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Dr. Gopinath P
* Asst Professor, Department of Orthopedics,
   Medical College, Calicuta

Address for Correspondence

Dr. P. Gopinath,
Dept of Orthopaedics, Medical College, Calicut,
Kerala, India.




Post operative spondylo-discitis is a rare but unavoidable complication of lumbar disc surgery.    The typical clinical symptoms and diagnostic procedures of this particular complication are varied.   Clinical findings are the mainstay in diagnosing this condition.  Meaningful results can be obtained by MRI.  The sequelae of spondylodiscitis is so severe that, the patient may not be able to take up the original occupation, and so at any cost, this complication should be avoided if possible and once it sets in, it should be diagnosed and treated early.

J.Orthopaedics 2004;1(3)e1


Bircher MD et al(1) in their study concluded that although well described in orthopaedic literature and some orthopaedic textbooks postoperative discitis is regularly missed or diagnosed late. If the ESR is routinely measured preoperatively and at 2 weeks postoperatively this condition should not be missed. 

Fouquet B et al(2)  concluded that two major types of potsop discitis have been previously described: septic discitis and avascular or chemical discitis. Percutaneous discal biopsy is an important way of distinguishing these two entities. This study further confirmed that there are two major features of discitis that can be recognized by histological and biological tests allowing for different tests 

Frank AM (3) et al made the final conclusion in their study that spondylodiscits is a well known as well as unavoidable complication of lumbar disc surgery. MRI is proved to be the most sensitive and reliable investigation. Therapy of spondylodiscits using light corset described along with antibiotics gave good results. 

Frank AM et al (4), in their study found the main symptom is increasing low back pain, with difficulty in forward flexion of the body, with a raised ESR.  And they observed good long term results in all patients with light corset and long antibiotic therapy. 

Friedman JA (5) et al concluded spontaneous discitis has predominantly has been described in children and needed a broader spectrum of antibiotic coverage.   Outcomes were similar between the groups. 

Hadjipavlou Ag et (6)all  concluded that  Serretia  spondylodiscits can cause severe spinal infections after elective spinal surgery.   And that one should maintain high index of suspicion in diagnosing and treating the infection caused by this potential pathogen.  They also pointed out that one should not procrastinate in initiating treatment. 

Imae S et al(7) in their study concluded that post operative spondylodiscits is a rare but severe complication of disc surgery.   They were of the view that low back pain gradually receded along with ESR and C reactive protein, with long term antibiotics.   About 40 days later these patients were almost free of back pain. 

Jimenez Mejias ME,(8) studied 31 cases of postoperative pyogenic spondylodiscits comparing them with 72 cases of non postoperative pyogenic spondylodiscits.  Predisposing factors were less frequent in post operative pyogenic spondylodiscits than Non post operative spondylodiscits cases.   

Kylanpaa-Back ML (9) observed that MRI has proven to be the most effective method for demonstrating postoperative discitis.   They also concluded that patients with post operative spondylodiscits are rarely capable to return to a physically strenuous work.   Every effort, including antibiotic prophylaxis, should be undertaken to reduce the risk of this serious complication. 

Ledermann HP et al(10)  reached the final conclusion that most MR imaging criteria commonly used to diagnose disc infection offer good sensitivity. In typical manifestations of proven spinal infections some of the described imaging criteria may not be observed. 

Lunge PC(11)  concluded in his study that in microdiscectomy prophylactic antibiotic should be given and a complete removal of the ligamentum flavum on the side of surgery should be ensured to avoid infection and recurrent root impingement. 

Lindholm TS et al(12) were of the view that the incidence of discitis is 75%. About 50% of patients in their study had retired from regular work. They concluded that early diagnosis and appropriate management of the disease is especially urgent to overcome and inhibit the consequences of post op discitis.

Maiuri F et al(13) opined that early diagnosis of spondylodiscits is often difficult because of long latent period.   Radiographs of the spine, CT Scan and bone scan provided insufficient data.   MRI is the investigation of choice in diagnosing spondylodiscits. 

Natale M et al(14) in their experience reported 19 cases of spondylodiscits developed after operations for herniated lumbar disc.    

Nielsen VA, et al(15) observed that the earliest lesion was blurring of the end plate or minor destructions, leading to cavitations of the vertebral body.  Mean time from operation to the first clinical symptoms was 3 weeks.  Mean time from operation to first radio logic lesion was 2 months, from operation to maximal lesion 4 months, and to the first radiologic sign of healing 5.5 months.   A follow up study was carried out and the radiologic findings were compared to those of a matched control group.   A significantly higher incidence of decrease in disc height, intercorporal fusion and major osteophytes was found in the discitis group..

Parry MF et al(16) were of the view that postop wound infection after laminectomy was uncommon. They observed 3 patients with discitis due to candida aqlbicans. 

Peruzzi P et al(17) were of the view that , discitis is a rare complication of disc operation, with an incidence of 0.2 to 0.8 %.  Discitis may be suspected within 2 weeks with a clinical feature of back pain and spasm. 

Postacchini F, et al(!8) I their study noted twelve cases of intervertebral discitis following lumbar discetomy in 70 patients without evidence of postoperative fiction.  They advised close post operative  observation permitted early detection of intervertebral discitis.   Early and high dose antibiotic treatment, even if unspecific, can resolve this infection in  a few weeks. 

Rohde V et al(19) concluded that spondylodiscits is  rare complication.   Theoretically it can be prevented by treating these patients with prophylactic antibiotics.   In their study 3.7% of incidence of postoperative spondylodiscits was found in absence of prophylactic antibiotics.   Gentamicins containing caliginous sponges placed in the cleared disc spaces were effective in preventing post operative spondylodiscits.   

Schinkel C et al(20) were of the view that, spondylodiscits is a rare bacterial infection of the vertebra and intervertebral disc and an inflammatory destructive course.   They were of the view that spondylodiscits requires immediate debridement of the focus, when conservative management fails. 

Schulitz K.P et al(21) were of the view that infection of the retro or intradiscal space is probable when the temperature rises above 37 degrees and CRP exceeds 2 microgram/ml 5 days postop. Infection can be cured by treatment with antibiotics bed rest and plaster cast.

Schulitz KP et al(22) in another study concluded that after discectomies CRP ESR and temperature should be measured from the 3rd day on. Pathologic values should initiate  MRI examination. In cases of retrodiscal infection or discitis conservative treatment with antibiotics is sufficient. In cases of retrodiscal abscess operative intervention should be considered. 

Siddiqui AR et al(23) concluded that endemic conditions require that laminectomy at a hospital be limited to those situations where the benefits of surgery exceed the considerable risk of potsop discitis. 

Silber JS et al (24) concluded that fortunately the incidence of potsop discitis is low around .2%. The commonest etiologic agent is staph.  aureus and the most sensitive test for diagnosis as well as assessment of treatment is CRP. MRI is the most diagnostic tool.  They stressed that the treating surgeon should maintain a index of suspicion for early diagnosis. They observed good long term outcome with antibiotic treatment and spinal immobilization. Operative intervention is rarely necessary in patients in patients who do not respond to conservative treatment. 

Trappe AE, et al(25) observed that postoperative lumbar spondylodiscits can cause a failed back syndrome.  With 0.1 to 3 % according to the literature it belongs to rarer complication following lumbar disc surgery.  Principles of therapy consist of lumbar immobilization with a light cast orthosis for an average of 12 weeks and additional antibiotic therapy up to two weeks beyond normalization of ESR.   Finally results of therapy are presented wth a satisfying outcome in 84.2% of cases. 

Tronnier V(26)  in their study reported that 17% of patients had positive bacteriological culture in their intervertebral disc space.  They noted possible involvement of other predisposing factors like pre or perioperative infections or immunocompromise.  They also noted that routine application of antibiotics or antiseptic solution to the disc space at the end of the operation could decontaminate the operative site and prevent clinical infection despite positive culture findings. 

Van Goethen JW et al(27) inferred that spondylodiscits is a serious complication of surgery the diagnosis depending on the correlation of clinical .laboratory and imaging findings. They also concluded that MRI appears to be more useful for exclusion rather than conclusion of potsop discitis. 

Weber M et al(28) inferred that when pyogenic osteomyelitis may no longer be overlooked b after discectomy due to its progression it is misinterpreted as as discitis following removal of intervertebral their study 9 patients with vertebral oseomyelitis suffered from potsop discitis. They also concluded that osteomyelitis may mimic degenerative changes preoperatively. 

Wirtz DC et al(29) were of the view that at the time of diagnosis signs of florid inflammation were seen in 60% x rays ,93% CT and all MRIs. Therapeutically speaking conservative minimally invasive and  other operative procedures are not rival but rather complimentary.

Zink PM, et al (30) in their study observed that spondylodiscits is a well know complication of frequency 0.1 to 3%.   According to the authors, the etiological factors are combination of the operated segment instability, damage to the upper and lower end plates due to disc space curettage and transmission of  germs.  Their basic treatment consisted of 3 X 80 mg of perioperative doses of Gentamicin I/M.    They recommended the following for the prevention of post operative spondylodiscits.    A careful operating technique, perioperative antibiotic, and insertion of Sulmycin Implants in the disc spaces.  

The final conclusion is that post operative spondylodiscits is an unavoidable complication of spine surgery. Considering the septic and aseptic forms of discitis every precaution should be taken to prevent the septic form. Discitis should be suspected in any patient with exaggerated symptoms after surgery and should be properly investigated to confirm the diagnosis. Once the diagnosis is confirmed early parenteral antibiotics should be administered. Many authors claim that all these patients will become asymptomatic over time and the long term  results are good.


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27. Van Goethem JW, Parizel PM, van den Hauwe L, Van de Kelft E, Verlooy J, De Schepper AM. Neuroradiology 2000 Aug. 42(8): 580-5.

28. Weber M. Infectious damage to the intervertebral disk – before and following discotomy. Z Orthop Ihre Grenzgeb 1988 Sep-Oct. 126(5): 555-62.

29. Wirtz DC, Genius I, Wildberger JE, Adam G, Zilkens KW, Niethard FU. Diagnostic and therapeutic management of lumbar and thoracic spondylo- discitis – an evaluation of 59 cases. Arch Orthop Trauma Surg. 2000; 120(5-6): 245-51.

30. Zink PM, Frank AM, Trappe AE. Prophylaxis of postoperative lumbar spondylodiscitis. Neurosurg Rev. 1989; 12(4): 297-303.




 This is a peer reviewed paper 

Please cite as :
Dr. P. Gopinath: Discitis
J.Orthopaedics 2004;1(3)e1





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