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(Radiology. 2001;218:211-214.)
© RSNA, 2001

Vascular and Interventional Radiology

Diagnostic Yield of CT-guided Percutaneous Aspiration Procedures in Suspected Spontaneous Infectious Diskitis1

Felix S. Chew, MD and Mitchell J. Kline, MD 2

1 From the Department of Radiology, Wake Forest University School of Medicine, Medical Center Dr, Winston-Salem, NC 27157-1088. Received January 17, 2000; revision requested March 5; revision received April 18; accepted May 8. Address correspondence to F.S.C. (e-mail: fchew@wfubmc.edu).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
PURPOSE: To evaluate the diagnostic yield of computed tomography (CT)-guided percutaneous needle aspiration procedures in the setting of suspected spontaneous infectious diskitis and to assess the usefulness of concurrent cytologic examination as a supplement to microbiologic evaluation.

MATERIALS AND METHODS: A retrospective study was performed to evaluate 105 consecutive CT-guided percutaneous disk space aspiration procedures in 92 patients suspected of having spontaneous (non-postoperative) infectious diskitis. Our criterion standard for the presence of active infection was the identification of a pathogen either from the CT-guided aspiration specimen or from a surgical specimen. All cases had microbiologic analysis, 78 cases had cytopathologic analysis, and 31 cases had open surgery.

RESULTS: Microbiologic analysis of the CT-guided percutaneous aspiration specimens was positive in 39 of 43 cases proved to have active infections, with four false-negative and no false-positive cases (sensitivity, 91%; specificity, 100%). The false-negative cases were all active fungal infections identified from surgical specimens. Adding cytopathologic analysis to microbiologic analysis improved sensitivity but reduced specificity. The most common pathogens were species of Staphylococcus, Streptococcus, Candida, and Mycobacterium. All 30 active bacterial infections were identified with the CT-guided procedures, but only five of nine fungal infections were identified.

CONCLUSION: CT-guided percutaneous needle aspiration is an accurate method for identifying active bacterial disk space infections but is less reliable for identifying fungal infections.

Index terms: Computed tomography (CT), guidance, 316.12119, 326.12119, 336.12119 • Spine, biopsy, 316.1262, 326.1262, 336.1262 • Spine, infection, 316.20, 326.20, 336.20 • Spine, intervertebral disks, 316.1262, 326.1262, 336.1262


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Spontaneously occurring infections of the intervertebral disk space typically manifest with nonspecific symptoms of discomfort with a slow or insidious onset that may be difficult to distinguish from neck or back pain due to other causes. Most of these patients are older than 50 years and may have other painful back conditions. Several weeks or months may pass before the diagnosis is suspected (1,2), and further delays may occur until specific antibiotic treatment is begun. Even when the diagnosis of infectious diskitis is established by means of diagnostic imaging (3–5), a specific microbiologic diagnosis is highly desirable for definitive medical treatment with the antibiotics to which the pathogens are sensitive (6). A majority of patients with diskitis do not require surgical treatment if medical therapy is successful; therefore, computed tomography (CT)-guided percutaneous needle aspiration that leads to the identification of a specific pathogen may obviate surgery.

We performed a retrospective study to establish the diagnostic yield of CT-guided percutaneous aspiration in the clinical setting of suspected spontaneous infectious diskitis. In particular, we sought to learn how frequently a pathogen was specifically identified for purposes of tailoring antibiotic therapy. We also evaluated the usefulness of concurrent cytologic examination as a supplement to the microbiologic evaluation.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
A retrospective study was performed by using case material from two tertiary-care medical institutions. The materials reviewed by the authors for this study were medical records, including outpatient and emergency room notes, admission notes, inpatient progress and nursing notes, discharge summaries, procedure notes, surgical reports, radiology reports, pathology reports, and microbiology laboratory results. Pathology reports included reports of cytopathology, and each such report described the volume and adequacy or inadequacy of the specimen for analysis. Microbiology reports included microscopy and culture results and listed any specific pathogens identified by either method.

The case lists were developed from computer searches according to procedure codes (for CT-guided spine biopsy and microbiology) and from procedure logbooks. The study group consisted of patients suspected on clinical grounds of having spontaneous disk space infections in whom CT-guided percutaneous needle aspiration procedures of the intervertebral disk space were performed by radiologists. The criteria used by clinicians for referral of patients for this procedure were not recorded consistently.

Between January 1988 and June 1996, 71 CT-guided percutaneous needle biopsy procedures of the intervertebral disk were performed at one medical center, and between September 1996 and November 1999, 34 such procedures were performed at another medical center. These consecutive cases were combined to form the study sample and excluded patients who underwent recent spine surgery or who had recent penetrating trauma to the spine. We also excluded patients in whom the infection involved the vertebral body but not the adjacent disk space, on the basis of the reports of imaging. A total of 105 procedures were performed in 92 patients (56 male, 36 female patients; mean age, 57 years ± 16.2 [SD]; age range, 13–88 years): Eighty-one patients underwent one procedure, nine patients underwent two procedures each, and two patients underwent three procedures each. In all patients in whom multiple procedures were performed, the procedures were performed at the same levels but at different times. The cervical region was involved in two (2%) of the 105 procedures, the thoracic region in 41 procedures (39%), and the lumbar region in 62 procedures (59%). In the context of ongoing medical care, informed consent was obtained from each patient prior to each procedure.

All procedures were performed with local anesthesia or conscious sedation under CT guidance by using techniques previously described (7,8). Microbiologic analysis, performed in all cases, consisted of various combinations of cultures (aerobic, anaerobic, fungus, and mycobacterium) and preparations for microscopy (Gram stain for bacteria, wet preparation and various stains for fungus, and acid-fast stain for mycobacteria), depending on the clinical circumstance. In 78 cases, material from the CT-guided aspiration procedure was submitted for cytopathology. In 31 cases, specimens from open surgery were obtained subsequent to the CT-guided percutaneous procedure. In all cases, surgery was performed solely for the purpose of patient care. Our criterion standard for the presence of an active disk space infection was positive microbiologic results in material obtained from the disk space, regardless of whether the material was obtained from percutaneous needle biopsy or open surgery. A positive microbiologic result was defined as the demonstration of a pathogenic organism, either by growth in culture or by microscopy (positive Gram stain, fungal stain, or acid-fast stain). A patient without positive results from microbiology was considered not to have an active disk space infection. The strict criteria for the presence of active disk space infection used for the purposes of this retrospective study are not necessarily the criteria that one might use in a clinical setting to guide patient care because our criteria place exclusive reliance on the results of microbiologic analysis. A positive cytopathologic result was defined as the demonstration of acute, chronic, or granulomatous inflammation or of actual pathogens.

Calculations of sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were made independently for the two methods of specimen analysis—microbiology and cytopathology. Calculations of sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were also made of the combined results of microbiology and cytopathology. The usefulness of concurrent cytopathology as a supplement to microbiology was assessed by comparing the measures of diagnostic test performance for microbiology alone with those of microbiology combined with cytopathology.

Clinical management and ultimate patient outcome were not part of our study. Imaging features of patients in our study sample were also not evaluated.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Of the 105 CT-guided intervertebral disk space aspiration procedures, 43 (41%) were performed in patients with active disk space infections and 62 (59%) were performed in patients without active disk space infections (Table 1). There were 39 patients whose CT-guided aspiration procedures yielded material that was positive for active infection at microbiologic analysis. Of these, there were 36 patients whose pathogens were identified from cultures, two patients with fungus identified only at microscopy, and one patient with bacteria identified only with Gram stain. Among the 66 cases whose CT-guided aspiration procedures yielded material that was negative at microbiologic analysis, there were four cases in which the analysis of specimens obtained at open surgery were positive. In these four cases, fungus was identified only at microscopy, and cultures were negative. Surgical specimens confirmed the presence or absence of active disk space infection in 16 and 11 cases, respectively. Alternative diagnoses were made from surgical specimens or surgical findings in nine cases, including four cases of healing fractures, two cases of myeloma, and one case each of osteochondritis, lymphoma, and metastatic adenocarcinoma.


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  		TABLE 1. Results of CT-guided Disk Space Aspiration
 
The diagnostic performance of CT-guided aspiration (Table 2) when using microbiology as the only method of analysis was a sensitivity of 91% (39 of 43 CT-guided aspiration procedures), specificity of 100% (62 of 62), positive predictive value of 100% (39 of 39), and negative predictive value of 94% (62 of 66). The most common pathogens identified at culture from CT-guided disk space aspirations were species of Staphylococcus, Streptococcus, Candida, and Mycobacterium (Table 3). There were three cases in which pathogens were identified at microscopy of material obtained from CT-guided aspiration but not culture: two cases of Candida and one case of Gram-positive cocci.


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  		TABLE 2. Diagnostic Performance of CT-guided Disk Space Aspiration
 

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  		TABLE 3. Pathogens Identified by Means of Culture from CT-guided Disk Space Aspiration
 
Cytopathologic analysis was obtained in 78 cases. Of these, 59 specimens were deemed adequate for review by the cytopathologists, and these cases form the basis for further analysis of this data. Cytopathologic results were considered to be positive if there was demonstration of acute, chronic, or granulomatous inflammation or of actual pathogens. There were 35 cases in which cytopathologic results were positive; 28 were considered true-positive for this study because concurrent microbiologic results were positive, and seven were considered false-positive for this study because concurrent microbiologic results were negative. There were three false-negative cases with positive microbiologic but negative cytopathologic results.

The diagnostic performance of CT-guided aspiration when cytopathology was the only method of analysis was a sensitivity of 90% (28 of 31 CT-guided aspiration procedures), specificity of 75% (21 of 28), positive predictive value of 80% (28 of 35), and negative predictive value of 88% (21 of 24). Of the 19 inadequate samples, six had positive microbiologic results and 13 had negative microbiologic results. The technical reasons for the inadequacy of sampling are not known, but there was no consistent pattern with regard to the operator, the sampling needles, the anatomic location, or the number of passes. Alternative diagnoses were made from cytopathology in two cases, including one healing fracture and one plasmacytoma.

In clinical practice, analysis of specimens from CT-guided disk space aspiration procedures is likely to combine microbiology and cytopathology. If one requires that either microbiologic or cytopathologic results be positive (but not necessarily both), the sensitivity of the procedure with combined analysis improves over the use of either method alone to 95% (41 of 43). If one requires that both microbiologic and cytopathologic results be positive, the sensitivity of the procedure with combined analysis declines from the use of either method alone to 79% (26 of 33) (Table 2). The specificity of microbiology alone cannot be improved by combining it with the results of cytopathology.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Spontaneous infectious diskitis can be a challenging disease to study. First, it is a rare condition with a common, nonspecific clinical manifestation of acute or chronic back pain. The incidence of vertebral osteomyelitis and diskitis in one study (9) was 5.3 cases per million (as compared with a 7.6% and 3.9% prevalence in the general adult population of acute [10] and chronic [11] low back pain, respectively). Erroneous initial diagnoses are commonly made, delaying diagnosis for several weeks or months (9). Second, current medical therapy is effective in a large enough proportion of cases so that open surgical treatment is not performed in the preponderance of cases, which reduces the availability of correlative histologic specimens. We chose to use strict microbiologic criteria (identification of a pathogen by means of culture or microscopy) as our criterion standard for the presence or absence of active disk space infection. Although these criteria undoubtedly excluded some cases of infections that would have been included if our criteria included clinical course, response to antibiotics, or histologic findings of inflammation, our retrospective study sample did not allow us to apply these other criteria consistently. In any event, without the identification of a specific pathogen, the choice of antibiotic therapy would remain empiric, and patient care might not be changed by a diagnosis of infection without an identifiable pathogen. The inability to identify a pathogen does not necessarily indicate that no infection is or was present or that such patients would not benefit from empirically chosen antibiotic therapy.

There are several limitations to this study. Our study sample consisted of consecutive cases referred to us by other physicians. We were unable to evaluate the criteria used by those various physicians for referral, but, in general, patients in whom surgical treatment was already indicated would be much less likely to be referred, biasing the sample toward less severe disease. General indications for surgical treatment or drainage in patients with diskitis would include extensive vertebral body infection, epidural abscess formation, and cord compression (12). If the cause of septicemia were known or cultures of the blood were positive, patients would also be less likely to be referred for an additional invasive procedure. Retrieval of a pathogen from the disk space may be compromised by previous or ongoing antibiotic treatment, and we did not have reliable information regarding previous or ongoing antibiotic treatment at the time of CT-guided aspiration. Consequently, our study cannot address that issue. Our CT-guided aspirations were performed at the disk space, and it is uncertain whether tissue sampling from the adjacent vertebral body or endplate might have changed our results.

Previously reported series of imaging-guided needle biopsy in the setting of spontaneous infectious diskitis have been variable in their yield of microbiologically identified pathogens. Honan et al (13) reported an 83% yield (10 of 12 patients with infection), Perronne et al (14) reported a 74% yield (29 of 39) with use of fluoroscopically guided needle biopsy, Torda et al (15) reported a 73% yield (11 of 15), Carragee (6) reported a 61% yield (27 of 44), and Palestro et al (3) reported a 58% yield (14 of 24). The yield in our study was 91% (39 of 43), but our study sample had much stricter microbiologic criteria, whereas these studies used a combination of laboratory findings, imaging findings, clinical presentation, and clinical course.

Identification of fungal infections appears to be an important limitation in the percutaneous method of disk space sampling, as compared with open surgery. Of the nine cases in whom the pathogen identified was Candida albicans, only five (56%) were identified from the CT-guided aspiration procedure (three from cultures and two from microscopic examination alone), while four additional cases were identified from open surgical specimens. A review of cases of candidal spondylodiskitis found that 26 (87%) of 30 cases were diagnosed by means of percutaneous puncture (16). All false-negative results from CT-guided aspiration procedures were cases of fungal diskitis. There were no instances in which a bacterial or granulomatous infection of the disk space was missed with the CT-guided percutaneous aspiration method. We found that the addition of cytopathologic analysis to the microbiologic analysis improved the overall diagnostic performance of the procedure only modestly, not as much as has been reported by others in patients with osteomyelitis (17) or tuberculosis (18) outside the spine, or tumors involving bone (19,20).

The wide range of pathogens identified in our study is similar to those reported by others (13–15, 21–23). Many of these pathogens are of low virulence, underscoring the importance of obtaining microbiologic samples from the disk space. Investigators in one series found that as few as 10% of blood cultures were positive in patients with positive disk space cultures who were treated nonsurgically (23). The importance of using preparations for identifying fungal and mycobacterial pathogens should also be emphasized. The volume of the biopsy specimen and the rapidity with which it is delivered to and processed by the microbiology laboratory are other major determinants of culture yield.

In conclusion, we found that CT-guided percutaneous needle aspiration is an accurate method for identifying the pathogens in active bacterial disk space infections but is less reliable for identifying fungal infections. The addition of cytopathologic analysis did not improve the diagnostic performance.


   FOOTNOTES
 
2 Current address: Department of Radiology, Cleveland Clinic Foundation, Ohio. Back

Author contributions: Guarantors of integrity of entire study, F.S.C., M.J.K.; study concepts and design, F.S.C., M.J.K.; definition of intellectual content, F.S.C., M.J.K.; literature research, F.S.C., M.J.K.; clinical studies, F.S.C., M.J.K.; data acquisition and analysis, F.S.C., M.J.K.; statistical analysis, F.S.C., M.J.K.; manuscript preparation, editing, review, and final version approval, F.S.C., M.J.K.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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