- Clinical science
Osteitis and osteomyelitis are infections of the bone and bone marrow, respectively. Because these terms are often used interchangeably in clinical settings, both conditions will be referred to as osteomyelitis here. Staphylococcus aureus accounts for the majority of acute osteomyelitis cases; however, there are a number of other pathogens associated with this condition. How the pathogen enters the bone determines the type of osteomyelitis: hematogenous and exogenous forms exist. Hematogenous osteomyelitis is caused by seeding from a remote source and is most common among IV drug users and children. Exogenous osteomyelitis is more common in adults and results from direct inoculation through trauma (posttraumatic osteomyelitis) or contiguous spread from infected adjacent tissue (contiguous osteomyelitis due to, e.g., diabetic foot, contaminated prosthetic device). Osteomyelitis may be either acute or chronic and presents with general signs of local inflammation, including swelling, pain, redness, and warmth. Systemic signs, such as fever and chills, are more indicative of an acute infection. Diagnosis of clinically suspected cases is supported via laboratory tests, biopsy, and/or imaging. The treatment of choice for hematogenous osteomyelitis is IV antibiotics. Surgery may be necessary to remove necrotic bone, abscesses, infected foreign bodies, or fistulae. While osteomyelitis in adults often assumes a chronic course and requires prolonged treatment, children typically make a quick and full recovery.
- More common in children and adolescents (> 50% of cases occur in children ≤ 5 years)
- Vertebral osteomyelitis (a form of hematogenous osteomyelitis) occurs mainly in adults aged > 50 years
- Exogenous osteomyelitis: more common in adults
Epidemiological data refers to the US, unless otherwise specified.
Routes of infection
Hematogenous osteomyelitis: most commonly due to a single pathogen
- Hematogenous dissemination of pathogen
- Exogenous osteomyelitis: usually due to multiple pathogens
- Poor tissue perfusion
- Open fractures
- Severe soft tissue injury (poor tissue perfusion)
- Microbial: highly virulent pathogens
|Pathogens||Commonly affected groups|
|Fungal pathogens|| |
- Onset: usually gradual, over several days
- Chief complaint: pain at the site of infection, possibly related to movement
- Possible localized findings: point tenderness, swelling, redness, warmth
- Possible systemic findings: malaise, fever, chills
- Common localization of hematogenous osteomyelitis:
- Infants: long bone metaphysis, joints
- Children: long bone metaphysis, joint infection very rare
- Adults: vertebral involvement is most common In adults, involvement of the long bones is uncommon. However, if a long bone is involved, there is also a risk of joint involvement because blood vessels of the metaphysis also perfuse the epiphysis, which is ossified.
- Onset: usually following a prior episode of osteomyelitis; may last for months
- Chief complaint: recurrent pain
- Swelling, redness
- Local sinus tract formation, perhaps draining pus
- Definition: osteomyelitis of the vertebrae
Pathophysiology: hematogenous seeding of a distant infectious focus → infection of the vertebral bone → contiguous spread to the intervertebral discs (and adjacent vertebrae)
- Discitis refers to the infection of the vertebral disc
- Classification according to the underlying pathogen
- Clinical features: often latent, nonspecific symptoms
- Assess patient for clinical features and history suggestive of vertebral osteomyelitis
- Initial work-up: see flowchart
- Blood cultures
- Inflammatory markers
X-ray imaging (anterior-posterior and lateral views)
- Often inconclusive in the first 2 weeks of infection
- Initial narrowing of intervertebral spaces and end plate sclerosis
- Progressive kyphosis, vertebral body squaring, and development of
Contrast-enhanced MRI: the most sensitive diagnostic study; for vertebral osteomyelitis
- Disruption of vertebral structure, fusion of vertebral bodies and discs
- Contrast enhancement
- Gallium bone scan if MRI is contraindicated (metal foreign body implants) → detects sites of infection
- CT-guided needle aspiration biopsy (confirmatory test): culture and histology
- Bed rest and immobilization of the affected vertebral segment; spinal orthosis required in severe cases
- Antibiotic treatment (IV administration, for weeks or months)
- mycobacterium tuberculosis is the underlying pathogen : if
- CT-guided catheter drainage of paravertebral abscess
- Indications: spinal instability, neurological deficits, cord compression, large epidural or paravertebral abscess, refractory osteomyelitis
- ; stabilization of collapsed vertebrae/spinal instabilities with or without interbody fusion
- Psoas abscess; : abscess formation in the psoas muscle, causing pain and swelling in this region
Prevertebral abscess formation in the cervical spine can be life threatening → risk of tracheal compression and airway obstruction
- Symptoms: neck pain, difficulty swallowing, difficulty breathing, and possible respiratory failure
- Vertebral collapse and spinal instability → cord compression → paraplegia
Complications of tuberculous spondylitis
- Pott's paraplegia is primarily a phenomenon of the past; cases have become very rare as a result of improved treatment regimens.
- Gibbus deformity
- Abscess formation
Definition/Pathophysiology: an intraosseous abscess secondary to chronic hematogenous osteomyelitis that appears in immunocompetent children
- Osteomyelitis due to pathogens of low virulence may be contained locally in the form of an abscess.
- Localization: most commonly the metaphysis and epiphysis of long bones (especially in the distal femur and proximal tibia)
- Clinical features: frequently asymptomatic or only mild symptoms; pain
- Treatment: surgical drainage
- Suspect osteomyelitis in patients with focal symptoms (point tenderness) accompanied by nonspecific signs and symptoms of inflammation.
- Initial work-up includes blood cultures, inflammatory markers, and x-ray imaging.
- Rule out possible primary sources of infection and/or sites of dissemination (e.g., dental infection, furuncle, and urinary tract infections)!
- Early stages (< 2 weeks of symptoms onset): typically no pathological findings
- Later stages: bone destruction, sequestrum formation,
- MRI: the most sensitive diagnostic study; shows signs of inflammation ≤ 5 days after onset of infection → cortical destruction, bone marrow inflammation, soft tissue involvement
- Skeletal scintigraphy: visualizes areas of bone with increased bone turnover
- Radionuclide-labeled leukocyte scintigraphy: detects sites of infection or inflammation
- Sonography: assess soft tissue involvement
Early stages of osteomyelitis are not visible on x-ray!
Biopsy (confirmatory test)
- Bone biopsy: MRI/CT-guided needle or open biopsy + gram staining, culture, and histology
- Bed rest and immobilization of the affected extremity
- Antibiotic treatment
|Initial empiric antibiotic treatment|
|In children||< 3 months of age|
|> 3 months of age|
|Pathogen-directed IV antibiotics (according to bone biopsy findings)|
|Methicillin-susceptible S. aureus (MSSA)|
|MRSA or S. epidermidis|| |
|Gram-negative pathogens (including Pseudomonas)|
|Secondary osteomyelitis (e.g., prosthetic joints or foreign bodies)||Rifampicin in addition to the antibiotic regimen|
Treatment of osteomyelitis should not be delayed, especially in children! Osteomyelitis can have detrimental effects on bone development, resulting in severe long-term complications.
- Pyarthrosis: infiltration of nearby joints
- Course: recurring/chronic cases
- In children: growth impairment
We list the most important complications. The selection is not exhaustive.
- Quick, full recovery is common in children receiving appropriate antimicrobial treatment → > 95% of cases resolve completely.
- Acute osteomyelitis in adults often relapses and transforms into chronic osteomyelitis.
- Chronic osteomyelitis