Isolated vertebral osteomyelitis/diskitis in a patient without neurologic deficit can be treated initially with nonsurgical management. Typical nonsurgical treatment regimens consist of intravenous antibiotics and mobilization of the affected patient. To maximize the efficacy of antibiotics, an organism should be identified to allow for appropriate targeting of antimicrobial therapy. Blood cultures that are obtained before the initiation of antibiotics can help identify an organism. CT-guided bone biopsy is commonly used for obtaining a sample of the affected vertebrae. The efficacy of this treatment modality is controversial. Sehn et al studied 323 patients with possible PVO who underwent image-guided biopsy of the vertebral body. The authors found that among 92 patients who had a high suspicion for infection before the biopsy based upon imaging and clinical data, the biopsy was positive for a bacterial pathogen 30.4% of the time.¹¹ In patients with intermediate and low prebiopsy probability of infection, the biopsy was positive in 16.1% and 5.0% of cases, respectively.¹¹

If a patient with suspected PVO has a negative CT-guided bone biopsy, the next step would commonly be to repeat the biopsy.¹² Gras et al¹² assessed 136 patients with suspected PVO and found that patients who underwent one biopsy only had a pathogen identified 44.1% of the time, whereas patients who underwent an additional biopsy if the first one was negative had a pathogen identified 79.6% of the time. The authors concluded that obtaining a second biopsy if the first biopsy is negative is a reasonable treatment strategy.

Consultation with infectious disease physicians regarding the length and choice of antibiotics should be performed. Typically, intravenous antibiotics are administered for at least 6 weeks with subsequent transition to PO antibiotics.¹ Throughout this time course there should be tracking of WBC, ESR, CRP to monitor the patient’s response to the treatment. For non-MRSA gram-positive infections, IV cefazolin is a commonly used antibiotic, whereas IV vancomycin remains the most common antibiotic for MRSA (methicillin-resistant Staphylococcus aureus) osteomyelitis.¹⁰

Bracing treatment is typically performed for patients with osteomyelitis/diskitis as the architectural integrity of the spinal column is compromised from the infectious process, and external bracing treatment is thought to provide additional stability to the spinal column.¹ The specific bracing treatment regimen depends on the level of the vertebral osteomyelitis. For lumbar osteomyelitis, a lumbosacral orthosis is commonly used, whereas for thoracic osteomyelitis a thoracolumbar orthosis or Jewett extension brace can be employed.¹ Bracing treatment has the theoretical benefit of providing external support to the weakened vertebral column although long-term studies have not been performed to demonstrate the added benefit of bracing treatment in patients with vertebral osteomyelitis.

Surgical treatment of vertebral osteomyelitis is commonly performed for a wide spectrum of reasons. Patients who are surgical candidates include those whose infection progresses despite nonsurgical treatment, those who develop associated epidural abscesses/diskitis, those who develop neurologic deficit, and those who develop bony instability of the spinal column or significant kyphotic deformity.¹ The goals of surgical
treatment of vertebral osteomyelitis are débridement of the infectious pathology, preservation of neurologic function, and stabilization of the spinal column. Secondary goals include the correction of any sagittal or coronal plane deformities caused by the infectious process.¹

Because vertebral osteomyelitis affects the vertebral body, resection of the infectious process often requires subtotal or total corpectomy with reconstruction of the bony defect with autograft, allograft, or cage placement.¹ This can be accomplished through a variety of anterior, lateral, and posterior surgical approaches depending on the level of pathology.¹ Pedicle screw instrumentation is typically performed to stabilize at least two levels above and below the affected level.¹ If there is a concomitant epidural abscess, a laminectomy can be performed to evacuate the epidural infectious collection.¹

Dragsted et al performed a retrospective review of 65 patients diagnosed with osteomyelitis/diskitis related to recent spinal surgery.¹³ The authors followed up the patients for a median follow-up of 2 years and found that the overall 1-year mortality rate was 6%.¹³ Preoperative neurologic impairment was present in 36% of patients and at final follow-up the authors noted that patients with osteomyelitis/diskitis had significantly lower quality of life scores, as measured by EuroQol 5-dimension (EQ-5D) questionnaire and Oswestry Disability Index (ODI) relative to unaffected individuals.¹³ Meanwhile, in a retrospective cohort analysis of 1,505 Danish individuals with osteomyelitis/diskitis who were alive 1 year after initial diagnosis and were sex/age matched with unaffected people, Aagaard et al¹⁴ found that osteomyelitis/diskitis patients had a 1.47 mortality rate ratio relative to the affected individuals.