A complete blood count (CBC) with differential, a C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are routinely ordered when evaluating for an infection. Laboratory tests are frequently used to diagnose spine infections. Because tuberculosis of the cervical spine is quite rare, and the radiographic pattern of destruction is often similar to that of a spine tumor or cancer, a thorough work-up to rule out cancer should always be undertaken if this radiographic pattern is encountered. Spinal infections caused by tuberculosis demonstrate a different radiographic appearance than bacterial infections tuberculous infections affect the vertebral body primarily and usually do not affect the disc whereas pyogenic vertebral osteomyelitis preferentially destroys the endplate and intervertebral disc. An MRI test can also define the severity and extent of the infection, and whether it involves the spinal canal (epidural abscess). The most sensitive imaging test for a spine infection is a magnetic resonance imaging test (MRI) with gadolinium. Plain x-rays of the spine will show subtle signs of endplate erosion and destruction, but usually this is not evident in the first 1-3 weeks of a pyogenic infection. The neurologic examination will generally be normal unless the spinal infection is advanced and causing neurologic compression or irritation. Patients may demonstrate tenderness and spasm with decreased cervical range-of motion. Patients may or may not have a fever (Temperature > 101 degrees). The physical findings for patients with a spine infection are limited. In addition, patients may have constitutional symptoms such as low-grade fever, chills, night sweats, fatigue, malaise, and/or loss of appetite, among others. Patients may have weakness or numbness if the infection is advanced and causing neurologic compression or irritation. Patients will often have neck stiffness and decreased range-of-motion. Patients often have unrelenting pain, as well as night pain, that is not relieved by rest or traditional measures. Neck pain is the most common presenting symptom of patients with a cervical spine infection. If the infection goes untreated, it will gradually erode a large portion of the bone away, which may destabilize the spine and compromise the neurologic structures. Once seeded, the entire endplate becomes infected the infection then spreads into the disc and to the endplate of the adjacent vertebrae. Initially, the infection begins near the vertebral endplate, where the vascular flow is diminished. Spinal infections are much more common in elderly patients, patients with significant medical problems (diabetes, etc), and immunocompromised patients (transplant patients). Urinary tract infections or wound infections are the most frequent originating source of a spinal infection. The most common cause of spinal infections is the spread of another infection, through the bloodstream, from another part of the body. Although spinal osteomyelitis is less likely to occur in the cervical spine than other areas of the spine, patients with cervical osteomyelitis are most likely to develop catastrophic neurologic deficits and paralysis compared with infections of the thoracolumbar spine. The incidence of pyogenic (bacterial) vertebral osteomyelitis, which is the most common form, is reported to be 1 in 250,000, and occurs in the region of the cervical spine in approximately 3-6% of these cases. Infections of the spine can be caused by bacterial infection, fungus, or tuberculosis. Most often, patients will present with only one or two of these clinical entities, yet some patients present with all three of these entities and are usually extremely ill. An infection of the disc is called discitis an infection with pus within the spinal canal is called an epidural abscess. Spine infections that involve the vertebrae are called vertebral osteomyelitis. Infections of the spine, although uncommon, are extremely destructive and can lead to spinal instability, neurologic damage including paraplegia, and death if not properly treated.
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