Vertebral osteomyelitis in adults: an update.

INTRODUCTION: The incidence of vertebral osteomyelitis is increasing, attributed to an ageing population with inherent co-morbidities and improved case ascertainment. SOURCES OF DATA: References were retrieved from the PubMed database using the terms 'vertebral osteomyelitis' and 'spondylodiscitis' between January 1, 2009 and April 30, 2014 published in English as checked in May 2014 (>1000 abstracts checked). AREAS OF AGREEMENT: Blood cultures and whole spine imaging with magnetic resonance imaging are essential investigations. Thorough debridement is the mainstay of surgical management, although placing metalwork in active infection is becoming increasingly common. AREAS OF CONTROVERSY: The extent of pursuing spinal biopsies to determine aetiology, antimicrobial choices and duration, monitoring the response to treatment, and surgical techniques and timing all vary widely in clinical practice with heterogeneous studies limiting comparisons. Surgery, rather than conservative approaches, is being proposed as the default management choice, because it can, in carefully selected patients, offer faster reduction in pain scores and improved quality of life. AREAS TIMELY FOR DEVELOPING RESEARCH: Further studies are needed to define the most effective technique for spinal biopsies to maximize determining aetiology. High-quality trials are required to provide an evidence base for both the medical and surgical management of vertebral osteomyelitis, including challenging medical management as the default option.