Definition
- Bacterial infection of the vertebral body and disc (spondylodiscitis), with or without spinal epidural abscess
- For tuberculosis see Spinal
Aetiology
- Haematogenous spread is most common, seeding the vertebral endplate via segmental arterioles
- Disc is infected secondarily in adults
- Direct inoculation after spinal surgery or injection
- Staphylococcus aureus in about half of cases. Also streptococci, gram negatives and coagulase negative staphylococci after surgery
Epidemiology
- Lumbar spine most often affected, then thoracic and cervical
- Risk factors are diabetes, IV drug use, haemodialysis, immunosuppression and endocarditis
Clinical Features
- Unremitting back pain, worse at night
- Fever in about half
- Epidural abscess triad of back pain, fever and neurological deficit, all three present in a minority
Investigations
- CRP and ESR raised in most. CRP tracks response
- Blood cultures before antibiotics, positive in about half
- MRI with gadolinium is the imaging of choice
- Disc involvement with endplate destruction favours pyogenic infection. Disc sparing favours tuberculosis
- CT guided biopsy if cultures negative and the patient is stable
- Echocardiogram with S. aureus bacteraemia
Management
- Withhold antibiotics until cultures or biopsy are taken if neurologically intact and not septic
- Six weeks of targeted antibiotics is non-inferior to twelve weeks (Bernard, Lancet 2015)
- Brace for comfort and mobilise
- Surgery for neurological deficit, epidural abscess with compression, instability, progressive deformity or failed medical treatment
- Debridement and stabilisation, with instrumentation safe in active infection
- Infectious diseases input for agent and duration. See Antibiotics
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.