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Child s Nerv Syst (1997) 13: 101 – 104
© Springer-Verlag 1997

Lloyd I. Maliner
Dennis L. Johnson

Received: 25 April 1996

L. I. Maliner · D. L. Johnson (½)
Division of Neurosurgery,
Milton S. Hershey Medical Center,
P.O. Box 850,
Hershey, PA 17033, USA
Fax: (717) 531-3858

CASE REPORT

Intervertebral disc space inflammation
in children

Abstract Discitis in children commonly presents with fever, back
pain, irritability, and an inability to
walk. An elevated ESR and characteristic changes on plain X-rays or
bone scan are sufficient for diagnosis, but MRI is more sensitive and
more specific, and it shows pathologic changes earlier. Intravenous
antibiotics are administered when
cultures of the disc space are posi-

Introduction

Intervertebral disc space inflammation is uncommon in
children. Even though one of the most common presenting symptoms is gait impairment, discitis in children has
not been widely reported in the neurosurgical literature
[13]. We report on a patient with aseptic intervertebral disc
space inflammation, who presented with acute scoliosis
and then an inability to walk or stand. The literature is reviewed and a management strategy recommended.

Case report
This previously healthy 19-month-old Caucasian girl presented with
a 1-month history of increasing irritability, progressive scoliosis, reluctance to walk and, finally, inability to stand. The immediate and
extended family were healthy with no intercurrent illnesses. The parents denied a history of fever, travel abroad, or exposure to barnyard
animals. Examination revealed a very irritable child who refused to
stand or walk, but who moved her extremities uniformly. Bowel and
bladder function were normal. Sensation was appropriate to touch.

tive, but in more than half of the
cases, no organism can be grown.
Symptoms are alleviated with bedrest or external orthoses, but neither
the duration nor the kind of symptomatic treatment influences outcome.
Key words Discitis ·
Gait impairment · Children ·
Scoliosis · MRI

Deep tendon reflexes were symmetrically hypoactive, and plantar reflexes were flexor.
The girl was afebrile with a serum white blood cell count of
18,000 and erythrocyte sedimentation rate (ESR) of 54. AP and lateral plain films of the lumbosacral spine revealed a dextroscoliosis,
narrowing of the L3–4 disc space and indistinct superior and inferior vertebral endplates (Fig. 1A). T1-weighted coronal and sagittal
(TR=500, TE=15) and axial images (TR=600, TE=11) confirmed
narrowing of the L3–4 disc space and revealed a phlegmon that deformed the thecal sac and extended through the left intervertebral foramen (Fig. 2A,B). The T2-weighted coronal image (TR=3000,
TE=102) showed a dextroscoliosis, narrowing of the L3–4 disc space,
and the left paraspinal phlegmon with elevation of the left psoas muscle (Fig. 3). Chest X-ray was normal. Skin test for TBc was nonreactive.
The patient responded dramatically to intravenous dexamethasone and was walking within 24 h. To exclude the possibility of an
epidural abscess and to culture the disc space, the intervertebral disc
space was explored posterolaterally through a hemilaminectomy: the
posterior longitudinal ligament was thickened and the intervertebral
disc space was vacuous. Cultures of the intervertebral disc space for
aerobic and anaerobic bacteria, fungus, TBc, or virus revealed no
growth. Dexamethasone was stopped on the 3rd postoperative day,
and intravenous Vancomycin was continued for 10 days. The child’s
postoperative course was unremarkable. She remained afebrile and
was walking, albeit stiffly, by the 10th postoperative day. One month
after discharge, her gait and posture were normal.

102

Fig. 1 A, B AP and lateral
spine radiographs reveal a dextroscoliosis, L3–4 disc space
narrowing with indistinct inferior and superior vertebral end
plates at this level
Fig. 2 A Sagittal T1W image
(TR=500, TE=15) shows disc
space narrowing at L3–4 and
phlegmon, isointense to muscle, extending posteriorly from
the disc space with deformation
of the thecal sac. B Axial T1W
image (TR=600, TE=11) shows
phlegmon deforming the left
anterolateral aspect of the thecal sac with extension through
the left intervertebral foramen
Fig. 3 Coronal T2W image
(TR=3000, TE=102) reveals increased signal intensity of
phlegmon which elevates the
left psoas muscle. Note dextroscoliosis and disc space narrowing at L3–4

Discussion

Intervertebral disc space inflammation in children usually
presents with fever, back pain, irritability, and refusal to
walk [1]. It mimics neuromuscular disorders, Scheuermann’s disease, septic arthritis, pyelonephritis, appendicitis, meningitis, and osteomyelitis. Disc space inflammation most commonly involves the L2–3 and L3–4 discs [7],
whereas the mid- and lower thoracic spine are the most
common sites of involvement for osteomyelitis. Bone
scan localizes the pathologic process to the disc space or
vertebral body (osteomyelitis). Bone scan is negative in
Scheuermann’s disease.
The pathophysiology is frequently not known [17], but
hematogenous spread of infecting organisms through capillary tufts in the cartilaginous vertebral endplates and vascular channels of the immature intervertebral disc is the

most probable mechanism [2, 3, 6]. Since blood vessels
and lymphatics have been found in the annulus of the disc
up to age 20 years and in the cartilage end-plate up to age
7 years [14], children are more vulnerable to discitis.
Staphylococcus aureus is the most common infecting organism, but cultures of the disc space are negative in
50–70% of patients.
Since in many children the diagnosis has to be made
when they are at an age when they are difficult to examine, the diagnosis rests on plain X-rays, scintigraphy (bone
scan), CT, and MRI. Radiographic changes on plain films
may be delayed for 2–8 weeks after the onset of symptoms
[10, 11]. Gallium and technetium bone scans may be abnormal as early as 1 week after symptoms appear. However, bone scans are nonspecific and the use of gallium in
infants is discouraged because of the greater radiation dose.
Also, discitis is not excluded by a normal gallium or technetium bone scan [10]. The sensitivity of MR for detection

103

of infections of the musculoskeletal system early in their
course is greater than that of plain films and CT, and similar to that of radionuclide scanning [3, 8, 15]. In addition,
the multiplanar imaging capability and the superior anatomic detail with MR allows better definition of the extent
of disease and encroachment of the spinal canal, and makes
it possible to assess the presence of a paraspinal or epidural abscess [12]. MR can be used to localize a site of potential biopsy. Gadolinium enhancement has been used to
delineate disease better and to distinguish inflammatory
reaction (phlegmon) from well-defined abscess formation
[4]. Since scintigraphy becomes negative early after antibiotic treatment [5], MR imaging may be of greater value
in partially treated cases. Needle aspiration or direct exploration of the disc space is necessary for culture, especially if a contiguous abscess is suspected. In our case, direct inspection seemed to offer more conclusive results,
but needle aspiration could also rule out an epidural abscess and allow culture of the disc space.

Treatment has largely been empiric and has historically
included bedrest, external immobilization, and antibiotics.
Resolution of discitis does not appear to be influenced by
the type or duration of antibiotic therapy or the kind or duration of immobilization [3, 16, 17]. Long-term outcome
(>20 years) is characterized clinically by backache and radiographically by block vertebrae. The use of external fixation orthoses does not appear to influence outcome [9].
For the febrile child who is irritable and refuses to walk,
an elevated ESR and characteristic changes on plain
X-rays (narrowing disc space and erosion of end plates) or
bone scan are sufficient for the diagnosis of discitis. MRI
provides multiplanar images, shows pathologic changes
earlier, and is able to define complicating epidural or paraspinal inflammatory processes. Antibiotic treatment is
guided by culture of the disc space. Symptoms are relieved
by bedrest and/or external orthoses but neither the duration nor the kind of symptomatic treatment influences outcome.

References
1. Boston HC, Bianco AJ, Rhodes KH
(1975) Disk space infections in children. Orthop Clin North Am
6:953–964
2. Coventry MB, Ghormley RK, Kernohan JW (1945) The intervertebral disc:
its microscopic anatomy and pathology. J Bone Joint Surg 27:105–112
3. Crawford AH, Kucharzyk DW, Ruda
R, Smitherman HC (1991) Diskitis in
children. Clin Orthop Rel Res
266:70–79
4. Donovan-Post J, Sze G, Quencer RM,
Eismont FJ, Green,Gahbauer H (1990)
Gadolinium-enhanced MR in spinal
infection. J Comput Assist Tomogr
14:721–729
5. DuLac P, Panuel M, Devred P, Bollini
G, Padovani J (1990) MRI of disc
space infection in infants and children.
Pediatr Radiol 20:175–178

6. Ferguson WR (1950) Some observations on the circulation in foetal and
infant spines. J Bone Joint Surg [Am]
32:640–648
7. Fischer GW, Popich GA, Sullivan DE,
Mayfield G, Mazat BA, Patterson PH
(1978) Discitis: a prospective diagnostic analysis. Pediatrics 62:543–548
8. Gabriel KR, Crawford AH (1988)
Magnetic resonance imaging in a child
who had clinical signs of discitis.
J Bone Joint Surg [Am] 70:938–941
9. Jansen BRH, Hart W, Schreuder O
(1993) Discitis in childhood.
Acta Orthop Scand 64:33–36
10. Magera BE, Klein SG, Derrick CW,
Wood BP (1989) Radiological cases of
the month. Am J Dis Child 43:
1479–1480
11. Moregenlander JC, Rossitch E, Rawlings CE (1989) Aspergillus disc space
infection: case report and review of the
literature. Neurosurgery 25:126–129
12. Numaguchi Y, Rigamonti D, Rothman
MI, Sato S, Mihara F, Sadato N (1993)
Spinal epidural abscess: evaluation
with gadolinium enhanced MR imaging. Radiographics 13:545–559

13. Onofrio BM (1980) Intervertebral discitis: incidence, diagnosis, and management. Clin Neurosurg 27:481–615
14. Rudert M, Tillmann B (1993) Lymph
and blood supply of the human intervertebral disc. Acta Orthop Scand
64:37–40
15. Sartoris DJ, Moskowitz PS, Kaufman
RA, Ziprkowski MN, Berger PE
(1983) Childhood diskitis: computed
tomographic findings. Radiology
149:701–707
16. Spiegel PG, Vengla KW, Isaacson AS,
Wilson JC (1972) Intervertebral disc
space inflammation in children. J Bone
Joint Surg [Am] 54:284–296
17. Wenger DR, Bobechko WP, Gilday DL
(1978) The spectrum of intervertebral
disc-space infection in children.
J Bone Joint Surg [Am] 60:100–108

104

EDITORIAL COMMENT

Discitis is an uncommon condition,
which usually affects children. In addition to the clinical signs, which the
authors have reviewed, and the radiological signs, I have always relied
on a blood culture in cases of discitis. The blood cultures are usually
positive for staphylococcus. The pa-

tients are treated with antibiotics and
there is no need to aspirate the disc
or to operate on the disc, because of
the positive blood culture and the
radiological signs. Serial blood cultures are very important diagnostic
tests in patients with discitis.

Harold J. Hoffman
Division of Neurosurgery,
Department of Surgery,
The Hospital for Sick Children,
University of Toronto,
555 University Avenue, Suite 1504,
Toronto, Ontario M5G 1X8, Canada


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