Vertebral Osteomyelitis, Discitis, and Spinal Epidural Abscess in Adults

[2013 new]

Introduction to this self-study CME activity

Purpose

Vertebral osteomyelitis (VO) and spinal epidural abscess (SEA) are rare infections or inflammations of the bone, bone marrow of the spinal region, or epidural space. Although rare (2.4 cases per 100,000 persons annually), they are relatively easy to treat when recognized. However, failure to recognize, diagnose and treat it in a timely manner can lead to permanent paralysis. Unfortunately, diagnostic delays occur frequently, with reports of symptom onset to diagnosis ranging from 11 to 59 days.

 Factors contributing to diagnostic delays include:

  • The difficulty of the diagnosis.  No “classic” history and physical exam findings easily and reliably identify VO/SEA. The primary symptom of back pain is a common complaint frequently associated with many less immediately serious conditions. 
  • Inconsistent approaches to diagnosis and treatment.  Differing approaches to VO/SEA limit the development of standard, evidence-based procedures.  For example, when should empiric antibiotics be started and which antibiotic combination should be used?
  • Delays in performing needed studies and services.  The risk of rapid progression of VO/SEA means that the processes of care such as imaging and consultations must be performed more rapidly than organizational infrastructures may allow.  For example, imaging within a few hours is necessary to help confirm the diagnosis and initiate appropriate treatment.  However, care systems are often not in place to assure that imaging can occur on evenings or weekends, resulting in delays of a day or longer in performing some “stat” imaging orders. 

This CME activity addresses the diagnosis and initial treatment of vertebral osteomyelitis, discitis or paravertebral abscess with or without spinal epidural abscess in adult patients.  The CME activity does not address antimicrobial adjustments once microorganisms have been identified, or indications for surgery.

 Problem. While vertebral osteomyelitis (VO) and spinal epidural abscess (SEA) are rare, their diagnosis and treatment must be timely or permanent paralysis may result.

 Diagnosis

  • Evaluation should include a complete neurological exam and laboratory evaluation
  • Prompt imaging: within 2 hours if neurological deficits, or 6 hours if without neurological deficits
  • If imaging evidence of VO and negative blood culture: within 24 hours image-guided biopsy by Neuroradiology.

 Treatment

  • If abnormal neurological exam or imaging evidence of SEA: stat antibiotics, stat imaging within 2 hours (if not already imaged), and stat neurosurgical consult
  • If imaging evidence of VO: if unstable, stat antibiotics; if stable, hold antibiotics until after blood culture results are returned; consider neurosurgery consult, neurological check every 4 hours.
  • If stable, and no positive imaging findings, consider other diagnosis. If pain persists, repeat imaging in 2-3 weeks.
  • Consult Infectious Disease Service to assist with antibiotic management and further evaluation.

 Objectives

Participants in this CME activity will understand and be able to implement evidence-based cost-effective clinical strategies for the diagnosis and treatment vertebral osteomyelitis, discitis, and spinal epidural abscess in adults.

Audience

This self-study activity is appropriate for physicians in Emergency Medicine, Family Medicine, Infectious Diseases, Internal Medicine, Neurosurgery, Orthopedics, Radiology, and other health care providers participating in inpatient care.

Authors

Team Leaders

  • Carol E Chenoweth, MD
    Infectious Diseases

Team Members

  • Benjamin S Bassin, MD
    Emergency Medicine
  • Sarah E Hartley, MD
    Internal Medicine
  • Megan R Mack, MD
    Internal Medicine
  • Anjly Kunapuli, PharmD
    College of Pharmacy
  • Paul Park, MD
    Neurosurgery
  • Douglas J Quint, MD
    Radiology
  • F Jacob Seagull, PhD
    Medical Education
  • David H Wesorick, MD
    Internal Medicine

Consultants

  • Rakesh D Patel, MD
    Orthopaedic Surgery
  • James Riddell IV, MD
    Infectious Diseases
  • Kathleen M Lanava
    UMHS Office of Clinical Safety

Author Disclosures

Neither the team lead, the team members, nor the consultants have financial relationships with commercial companies whose products are discussed in this CME activity.
Benjamin S Bassin, MD
(none)
Carol E Chenoweth, MD
(none)
Sarah E Hartley, MD
(none)
Kathleen M Lanava
(none)
Megan R Mack, MD
(none)
Anjly Kunapuli, PharmD
(none)
Paul Park, MD
Consultant
Medtronic, Globus Medical
Rakesh D Patel, MD
(none)
James Riddell IV, MD
(none)
Douglas J Quint, MD
(none)
F Jacob Seagull, PhD
(none)
David H Wesorick, MD
(none)

Other Acknowledgements

UMHS Guidelines Oversight Team

  • Sarah E Hartley, MD
  • David H Wesorick, MD
  • F Jacob Seagull, PhD

Literature Search Services

  • Taubman Medical Library

Production of Internet Format and Website Maintenance

  • Ellen Patrick-Dunlavey, MA

CME Accreditation and Credit Designation

The University of Michigan Medical School is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The University of Michigan Medical School designates this enduring material for a maximum of 1 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This CME activity was released in August 2013, with credit available through July 2016. The activity was reviewed for currency of content in July 2016 and availability of credit extended through June 2019. Continuation of credit from that date depends on a thorough review of the content currency and accuracy.

Method of Participation

  1. View the web pages. You may print the self-study text to read off-line.
  2. Complete the on-line learning assessment test with a score of 70% or higher.  After you initially take the test, the test will be immediately electronically scored. 
    If fewer than 70% of the questions are answered correctly, the questions that were not answered correctly will be noted in red.  Review the CME content related to those topics and retake the test.
    If 70% or more of the questions are answered correctly, the correct and incorrect answers for all questions will be shown along with explanations of the basis for the correct answer.  The link to register and receive credit is shown at the end of the items and explanations. 
  3. Complete the electronic credit request and activity evaluation.  An electronic certificate of participation will be provided immediately.
  4. Print the certificate of participation for your personal records.