Persistent severe back pain could signify rare spine infection: new IDSA guideline

Patients with back pain that doesn't go away despite therapy may have a spine infection that could lead to paralysis or death if not diagnosed and treated correctly, note the first U.S. guidelines on vertebral osteomyelitis, released by the Infectious Diseases Society of America and published in the journal of Clinical Infectious Diseases.

Vertebral osteomyelitis is fairly rare, and therefore often is overlooked because it causes back pain, a common ailment usually triggered by a pulled muscle or spine injury. Because the consequences of the infection are dire, it's important that an expert such as an infectious diseases (ID) physician help manage the patient.

"Back pain is so common - and usually not caused by infection - that diagnosis often is missed or delayed," said Elie F. Berbari, MD, lead author of the guidelines and associate chair of education for the division of infectious disease at Mayo Clinic College of Medicine, Rochester, Minn. "The infection causes severe pain that often wakes the person at night and does not go away after pain management or rest. If that's the case, the doctor needs to start considering that something else is going on, especially if the patient has a fever."

Every year, two to six out of 100,000 people get vertebral osteomyelitis, in which bacteria enter into the blood stream and lodge in a disc, the structure that acts as a shock absorber between vertebrae in the spine. While vertebral osteomyelitis can occur in anyone, the infection is most common in older patients, noted Dr. Berbari.

Simple blood tests to check for inflammation (including sedimentation rate and C-reactive protein) can help determine if vertebral osteomyelitis may be causing the pain, the guidelines note. If those tests are positive, the guidelines recommend the patient have a magnetic resonance imaging (MRI) test, which can differentiate between an infection and a common back problem, such as a slipped disc. If vertebral osteomyelitis is suspected after the MRI, the patient should have a biopsy to confirm infection and determine the bacteria responsible. Treatment typically involves six weeks of intravenous (IV) antibiotics. In about half of patients, surgery to remove the infection may be necessary, Dr. Berbari said.

If the patient's pain improves after antibiotics or surgery, a repeat MRI usually is not necessary, the guidelines say.

"It's important that the patient is seen by an expert familiar with the signs and symptoms of spine infections, who can differentiate between back pain due to mechanical reasons vs. infection," said Steven K. Schmitt, MD, co-author of the guidelines, member of the IDSA Board of Directors and an ID physician at Cleveland Clinic. "Early diagnosis and appropriate management can prevent disability, so a high index of suspicion and early ID consultation are central to a good outcome."

The voluntary guidelines are not intended to take the place of a doctor's judgment, but rather to support the decision-making process, which must be individualized according to each patient's circumstances.

The 11-member vertebral osteomyelitis guidelines panel comprises experts representing a variety of specialties, including infectious diseases physicians, an orthopedic surgeon and a radiologist. In addition to Drs. Berbari and Schmitt, the panel includes: Souha S. Kanj, Todd J. Kowalski, Rabih O. Darouiche, Andreas Widmer, Edward Hendershot, Paul Holtom, Paul Huddleston III, Gregory Petermann and Douglas Osmon.