• Skip to primary navigation
  • Skip to main content
  • Skip to primary sidebar
bone and spine logo

Bone and Spine

Your Trusted Resource for Orthopedic Health Information

  • Home
  • About
  • Contact Us
  • Policies
  • Show Search
Hide Search
You are here: Home / Spine disorders / Pyogenic Vertebral osteomyelitis Presentation and Treatment

Pyogenic Vertebral osteomyelitis Presentation and Treatment

Dr Arun Pal Singh ·

Last Updated on October 29, 2023

Pyogenic vertebral osteomyelitis is a type of spinal infection which may result from direct trauma, the spread of infection from adjacent structures or hematogenous spread from the distant focus of infection. It can have devastating complications if untreated which could be a pathological fracture, epidural infection, and compression of the neural structures.

Vertebral osteomyelitis is considered uncommon, there is a suggested increase in spinal infections because of increased use of vascular devices, other instrumentation and increasing rates of IV drug abuse.

vertebral osteomyelitis image

Contents hide
1 Pathophysiology of Vertebral Osteomyelitis
2 Risk Factors for Vertebral Osteomyelitis
3 Clinical Presentation
4 Lab Studies
5 Imaging Studies
5.1 X-rays
5.2 CT
5.3 MRI
5.4 Radionuclide scanning
6 Treatment of Vertebral Osteomyelitis
6.1 Medical Treatment
6.2 Microorganism
6.3 First Choice
6.4 Alternatives
6.5 Surgical Treatment

Pathophysiology of Vertebral Osteomyelitis

The spine is column formed by stacking of vertebrae, intervertebral discs and associated joints stabilized by muscles, tendons, and ligaments. Cord and roots are contained in the vertebral column and it serves to protect them.

The spine starts below the skull and forms articulations with the skull for neck motion. It ends at the coccyx, a point palpable below the beginning of gluteal cleft posteriorly.

It has the following regions –

  • Cervical spine – First seven vertebrae in the spinal column (C1-7)
  • Thoracic – Next 12 vertebrae (T1-12) and is stabilized by the attached rib cage and intercostal musculature.
  • Lumbar spine – Next five vertebrae (L1-5), located between the relatively immobile segments of the thoracic and sacral segments.

95% of pyogenic spinal infections involve the vertebral body, and only 5% involve the posterior elements of the spine. The difference of involvement is due to blood supply which is more in vertebral bodies.

A distant focus of infection provides an infective nidus from which bacteria spread by the bloodstream to the spinal column. The skin and the genitourinary tract are sites. Septic arthritis, sinusitis, subacute bacterial endocarditis, and respiratory, oral, or gastrointestinal infection could be other sources of infective agents.

[Approximately 30-70% of patients with vertebral osteomyelitis have no obvious prior infection.]

Circulating bacteriae may enter the vertebra or a disc space via small metaphyseal arteries arising from larger primary periosteal arteries that, or venous system.

Bone infarct may result from blockage of metaphyseal arteries by septic thrombi. The sequestrum facilitates colonization.

The disc is avascular and is secondarily invaded by bacteria from the endplate region after the metaphyseal bone is infected.

Retrograde seeding of venous blood via the Batson plexus can also cause the infection. During periods of increased intra-abdominal pressure, venous blood is shunted toward the vertebral venous plexus.

Spread of contiguous infection into the vertebrae and disc from a retropharyngeal abscess or a retroperitoneal abscess may cause resulting in osteomyelitis and discitis.

Pyogenic infection can affect any vertebra but most vertebral body infections occur in the lumbar spine because of the blood flow to this region of the spine. Tuberculosis has a predilection for the thoracic spine, and IV drug abusers are more likely to contract an infection of the cervical spine.

The combination of mechanical compression of the spinal cord by pus or granulation tissue can result in ischemia with spinal cord infarction, which accounts for the rapid neurologic progression.

Patients with a spinal epidural abscess may progress to complete paralysis within minutes to hours, even while receiving optimal antibiotic therapy.

Pathological fractures can occur due to the softening of the bone, and present with acute spinal cord compression.

Risk Factors for Vertebral Osteomyelitis

Risk factors for developing osteomyelitis include conditions that compromise the immune system, such as the following:

  • Advanced age
  • Intravenous (IV) drug use
  • Diabetes mellitus  
  • Organ transplantation
  • Malnutrition
  • Congenital immunodepression
  • Long-term systemic administration of steroids
  • Cancer
  • Surgical site infection

The common microorganisms that cause vertebral osteomyelitis are

  • Staphylococci
  • Enterococcus species
  • Enterococcus species
  • Pseudomonas aeruginosa
  • Enterobacteriaceae
  • Beta-hemolytic streptococci
  • Propionibacterium acnes
  • Tuberculosis
  • Fungus
  • Yeast
  • Parasitic organisms

Clinical Presentation

Adult patients usually present with insidious onset back pain. There is often a history of back pain several weeks or months of gradually progressing neck or back pain that increases with movement.

The pain gradually increases in intensity and eventually becomes severe and unrelieved by medication and rest.

Neural signs are often not present until late.

The children present with more acute symptoms and discitis. [More about that here]

In most of the patients, there is only mild tenderness over the spinous process of the involved vertebra, and minimal spasm may be present.

The range of motion may be decreased. Fever is not present in 50% of the patients.

In advanced disease, bony collapse, the spread of the infection underneath the posterior longitudinal ligament, or frank epidural abscess may cause compression of the spinal cord or nerve roots.

Radicular signs followed by neural deficit suggests epidural abscess. [Spinal epidural abscess occurs in 5-18% of cases]

It may be noted that cervical vertebral osteomyelitis is associated with paralysis more commonly than either thoracic or lumbar infection.

A detailed motor and sensory examination should be performed

Sensorimotor examination suggests the level of the affliction of the spinal cord. [Neural deficits occur in about 15%]

Secondary sepsis may occur in uncontrolled infections.

Lab Studies

  • Elevated ESR and CRP
  • A minimal increase of leucocytes [Unlike other infections]
  • Blood cultures for establishing the diagnosis
  • Aspiration biopsy for cytology, culture, and sensitivity
    • CT guided
    • Positive only 60-70% of the time.
    • Trocar Biopsy/open biopsy when does not yield material

Imaging Studies

X-rays

  • Normal in the first 2-4 weeks
  • Reduced disc space
  • Destruction of the endplates around the disc
  • Rarefaction, loss of bony trabeculation close to the cartilaginous plate, and an irregular narrowing of the vertebral disk space
  • Vertebral body collapse
  • Evidence of rapid bone regeneration
    • Bone spurs
    • Dense new bone
  • Paravertebral soft-tissue shadow

CT

  • Depicts osteomyelitis earlier
  • Hypodensity at the site of infected discs
  • Lytic fragmentation of the involved bone,
  • Gas within an involved vertebra
  • Decreased density of adjacent vertebrae
  • Epidural and paraspinal extension of infection

MRI

  • Destructive and expansile lesions involving two adjacent vertebrae and the in-between disc
  • Low-density changes in bone and disc on T1- weighted images
  • High-density changes are seen in these structures on T2-weighted images,
  • Gadolinium enhancement shows the involved structures.
  • Soft tissue infections are visualized better
    • Paravertebral infection
    • Collections under the posterior longitudinal ligament
    • Epidural abscesses

Radionuclide scanning

Radionuclide scan findings become positive long before plain film changes are evident.

Treatment of Vertebral Osteomyelitis

Most patients with pyogenic vertebral osteomyelitis respond to medical management. Surgery is indicated where medical treatment is not successful.

Medical Treatment

The treatment of vertebral osteomyelitis must be individualized according to the patient’s condition. Underlying infections (eg, retropharyngeal, pelvic, decubital) require simultaneous treatment.

Initially, broad-spectrum antibiotics are given covering both gram-positive and gram-negative organisms, aerobes and anaerobes, including methicillin-resistant S aureus.

As S aureus is the most common agent, it should be covered by most of the antibiotics. Specific antibiotics can be instituted when culture and sensitivity reports are available.

With lack of response to antibiotics and negative cultures, less common organisms should be considered.

Antibiotics are given for 6-8 weeks.

Choice of antibiotics as per agent is given in the table below, as per IDSA guidelines

Microorganism

First Choice

Alternatives

Staphylococci, oxacillin susceptible
  • Nafcillin sodium or oxacillin
  • Cefazolin
  • Ceftriaxone
  • Vancomycin
  • Vaptomycin
  • Llinezolid
  • Levofloxacin
  • Rifampin
  • Clindamycin
Staphylococci, oxacillin resistant Vancomycin
  • Daptomycin
  • Linezolid
  • Levofloxacin
  • Rifampin
Enterococcus species, penicillin susceptible
  • Penicillin
  • Ampicillin sodium
  • Vancomycin
  • Daptomycin
  • Linezolid
Enterococcus species, penicillin resistant Vancomycin
  • Daptomycin
  • Linezolid
Pseudomonas aeruginosa
  • Cefepime
  • Meropenem
  • Doripenem
  • Ciprofloxacin
  • Aztreonam
    • For severe penicillin allergy
    • Quinolone-resistant strains
    • Ceftazidime ++
Enterobacteriaceae
  • Cefepime
  • Ertapenem
Ciprofloxacin
?-hemolytic streptococci
  • Penicillin
  • ceftriaxone 2 g IV q24 h
Vancomycin
Propionibacterium acnes
  • Penicillin
  • ceftriaxone
  • Clindamycin
  • Vancomycin
Salmonella species Ciprofloxacin Ceftriaxone

 

ESR and CRP are markers of the disease. Antibiotics can be withdrawn when the patient is without fever and pain, ESR has fallen to at least two-thirds of the pretherapy level, and there are not as neurologic deficits.

A persistent high ESR demands additional antibiotics. Repeat biopsy can be taken from the infected vertebra to see if organisms not susceptible to the chosen antibiotics.

Bracing is recommended for 6-12 weeks. It provides rest to spine, restrict motion and allows fusion of the vertebrae. A rigid brace is preferred.

A residual kyphosis after healing, if severe, may require corrective surgery later.

Surgical Treatment

Indications for surgery include the following:

  • Significant bony involvement requiring debridement and stabilization
  • Neural deficits
    • Significant kyphosis
    • Compression due to abscess/collapse
    • Infection in the epidural space
  • Infection not responding to antibiotics

Goals of surgery are the preservation of neural function and achievement of stable bony fusion without deformity.

The anterior disease is best addressed by an anterior or anterolateral surgical decompression and debridement. Debridement and drainage should be followed by extensive irrigation with antibiotic solution. In most cases, the closure can be done primarily, with a surgical drain left in place.

Patients with extensive vertebral destruction usually require instrumentation and fusion.

Postoperatively orthosis for a variable period is given. The antibiotics are adjusted according to the culture results.

The patient should be watched for decubitus ulcers, lung problems, and deep vein thrombosis.

Once the correct treatment is implemented, patients require neurologic monitoring to exclude progressive neurologic deterioration.

 

Spine disorders This article has been medically reviewed by Dr. Arun Pal Singh, MBBS, MS (Orthopedics)

About Dr Arun Pal Singh

Dr. Arun Pal Singh is a practicing orthopedic surgeon with over 20 years of clinical experience in orthopedic surgery, specializing in trauma care, fracture management, and spine disorders.

BoneAndSpine.com is dedicated to providing structured, detailed, and clinically grounded orthopedic knowledge for medical students, healthcare professionals, patients and serious learners.
All the content is well researched, written by medical expert and regularly updated.

Read more....

Primary Sidebar

Know Your Author

Dr. Arun Pal Singh is an orthopedic surgeon with over 20 years of experience in trauma and spine care. He founded Bone & Spine to simplify medical knowledge for patients and professionals alike. Read More…

Explore Articles

Anatomy Anatomy Fractures Fractures Diseases Diseases Spine Disorders Spine Disorders Patient Guides Patient Guides Procedures Procedures
featured image for orthopedics traction

Orthopedic Traction – Principles, Types, and Uses

Traction is a fundamental concept in orthopedics for managing …

featured image of gower sign for segmenatal instability of lumbar spine

Clinical Tests for Lumbar Segmental Instability

Lumbar segmental instability may not always be visible on standard …

mesurement of scoliosis for braces

Braces for Scoliosis- Types, Uses and Results

Braces for scoliosis are recommended to prevent the scoliotic curve …

discogenic back pain

Discogenic Back Pain Causes, Diagnosis and Treatment

Discogenic back pain is a common cause of axial low back pain [the …

Elbow arthrodesis using internal fixation

Elbow Arthrodesis- Indications, Methods and Complications

Elbow arthrodesis refers to the surgical fusion of the elbow joint. It …

Popular articles

Do backpacks cause back pain children

Backpacks and Back Pain- Tips to Use Backpacks in Children?

Back pain in children is not that common …

Essex Lopresti Fracture

Essex Lopresti Fracture

The Essex Lopresti fracture is also …

Impingement can lead to Rotator Cuff Tendonitis

Rotator Cuff Tendonitis

Rotator cuff tendonitis [also termed as …

Different ratios for calculating patellar height

Patella Baja or Low Lying Patella

Patella Baja or patella infera is an …

Bone and Spine

© 2025 BoneAndSpine.com · All Rights Reserved
The content provided on BoneAndSpine.com is intended for informational and educational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Read Disclaimer in detail.