Vertebral Discitis (Spondylodiscitis)
Infection of the disc and adjacent vertebral bodies causing back pain and fever
ICD-10: M46.40 · tumors condition
Vertebral discitis, also called spondylodiscitis or vertebral osteomyelitis, is an infection involving the intervertebral disc and adjacent vertebral bodies. The disc is relatively avascular in adults, and infection typically reaches the disc by hematogenous spread through the subchondral end-plate vessels that supply adjacent bone. The infection erodes through the end plate into the disc space, involving the disc and both bordering vertebrae in a contiguous pattern (hence the term "spondylodiscitis"). Staphylococcus aureus is the most common causative organism, followed by gram-negative enteric bacteria (particularly in elderly or urinary tract infection-prone patients) and Mycobacterium tuberculosis (Pott disease) in endemic regions. Risk factors include bacteremia, intravenous drug use, diabetes, immunosuppression, urinary tract procedures, and cardiovascular or gastrointestinal instrumentation. The lumbar spine is most commonly affected, followed by thoracic and cervical levels. MRI with gadolinium is the diagnostic gold standard, showing T2 signal hyperintensity within the disc and adjacent end plates with enhancement. CT-guided percutaneous biopsy (performed off antibiotics) achieves microbiological diagnosis in approximately 50–75% of cases and guides targeted antibiotic selection. Treatment is typically 6–8 weeks of intravenous followed by oral antibiotics; surgery is reserved for spinal instability, neurological deficits, or failure of medical management.
Anatomy & Pathology
The intervertebral disc consists of the outer fibrous annulus fibrosus and the inner gel-like nucleus pulposus. In adults, the disc has no direct blood supply — nutrients diffuse from capillaries in the vertebral end plates above and below. Bacterial seeding typically starts at the end plate, then spreads into the disc and across to the adjacent vertebra, forming the classic "discovertebral" pattern of destruction seen on MRI and CT.
Symptoms
- Severe, progressive back or neck pain, often constant and worse at night
- Fever and chills — present in about 50% of cases
- Point tenderness to percussion over the affected vertebral segment
- Elevated ESR, CRP, and white blood cell count on blood tests
- Neurological deficits if epidural abscess or vertebral collapse occurs
- Reluctance to flex or extend the spine due to pain
- Recent history of bacteremia, UTI, or invasive procedure
Causes & Risk Factors
- Hematogenous seeding by Staphylococcus aureus (most common; MRSA in healthcare-associated cases)
- Gram-negative organisms from urinary tract infection: E. coli, Klebsiella, Proteus
- Mycobacterium tuberculosis (Pott disease) — common in high-prevalence regions; destroys disc and anterior vertebral bodies
- Direct inoculation from spinal surgery, discography, or epidural catheter
- Risk factors: diabetes mellitus, IV drug use, immunosuppression, chronic renal failure, hemodialysis
Treatment Options
Conservative
- Prolonged IV antibiotics (4–6 weeks) followed by oral antibiotics targeting identified organism (total 6–12 weeks)
- CT-guided percutaneous biopsy for microbiological diagnosis (perform before starting antibiotics when possible)
- Spinal immobilization with TLSO or cervical orthosis for pain management and stability monitoring
Surgical
- Surgical debridement and fusion for spinal instability, progressive vertebral collapse, or failed antibiotic therapy
- Emergency decompression laminectomy for associated epidural abscess causing neurological deficits
- Anterior debridement with strut graft and posterior instrumented fusion for extensive vertebral destruction and kyphosis
When to see a spine specialist
Seek evaluation for persistent back pain with fever, especially with a history of recent infection, urological procedure, or intravenous drug use. Spondylodiscitis is frequently misdiagnosed as mechanical back pain for weeks to months. Any new neurological symptom (weakness, sensory change, bladder dysfunction) in the context of spondylodiscitis is an emergency requiring immediate MRI.
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Search spine specialists →Frequently Asked Questions
How is vertebral discitis diagnosed?
MRI with gadolinium is the most sensitive and specific diagnostic imaging test, showing T2 hyperintensity within the disc and adjacent end plates with post-contrast enhancement. CT demonstrates bone destruction and soft tissue extension. Blood cultures are positive in approximately 50–60% of cases. CT-guided biopsy of the disc and end plate (ideally before antibiotic initiation) achieves microbiological diagnosis in 50–75% of cases. ESR, CRP, and procalcitonin are typically elevated and are useful for monitoring treatment response.
How long is the antibiotic treatment for vertebral discitis?
Standard antibiotic duration is 6 weeks of IV antibiotics followed by oral completion for a total of 8–12 weeks, though this varies based on organism, patient immune status, and radiographic response. ESR and CRP trends are used to monitor treatment response. A multicenter randomized trial (OVIVA, 2019) demonstrated non-inferiority of early oral antibiotic switch after 1 week of IV therapy for bone and joint infections, including spondylodiscitis, potentially reducing the need for prolonged IV access.
What is Pott disease?
Pott disease is spinal tuberculosis (Mycobacterium tuberculosis infection of the spine), the most common form of skeletal TB. Unlike pyogenic spondylodiscitis, TB characteristically spares the disc space early (lacking the protease enzymes that destroy disc cartilage) while causing anterior vertebral body destruction, leading to wedge collapse and severe kyphotic deformity (gibbus deformity). Large paraspinal cold abscesses (without fever due to the low-grade infectious nature) are characteristic. Treatment requires 6–12 months of anti-tuberculous chemotherapy; surgery is reserved for progressive neurological deficits or spinal instability.