Discitis in young children

Abstract

Discitis is uncommon in children and presents in different ways at different ages. It is most difficult to diagnose in the uncommunicative toddler of one to three years of age. We present 11 consecutive cases. The non-specific clinical features included refusal to walk (63%), back pain (27%), inability to flex the lower back (50%) and a loss of lumbar lordosis (40%). Laboratory tests were unhelpful and cultures of blood and disc tissue were negative.MRI reduces the diagnostic delay and may help to avoid the requirement for a biopsy. In 75% of cases it demonstrated a paravertebral inflammatory mass, which helped to determine the duration of the oral therapy given after initial intravenous antibiotics.At a mean follow-up of 21 months (10 to 40), all the spines were mobile and the patients free from pain. Radiological fusion occurred in 20% and was predictable after two years. At follow-up, MRI showed variable appearances: changes in the vertebral body usually resolved at 24 months and recovery of the disc was seen after 34 months.

Infectious spondylodiscitis

“…It is thought that the abundant intraosseous arterial anastomoses both predispose to an infective agent settling in the disc, as well as promoting clearance of microorganisms and allowing a more rapid resolution of infective discitis than that which is observed in adults. 62,64 Staphylococcus aureus is isolated in 34e48% of non-tuberculous cases. 2 Cultures are negative in 29e37%, which is higher than the rate observed in adults; this may reflect a brisk host-defence response to a low-grade pathogen, or may support a non-infective process.…”

“…2 Cultures are negative in 29e37%, which is higher than the rate observed in adults; this may reflect a brisk host-defence response to a low-grade pathogen, or may support a non-infective process. 62,64 Brown et al discourage both open and needle disc biopsies in toddlers in view of the low rate of positive cultures and unknown long-term effects of the procedure. 64 They argue that disc biopsies have minimal influence on antibiotic selection in this age group and are not required if a diagnosis is confirmed on MRI.…”

Practical approach to the child presenting with back pain

“…The presenting symptoms in children are usually back pain and persistent night time pain. Other symptoms may include abdominal pain, low grade fever, loss of appetite and/or weight, inability to flex the lower back, and loss of lumbar lordosis [5,7,10,24]. In toddlers, pain is manifested by a general irritability, limping, refusal to move or sit, and night time crying [24].…”

“…In toddlers, pain is manifested by a general irritability, limping, refusal to move or sit, and night time crying [24]. Laboratory investigations are usually nonspecific with an elevation of the white blood count and erythrocyte sedimentation rate [5,7,8,10,19]. Blood culture is often negative.…”

“…Treatment is usually conservative and consists of rest and antibiotics [10,19]. Biopsy is not recommended and is reserved for patients who are not responding to treatment [5,24].…”