Discitis is a rare inflammatory disorder of the intervertebral disc space. It may involve only the disc or the adjacent vertebral end plates as well (spondylodiscitis).1,2 Children are affected more often than adults, with dual peaks in incidence in early childhood (<5 years) and adolescence.3–5 In adults, discitis is usually caused by contiguous spread of infection from skin, soft tissue and bones or by hematogenous spread from other distant sites, such as the genitourinary tract, respiratory tract, endocardium and oral cavity.6,7 In children, the cause is less clear. Most cases are attributed to hematogenous spread of bacteria, although findings in blood and disc aspirate tend to be negative.3 The primary focus of infection is generally not recognized.8,9
Discitis occurs nearly exclusively in the lumbar region of the spine. Cervical discitis has been reported only anecdotally,4,10–15 and data remain sparse. Nevertheless, early detection of the disease is important for the initiation of prompt and appropriate treatment. The aim of this study was to describe the 10-year experience of a pediatric tertiary medical center with cervical discitis. The medical literature on discitis in the pediatric population is reviewed.
MATERIAL AND METHODS
The study was conducted in the pediatric infectious diseases unit of Schneider Children’s Medical Center of Israel. The hospital’s electronic database was searched for all patients diagnosed with discitis from January 2004 to August 2014 by bone scan, magnetic resonance imaging (MRI) or both. The medical files were reviewed to identify the patients with inflammation, specifically of the cervical spine discs, according to our diagnostic criteria: MRI findings of a low attenuated signal from the intervertebral discs at the cervical spine (CI/C2–C7/T1), with an irregularity of the adjacent end plates on T1-weighted images and a high signal in the disc space and adjacent endplates on T2-weighted images. For this study, all MRI scans were reviewed by a pediatric radiologist, and the diagnosis of cervical discitis was verified.
The following data were collected from the medical files: demographics (sex, age), clinical and neurologic presentation, findings on imaging and laboratory examinations, treatment protocol and outcome.
The study was approved by the Institutional Review Board. The need for patient consent was waived owing to the retrospective nature of the study.
During the study period, 52 patients were diagnosed with discitis at our hospital, accounting for 0.06% of all acute admissions. The lumbar spine was involved in 42 cases (80%), the (mostly lower) thoracic spine in 5 (10%) and the cervical spine in 5 (10%). The latter patients formed the study group.
The characteristics of the patients with cervical discitis are shown in Table 1. There were 3 male and 2 female patients of median age 10 months (range 9 months to 6 years). All were otherwise healthy. Past medical history revealed mild neck trauma or neck pain (stiff neck) in 2 patients, fever in 2 patients and stomatitis in 1 patient. In 2 cases, parents reported a neurodevelopmental regression in motor skills. Both these children had stopped crawling and were unable to turn around or lift their head in the prone position. On physical examination, limitation of neck movements was found in 2 patients, upper limb hypertonicity in 1 and limitation of head rotation and torticollis in 1. The 2 patients with neurologic deterioration (one of whom had no other symptoms) were referred to a pediatric neurologist. The average time to diagnosis from onset of symptoms was 6 weeks. All patients were followed by the primary physician. One patient was discharged from the emergency department 2 weeks before diagnosis. Two patients were referred to cervical MRI by outpatient neurologist and then diagnosed as cervical discitis.
Laboratory work-up revealed leukocytosis in 1 patient and elevated C-reactive protein (CRP) level in 3 patients (1, 4.5 and 7 mg/dL; normal range 0–0.5 mg/dL). In 2 patients with elevated CRP, the CRP normalized after 7–10 days of treatment. Two patients did not have leukocytosis or elevations in inflammatory markers. Blood cultures were negative in all patients. Spinal radiograph was diagnostic for discitis in 1 patient; the others had only minor or no vertebral changes. The diagnosis was confirmed in all cases on the basis of our MRI criteria.
All patients were treated with antibiotics (cefazolin, cefuroxime and ceftriaxone) administered intravenously for 1–4 weeks followed by oral treatment to a total of 4–6 weeks. There was no need for surgery. All patients recovered fully with no evidence of disease on follow-up examination at termination of antibiotic treatment. Full reversal of the neurologic regression was observed.
This study describes the experience of a pediatric medical center with cervical discitis in the last decade. In agreement with the literature,3 discitis (at any location) was found in only a small percentage of the total children admitted during the study period (0.06%). Most cases of cervical discitis occurred in early childhood (80% of the patients were infants).
To our knowledge, this is the largest cohort of pediatric cervical discitis patients in the literature. Cervical discitis has been reported mainly in isolated case reports, whereas in larger studies, there were no cases of cervical involvement.3,4,10–15 No cases were described among the 36 patients with discitis described by Fernandez et al,3 and only 1 case (C2–C3) among the 25 patients described by Kayser et al.4 The latter patient presented with stiffness of the cervical spine and neck and shoulder pain. She was treated with a brace and antibiotics, with full clinical recovery.4 Natarajan et al13 described a 5-year-old child who presented with complaints of neck and back pain. On further evaluation, blood count and CRP value were within normal range, and no abnormalities were found on computed tomography and radiologic studies. Cervical discitis (C6–C7) was diagnosed by MRI.13 Some reports described the occurrence of spondylodiscitis in children after button battery ingestion or dental extraction.10,11,15
Cervical discitis has a different clinical picture from lumbar or lower thoracic discitis, which typically presents as pain on flexing the thighs, back pain, pain on walking (young children may refuse to walk) and a progressive limp.3 Neurologic findings include decreased muscle strength and hypotonicity.16 In cervical discitis, symptoms include limitation of or painful neck movements, torticollis and pain on flexion, extension or rotation of the head, and more profound neurologic deterioration than in lumbar discitis.16 Like in lumbar discitis, however, body temperature and laboratory markers of inflammation (white blood cell count, CRP and erythrocyte sedimentation rate) may be normal or only mildly elevated.
Sometimes neurologic deterioration, manifested by poor head control and regression of motor milestones, is the sole presentation of cervical discitis, leading to misdiagnosis or delayed diagnosis. It is, therefore, important that clinicians maintain a high index of suspicion of cervical discitis in patients with this clinical picture. Careful physical examination including the cervical spine and upper limbs is warranted, and brain MRI, if performed, should include the cervical spine.
The diagnosis of cervical discitis may also be delayed in patients with a history of minor head trauma, which can itself be a direct cause of head movement limitations and neck pain.
Abnormalities may be seen on radiographic film 2–3 weeks into the illness, namely, narrowing of the intervertebral disc space and variable degrees of destruction of adjacent vertebral end plates. However, in some cases, the C-spine radiograph is normal even after prolonged disease. In our experience, spinal radiograph was diagnostic for discitis in only 1 patient. Nuclear bone scan may be pathologic but often shows only nonspecific changes. The most sensitive imaging method is MRI.
The treatment protocol of cervical discitis is not well established.4,17 Lumbar discitis is usually treated by a short course of intravenous antibiotics supplemented with oral antibiotics for a couple of weeks. It is not known whether cervical discitis warrants a longer course. Our patients received intravenous antibiotics for 1–4 weeks followed by oral treatment, and all recovered fully. None required surgery. Because cervical disc aspiration is challenging and because of the good response to antibiotics, we think that aspiration of the disc is not mandatory in cervical discitis like patients with lumbar discitis.
Although it is the largest cohort of patients with cervical discitis, the limitation of this study was the small number of patients. The literature is sparse, and the description of patients with cervical discitis is lacking. Thus, it is difficult to describe the “typical” child with cervical discitis. Cervical discitis should be considered in patients, especially infants (<1 year), with torticollis, neck pain or stiff neck, loss of head control and neurodevelopmental regression in motor skills.
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