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Disk Space Infection - Pediatric

Topic updated on 08/20/16 5:13pm
Introduction
  • Epidemiology
    • demographics
      • more common in pediatric patients relative to adults
      • more common in males 
      • usually affects patients less than 5 years old
    • location
      • most common in lumbar spine (50-60%)
  • Pathophysiology
    • pathoanatomy
      • in children blood vessels extend from the cartilaginous end plate into the nucleus pulposus
        • this allows direct inoculation of the disc
        • infection may spread from the end plate to the disc space and vertebral body
      • in adult patients, blood vessels extend only to the annulus fibrosis
        • this limits the incidence of isolated disc space infections in adults 
    • microbiology
      • staphylococcus aureus
        • is most common causative organism (>80%)
      • tuberculosis
        • always consider as organism, especially if patient is not improving with first line antibiotics
      • salmonella
        • in sickle cell anemia patients, salmonella may be the causative organism
Anatomy
  • Disc anatomy
    • in pediatric patients, blood vessels extend from the cartilaginous end plate into the nucleus pulposus
    • in adult patients, blood vessels extend only to the annulus fibrosis
Presentation
  • Symptoms depend on age of child
    • toddler
      • refusal to sit or walk, or painful limping
      • loss of appetite
      • fever (only 25% of patients will be febrile)
      • abdominal pain
    • older children
      • back pain with point tenderness
  • Physical exam
    • tender to palpation over involved level
    • limited range of motion
Imaging
  • Radiographs
    • radiographic findings are unreliable
    • earliest manifestation is at 1 week
    • findings
      • usually normal radiographs early in process
      • loss of lumbar lordosis may be earliest radiographic sign 
      • disc space narrowing (10-21 days after infection begins) 
      • endplate erosion (10-21 days after infection begins)
  • MRI
    • diagnostic test of choice 
Studies
  • Serum Labs
    • ESR
      • high normal or mildly elevated
    • C-reactive protein
      • high normal or mildly elevated
    • WBC
      • high normal or mildly elevated
  • Blood Cultures
    • blood cultures should be obtained to identify organism
Treatment
  • Nonoperative
    • bedrest, immobilization, and antibiotics for 4-6 weeks
      • indications
        • early infection with no abscess or displacement of thecal sac
      • modalities
        • initial treatment is with parenteral antibiotics directed at Staph aureus for 7-10 days
      • followup
        • watch serial labs to monitor efficacy of antibiotic treatment
        • obtain CT-guided biopsy if no response (rule out TB)
  • Operative
    • surgical debridement followed by antibiotic treatment
      • indications
        • late infection 
        • paraspinal abscess in the presence of neurologic deficits
        • limited responsiveness to nonoperative measures
      • technique
        • important to obtain cultures 
        • followed with antibiotics and bracing
Complications
  • Long term narrowing of disk space
  • Fusion between vertebra
  • Back pain

 

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(OBQ06.21) In pediatric discitis, which of the following is the most accurate description of the radiographic findings. Topic Review Topic

1. The earliest radiographic finding is loss of normal lumbar lordosis, followed by disc space narrowing and endplate erosion.
2. The earliest radiographic finding is disc space narrowing, followed by endplate erosion and loss or normal lumbar lordosis.
3. The earliest radiographic finding is endplate erosion, followed by disc space narrowing and loss or normal lumbar lordosis.
4. The earliest radiographic finding is scalloping of the inferior endplate, followed by disc space narrowing and endplate erosion.
5. The earliest radiographic finding is vertebra magna, followed by disc space narrowing and endplate erosion.

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