Pediatric emergency medicine trisk 3976 3976
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Clinical Considerations
Clinical Recognition. Children with discitis are a diagnostic challenge for
clinicians. The condition is uncommon, symptoms may not involve the back and
are often nonspecific and vague, especially in the younger child. They usually
have been present for more than 1 week at the time of diagnosis.
Initial Assessment/H&P. Limp, refusal to walk, leg pain, hip pain, and abdominal
pain and irritability are common presenting complaints. Back pain is often not
reported. Unlike vertebral osteomyelitis, which more often is associated with
fever, only about a quarter of patients with discitis are febrile.
Physical findings suggesting discitis will be missed if this entity is not
considered because careful examination of the spine is not performed routinely by
most clinicians. Many children assume a recumbent position of comfort from
which they do not want to be moved. Decreased range of motion of the spine and
paravertebral muscle spasm are usually present. There is often a change in the
lumbar lordosis, which may be decreased or increased. Tenderness to palpation of
the disc space can usually be demonstrated. Range of motion of the hips is
essentially normal, but inadvertent movement of the lumbar spine during hip
examination may cause pain that is misinterpreted to suggest hip pathology.
Straight leg raise may be limited by muscle spasm in the hamstrings. Neurologic
assessment of the lower extremities is generally normal, but there are reports of
discitis with neurologic involvement. Abnormalities in strength, sensation, and/or
deep tendon reflexes suggest a spinal cord lesion, tumor, epidural abscess, or
herniation of the disc (rare). Signs of discitis may vary, depending on the location
of the inflamed disc. Patients with lesions of the upper spine may have
meningismus.
Management/Diagnostic Testing. Imaging studies can be useful in the diagnosis
of discitis. Plain radiographs may be normal initially, but intervertebral disc space
narrowing develops after 2 to 3 weeks of illness ( Fig. 121.17 ). At the time of
diagnosis, 76% of children with discitis will have abnormal radiographs. MRI,
which is becoming the imaging test of choice, is 90% sensitive and can help
differentiate discitis from vertebral osteomyelitis. Bone scan is also a sensitive
imaging modality, especially early in the course of this disease. Increased uptake
at the level of the involved disc can confirm the diagnosis. CT scanning can
demonstrate the degree of bony erosion of the vertebral end plates and
paravertebral soft tissue involvement.
