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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Andre V, Pot-Vaucel M, Cozic C, et al. Septic arthritis of the facet joint. Medecine et Maladies Infectieuses. 45(6):215-21, 2015 Jun. Review/Other-Dx 11 patients To report the experience through a retrospective series of cases of facet joint infections diagnosed. The clinical symptoms are similar to those of infectious spondylodiscitis: back pain with stiffness (11/11), fever (9/11), radicular pain (5/11), and asthenia. Ten patients presented with lumbar infection and 1 with dorsal infection. An inflammatory syndrome was observed in every case. A rapid access to spine MRI allowed making the diagnosis in every case, and assessing a potential extension of infection (epidural extension 5/11, paraspinal extension 5/11). Blood culture (8/11) or culture of spinal samples allowed identifying the causative bacterium in every case and adapting the antibiotic treatment. The bacteria identified in our series were different from previously reported ones, with less staphylococci. The origin of the infection was found in 4 cases. Another localization of infection was observed in 4 cases. The outcome was favorable with medical treatment in 10 cases. An abscess was surgically drained in 1 case. None of our patients presented with neurological complications, probably because of the rapid diagnosis. 4
2. Crete RN, Gallmann W, Karis JP, Ross J. Spinal Coccidioidomycosis: MR Imaging Findings in 41 Patients. Ajnr: American Journal of Neuroradiology. 39(11):2148-2153, 2018 11. Review/Other-Dx 41 patients To describe the various spinal manifestations resulting from coccidioidal infection and provide MR imaging examples from 41 pathologically proved cases. Forty-one patients were included. Positive findings were categorized as leptomeningeal enhancement (26 patients, 63%), arachnoiditis (22 patients, 54%), osteomyelitis-discitis (14 patients, 34%), cord edema (11 patients, 27%), and true syrinx (3 patients, 7%). Thirty patients had documented brain involvement (73%), most commonly in the form of basilar meningitis. Four patients were positive for HIV (10%). Fifteen patients had pulmonary manifestations at presentation (37%). 4
3. Diehn FE. Imaging of spine infection. [Review]. Radiologic Clinics of North America. 50(4):777-98, 2012 Jul. Review/Other-Dx N/A To review the imaging and relevant clinical details of infection of the extradural spine. No results stated in the abstract. 4
4. Ganesh D, Gottlieb J, Chan S, Martinez O, Eismont F. Fungal Infections of the Spine. [Review]. Spine. 40(12):E719-28, 2015 Jun 15. Review/Other-Dx 130 articles To retrospectively examine the frequency of published fungal infections by species and the treatment algorithms used to eradicate the disease. A total of 130 articles, representing 157 cases, were included in the review. Aspergillus (60 cases, 38.2% of the total) and Candida species (36 cases, 22.9% of the total) were the 2 most common organisms. Surgery was associated with a greater survival rate than medical management alone in patients with Aspergillus (26.9% mortality in surgical patients; 60% in medically treated patients) and Candida (0% vs. 28.6%). Overall mortality was 19.3%. The overall recurrence rate was 7.4%. Amphotericin use was associated with a higher mortality rate than azoles. 4
5. Marais S, Roos I, Mitha A, Mabusha SJ, Patel V, Bhigjee AI. Spinal Tuberculosis: Clinicoradiological Findings in 274 Patients. Clinical Infectious Diseases. 67(1):89-98, 2018 06 18. Review/Other-Dx 11 patients To report 11 cases of facet joint infections diagnosed in our institution. The clinical symptoms are similar to those of infectious spondylodiscitis: back pain with stiffness (11/11), fever (9/11), radicular pain (5/11), and asthenia. Ten patients presented with lumbar infection and 1 with dorsal infection. An inflammatory syndrome was observed in every case. A rapid access to spine MRI allowed making the diagnosis in every case, and assessing a potential extension of infection (epidural extension 5/11, paraspinal extension 5/11). Blood culture (8/11) or culture of spinal samples allowed identifying the causative bacterium in every case and adapting the antibiotic treatment. The bacteria identified in our series were different from previously reported ones, with less staphylococci. The origin of the infection was found in 4 cases. Another localization of infection was observed in 4 cases. The outcome was favorable with medical treatment in 10 cases. An abscess was surgically drained in 1 case. None of our patients presented with neurological complications, probably because of the rapid diagnosis. 4
6. Talbott JF, Narvid J, Chazen JL, Chin CT, Shah V. An Imaging-Based Approach to Spinal Cord Infection. [Review]. Seminars in Ultrasound, CT & MR. 37(5):411-30, 2016 Oct. Review/Other-Dx N/A To provide an overview of MRI findings for spinal cord infections with special focus on imaging patterns of infection that are primarily confined to the spinal cord, spinal meninges, and spinal nerve roots. No results stated in the abstract. 4
7. Zhang N, Zeng X, He L, et al. The Value of MR Imaging in Comparative Analysis of Spinal Infection in Adults: Pyogenic Versus Tuberculous. World Neurosurgery. 128:e806-e813, 2019 Aug. Observational-Dx 70 patients To identify key distinguishing features between  pyogenic spondylitis (PS)  and tuberculous spondylitis (TS), and with that establish a systematic scoring method to help clinicians. Among the 70 cases, the average age was 54.5 years, and 43 were male. Sixteen parameters were significantly different between the PS and TS groups. We hypothesized that a diagnosis of PS could be made when the number of parameters characteristic of PS exceeded the number of parameters characteristic of TS, and vice versa. We randomly selected 70% (49 patients) of the 70 patients for analysis, and then validated in the remaining 30% (21 patients) of cases. Using 0.5 as the cutoff value, of the remaining 21 patients, the correct coincidence rate was 95.23%, sensitivity was 91.67%, specificity was 100%, false-positive rate was 0%, and false-negative rate was 8.3%. The MRI parameter scores of PS and TS were analyzed with the receiver operating characteristic; area under the curve was 1.00. 2
8. Duarte RM, Vaccaro AR. Spinal infection: state of the art and management algorithm. [Review]. Eur Spine J. 22(12):2787-99, 2013 Dec. Review/Other-Dx N/A To highlight the importance of a methodological attitude towards accurate and prompt diagnosis using an algorithm to aid on spinal infection management. Literature reveals that histopathological analysis of infected tissues is a paramount for diagnosis and must be performed routinely. Antibiotic therapy is transversal to both conservative and surgical approaches and must be initiated after etiological diagnosis. Indications for surgical treatment include neurological deficits or sepsis, spine instability and/or deformity, presence of epidural abscess and upon failure of conservative treatment. 4
9. Jimenez-Mejias ME, de Dios Colmenero J, Sanchez-Lora FJ, et al. Postoperative spondylodiskitis: etiology, clinical findings, prognosis, and comparison with nonoperative pyogenic spondylodiskitis. Clin Infect Dis 1999;29:339-45. Observational-Dx 103 patients To discuss the etiology, clinical findings, prognosis of postoperative spondylodiskitis and comparison with nonoperative pyogenic spondylodiskitis. The onset of symptoms occurred an average (+/-SD) of 27.7 (+/- 25.3) days following surgery. Predisposing factors were less frequent in POS than NPOS cases (P = .002). Neurological complications and inflammatory signs in the spine were more frequent with POS than with NPOS (P = .002 and P < .00001). Coagulase-negative Staphylococcus and anaerobic bacteria were more frequent in POS than in NPOS (P = .0001 and P = .05). Percutaneous bone biopsies yielded the etiology in 66.7% of cases, open bone biopsies in 100%, blood cultures in 55.6%, and cultures of adjacent foci in 94.4%. Eleven patients (35.5%) were cured with antimicrobial treatment, but surgical treatment was necessary in 64.5%. No relapses or deaths were recorded. Seventeen patients (54.8%) had severe functional sequelae, which were associated with inflammatory signs in the spine (P = .033), higher levels of leukocytosis (P = .05), higher erythrocyte sedimentation rates (P = .05), and paravertebral abscesses (P = .04). 2
10. Lazzeri E, Bozzao A, Cataldo MA, et al. Joint EANM/ESNR and ESCMID-endorsed consensus document for the diagnosis of spine infection (spondylodiscitis) in adults. European Journal of Nuclear Medicine & Molecular Imaging. 46(12):2464-2487, 2019 Nov. Review/Other-Dx 20 consensus statements To review the literature from January 2006 to December 2015 and proposed 20 consensus statements in answer to clinical questions regarding SD diagnosis. 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. 4
11. Tschugg A, Lener S, Hartmann S, Rietzler A, Neururer S, Thome C. Primary acquired spondylodiscitis shows a more severe course than spondylodiscitis following spine surgery: a single-center retrospective study of 159 cases. Neurosurgical Review. 41(1):141-147, 2018 Jan. Observational-Dx 159 patients To investigate differences between primary and postoperative spondylodiscitis. The demographic details and patients’ characteristics are presented in Table ?Table2.2. One hundred fifty-nine patients who underwent surgical and conservative treatment for spondylodiscitis have been identified at the Department of Neurosurgery. Thereby, the proportion of spondylodiscitis following surgery was 35% (group S, n = 55) versus 65% (group NS, n = 104) for primary spondylodiscitis. Altogether, 73/159 (46%) patients were female. The most common ASA score was ASA 3° in both groups (p > 0.05). Drug abuse was more common in group NS (23/104 (22%); p = 0.041). A dorsal decompression was initially performed in 67% of patients in group S. The infection was mostly located in the lumbar spine followed by the thoracic and cervical spine. 2
12. Akiyama T, Chikuda H, Yasunaga H, Horiguchi H, Fushimi K, Saita K. Incidence and risk factors for mortality of vertebral osteomyelitis: a retrospective analysis using the Japanese diagnosis procedure combination database. BMJ Open. 3(3), 2013 Mar 25. Observational-Dx 7118 patients To examine the incidence of vertebral osteomyelitis (VO) and the clinical features of VO focusing on risk factors for death using a Japanese nationwide administrative database. Overall, 58.9% of eligible patients were men and the average age was 69.2 years. The estimated incidence of VO increased from 5.3/100 000 population per year in 2007 to 7.4/100 000 population per year in 2010. In-hospital mortality was 6%. There was a linear trend between higher rates of in-hospital mortality and greater age. A higher rate of in-hospital mortality was significantly associated with haemodialysis use (ORs, 10.56 (95% CI 8.12 to 13.74)), diabetes (2.37 (1.89 to 2.98)), liver cirrhosis (2.63 (1.49 to 4.63)), malignancy (2.68, (2.10 to 3.42)) and infective endocarditis (3.19 (1.80 to 5.65)). 2
13. Bhavan KP, Marschall J, Olsen MA, Fraser VJ, Wright NM, Warren DK. The epidemiology of hematogenous vertebral osteomyelitis: a cohort study in a tertiary care hospital. BMC Infect Dis 2010;10:158. Observational-Dx 70 patients To perform a 2-year retrospective cohort study of adult patients with hematogenous vertebral osteomyelitis at a tertiary care hospital. Seventy patients with hematogenous vertebral osteomyelitis were identified. The mean age was 59.7 years (+/-15.0) and 38 (54%) were male. Common comorbidities included diabetes (43%) and renal insufficiency (24%). Predisposing factors in the 30 days prior to admission included bacteremia (19%), skin/soft tissue infection (17%), and having an indwelling catheter (30%). Back pain was the most common symptom (87%). Seven (10%) patients presented with paraplegia. Among the 46 (66%) patients with a microbiological diagnosis, the most common organisms were methicillin-susceptible S. aureus [15 (33%) cases], and methicillin-resistant S. aureus [10 (22%)]. Among the 44 (63%) patients who had a diagnostic biopsy, open biopsy was more likely to result in pathogen recovery [14 (93%) of 15 with open biopsy vs. 14 (48%) of 29 with needle biopsy; p = 0.003]. Sixteen (23%) patients required surgical intervention for therapeutic purposes during admission. 2
14. Arbelaez A, Restrepo F, Castillo M. Spinal infections: clinical and imaging features. [Review]. Topics in Magnetic Resonance Imaging. 23(5):303-14, 2014 Oct. Review/Other-Dx N/A To review the clinical and imaging features of spinal infections. No results stated in abstract. 4
15. Fucs PM, Meves R, Yamada HH. Spinal infections in children: a review. Int Orthop 2012;36:387-95. Review/Other-Dx N/A To review the spinal infections in children. No results stated in the abstract. 4
16. Ledbetter LN, Salzman KL, Shah LM. Imaging Psoas Sign in Lumbar Spinal Infections: Evaluation of Diagnostic Accuracy and Comparison with Established Imaging Characteristics. Ajnr: American Journal of Neuroradiology. 37(4):736-41, 2016 Apr. Observational-Dx 101 patients To determine the added accuracy of psoas musculature T2 hyperintensity (imaging psoas sign) in the MR imaging diagnosis of lumbar discitis-osteomyelitis. Psoas T2 hyperintensity demonstrated a high sensitivity (92.1%; 95% CI, 80%-97.4%) and specificity (92%; 95% CI, 80%-97.4%), high positive likelihood ratio (11.5; 95% CI, 4.5-29.6), low negative likelihood ratio (0.09; 95% CI, 0.03-0.20), and individual area under the receiver operating characteristic curve of 0.92; 95% CI, 0.87-0.97. Identification of psoas T2 abnormality significantly improved (P = .02) the diagnostic accuracy of discitis-osteomyelitis in noncontrast examinations from an area under the receiver operator characteristic curve of the established variables (vertebral body T2 and T1 signal, endplate integrity, disc T2 signal, and disc height) from 0.93 (95% CI, 0.88-0.98) to 0.98 (95% CI, 0.96-1.0). Psoas T2 abnormalities also had the highest interobserver reliability with a ? coefficient of 0.78 (substantial agreement). 2
17. Shifrin A, Lu Q, Lev MH, Meehan TM, Hu R. Paraspinal Edema Is the Most Sensitive Feature of Lumbar Spinal Epidural Abscess on Unenhanced MRI. AJR. American Journal of Roentgenology. 209(1):176-181, 2017 Jul. Observational-Dx 136 patients To evaluate the sensitivity and specificity of imaging features suggestive of Spinal epidural abscess (SEA) at unenhanced spine MRI. Paraspinal edema was highly sensitive (97%) for SEA, with lower sensitivities for psoas (54%), bone marrow (65%), and disk edema (66%). Each of these markers was highly significant in univariate analysis (p < 0.001). A multivariate logistic regression model adjusting for age and sex found that paraspinal (p < 0.001) and bone marrow edema (p = 0.006) were significant independent predictors of SEA (odds ratio, 58; p < 0.001), with a trend toward significance for psoas edema and abnormal disk signal. Psoas muscle edema was the most specific (96%) finding for the presence of SEA. 2
18. Davis DP, Salazar A, Chan TC, Vilke GM. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain. Journal of Neurosurgery Spine. 14(6):765-70, 2011 Jun. Review/Other-Dx 86 patients To explore the use of a novel clinical decision guideline to screen patients who present to the emergency department (ED) with spine pain for spinal epidural abscess (SEA) and to determine the diagnostic test characteristics of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level in patients at risk for SEA. A total of 55 patients with an SEA in the 9-year control period and 31 patients with an SEA in the 5-year study period were identified. Diagnostic delays were observed in 46 (83.6%) of 55 patients before guideline implementation versus 3 (9.7%) of 31 after guideline implementation (p < 0.001). Motor deficits were present at the time of diagnosis in 45 (81.8%) of 55 patients before guideline implementation versus 6 (19.4%) of 31 after guideline implementation (p < 0.001). The sensitivity and specificity of ESR in patients with an SEA risk factor were 100% and 67%, respectively. The receiver operating characteristic curve analysis revealed better test characteristics for ESR (area under curve 0.96) than for CRP (area under curve 0.81). 4
19. Yokota H, Yamada K. Viral infection of the spinal cord and roots. [Review]. Neuroimaging Clinics of North America. 25(2):247-58, 2015 May. Review/Other-Dx N/A To summarize myelopathy and radiculopathy caused by different viruses. No results stated in the abstract. 4
20. Berbari EF, Kanj SS, Kowalski TJ, et al. Executive Summary: 2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults. [Review]. Clinical Infectious Diseases. 61(6):859-63, 2015 Sep 15. Review/Other-Dx N/A To discuss the executive summary of the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults. No results stated in the abstract. 4
21. Cox M, Curtis B, Patel M, Babatunde V, Flanders AE. Utility of sagittal MR imaging of the whole spine in cases of known or suspected single-level spinal infection: Overkill or good clinical practice?. Clin Imaging. 51:98-103, 2018 Sep - Oct. Review/Other-Dx 82 patients To determine the frequency of multifocal infection. MRI identified 82 patients with single-level infection. All 82 had entire spine imaging performed within 72 h of admission, showing additional non-continuous sites of infection in 19 patients (23%). Remote levels of spondylodiscitis were present in 11 patients (13%). 4
22. von Kalle T, Heim N, Hospach T, Langendorfer M, Winkler P, Stuber T. Typical patterns of bone involvement in whole-body MRI of patients with chronic recurrent multifocal osteomyelitis (CRMO). ROFO Fortschr Geb Rontgenstr Nuklearmed. 185(7):655-61, 2013 Jul. Observational-Dx 53 patients To evaluated the spectrum of bone involvement in whole-body magnetic resonance imaging (WB-MRI) and assessed its potential contribution to a more rapid diagnosis. WB-MRI revealed multifocal lesions in all but one patients. Only 26 of them had presented with multifocal complaints. We detected 1 - 27 geographic lesions/patient (mean 9.7). 510 of 513 lesions were significantly hyperintense compared to normal bone marrow. The pelvis, lower extremities, shoulders and spine were most frequently involved. 40 patients (75 %) had bilateral symmetrical involvement of bones. Most of the lesions were located in tubular bones, in 87 % adjacent to one or both sides of a growth plate. 32 % of lesions showed periosteal involvement. Of 456 affected bones, 33 (7.2 %) were deformed, 6 (18 %) were vertebra plana. 2
23. do Amaral LL, Nunes RH, da Rocha AJ. Parasitic and rare spinal infections. [Review]. Neuroimaging Clin N Am. 25(2):259-79, 2015 May. Review/Other-Dx N/A To discuss key features of trypanosomiases and echinococcosis. Additionally, severalnonparasitic diseases are herein discussed, including syphilis, Baggio-Yoshinari syndrome, para-coccidioidomycosis, and HTLV-1–associated myelopathy. No results is stated in the abstract. 4
24. Khalid M, Siddiqui MA, Qaseem SM, Mittal S, Iraqi AA, Rizvi SA. Role of magnetic resonance imaging in evaluation of tubercular spondylitis: pattern of disease in 100 patients with review of literature. [Review]. Jnma, Journal of the Nepal Medical Association. 51(183):116-21, 2011 Jul-Sep. Observational-Dx 100 patients To evaluate the role of magnetic resonance imaging (MRI) in evaluation of tubercular spondylitis and to correlate imaging findings with clinical severity of the disease. Backache was the most common presenting symptom present in 86 %, while paraparesis was the most common sign seen in 62 %. The neurological status of the patients correlated well with MRI findings in the majority of the cases with an overall good correlation obtained in 96 % of cases. The majority of the vertebrae and intervertebral discs affected showed hypointensity or isointensity on T1W images and hyperintensity on T2W images. Epidural/dural disease was present in 74 % while 68 % of patients demonstrated decreased intervertebral disc height. Epidural extension and subligamentous spread was in 74 % and 90 % of patients respectively. 2
25. Strauss SB, Gordon SR, Burns J, Bello JA, Slasky SE. Differentiation between Tuberculous and Pyogenic Spondylodiscitis: The Role of the Anterior Meningovertebral Ligament in Patients with Anterior Epidural Abscess. AJNR Am J Neuroradiol 2020;41:364-68. Observational-Dx 35 patients To determine whether violation of the anterior meningovertebral ligament in the setting of anterior epidural abscess discriminates between these entities. Five of 6 (83.3%) cases of tuberculous epidural abscess had an intact anterior meningovertebral ligament, and 0/35 cases of pyogenic epidural abscess demonstrated an intact ligament (P < .001). The presence of an intact anterior meningovertebral ligament had 83.3% sensitivity and 100% specificity for tuberculous spondylodiscitis, a 100% positive predictive value, and a 97.2% negative predictive value. 2
26. Tali ET, Koc AM, Oner AY. Spinal brucellosis. [Review]. Neuroimaging Clinics of North America. 25(2):233-45, 2015 May. Review/Other-Dx N/A To report on Spinal brucellosis. No results stated in the abstract. 4
27. Kowalski TJ, Layton KF, Berbari EF, et al. Follow-up MR imaging in patients with pyogenic spine infections: lack of correlation with clinical features. AJNR Am J Neuroradiol. 28(4):693-9, 2007 Apr. Observational-Dx 33 patients To describe follow-up MR imaging examination findings 4-8 weeks after diagnosis and initiation of treatment of spine infections and to compare with clinical findings. Compared with baseline MR imaging examinations, follow-up MR imaging more frequently demonstrated vertebral body loss of height (26/33 [79%] versus 14/33 [47%]; P < .001) and less frequently demonstrated epidural enhancement (19/32 [59%] versus 29/33 [88%]; P = .008), epidural canal abscess (3/32 [9%] versus 15/33 [45%]; P = .001), and epidural canal compromise (10/32 [31%] versus 19/33 [58%]; P = .008). Most follow-up MR imaging examinations demonstrated less paraspinal inflammation and less epidural enhancement compared with baseline. However, vertebral body enhancement, disk space enhancement, and bone marrow edema more often were equivocal or appeared worse compared with baseline. Twenty-one of 32 (66%) follow-up MR imaging examination overall grades were considered improved, 5 (16%) were equivocal, and 6 (19%) were worse. No single MR imaging finding was associated with clinical status. 2
28. Mazzie JP, Brooks MK, Gnerre J. Imaging and management of postoperative spine infection. [Review]. Neuroimaging Clinics of North America. 24(2):365-74, 2014 May. Review/Other-Dx N/A To distinguishing between postsurgical inflammatory changes and spondylodiskitis, as well as in-fected postoperative fluid collections, is crucial for successful interpretation and successful patient management. No results stated in the abstract. 4
29. Radcliff K, Morrison WB, Kepler C, et al. Distinguishing Pseudomeningocele, Epidural Hematoma, and Postoperative Infection on Postoperative MRI. Clinical Spine Surgery : A Spine Publication. 29(9):E471-E474, 2016 11. Review/Other-Dx 33 patients To identify specific magnetic resonance imaging (MRI) characteristics of epidural fluid collections associated with infection, hematoma, or cerebrospinal fluid (CSF). The study population includes consecutive patients between 2006 and 2010 who had MRIs performed within 2 weeks after elective surgery for evaluation of possible CSF fluid collection, hematoma, or infection. Patients with known previous infection (discitis/osteomyelitis) or inadequate MRIs were excluded from the study. Medical records were reviewed to determine the diagnosis (infection, hematoma, or pseudomeningocele) underlying the fluid collection. MRIs were retrospectively evaluated by a musculoskeletal radiologist and orthopedic spine attending who were blinded to the pathologic diagnosis for characteristics of the fluid collection. MRI characteristics include location of lesion: osseous involvement, disk location, anterior versus posterior versus anteroposterior, soft-tissue involvement, and iliopsoas involvement. Characteristics of the lesion include: volume of lesion, loculation, satellite lesions, multiple loci, destructive characteristics, and mass effect upon thecal sac. Enhancement was scored based upon the following variables: rim enhancement, smooth versus irregular, thin versus thick, heterogeneity, diffuse enhancement, nonenhancement, and rim thickness. General fluid collection intensity and complexity on T1, T2, and T1 postcontrast images was scored as high, medium, and low. The ? test was used to compare the incidence of imaging characteristics between patient groups (infection, hematoma, and CSF). 4
30. Rayes M, Colen CB, Bahgat DA, et al. Safety of instrumentation in patients with spinal infection. Journal of Neurosurgery Spine. 12(6):647-59, 2010 Jun. Observational-Dx 47 patients To report cases of spinal infection that were surgically treated with debridement and placement of instrumentation at their institution between 2000 and 2006. Forty-seven patients (32 men, 15 women) were treated with instrumented surgery for spinal infection. Their average age at presentation was 54 years (range 37-78 years). Indications for placement of instrumentation included instability, pain after failure of conservative therapy, or both. Patients underwent surgery within an average of 12 days (range 1 day to 5 months) after their presentation to the authors' institution. The average length of hospital stay was 25 days (range 9-78 days). Follow-up averaged 22 months (range 1-80 months). Eight patients died; causes of death included sepsis (4 patients), cardiac arrest (2), and malignancy (2). Only 3 patients were lost to follow-up. Using American Spinal Injury Association scoring as the criterion, the patients' conditions improved in 34 cases and remained the same in 5. Complications included hematoma (2 cases), the need for hardware revision (1), and recurrent infection (2). Hardware replacement was required in 1 of the 2 patients with recurrent infection. 2
31. Raghavan M, Lazzeri E, Palestro CJ. Imaging of Spondylodiscitis. [Review]. Seminars in Nuclear Medicine. 48(2):131-147, 2018 03. Review/Other-Dx N/A To discuss the review of the imaging of Spondylodiscitis. No results stated in the abstract. 4
32. Pola E, Autore G, Formica VM, et al. New classification for the treatment of pyogenic spondylodiscitis: validation study on a population of 250 patients with a follow-up of 2 years. European Spine Journal. 26(Suppl 4):479-488, 2017 10. Review/Other-Dx 250 patients To propose a clinical-radiological classification of pyogenic spondylodiscitis to define a standard treatment algorithm. Type A PS occurred in 84 patients, while 46 cases were classified as type B and 120 as type C. Average time of hospitalization was 51.94 days and overall healing rate was 92.80%. 140 patients (56.00%) were treated conservatively with average time of immobilization of 218.17 ± 9.89 days. Both VAS and SF-12 scores improved across time points in all classes. Residual chronic back pain occurred in 27 patients (10.80%). Overall observed mortality was 4.80%. 4
33. Rausch VH, Bannas P, Schoen G, et al. Diagnostic Yield of Multidetector Computed Tomography in Patients with Acute Spondylodiscitis. Rofo: Fortschritte auf dem Gebiete der Rontgenstrahlen und der Nuklearmedizin. 189(4):339-346, 2017 Apr. Observational-Dx 43 patients To determine the value of multidetector computed tomography (MDCT) in patients with acute spondylodiscitis. In 34 of 43 patients with acute spondylodiscitis on MRI, correct diagnosis was already made by the initial MDCT scan. The specificity and positive predictive value were 100 % for MDCT. The sensitivity was 79 % and the negative predictive value was 72 %. The overall accuracy was 87 %. Accuracy was higher for CECT (89 %) than for NECT (84 %), however without statistical significance (p = 0.55). MDCT detected 90 % of paravertebral abscesses (34/38), but only 6 % of epidural abscesses (2/36). Conclusion MDCT has moderate sensitivity, but high specificity for acute spondylodiscitis. Thus, if MDCT is positive for spondylodiscitis, treatment can be started without further delay. However, MRI should be added to both MDCT negative and positive cases to rule out complications such as epidural abscesses that cannot reliably be detected by MDCT. Key Points: · Patients with acute spondylodiscitis are often initially suspected of having other differential diagnosis because of nonspecific symptoms.. · Therefore, MDCT is frequently performed prior to MRI in patients with acute spondylodiscitis.. · MDCT proved moderate sensitivity but high specificity for the diagnosis of acute spondylodiscitis.. · Paravertebral abscess is a strong indicator for the presence of spondylodiscitis on MDCT.. · However, MRI is crucial to rule out epidural abscesses, an important complication. 2
34. Russo A, Graziano E, Carnelutti A, et al. Management of vertebral osteomyelitis over an eight-year period: The UDIPROVE (UDIne PROtocol on VErtebral osteomyelitis). Int J Infect Dis. 89:116-121, 2019 Dec. Observational-Dx 98 patients To discuss the results of the management of vertebral osteomyelitis over an eight-year period During the study period, 133 episodes of confirmed VO were observed. The etiology of infection was obtained in 73.6% of cases: 70.5% were gram-positive, 16.3% were gram-negative, and 13.2% were mycobacteria. 18F-Fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) showed that for tubercular VO, the median standard uptake value (SUV) was higher when compared with VO caused by other bacteria. Clinical cure at the end of therapy was reported in 85.7% of patients. Previous antimicrobial therapy and a delay of more than 5 days in performing biopsy were associated with an undiagnosed etiology of VO. Targeted antibacterial therapy and follow-up with FDG-PET/CT were associated with clinical cure at the end of therapy, while the involvement of more than two vertebrae and inadequate drainage were associated with failure. 2
35. Shah LM, Ross JS. Imaging of Degenerative and Infectious Conditions of the Spine. [Review]. Neurosurgery. 79(3):315-35, 2016 Sep. Review/Other-Dx N/A To discuss the evaluation of patients with with degenerative disease and infectious processes. No results state din the abstract. 4
36. Tamm AS, Abele JT. Bone and Gallium Single-Photon Emission Computed Tomography-Computed Tomography is Equivalent to Magnetic Resonance Imaging in the Diagnosis of Infectious Spondylodiscitis: A Retrospective Study. Canadian Association of Radiologists Journal. 68(1):41-46, 2017 Feb. Observational-Dx 34 patients To compare the sensitivities and specificities of bone and gallium SPECT-CT and MRI in infectious spondylodiscitis. Spondylodiscitis was diagnosed in 18 patients and excluded in 16. Bone or gallium SPECT-CT and MRI had similar (P > .05; ? = 0.74) sensitivities (0.94 vs 0.94), specificities (1.00 vs 1.00), positive predictive values (1.00 vs 1.00), negative predictive values (0.94 vs 0.80), and accuracies (0.97 vs 0.95) when compared to the reference standard. 2
37. Homagk L, Marmelstein D, Homagk N, Hofmann GO. SponDT (Spondylodiscitis Diagnosis and Treatment): spondylodiscitis scoring system. Journal of Orthopaedic Surgery. 14(1):100, 2019 Apr 11. Observational-Dx 296 patients To develop a diagnosis and course-of-disease index to optimize its treatment. The number of patients receiving treatment increased over the past 15 years of our study. We also found an increasing age of patients at the point of diagnosis across the study, with an average age of 67.7 years. In 34% of patients, spondylodiscitis developed spontaneously. Almost 70% of them did not receive treatment until the first diagnosis using SponDT. Following treatment against spondylodiscitis, pain intensity decreased from 6.0 to 3.1 NRS. The inflammatory markers also decreased (CRP from 119.2 to 46.7 mg/dl). Similarly, MRI revealed a regression in inflammation following treatment. By employing SponDT, patients were diagnosed and entered into treatment with a score of 5.6 (severe spondylodiscitis) and discharged with a score of 2.4 (light/healed spondylodiscitis). 2
38. Bassetti M, Merelli M, Di Gregorio F, et al. Higher fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) uptake in tuberculous compared to bacterial spondylodiscitis. Skeletal Radiology. 46(6):777-783, 2017 Jun. Observational-Dx 10 patients To discuss a case-control study comparing tuberculous spondylodiscitis with biopsy-confirmed pyogenic spondylodiscitis in the period 2010-2012. Ten cases of tuberculous spondylodiscitis and 20 controls were included. Compared to pyogenic, tuberculous spondylodiscitis was more frequent in younger patients (P = 0.01) and was more often associated with thoraco-lumbar tract lesions (P = 0.01) and multiple vertebral involvement (P = 0.01). Significantly higher maximum standardized uptake values (SUV) at FDG-PET were displayed by tuberculous spondylodiscitis compared to controls (12.4 vs. 7.3, P = 0.003). SUV levels above 8 showed the highest value of specificity (0.80). Mean SUV reduction of 48% was detected for tuberculous spondylodiscitis at 1-month follow-up. 2
39. Dauchy FA, Dutertre A, Lawson-Ayayi S, et al. Interest of [(18)F]fluorodeoxyglucose positron emission tomography/computed tomography for the diagnosis of relapse in patients with spinal infection: a prospective study. Clinical Microbiology & Infection. 22(5):438-43, 2016 May. Observational-Dx 30 patients To assess the diagnostic performance of [(18)F]fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) in this setting. Thirty patients (21 men, nine women; median age 61.2 years) with a suspected spinal infection relapse were prospectively included between March 2010 and June 2013. The initial diagnosis of spinal infection was confirmed by positive bacterial cultures. The patients underwent [(18)F]FDG PET/CT and magnetic resonance imaging (MRI) 1 month after antibiotic treatment interruption. PET/CT data were interpreted both visually and semi-quantitatively (SUVmax). The patients were followed for =12 months and the final diagnosis of relapse was based on new microbiological cultures. Seven patients relapsed during follow up. Sensitivity, specificity, positive predictive value and negative predictive value were 66.6%, 61.9%, 33.3% and 86.6%, respectively for MRI and 85.7, 82.6, 60.0 and 95.0 for PET/CT. Although these values were higher for PET/CT than for MRI, the difference was not statistically significant (p=0.3). [(18)F]FDG PET/CT may be useful for diagnosing a relapse of spinal infections, in particular if metallic implants limit the performance of MRI. 2
40. Follenfant E, Balamoutoff N, Lawson-Ayayi S, et al. Added value of [18F]fluorodeoxyglucose positron emission tomography/computed tomography for the diagnosis of post-operative instrumented spine infection. Joint, Bone, Spine: Revue du Rhumatisme. 86(4):503-508, 2019 07. Observational-Dx 44 patients To evaluate the diagnostic performance of [18F]fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) in PISI Forty-nine PET/CT were performed in 44 patients (22 women, median age 65.0 years). Twenty-two patients had a diagnosis of infection during follow-up. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for PET/CT were 86.4%, 81.5%, 79.2%, and 88.0%. Sensitivity, specificity, PPV and NPV were 66.7%, 75.0%, 66.0%, 75.0% respectively for MRI and 50.0%, 92.6%, 84.6% and 69.4% for serum C-reactive protein (CRP). Although these values were higher for PET/CT than for MRI or CRP, the differences were not statistically significant. In this setting, false positives with PET/CT can be observed in case of previous spine infection or adjacent segments disc disease. False negatives can result of extensive instrumented arthrodesis or infection with low virulence bacteria. 2
41. Frenkel Rutenberg T, Baruch Y, Ohana N, et al. The Role of 18F-Fluorodeoxyglucose Positron-Emission Tomography/Computed Tomography in the Diagnosis of Postoperative Hardware-Related Spinal Infections. Isr Med Assoc J. 21(8):532-537, 2019 Aug. Observational-Dx 9 patients To evaluate the accuracy and diagnostic value of 18F-fluorodeoxyglucose positron-emission tomography/computed tomography (18F-FDG PET/CT) in the workup of patients with suspected implant-related infections of the spine and to assess the clinical impact of PET/CT results on the management of these infections. Among the patients, five experienced hardware-related spinal infection. 18F-FDG PET/CT sensitivity was 80%, specificity 100%, and accuracy 88.9%. One scan produced a false negative; however, a second PET/CT scan revealed an infection. 2
42. Gunes BY, Onsel C, Sonmezoglu K, et al. Diagnostic value of F-18 FDG PET/CT in patients with spondylodiscitis: Is dual time point imaging time worthy?. Diagnostic Microbiology & Infectious Disease. 85(3):381-385, 2016 Jul. Observational-Dx 32 patients To investigate the value of FDG-PET/CT in the diagnosis of spondylodiscitis (SD), the significance of dual time point imaging (DTPI) for SD diagnosis and the worth of SUVmax data for distinguishing tuberculous vs. non-tuberculous SD. Specific pathogens were isolated in 21 patients; other patients were accepted as nonspecific bacterial SD. In all patients, FDG-PET/CT results were compatible with SD diagnosis. The SUVmax data for tuberculous and non-tuberculous SD and DTPI results were statistically insignificant. 2
43. Kouijzer IJE, Scheper H, de Rooy JWJ, et al. The diagnostic value of 18F-FDG-PET/CT and MRI in suspected vertebral osteomyelitis - a prospective study. Eur J Nucl Med Mol Imaging. 45(5):798-805, 2018 05. Observational-Dx 32 patients To determine the diagnostic value of 18F-fluorodeoxyglucose (FDG) positron emission tomography and computed tomography (PET/CT) and magnetic resonance imaging (MRI) in diagnosing vertebral osteomyelitis. For 18F-FDG-PET/CT, sensitivity, specificity, PPV, and NPV in diagnosing vertebral osteomyelitis were 100%, 83.3%, 90.9%, and 100%, respectively. For MRI, sensitivity, specificity, PPV, and NPV were 100%, 91.7%, 95.2%, and 100%, respectively. MRI detected more epidural/spinal abscesses. An important advantage of 18F-FDG-PET/CT is the detection of metastatic infection (16 patients, 50.0%). 2
44. Treglia G, Pascale M, Lazzeri E, van der Bruggen W, Delgado Bolton RC, Glaudemans AWJM. Diagnostic performance of 18F-FDG PET/CT in patients with spinal infection: a systematic review and a bivariate meta-analysis. [Review]. European Journal of Nuclear Medicine & Molecular Imaging. 2019 Nov 15. Meta-analysis 12 studies (833 patients) To perform a systematic review and a bivariate meta-analysis on the diagnostic role of 18F-FDG PET/CT in patients with SI. Twenty-six articles (833 patients) using 18F-FDG PET/CT were eligible for the qualitative analysis. Twelve studies (396 patients) were selected for the meta-analysis. Overall, 18F-FDG PET/CT demonstrated a very good diagnostic performance in patients with SI and several studies underlined the value of 18F-FDG PET/CT in assessing the response to treatment. The bivariate meta-analysis on 18F-FDG PET/CT in patients with suspected SI provided the following results: sensitivity 94.8% (95% CI 88.9-97.6%) and specificity 91.4% (95% CI 78.2-96.9%). The pooled LR+, LR- and DOR were 4.7 (95% CI 2.9-7.7), 0.11 (95% CI 0.07-0.16) and 63.4 (95% CI 28.9-139), respectively. No significant heterogeneity or publication bias was found. Good
45. Yin Y, Liu X, Yang X, Guo J, Wang Q, Chen L. Diagnostic value of FDG-PET versus magnetic resonance imaging for detecting spondylitis: a systematic review and meta-analysis. Spine Journal: Official Journal of the North American Spine Society. 18(12):2323-2332, 2018 12. Meta-analysis 6 studies To compare the diagnostic values of 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) and magnetic resonance imaging (MRI) in detecting spondylitis. The summary results for 18F-FDG-PET were as follows: sensitivity=0.96 [95% confidence intervals (CI), 0.84-0.99]; specificity=0.90 (95% CI, 0.79-0.96); PLR=9.83 (95% CI, 4.39-22.03); NLR=0.05 (95% CI, 0.01-0.19); DOR=124.08 (95% CI, 39.04-394.34); and area under the SROC=0.97 (95% CI, 0.95-0.98). The summary sensitivity, specificity, PLR, NLR, DOR, and area under the SROC for MRI were 0.76 (95% CI, 0.65-0.84), 0.62 (95% CI, 0.45-0.77), 2.01 (95% CI, 1.36-2.98), 0.39 (95% CI, 0.27-0.56), 5.08 (95% CI, 2.66-9.69), and 0.77 (95% CI, 0.73-0.80), respectively. The summary results of sensitivity (p=.034), specificity (p=.006), PLR (p<.001), DOR (p<.001), and area under the SROC (p<.001) were higher in 18F-FDG-PET than in MRI. However, NLR (p=.003) was lower in 18F-FDG-PET than in MRI. Good
46. Fahnert J, Purz S, Jarvers JS, et al. Use of Simultaneous 18F-FDG PET/MRI for the Detection of Spondylodiskitis. Journal of Nuclear Medicine. 57(9):1396-401, 2016 09. Observational-Dx 30 patients To assess the diagnostic value of 18F-FDG PET combined with MRI (combined 18F-FDG PET/MRI) in patients with suspected spondylodiskitis and an inconclusive clinical or MRI presentation. The reference standards identified spondylodiskitis in 12 disks and excluded spondylodiskitis in 17 disks. For MRI alone, the sensitivity was 50%, the specificity was 71%, the positive predictive value was 54%, and the negative predictive value was 67%. Adding the PET data resulted in sensitivity, specificity, positive predictive value, and negative predictive value of 100%, 88%, 86%, and 100%, respectively. In a receiver operating characteristic curve analysis, an SUVmax ratio threshold of 2.1 resulted in 92% sensitivity and 88% specificity (area under the receiver operating characteristic curve, 0.95). Neither the level of C-reactive protein nor the leukocyte count at the time of PET/MRI was related to the reference standard diagnosis of spondylodiskitis. 1
47. An HS, Seldomridge JA. Spinal infections: diagnostic tests and imaging studies. [Review] [33 refs]. Clin Orthop. 444:27-33, 2006 Mar. Review/Other-Dx N/A To discuss the diagnostic tests and studies for spinal infections. No results stated in the abstract. 4
48. Dowdell J, Brochin R, Kim J, et al. Postoperative Spine Infection: Diagnosis and Management. Global Spine J 2018;8:37S-43S. Review/Other-Dx N/A To discuss the review of the literature on postoperative spinal infections, their diagnosis, and management. Currently, the gold standard for diagnosis of postoperative spine infection is positive deep wound culture. Many of the current radiologic and laboratory tests can assist with the initial diagnosis and monitoring treatment response. Currently erythrocyte sedimentation rate, C-reactive protein, computed tomography scan, and magnetic resonance imaging with and without contrast are used in combination to establish diagnosis. Management of postoperative spine infection involves thorough surgical debridement and targeted antibiotic therapy. 4
49. Lee Y, Lim J, Choi SW, Han S, Park B, Youm JY. Changes of Biomarkers before and after Antibiotic Treatment in Spinal Infection. Korean Journal of Neurotrauma. 15(2):143-149, 2019 Oct. Observational-Dx 29 patients To compare the changes of conventional biomarker and PCT in patients with spinal infection before and after antibiotic treatment. A total of 29 patients were enrolled, with a mean age of 67.8 years, consisting of 16 men and 13 women. Twenty-five patients had lumbar infections, and 2 each had cervical and thoracic infections. The mean ESR, CRP, PCT, and WBCs decreased at week 4 of antibiotic treatment compared to their baseline values. CRP and WBCs were significantly decreased after 4 weeks of treatment compared to before treatment. The mean ESR and PCT was not statistically significant compared to pretreatment and after antibiotic treatment (p-value>0.05). 2
50. Torrie PA, Leonidou A, Harding IJ, Wynne Jones G, Hutchinson MJ, Nelson IW. Admission inflammatory markers and isolation of a causative organism in patients with spontaneous spinal infection. Annals of the Royal College of Surgeons of England. 95(8):604-8, 2013 Nov. Observational-Dx 96 patients To investigate the significance of the inflammatory markers on admission in the isolation of a causative pathogen in patients with spinal infection. Spinal infection is treated frequently at spinal units and can encompass a broad range of clinical entities. Its diagnosis is often delayed because of the difficulty of identifying the responsible pathogen. The CRP levels on admission were correlated significantly with the overall potential for isolation of a pathogen (p<0.0001) and positive biopsy cultures (p=0.0016). Admission WCC levels were associated significantly with the overall potential for isolation of a pathogen (p=0.0003) and positive biopsy cultures (p=0.0023). Both CRP and WCC levels were significantly negatively correlated with the duration of the preceding symptoms (p=0.0003 and p<0.0001 respectively). Delay in presentation was significantly negatively correlated with organism isolation (p=0.0001). Multivariate analyses identified the delay in presentation as the strongest independent variable for organism isolation (p=0.014) in cases of spontaneous spinal infection when compared with the admission CRP level (p=0.031) and WCC (p=0.056). 2
51. Gasbarrini A, Boriani L, Nanni C, et al. Spinal infection multidisciplinary management project (SIMP): from diagnosis to treatment guideline. International Journal of Immunopathology &#38; Pharmacology. 24(1 Suppl 2):95-100, 2011 Jan-Mar. Review/Other-Dx 41 patients To discuss the assessment of the Spinal infection multidisciplinary management project (SIMP) flow-chart and of every single aspect that characterizes it. No results state din the abstract. 4
52. Kasalak O, Adams HJA, Jutte PC, et al. Culture yield of repeat percutaneous image-guided biopsy after a negative initial biopsy in suspected spondylodiscitis: a systematic review. Skeletal Radiology. 47(10):1327-1335, 2018 Oct. Review/Other-Dx 8 studies (107 patients) To systematically review the published data on the culture yield of a repeat (second) percutaneous image-guided biopsy after negative initial biopsy in suspected spondylodiscitis. Eight studies, comprising a total of 107 patients who underwent a second percutaneous image-guided biopsy after a culture-negative initial biopsy in suspected spondylodiscitis, were included. All eight studies were at risk of bias and were concerning with regard to applicability, particularly patient selection, flow of patients through the study, and timing of the biopsy. The proportions of positive cultures among all initial biopsies ranged from 10.3 to 52.5%, and were subject to heterogeneity (I2 = 73.7%). The proportions of positive cultures among all second biopsies after negative initial biopsy ranged from 0 to 60.0%, and were not subject to heterogeneity (I2 = 38.7%). 4
53. Matsubara T, Yamada K, Sato K, Gotoh M, Nagata K, Shiba N. Clinical outcomes of percutaneous suction aspiration and drainage for the treatment of infective spondylodiscitis with paravertebral or epidural abscess. Spine Journal: Official Journal of the North American Spine Society. 18(9):1558-1569, 2018 09. Review/Other-Dx 52 patients To evaluate the clinical outcomes of PSAD for infective spondylodiscitis with paravertebral or epidural abscess. Fifty-two patients (31 men and 21 women; average age, 70.6 years) were included in our analysis. The median (range) CRP levels and ESR values at the time of diagnosis were 6.86 (0.04-20.15) mg/dL and 78.8 (26-120) mm/h, respectively. At 1 year postoperatively, these values had decreased to 0.18 (0.0-1.2) mg/dL and 13.8 (4-28) mm/h for CRP and ESR, respectively. At final follow-up, bone union was observed in 80.8% (42 of 52) of patients, with instability identified in five patients. Regarding functional mobility, excellent outcomes were obtained in 26.9% (14 of 52) of patients, whereas good, fair, and poor outcomes were noted in 42.3% (22 of 52), 3.9% (2 of 52), and 26.9% (14 of 52) of patients, respectively. Overall, treatment was considered effective in 69.2% (36 of 52) of patients. 4
54. McGauvran AM, Kotsenas AL, Diehn FE, Wald JT, Carr CM, Morris JM. SAPHO Syndrome: Imaging Findings of Vertebral Involvement. AJNR Am J Neuroradiol. 37(8):1567-72, 2016 Aug. Observational-Dx 18 patients To evaluate the prevalence of this distinctive morphology in patients dignosed with SAPHO syndrome. Eighteen patients (16 women [89%]; mean age, 52.9 years) with SAPHO and spine involvement were included. Contiguous involvement of =2 vertebral bodies was found in 16 patients (89%), with a curvilinear or "semicircular" pattern involving portions of adjacent vertebral bodies in 10 (63%, P = .14). Most intervertebral discs demonstrated absence of abnormal T2 hyperintensity (73%) and enhancement (89%). Subligamentous thickening was present in 12 (67%). Paraspinal soft-tissue involvement was present in 6 (33%). 2
55. Morales H.. Infectious Spondylitis Mimics: Mechanisms of Disease and Imaging Findings. Seminars in Ultrasound, CT & MR. 39(6):587-604, 2018 Dec. Review/Other-Dx N/A To review developmental, anatomical, and pathologic concepts correlating with imaging clues. No results stated in the abstract. 4
56. Rigal J, Thelen T, Byrne F, et al. Prospective study using anterior approach did not show association between Modic 1 changes and low grade infection in lumbar spine. European Spine Journal. 25(4):1000-5, 2016 Apr. Observational-Dx 313 patients To determine if an association existed between lumbar disc degeneration and chronic infection of the intervertebral disc. The mean age was 47 ± 8.6 years sterile cultures were obtained in 379 samples (98.4%) and 6 were positive (1.6%). The cultured bacteria were: Propionibacterium acnes (n:2), Staphylococcus epidermidis (n:2), Citrobacter freundii (n:1), and Saccharopolyspora hirsuta (n:1). Histopathological analysis did not demonstrate any evidence of a neutrophilia. There were no delayed or secondary infections. 1
57. Sertic M, Parkes L, Mattiassi S, Pritzker K, Gardam M, Murphy K. The Efficacy of Computed Tomography-Guided Percutaneous Spine Biopsies in Determining a Causative Organism in Cases of Suspected Infection: A Systematic Review. Can Assoc Radiol J. 70(1):96-103, 2019 Feb. Review/Other-Dx 11 articles To determine the diagnostic culture yield of CT-guided biopsies performed in cases of suspected spinal infections. 220 search results were screened; 11 met our inclusion criteria and were reviewed. In total, 647 biopsies of suspected infectious spinal lesions were performed. Positive cultures were obtained in 241 cases. Upon excluding one paper's skewed results, the net pooled results culture yield was 33%. Several cultures grew multiple organisms, leading to a total of 244 species identified. Most common isolated organisms include Staphylococcus aureus (n = 83), coagulase-negative Staphylococcus (n = 45), and Mycobacteria (n = 38). 4
58. Sheikh AF, Khosravi AD, Goodarzi H, et al. Pathogen Identification in Suspected Cases of Pyogenic Spondylodiscitis. Frontiers in Cellular & Infection Microbiology. 7:60, 2017. Observational-Dx 57 patients To discuss Pathogen Identification in Suspected Cases of Pyogenic Spondylodiscitis. A total of 21 samples amplified the 16S rRNA-PCR product. Sanger sequencing of the PCR products identified the following bacteriological agents: Mycobacterium tuberculosis (n = 9; 42.9%), Staphylococcus aureus (n = 6; 28.5%), Mycobacterium abscessus (n = 5; 23.8%), and Mycobacterium chelonae (n = 1; 4.8%). 36 samples displayed no visible 16S rRNA PCR signal, which suggested that non-bacterial infectious agents (e.g., fungi) or non-infectious processes (e.g., inflammatory, or neoplastic) may be responsible for some of these cases. The L3-L4 site (23.8%) was the most frequent site of infection. Single disc/vertebral infection were observed in 9 patients (42.85%), while 12 patients (57.15%) had 2 infected adjacent vertebrae. Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) inflammatory markers were noted in majority of the patients. 2
59. Balcescu C, Odeh K, Rosinski A, et al. High Prevalence of Multifocal Spine Infections Involving the Cervical and Thoracic Regions: A Case for Imaging the Entire Spine. Neurospine. 16(4):756-763, 2019 Dec. Observational-Dx 7 patients To identify predictors of multifocal spinal infections in comparison to unifocal spinal infections. Seven patients (35%) had multifocal infections. Three were bifocal, and 4 were trifocal. Patients with surgically treated cervical or thoracic spinal infections had a high rate of concomitant multifocal spinal infections (71% and 83%, respectively). Other potential predictors (e.g., patient age, body mass index, magnetic resonance image findings, etc.) did not reach statistical significance. Each of the multifocal infections involved the lumbar spine. 2
60. Alerhand S, Wood S, Long B, Koyfman A. The time-sensitive challenge of diagnosing spinal epidural abscess in the emergency department. [Review]. Internal & Emergency Medicine. 12(8):1179-1183, 2017 Dec. Review/Other-Dx 18 articles To demonstrate the challenges of diagnosing Spinal epidural abscess (SEA), describe key diagnostic pitfalls, and present a model and framework for its evaluation. Of the initial 219 articles found, 18 articles were selected based on their relevancy to emergency medicine. Lower back pain is a common chief complaint, whereas SEA is a rare condition and may not be anticipated. The "classic triad" of SEA symptoms presents infrequently. Moreover, the early symptoms of back pain and fever are non-specific, and patients seek medical attention at varying stages of disease progression. Once the more conspicuous and wide-ranging neurological symptoms develop, they are often irreversible. In fact, final outcomes correlate with the severity and duration of symptoms before surgery. Furthermore, discovering these late neurological symptoms can be particularly difficult in bed-bound and chronically ill patients. MRI is the best diagnostic imaging tool for SEA. Early diagnosis is the major prognostic factor for favorable outcome of SEA, and yet, making this diagnosis in the emergency department (ED) has proved challenging. Shifting from a "classic triad" screening to a risk factor-based model of evaluation represents the current optimal strategy for diagnosing SEA. An algorithm incorporating the most recent data is provided. 4
61. Colip CG, Lotfi M, Buch K, Holalkere N, Setty BN. Emergent spinal MRI in IVDU patients presenting with back pain: do we need an MRI in every case?. Emergency Radiology. 25(3):247-256, 2018 Jun. Observational-Dx 167 patients To assess the value of obtaining contrast-enhanced spinal MRI for patients presenting to the emergency department (ED) with acute back pain and a history of intravenous drug use (IVDU). Evidence of infectious spondylitis was demonstrated on the spinal MRIs of 39.5% (n = 66) of 167 patients, all of whom were admitted, and nearly half (48.5%; 32/66) underwent surgical or percutaneous intervention. Statistically significant differences in the decision to admit, blood cultures, and the type of treatment was demonstrated in patients with findings of spinal infection on MRI (p < 0.05). 2
62. Arko L 4th, Quach E, Nguyen V, Chang D, Sukul V, Kim BS. Medical and surgical management of spinal epidural abscess: a systematic review. [Review]. Neurosurgical Focus. 37(2):E4, 2014 Aug. Review/Other-Dx 12 articles To review these published reports and compares pooled data with historical treatment data. Twelve articles directly comparing surgical to nonsurgical management of SEA were obtained. These articles reported on a total of 1099 patients. The average age of treated patients was 57.24 years, and 62.5% of treated patients were male. The most common pathogens found in blood and wound cultures were Staphylococcus aureus (63.6%) and Streptococcus species (6.8%). The initial treatment was surgery in 59.7% of cases and medical therapy in 40.3%. This represented a significant increase in the proportion of medically managed patients in comparison with the historical control prior to 1999 (p < 0.05). Patients with no neurological deficits were significantly more likely to be treated medically than surgically (p < 0.05). There was no statistically significant difference overall between surgical and nonsurgical management, although several risk factors may predict failure of medical management. 4
63. Kihira S, Koo C, Mahmoudi K, et al. Combination of Imaging Features and Clinical Biomarkers Predicts Positive Pathology and Microbiology Findings Suggestive of Spondylodiscitis in Patients Undergoing Image-Guided Percutaneous Biopsy. AJNR Am J Neuroradiol 2020;41:1316-22. Observational-Dx 72 patients To predict whether MR imaging features will add diagnostic value when combined with clinical biomarkers to predict positive findings of spondylodiscitis on pathology and/or microbiology from percutaneous biopsy. Our patient cohort consisted of 72 patients, of whom 33.3% (24/72) had spondylodiscitis. The mean age was 63 ± 16 years with a male/female ratio of 41:31. Logistic regression revealed a combination with an area under the curve of 0.72 for pathology and 0.68 for pathology and/or microbiology. Epidural enhancement on MR imaging improved predictive performance to 0.87 for pathology and 0.78 for pathology and/or microbiology. 2
64. Daghighi MH, Poureisa M, Safarpour M, et al. Diffusion-weighted magnetic resonance imaging in differentiating acute infectious spondylitis from degenerative Modic type 1 change; the role of b-value, apparent diffusion coefficient, claw sign and amorphous increased signal. British Journal of Radiology. 89(1066):20150152, 2016 Oct. Observational-Dx 43 patients To examine the effect of using different b-values on the utility of diffusion-weighted (DW) MRI in differentiating acute infectious spondylitis from Modic type 1 and the discriminative accuracy of related apparent diffusion coefficient (ADC), claw-sign and amorphous increased signal. DW MRI differentiated infectious spondylitis from Modic type 1 change most accurately when a b-value of 800 s mm(-2) was chosen [sensitivity, 91.7%; specificity, 96.8%; positive-predictive value (PPV), 91.7%; negative-predictive value (NPV), 96.8%; and accuracy, 95.3%]. The optimal cut-off ADC value was 1.52 × 10(-3) mm(2) s(-1) (sensitivity, 91.7%; specificity, 100%; PPV, 100%; NPV, 96.9%; and accuracy, 97.7%). Best visualized at a b-value of 50 s mm(-2), claw sign (for degeneration) and amorphous increased signal (for infection) were 100% accurate. 2
65. Dumont RA, Keen NN, Bloomer CW, et al. Clinical Utility of Diffusion-Weighted Imaging in Spinal Infections. Clin Neuroradiol. 29(3):515-522, 2019 Sep. Observational-Dx 38 patients To correlate findings on diffusion-weighted imaging (DWI) of the spine to results of microbiological sampling in patients with suspected spinal infections. Of 38 patients with suspected spinal infections, 29 (76%) had positive microbiological sampling, and 9 (24%) had negative results. The median ADC value was 740 × 10-6 mm2/s for patients with positive microbiological sampling and 1980 × 10-6 mm2/s for patients with negative microbiological sampling (p < 0.001). Using an ADC value of 1250 × 10-6 mm2/s or less as the cut-off value for a positive result for spinal infection, sensitivity was 66%, specificity was 88%, positive predictive value was 95%, negative predictive value was 41% and accuracy was 70%. 2
66. Moritani T, Kim J, Capizzano AA, Kirby P, Kademian J, Sato Y. Pyogenic and non-pyogenic spinal infections: emphasis on diffusion-weighted imaging for the detection of abscesses and pus collections. British Journal of Radiology. 87(1041):20140011, 2014 Sep. Review/Other-Dx N/A To: 1.  Demonstrate Diffusion-weighted imaging (DWI) findings in pyogenic and non-pyogenic spinal infections involving epidural/subdural spaces, leptomeninges, spinal cord, paraspinal soft tissue and iliopsoas muscle as well as other disseminated infections. 2. Illustrate and discuss the differential diagnosis and imaging pitfalls. No results stated in the abstract. 4
67. Patel KB, Poplawski MM, Pawha PS, Naidich TP, Tanenbaum LN. Diffusion-weighted MRI "claw sign" improves differentiation of infectious from degenerative modic type 1 signal changes of the spine. AJNR Am J Neuroradiol. 35(8):1647-52, 2014 Aug. Observational-Dx 73 patients To analyze the utility and accuracy of a novel, diffusion-weighted "claw sign" for distinguishing symptomatic type 1 degeneration from vertebral diskitis/osteomyelitis. When the 2 neuroradiologists identified a definite claw, 38 of 39 patients (97%) and 29 of 29 patients (100%) proved to be infection-free. When the readers identified a probable claw, 14 of 14 patients (100%) and 16 of 19 patients (84%) proved to be infection-free. Conversely, when the readers identified the absence of claw sign (diffuse DWI pattern), there was proved infection in 17 of 17 cases (100%) and 13 of 14 cases (93%). 1
68. Kakigi T, Okada T, Sakai O, et al. Subcutaneous fluid collection: An imaging marker for treatment response of infectious thoracolumbar spondylodiscitis. European Journal of Radiology. 84(7):1306-12, 2015 Jul. Observational-Dx 20 patients To evaluate prevalence of subcutaneous fluid collection (SFC) in infectious thoracolumbar spondylodiscitis (SD) compared with control patients and to investigate correlation between volume changes of SFC and treatment response of SD. SFC was found in 20 patients with SD (83.3%) and 3 non-SD patients (12%) with significant difference (p<.001). In 20 SD patients with SFC, 17 patients had follow-up MRI. For the 1st MRI, no significant correlation was found between volume of SFC and initial status of patients, including body weight, body mass index (BMI), white blood cell (WBC), and erythrocyte sedimentation rate (ESR). However, significant positive correlations were found between changes of C-reactive protein (CRP) and SFC volume from the 1st to 2nd as well as from the 1st to the last MRI (each p<.05). 2
69. Boden SD, Davis DO, Dina TS, Sunner JL, Wiesel SW. Postoperative diskitis: distinguishing early MR imaging findings from normal postoperative disk space changes. Radiology 1992;184:765-71. Observational-Dx 15 patients To distinguish early magnetic resonance (MR) imaging findings in postoperative diskitis from normal postoperative changes, a prospective study was performed in 15 asymptomatic patients (17 disk levels) who underwent uncomplicated lumbar diskectomy and seven patients with proved postoperative diskitis. On postoperative MR images, four of the asymptomatic patients had a finding that could also be seen in patients with diskitis. Gadolinium enhancement was useful in making the distinction and occurred as follows: (a) vertebral bone marrow: all seven diskitis patients and one asymptomatic patient; (b) disk space: five diskitis patients and three asymptomatic patients; and (c) posterior anulus fibrosus: all seven diskitis patients and 13 asymptomatic patients (14 of 17 levels). This entire triad of findings, which is strongly suggestive of postoperative diskitis, was not seen in any of the asymptomatic patients. Changes in the disk space and adjacent bone marrow on pre- and post-contrast MR images after routine diskectomy are uncommon and should not be assumed to be normal postoperative changes without careful consideration and analysis for early diskitis. 2
70. Kimura H, Shikata J, Odate S, Soeda T. Pedicle Screw Fluid Sign: An Indication on Magnetic Resonance Imaging of a Deep Infection After Posterior Spinal Instrumentation. Clinical spine surgery 2017;30:169-75. Observational-Dx 81 patients To assess whether the "pedicle screw (PS) fluid sign" on magnetic resonance imaging (MRI) can be used to diagnose deep surgical site infection (SSI) after posterior spinal instrumentation (PSI). The PS fluid sign had a sensitivity of 88.2%, specificity of 89.1%, positive predictive value of 68.1%, and negative predictive value of 96.6%. The 2 patients with a false-negative PS fluid sign in the SSI group had an infection at the disk into which the interbody cage had been inserted. Three of the 7 patients with a false-positive PS fluid sign in the non-SSI group had a dural tear during surgery. 2
71. Peacock JG, Timpone VM. Doing More with Less: Diagnostic Accuracy of CT in Suspected Cauda Equina Syndrome. Ajnr: American Journal of Neuroradiology. 38(2):391-397, 2017 Feb. Observational-Dx 151 patients To evaluate discuss the diagnostic accuracy of CT in suspected cauda equina syndrome. Forty of 151 patients had a percentage thecal sac effacement of =50% on MR imaging. Nineteen of 40 had cauda equina impingement. Readers determined that there was a CT percentage thecal sac effacement of <50% in 97/151 cases, and CT percentage thecal sac effacement of =50% in 54/151 cases. Reader sensitivity for the detection of significant spinal stenosis (MR percentage thecal sac effacement of =50%) was 0.98; specificity, 0.86; positive predictive value, 0.72; and negative predictive value, 0.99. No cases read as CT percentage thecal sac effacement of <50% were found to have cauda equina impingement. 2
72. Talia AJ, Wong ML, Lau HC, Kaye AH. Safety of instrumentation and fusion at the time of surgical debridement for spinal infection. J Clin Neurosci. 22(7):1111-6, 2015 Jul. Observational-Dx 9 patients To assess the results of single-stage instrumentation and fusion at the time of sur-gical debridement of spinal infections; vertebral osteomyelitis or epidural abscess Seven patients with pyogenic and two with tuberculous spinal infection were encountered; the most common pathogen was Staphylococcus aureus. Five patients were predisposed to infection because of diabetes mellitus. Duration of antibiotic therapy lasted up to 12 months. Six patients had thoracic infection, two lumbar and one cervical. No post-operative complications were encountered. There was a significant reduction in pain scores compared to pre-operatively. All patients with neurological deficits improved post-operatively. Despite introduction of hardware, no patients had a recurrence of their infection in the 12 month follow up period. Single-stage debridement and instrumentation appeared to be a safe and effective method of managing spinal infections. The combination of debridement and fusion has the dual benefit of removing a focus of infection and stabilising the spine. The current series confirms that placing titanium cages into an infected space is safe in a majority of patients. Stabilisation and correction of spinal deformity reduces pain, aids neurologic recovery and improves quality of life. The small patient population and retrospective nature limit the present study. 4
73. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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