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Joint EANM/ESNR and ESCMID-endorsed consensus document for the diagnosis of spine infection (spondylodiscitis) in adults

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European Journal of Nuclear Medicine and Molecular Imaging Aims and scope Submit manuscript

Abstract

Purpose

Diagnosis of spondylodiscitis (SD) may be challenging due to the nonspecific clinical and laboratory findings and the need to perform various diagnostic tests including serologic, imaging, and microbiological examinations. Homogeneous management of SD diagnosis through international, multidisciplinary guidance would improve the sensitivity of diagnosis and lead to better patient outcome.

Methods

An expert specialist team, comprising nuclear medicine physicians appointed by the European Association of Nuclear Medicine (EANM), neuroradiologists appointed by the European Society of Neuroradiology (ESNR), and infectious diseases specialists appointed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), reviewed the literature from January 2006 to December 2015 and proposed 20 consensus statements in answer to clinical questions regarding SD diagnosis. The statements were graded by level of evidence level according to the 2011 Oxford Centre for Evidence-based Medicine criteria and included in this consensus document for the diagnosis of SD in adults. The consensus statements are the result of literature review according to PICO (P:population/patients, I:intervention/indicator, C:comparator/control, O:outcome) criteria.

Evidence-based recommendations on the management of adult patients with SD, with particular attention to radiologic and nuclear medicine diagnosis, were proposed after a systematic review of the literature in the areas of nuclear medicine, radiology, infectious diseases, and microbiology.

Results

A diagnostic flow chart was developed based on the 20 consensus statements, scored by level of evidence according to the Oxford Centre for Evidence-based Medicine criteria.

Conclusions

This consensus document was developed with a final diagnostic flow chart for SD diagnosis as an aid for professionals in many fields, especially nuclear medicine physicians, radiologists, and orthopaedic and infectious diseases specialists.

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Acknowledgements

We wish to thank the many people who contributed to this consensus document through active work on the document or simply by contributing with useful discussion. First of all, we thank the members of the previous EANM Committee on Infection and Inflammation (John Buscombe, Riddhika Chakravarrty, Paola Erba, Ora Israel, Francois Jamar, and Josè Martin-Comin) and the ESNR and ESCMID boards for supporting this work and disseminating our results in international congresses.

Each practice guideline, representing a strategic statement, has undergone a thorough consensus process as a result of an extensive review.

This document was brought to the attention of all other EANM committees and the European national societies of nuclear medicine. The comments and suggestions from the Oncology Committee and Physics Committee and from the Czech, Russian, German, Italian, Latvian and Belgian national societies are highly appreciated and have been considered for this consensus document.

Author information

Authors and Affiliations

  1. European Association of Nuclear Medicine (EANM), Vienna, Austria

    Elena Lazzeri & Alberto Signore

  2. Regional Center of Nuclear Medicine, Pisa University Hospital, Pisa, Italy

    Elena Lazzeri

  3. Regional Center of Nuclear Medicine, Azienda Ospedaliero Universitaria Pisana, 56123 Via Roma, 67, Pisa, Italy

    Elena Lazzeri & Mario Muto

  4. European Society of Neuroradiology (ESNR), Leuven, Belgium

    Alessandro Bozzao & Luigi Manfrè

  5. Neuroradiology Unit, Faculty of Medicine and Psychology, “Sapienza” University of Rome, Rome, Italy

    Alessandro Bozzao

  6. European Society of Clinical Microbiology and Infectious Diseases (ESCMID), Basel, Switzerland

    Maria Adriana Cataldo, Nicola Petrosillo & Andrej Trampuz

  7. National Institute for Infectious Diseases “Lazzaro Spallanzani”, Rome, Italy

    Maria Adriana Cataldo & Nicola Petrosillo

  8. Minimal Invasive Spine Therapy Department, Mediterranean Oncologic Institute (I.O.M.), Catania, Italy

    Luigi Manfrè

  9. Department of Internal Medicine, University Hospital “Charitè”, Berlin, Germany

    Andrej Trampuz

  10. Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, Faculty of Medicine and Psychology, “Sapienza” University of Rome, Rome, Italy

    Alberto Signore

  11. Diagnostic and Interventional Neuroradiology Unit, Cardarelli Hospital, Naples, Italy

    Mario Muto

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  1. Elena Lazzeri
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Corresponding author

Correspondence to Elena Lazzeri.

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Disclosure statements

The European Association of Nuclear Medicine (EANM), founded in 1985, is a professional nonprofit medical association that facilitates communication worldwide between individuals pursuing clinical and research excellence in nuclear medicine.

The European Society of Neuroradiology (ESNR), founded in 1977, is a professional society of European neuroradiologists and a leader in education and training, with courses including the brain, spine, and diagnostic neuroradiology, as well as a forum for professional development of European neuroradiology.

The European Society of Clinical Microbiology and Infectious Diseases (ESCMID), founded in 1983, is an influential component in the professional lives of microbiologists and infectious disease specialists around the world. ESCMID facilitates the advance of scientific knowledge and the dissemination of professional guidelines and consensus documents in the field of clinical microbiology and infectious diseases.

EANM, ESNR, and ESCMID members are physicians, biologists, technologists, and scientists specialising in the research and practice of nuclear medicine, neuroradiology, and infectious diseases, respectively.

This consensus paper, representing a policy statement by the EANM/ESNR (with ESCMID endorsement), has undergone a thorough consensus process in which an extensive review was performed. The EANM, ESNR, and ESCMID recognise that the safe and effective use of diagnostic imaging requires specific training, skills, and techniques, as described in the introduction section. Reproduction or modification of the published paper is not authorised.

They report what ideally should be done based on evidence from the literature. However, these recommendations should be carefully adapted to local practice, where not all diagnostic tests or imaging modalities may be available. Resources available to care for patients, as well as legislation and local regulations, may vary greatly from one European country to another.

The recommendations contained herein are intended as an educational tool to assist practitioners in providing appropriate care for patients. They are not inflexible rules or requirements of practice and are not intended, nor should they be used, to establish a legal standard of care. For these reasons and those set forth below, the EANM, ESNR, and ESCMID caution against the use of these recommendations in litigation in which the clinical decisions of a practitioner are called into question.

The ultimate judgement regarding the propriety of any specific procedure or course of action must be made by the physician or medical physicist in light of all the circumstances presented. A conscientious practitioner may responsibly adopt a course of action different from that set forth in this document when such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology subsequent to publication of these recommendations.

The practice of medicine includes the prevention, diagnosis, alleviation, and treatment of disease. The variety and complexity of human conditions make it impossible to always reach the most appropriate diagnosis or to predict with certainty a particular response to treatment. Therefore, it should be recognised that adherence to these guidelines will not ensure an accurate diagnosis or a successful outcome. All that should be expected is that the practitioner will follow a reasonable course of action based on current knowledge (evidence-based medicine), available resources, and the needs of the patient to deliver effective and safe medical care. The sole purpose of this document is, therefore, to assist practitioners in achieving this objective.

The EANM and ESNR (with ESCMID endorsement) will periodically define new guidelines for the diagnosis of spine infection in adults to improve the quality of service to patients throughout the world. Existing diagnostic guidelines will be reviewed for revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated.

Conflict of interest

Elena Lazzeri is a senior advisor of the EANM Committee on Inflammation and Infection. She has nothing to declare.

Alessandro Bozzao has nothing to declare.

Maria Adriana Cataldo has nothing to declare.

Nicola Petrosillo has nothing to declare.

Luigi Manfrè has nothing to declare.

Andrej Trampuz has nothing to declare.

Alberto Signore is a senior advisor of the EANM Committee on Inflammation and Infection. He has nothing to declare.

Mario Muto has nothing to declare.

Ethical approval

This consensus document does not contain any studies with human participants or animals performed by any of the authors. The human studies described herein have been published previously.

Informed consent

Not applicable.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Oncology – Brain.

Appendix

Appendix

Consensus statements

  1. 1)

    SD should be suspected in patients with new or worsening spine pain and/or new myelo-radicular symptoms, and at least one of the following: fever, elevated ESR or CRP, bloodstream infection, or infective endocarditis.

All papers found: 2289.

Included papers for thorough reading: 183.

Included papers evidence-based statement: 28.

  1. 2)

    CRP, ESR, and WBC counts should always be performed in patients with suspected SD.

P: spine infection OR spinal infection OR vertebral infection OR vertebral osteomyelitis OR post-surgical spine infection OR spondylodiscitis OR discitis OR infectious spondylitis.

I: diagnostic methods.

C: none.

O: diagnosis.

All papers found: 2289.

Included papers for thorough reading: 183.

Included papers evidence-based statement: 28.

  1. 3)

    Blood cultures (for both aerobic and anaerobic bacteria) should always be performed in patients with suspected SD.

P: spine infection OR spinal infection OR vertebral infection OR vertebral osteomyelitis OR post-surgical spine infection OR spondylodiscitis OR discitis OR infectious spondylitis.

I: diagnostic methods.

C: none.

O: diagnosis.

All papers found: 2289.

Included papers for thorough reading: 183.

Included papers evidence-based statement: 30.

  1. 4)

    For patients with suspected SD and epidemiological risk factors for brucellosis, specific serological tests should be performed.

P: spine infection OR spinal infection OR vertebral infection OR vertebral osteomyelitis OR post-surgical spine infection OR spondylodiscitis OR discitis OR infectious spondylitis.

I: diagnostic methods.

C: none.

O: diagnosis.

All papers found: 2289.

Included papers for thorough reading: 183.

Included papers evidence-based statement: 6.

  1. 5)

    For patients with suspected SD and risk factors for Mycobacterium tuberculosis , a PPD test and an interferon-γ release assay should be performed.

P: spine infection OR spinal infection OR vertebral infection OR vertebral osteomyelitis OR post-surgical spine infection OR spondylodiscitis OR discitis OR infectious spondylitis.

I: diagnostic methods.

C: none.

O: diagnosis.

All papers found: 2289.

Included papers for thorough reading: 183.

Included papers evidence-based statement: 8.

  1. 6)

    Plain film X-ray should always be performed in patients with suspicion of spine infection for purposes of differential diagnostic and follow-up.

P: spine infection OR spinal infection OR vertebral infection OR vertebral osteomyelitis OR post-surgical spine infection OR spondylodiscitis OR discitis OR infectious spondylitis = 9683.

I: radiography OR x-ray OR radiographic diagnosis OR digital radiography OR plain radiography = 497487.

C: none.

O: early diagnosis = 150145.

All papers found: 200.

Included papers for thorough reading: 6.

Included papers evidence-based statement: 6.

  1. 7)

    In haematogenous SD, the first diagnostic imaging modality is MRI, if patients have no specific contraindications.

P: spine infection OR spinal infection OR vertebral infection OR vertebral osteomyelitis OR post-surgical spine infection OR spondylodiscitis OR discitis OR infectious spondylitis = 9683.

I: magnetic resonance OR MR OR MRI = 392979.

C: none.

O: diagnosis of spine infection OR diagnosis of vertebral osteomyelitis OR diagnosis of vertebral infection OR diagnosis of soft tissue infection OR diagnosis of paravertebral soft tissue infection = 5623.

All papers found: 1545.

Included papers for thorough reading: 6.

Included papers evidence-based statement: 5.

  1. 8)

    MRI must be performed with T1, T2, and T2 fat-suppressed or STIR sequences without and with contrast medium with T1 fat suppression technique.

P: spine infection OR spinal infection OR vertebral infection OR vertebral osteomyelitis OR post-surgical spine infection OR spondylodiscitis OR discitis OR infectious spondylitis = 9683.

I: MRI must be performed with T1, T2, and T2 fat-suppressed or STIR sequences without and with contrast medium with T1 fat-suppressed technique = 25.

C: none.

O: diagnosis of spine infection OR diagnosis of vertebral osteomyelitis OR diagnosis of vertebral infection OR diagnosis of soft tissue infection OR diagnosis of paravertebral soft tissue infection = 5623.

All papers found: 8.

Included papers for thorough reading: 8.

Included papers evidence-based statement: 8.

  1. 9)

    MRI in suspected spine infection should be performed with at least a 1.5 Tesla magnet.

P: spine infection OR spinal infection OR vertebral infection OR vertebral osteomyelitis OR post-surgical spine infection OR spondylodiscitis OR discitis OR infectious spondylitis = 9683.

I: MRI must be performed with a 1.5 Tesla magnet = none.

C: none.

O: diagnosis of spine infection OR diagnosis of vertebral osteomyelitis OR diagnosis of vertebral infection OR diagnosis of soft tissue infection OR diagnosis of paravertebral soft tissue infection = 5623.

All papers found: 4.

Included papers for thorough reading: 4.

Included papers evidence-based statement: 4.

  1. 10)

    CT may be useful for diagnosis only when MRI is contraindicated, not available, or equivocal.

P: spine infection OR spinal infection OR vertebral infection OR vertebral osteomyelitis OR post-surgical spine infection OR spondylodiscitis OR discitis OR infectious spondylitis = 9683.

I: CT OR computed tomography OR CeT = 324788.

C: none.

O: diagnosis of spine infection OR diagnosis of vertebral osteomyelitis OR diagnosis of vertebral infection OR diagnosis of soft tissue infection OR diagnosis of paravertebral soft tissue infection = 5623.

All papers found: 5.

Included papers for thorough reading: 5.

Included papers evidence-based statement: 5.

  1. 11)

    In primary and post-surgical SD, if MRI is contraindicated, the imaging modality of choice is [ 18 F]FDG-PET/CT.

P: spine infection OR spinal infection OR vertebral infection OR vertebral osteomyelitis OR post-surgical spine infection OR spondylodiscitis OR discitis OR infectious spondylitis = 9683.

Contraindications to MRI = 120 (none on SD).

I: PET OR PET/CT OR FDG-PET OR fluorodeoxyglucose OR FDG OR positron emission tomography = 62923.

C: none.

O: diagnosis of spine infection OR diagnosis of vertebral osteomyelitis OR diagnosis of vertebral infection OR diagnosis of soft tissue infection OR diagnosis of paravertebral soft tissue infection = 5377.

All papers found: 94.

Included papers for thorough reading: 30.

Included papers evidence-based statement: 24.

  1. 12)

    In post-surgical SD, with or without spinal hardware, [ 18 F]FDG-PET/CT can detect both spine infection and soft tissue infection.

P: post-surgical spine infection OR post-surgical vertebral infection OR post-surgical vertebral osteomyelitis OR post-surgical spine OR post-surgical spondylodiscitis OR spinal hardware = 9683.

I: FDG-PET OR PET OR fluorodeoxyglucose OR FDG OR positron emission tomography OR PET/CT = 62923.

C: none.

O: diagnosis of spine infection OR diagnosis of vertebral osteomyelitis OR diagnosis of vertebral infection OR diagnosis of soft tissue infection OR diagnosis of paravertebral soft tissue infection = 5377.

All papers found: 2.

Included papers for thorough reading: 12.

Included papers evidence-based statement: 10.

  1. 13)

    In patients with suspected spine infection and elevated ESR and/or CRP and doubtful MRI, [ 18 F]FDG-PET/CT should be performed.

P: inconclusive MR OR doubtful MR OR not diagnostic MR OR inconclusive MRI OR doubtful MRI OR no diagnostic MRI = 23502.

P: spine infection and elevated ESR and/or CRP = 23299.

I: FDG-PET OR PET OR fluorodeoxyglucose OR FDG OR positron emission tomography OR PET/CT = 62923.

C: none.

O: diagnosis of spine infection OR diagnosis of vertebral osteomyelitis OR diagnosis of vertebral infection OR diagnosis of soft tissue infection OR diagnosis of paravertebral soft tissue infection = 5377.

All papers found: 18.

Included papers for thorough reading: 18.

Included papers evidence-based statement: 17.

  1. 14)

    In patients with suspected spine infection, elevated ESR and/or CRP, doubtful or unperformable MRI, and doubtful or unperformable [ 18 F]FDG-PET/CT, a CT scan should be performed with an image-guided biopsy.

P: spine infection OR spinal infection OR vertebral infection OR vertebral osteomyelitis OR post-surgical spine infection OR spondylodiscitis OR discitis OR infectious spondylitis = 9683.

I: Inconclusive FDG-PET OR PET OR inconclusive fluorodeoxyglucose OR inconclusive FDG OR inconclusive positron emission tomography OR inconclusive PET/CT OR doubtful FDG-PET OR doubtful PET/CT =47758.

C: none.

O: CT-guided vertebral biopsy OR vertebral biopsy = 23943.

All papers found: 30.

Included papers for thorough reading: 7.

Included papers evidence-based statement: 7.

  1. 15)

    The role of hybrid PET/MRI, although promising, needs to be evaluated.

P: spine infection OR spinal infection OR vertebral infection OR vertebral osteomyelitis OR post-surgical spine infection OR spondylodiscitis OR discitis OR infectious spondylitis = 9683.

I: PET/MRI OR PET/MR OR hybrid PET/MRI OR hybrid PET/MR = 949.

C: none.

O: diagnosis of spine infection OR diagnosis of vertebral osteomyelitis OR diagnosis of vertebral infection OR diagnosis of soft tissue infection OR diagnosis of paravertebral soft tissue infection = 5377.

All papers found: none.

Included papers for thorough reading: none.

Included papers evidence-based statement: none.

  1. 16)

    In case of negative MRI or negative [ 18 F]FDG-PET/CT, the diagnosis of SD should be excluded.

P: spine infection OR spinal infection OR vertebral infection OR vertebral osteomyelitis OR post-surgical spine infection OR spondylodiscitis OR discitis OR infectious spondylitis = 9683.

I: negative FDG-PET OR negative PET OR negative fluorodeoxyglucose OR negative FDG OR negative positron emission tomography OR negative PET/CT = 5800.

negative MR OR negative MRI OR negative magnetic resonance = 18549.

C: none.

O: absence of spine infection OR absence of vertebral infection OR absence of spondylodiscitis = 131.

All papers found: 5.

Included papers for thorough reading: 3.

Included papers evidence-based statement: 3.

  1. 17)

    An image-guided aspiration biopsy should be performed in all patients with suspected SD based on clinical, laboratory, and imaging studies.

P: spine infection OR spinal infection OR vertebral infection OR vertebral osteomyelitis OR post-surgical spine infection OR spondylodiscitis OR discitis OR infectious spondylitis.

I: diagnostic methods.

C: none.

O: diagnosis.

All papers found: 2289.

Included papers for thorough reading: 183.

Included papers evidence-based statement: 28.

  1. 18)

    Antibiotic therapy should be discontinued or postponed before biopsy.

P: spine infection OR spinal infection OR vertebral infection OR vertebral osteomyelitis OR post-surgical spine infection OR spondylodiscitis OR discitis OR infectious spondylitis.

I: diagnostic methods.

C: none.

O: diagnosis.

All papers found: 2289.

Included papers for thorough reading: 183.

Included papers evidence-based statement: 9.

  1. 19)

    In patients with suspected SD based on clinical, laboratory, and imaging studies and a negative biopsy (histology and microbiology), another biopsy should be done.

P: spine infection OR spinal infection OR vertebral infection OR vertebral osteomyelitis OR post-surgical spine infection OR spondylodiscitis OR discitis OR infectious spondylitis.

I: diagnostic methods.

C: none.

O: diagnosis.

All papers found: 2289.

Included papers for thorough reading: 183.

Included papers evidence-based statement: 11.

  1. 20)

    In patients with SD diagnosed by [ 18 F]FDG-PET/CT, a second [ 18 F]FDG-PET/CT scan should be performed to evaluate the response to antibiotic therapy.

P: spine infection OR spinal infection OR vertebral infection OR vertebral osteomyelitis OR post-surgical spine infection OR spondylodiscitis OR discitis OR infectious spondylitis = 9683.

I: FDG-PET OR PET OR fluorodeoxyglucose OR FDG OR positron emission tomography OR PET/CT = 62923.

C: none.

O: response to therapy OR treatment response OR antibiotic response = 416536.

All papers found: 19.

Included papers for thorough reading: 9.

Included papers evidence-based statement: 8.

Statements 1, 2, 3, 4, 5, 6, 18, 19, 20 (ESCMID)

(((“spine”[MeSH Terms] OR “spine”[All Fields] OR “vertebral”[All Fields]) AND (“osteomyelitis”[MeSH Terms] OR “osteomyelitis”[All Fields])) OR (spinal[All Fields] AND (“osteomyelitis”[MeSH Terms] OR “osteomyelitis”[All Fields])) OR (“discitis”[MeSH Terms] OR “discitis”[All Fields] OR “spondylodiscitis”[All Fields]) OR (“discitis”[MeSH Terms] OR “discitis”[All Fields] OR “spondylodiskitis”[All Fields]) OR (“discitis”[MeSH Terms] OR “discitis”[All Fields] OR “diskitis”[All Fields]) OR (“discitis”[MeSH Terms] OR “discitis”[All Fields]) OR (infectious[All Fields] AND (“spondylitis”[MeSH Terms] OR “spondylitis”[All Fields])) OR (septic[All Fields] AND (“spondylitis”[MeSH Terms] OR “spondylitis”[All Fields])) OR (spinal[All Fields] AND (“infection”[MeSH Terms] OR “infection”[All Fields])) OR (spinal[All Fields] AND (“infection”[MeSH Terms] OR “infection”[All Fields] OR “infections”[All Fields])) OR ((“spine”[MeSH Terms] OR “spine”[All Fields]) AND (“infection”[MeSH Terms] OR “infection”[All Fields])) OR ((“spine”[MeSH Terms] OR “spine”[All Fields]) AND (“infection”[MeSH Terms] OR “infection”[All Fields] OR “infections”[All Fields])) OR ((“spine”[MeSH Terms] OR “spine”[All Fields] OR “vertebral”[All Fields]) AND (“infection”[MeSH Terms] OR “infection”[All Fields])) OR ((“spine”[MeSH Terms] OR “spine”[All Fields] OR “vertebral”[All Fields]) AND (“infection”[MeSH Terms] OR “infection”[All Fields] OR “infections”[All Fields])) OR (disk[All Fields] AND space[All Fields] AND (“infection”[MeSH Terms] OR “infection”[All Fields])) OR (disk[All Fields] AND space[All Fields] AND (“infection”[MeSH Terms] OR “infection”[All Fields] OR “infections”[All Fields])) OR (disc[All Fields] AND space[All Fields] AND (“infection”[MeSH Terms] OR “infection”[All Fields])) OR (disc[All Fields] AND space[All Fields] AND (“infection”[MeSH Terms] OR “infection”[All Fields] OR “infections”[All Fields]))) AND ((“diagnosis”[Subheading] OR “diagnosis”[All Fields] OR “diagnosis”[MeSH Terms]) OR (“diagnosis”[MeSH Terms] OR “diagnosis”[All Fields] OR “diagnostic”[All Fields])) AND ((“2006/01/01”[PDAT]: “2015/12/31”[PDAT]) AND “humans”[MeSH Terms] AND English[lang] AND “adult”[MeSH Terms]) NOT (“case reports”[Publication Type] OR “case reports”[All Fields])

All papers found: 2289. Included papers for thorough reading: 183. Included papers evidence-based statement: 61.

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Lazzeri, E., Bozzao, A., Cataldo, M.A. et al. Joint EANM/ESNR and ESCMID-endorsed consensus document for the diagnosis of spine infection (spondylodiscitis) in adults. Eur J Nucl Med Mol Imaging 46, 2464–2487 (2019). https://doi.org/10.1007/s00259-019-04393-6

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  • DOI: https://doi.org/10.1007/s00259-019-04393-6

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