose: The clinical, laboratory, and radiologic characteristics of tuberculous and pyogenic spontaneous spondylodiscitis were compared in this study., Study Design: This multicenter retrospective study was conducted in 11 teaching hospitals in the Republic of Korea from January 2011 to December 2013., Patient Sample: Study subjects included adult patients (≥18 years) diagnosed with tuberculous (n=60) or pyogenic (n=117) spontaneous spondylodiscitis., Outcome Measures: Risk factors for tuberculous spondylodiscitis were determined, and their predictive performance was evaluated., Methods: Multivariate logistic regression analysis was performed to determine predictors independently associated with tuberculous spondylodiscitis. Receiver-operating characteristic curve analysis using the presence or absence of risk factors was used to generate a risk index to identify patients with increased probability of tuberculous spondylodiscitis., Results: Of 177 patients, multivariate logistic regression analysis showed that patients with tuberculous spondylodiscitis (n=60) were more frequently women, with increased nonlumbar spinal involvement and associated non-spinal lesions, delayed diagnosis, higher serum albumin levels, reduced white blood cell counts, and lower C-reactive protein and procalcitonin levels. Among 117 patients with pyogenic spondylodiscitis, the most frequent causative microorganism was Staphylococcus aureus (64.1%). The mean diagnostic delay was significantly shorter, which may reflect higher clinical expression leading to earlier diagnosis. A combination of clinical data and biomarkers had better predictive value for differential diagnosis compared with biomarkers alone, with an area under the curve of 0.93, and sensitivity, specificity, and positive and negative predictive values of 95.0%, 79.5%, 70.4%, and 96.9%, respectively., Conclusions: This study provides guidance for clinicians to predict the causative organisms of spondylodiscitis in uncertain situations and before culture or pathologic examinations. Clinical data and single biomarkers combined can be useful for differential diagnoses between tuberculous and pyogenic spondylodiscitis., (Copyright © 2015. Published by Elsevier Inc.)

Purpose: To evaluate prevalence of subcutaneous fluid collection (SFC) in infectious thoracolumbar spondylodiscitis (SD) compared with control patients and to investigate correlation between volume changes of SFC and treatment response of SD., Materials and Methods: This retrospective study was approved by our institutional review board. From April 2011 to March 2012, 49 patients (24 SD and 25 non-SD patients) were enrolled. Prevalence of SFC was evaluated respectively for SD and non-SD patients using magnetic resonance imaging (MRI) on the sagittal short tau inversion recovery (STIR) imaging or fat-saturated T2-weighted imaging (T2WI), and compared. In SD patients with SFC, correlation was investigated between SFC volume on the 1st MRI and initial clinical status. The same analysis was conducted also for SFC volume changes from the 1st to 2nd or last MRI., Results: SFC was found in 20 patients with SD (83.3%) and 3 non-SD patients (12%) with significant difference (p<.001). In 20 SD patients with SFC, 17 patients had follow-up MRI. For the 1st MRI, no significant correlation was found between volume of SFC and initial status of patients, including body weight, body mass index (BMI), white blood cell (WBC), and erythrocyte sedimentation rate (ESR). However, significant positive correlations were found between changes of C-reactive protein (CRP) and SFC volume from the 1st to 2nd as well as from the 1st to the last MRI (each p<.05)., Conclusion: SD patients had significantly higher prevalence of SFC than non-SD patients. Volume changes of SFC had significant correlation with changes of CRP, which can be used as an imaging marker for treatment response of SD on MRI., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Study Design: Retrospective clinical case series., Objective: To report on the epidemiological, microbiological, and clinical characteristics of spinal infections in patients who have undergone solid organ transplantation., Summary of Background Data: Spine infections remain a therapeutic challenge, particularly in patients who are immunocompromised. Solid organ transplant patients represent a growing population of immunocompromised hosts. To our knowledge, no previous reports have examined the clinical characteristics spinal infections in this at-risk population in a systematic fashion., Methods: The records of patients with a history of solid organ transplantation from January 2007 through December 2012 were identified using Current Procedural Terminology procedure codes. Patients with spine infections who have received transplants were then identified using International Classification of Diseases, Ninth Revision codes for spine infection. In addition to demographic data, we recorded medical comorbidities, immunosuppressant medications, laboratory results, culture data, treatment received, and short-term results., Results: During this 6-year period, 2764 solid organ transplants were performed at our institution. Of this cohort, 6 patients (0.22%) were treated for a spinal infection. Patient's age ranged from 51 to 80 years (mean, 63 yr). All spine infections occurred within 1 year after organ transplantation. All patients had an elevated erythrocyte sedimentation rate. Only 1 patient had an elevated white blood cell count. The most common organisms were Escherichia coli and Staphylococcus. Four patients required surgical treatment. All patients had complete resolution of symptoms., Conclusion: Our data suggest that patients with a history of solid organ transplantation may be more susceptible to developing spine infections than the general population. The most common organisms in our cohort were E. coli and Staphylococcus. Spine infections caused by atypical organisms do also occur in the organ transplant population, as is the case in other immunocompromised patients. The identification of these organisms and timely institution of treatment remains critical in the management of this at-risk population., Level of Evidence: 4.

Background: Infective spondylodiscitis usually occurs in patients of older age, immunocompromisation, co-morbidity, and individuals suffering from an overall poor general condition unable to undergo reconstructive anterior and posterior surgeries. Therefore, an alternative, less aggressive surgical method is needed for these select cases of infective spondylodiscitis. This retrospective clinical case series reports our novel surgical technique for the treatment of infective spondylodiscitis., Methods: Between January 2005 and July 2011, among 48 patients who were diagnosed with pyogenic lumbar spondylodiscitis or tuberculosis lumbar spondylodiscitis, 10 patients (7 males and 3 females; 68 years and 48 to 78 years, respectively) underwent transpedicular curettage and drainage. The mean postoperative follow-up period was 29 months (range, 7 to 61 months). The pedicle screws were inserted to the adjacent healthy vertebrae in the usual manner. After insertion of pedicle screws, the drainage pedicle holes were made through pedicles of infected vertebra(e) in order to prevent possible seeding of infective emboli to the healthy vertebra, as the same instruments and utensils are used for both pedicle screws and the drainage holes. A minimum of 15,000 mL of sterilized normal saline was used for continuous irrigation through the pedicular pathways until the drained fluid looked clear., Results: All patients' symptoms and inflammatory markers significantly improved clinically between postoperative 2 weeks and postoperative 3 months, and they were satisfied with their clinical results. Radiologically, all patients reached the spontaneous fusion between infected vertebrae and 3 patients had the screw pulled-out but they were clinically tolerable., Conclusions: We suggest that our method of transpedicular curettage and drainage is a useful technique in regards to the treatment of infectious spondylodiscitic patients, who could not tolerate conventional combined anterior and posterior surgery due to multiple co-morbidities, multiple level infectious lesions and poor general condition.

Solid organ transplant recipients are at increased risk for Aspergillus infections. However, the cases of Aspergillus spondylodiscitis are rare and mostly resulted from the hematogenous spread of invasive pulmonary Aspergillosis. Here, we report a case of primary spondylodiscitis in a liver transplant recipient. Six months after transplantation, a chronic and progressive lumbar back pain was presented. The patient had no fever and the white blood cell count was normal. High plasma (1→3)-beta-d-glucan (BDG) level was detected at the time of back pain. The pathogen was Aspergillus flavus. Clinical and radiological healing was achieved through posterior only debridement and voriconazole therapy.

Study Design: A case report., Objective: To report an unusual case of spondylodiscitis with multiple level involvement., Summary of Background Data: Spondylodiscitis, an infection of the intervertebral disc space, vertebral bodies, or the paraspinal epidural space can be a serious disease because of diagnostic delay and inadequate treatment., Methods: A previously healthy, 52-year-old man was presented to our outpatient clinic with a complaint of acute, atraumatic onset of severe back pain for more than 1 month. Initially, he was misdiagnosed at another clinic as myofascial pain and treated with nonsteroidal anti-inflammatories and physical therapy, which he did not benefit from. He never complained of fever; however, laboratory tests revealed raised erythrocyte sedimentation values, increased C-reactive protein values but normal leukocyte count. Thoracal and lumbal plain radiographs were nonspecific. Magnetic resonance imaging demonstrated increased signal intensity in vertebral bodies and intervertebral disc space through T12-L4 and in the paravertebral musculature at L2-L3 with contrast enhancement. Blood cultures and computed tomography-guided needle biopsy and cultures were negative., Results: The patient was treated with oral amoxicillin and clavulanate and responded very well clinically; however, imaging examinations were repeated up to 6 months because of multilevel involvement. Follow-up magnetic resonance imaging findings at 3 months and 6 months showed decreased signal intensity, and luckily, there was no evidence of vertebral destruction., Conclusion: Diagnosis of spondylodiscitis could be challenging and commonly missed; however, it should always be included in the differential diagnoses of back pain in the middle aged and healthy population.

Aim: The diagnosis of spondylodiscitis is often prolonged, but it is an important differential diagnosis of backache. The discrimination between a bacterial infection and an aseptic inflammation with laboratory examinations like ESG, CRP or leukocytes is not possible. The aim of the present study was to determine the value of procalcitonin (PCT) as a diagnostic tool and monitoring parameter for spondylodiscitis and for the discrimination between bacterial infection and aseptic inflammation of the spine., Method: A total of 17 patients with spondylodiscitis and 18 patients with disc herniation as control were included in this study and ESG, CRP, leukocytes, fibrinogen, PNM elastase und PCT were examined for 50 days. The median age was 65 (17-78) years and the ratio of males to females was 8 : 9 in patients with spondylodiscitis and 62 (32-87) years and 7 : 11 in patients with disc herniation. For microbiological examination, CT-guided punctures were performed in patients with spondylodiscitis., Results: In 64 % of the 17 patients with spondylodiscitis a microbiological agent was detected, in 73 % of these cases staphylococcus aureus was isolated. The laboratory parameters indicating an infection were increased except for two cases in patients with spondylodiscitis, the mean value of CRP was 115 mg/dL. Influenced by the therapy these parameters decreased during the observation period. Except for one patient with an infection of a cardiac pacemaker, the PCT concentration was not elevated in both groups (< 0.5 ng/mL). In the group with disc herniation there were no elevated laboratory parameters during the entire observation period., Conclusion: PCT is not useful as diagnostic tool or monitoring parameter for spondylodiscitis. Furthermore, it is not useful for the discrimination between a bacterial infection and an aseptic inflammation of the spine.

Backache, a common symptom, is rarely caused by infection of the lumbar discs. The authors present the case of a 60-year-old man with a Staphylococcus aureus septicemia and associated lumbar discitis in whom a pauci immune crescentic glomerulonephritis and renal failure developed. Treatment with antibiotics and not immunosuppressive agents resulted in improved renal function with a discharge creatinine level of 1.87 mg/dL (165 micromol/L). This case highlights an association of pauci-immune crescentic glomerulonephritis with discitis that responded to antibiotic therapy alone., (Copyright 2003 by the National Kidney Foundation, Inc.)

Case Reports: two elderly patients (aged 70 and 80 years) presented with severe back pain and restriction of spinal movements. Inflammatory markers were raised and in each case computed tomography findings confirmed infective discitis. One patient improved with antibiotics but the second developed paraplegia, a recognized complication of discitis., Conclusion: the association of back pain, restricted spinal movements and raised inflammatory markers should act as 'red flags', alerting the clinician to the presence of serious, but potentially treatable pathology.

This study demonstrates that infection of the retro- and intradiscal space is probable, when the temperature rises above over 37 degrees and CRP exceeds 2.0 mcg/ml 5 days postoperatively. MRI of 4 patients confirmed a retrodiscal infection that was indicated by a hyperintense band shaped structure in PS-sequences and which was space occupying with respect to the dural sac. Discitis was demonstrated by intradiscal hyperintensity in STIR images and by enhancement in T1 weighted images following the application of Gadolinium DTPHA. Diagnosis is simplified by comparison of pre- and postoperative MR-examination. Infection can be cured by treatment with antibiotics (Tobramycin and Clindamycin) bedrest and plaster cast.

Erythrocyte sedimentation rate is normal in 20% to 25% of patients with discitis due to common pathogens. We evaluated serum amyloid A (SAA) protein and urinary trypsin inhibitory activity in osteoarticular infections comparatively with erythrocyte sedimentation rate and serum C-reactive protein in 20 patients including 14 with discitis due to common pathogens and 6 with septic arthritis. Assays were performed on D0, D8, D15, D30, and D60 after initiation of antimicrobial therapy. On D0, all four markers were significantly higher in patients with septic arthritis than in patients with discitis. C-reactive protein levels exhibited the fastest kinetics with a return to normal values within 15 days in both conditions. Urinary trypsin inhibitory activity was only slightly elevated in patients with discitis and returned to normal within 30 days in both conditions. Serum amyloid A levels required 30 to 60 days to return to normal. Erythrocyte sedimentation rate exhibited the slowest kinetics, with normal values being achieved only after 60 days. Although simple, rapid, and inexpensive, urinary trypsin inhibitory activity determination exhibits poor sensitivity. Serum amyloid A assay is not routinely available but may be a valuable parameter for monitoring patients whose erythrocyte sedimentation rate and C-reactive protein level are normal (as in 2 of our patients with discitis).

Twelve cases of intervertebral discitis following lumbar discectomy were evaluated and ESR was assessed in 70 patients operated on and without evidence of postoperative infection. Six of the intervertebral discitis patients were studied retrospectively and 6 prospectively. In the retrospective group, patients reported that symptoms appeared on average 15 days after the operation. Antibiotic treatment generally began 31 days after the operation and lasted 62 days; symptoms regressed after 3.9 months. All patients showed long-term radiographic vertebral changes and osteolysis in the cases treated later. In the prospective group, the first symptoms appeared on average 5 days after the operation, treatment started after 8 days and lasted 41 days. Symptoms regressed after 1.8 months. There were only 3 cases of vertebral radiographic changes. In both groups, ESR was always more than 70. The most useful diagnostic imaging tests were conventional tomography and MRI. Needle biopsy had no effect on the length of treatment. In 14% of patients without infective complications, ESR increased noticeably a week after the operation but, in contrast to the intervertebral discitis patients, it did not then continue to increase. Close post-operative observation permitted early detection of intervertebral discitis. Early and high-dose antibiotic treatment, even if unspecific, can resolve this infection in a few weeks.

The erythrocyte sedimentation rate and total white cell count were measured in 110 patients who underwent lumbar spine surgery. Measurements were made before surgery; at 2 and 4 days; and at 1, 2, 6, and 16 weeks after surgery. A rapid increase of erythrocyte sedimentation rate was seen with peak value on the fourth postoperative day. After 2 weeks, the values were normalized for the majority of patients. Maximum mean peak value was seen 4 days after surgery for fusion (ESR = 102), which was higher than after disc surgery (ESR = 75). There was no corresponding change in total white cell count. No deep infection was noted in the study group. The erythrocyte sedimentation rate values and total white blood cell count at the time of diagnosis for five patients with postoperative deep infection were used for comparison. At the time of diagnosis, all patients with deep infection had an erythrocyte sedimentation rate value exceeding the corresponding mean value (+ 2 SD). Total white cell count was slightly elevated in one of the five infected patients; the remaining four had a normal count. Erythrocyte sedimentation rate determination shows a homogenous pattern with rapid increase and decline after lumbar spinal surgery in patients without postoperative infection, and patients with postoperative deep infection at the time of diagnosis show erythrocyte sedimentation rate elevation to a degree that usually makes the result diagnostic.

A series of nine patients with post-discography discitis were evaluated to help delineate the clinical course. The most consistent sign was the marked exacerbation of neck or back pain. This then was followed by an elevated sedimentation rate at an average of 20 days, followed by a positive bone scan at an average of 33 days. Of note is that seven patients initially had negative bone scans at an average of 18 days. Five out of nine patients had changes on plain roentgenograms between 14 and 51 days after discography. Magnetic resonance imaging was performed in six patients; two of these patients were scanned twice. Three scans were negative and five were positive (2 patients initially had negative scans that later became positive). The course of lumbar discitis ranged from 8 to 11 weeks, and cervical discitis from 6 to 7 weeks, with the latter usually resulting in spontaneous fusion.