This retrospective study of patients who underwent image-guided biopsy for suspected vertebral osteomyelitis-discitis aimed to assess how biopsy results impact clinical management. It was found that biopsy results changed management in 36% of cases, mostly in culture-positive cases allowing for customizing antibiotic treatment. While antibiotic therapy at the time of biopsy did not impact yield, it was concluded that it may lead to less management change.
Abstract
BACKGROUND AND PURPOSE:
Studies show a modest yield for image-guided biopsy of suspected vertebral osteomyelitis-discitis. Many studies evaluate factors to improve diagnostic yield, and few studies assess how biopsy results impact clinical management. We aim to evaluate the impact of biopsy results on clinical management in suspected vertebral osteomyelitis-discitis.
MATERIALS AND METHODS:
We performed a retrospective study of patients who underwent image-guided biopsy for suspected vertebral osteomyelitis-discitis. Data collected included risk factors, imaging findings, laboratory values, antibiotics, biopsy procedure details, microbiology and pathology results, and clinical course. Factors assessed for management change included whether biopsy results affected antibiotic type or course, decision to start or stop antibiotics, surgical decisions, or if an alternate diagnosis was determined.
RESULTS:
Three hundred ten biopsies were included. Biopsy yield with true-positive culture results was 34% (104/310) and similar for patients on antibiotics (36%, 34/94) and off antibiotics (32%, 66/204). Yield was greater when disc was sampled (36%, 82/228) versus bone only (8%, 2/24) and with aspiration of disc and/or bone (42%, 39/92) versus core only (29%, 56/193). With positive blood cultures before biopsy, biopsy yield was 50% (22/44) with concordance and discordance rates of 75% (18/24) and 17% (4/24), respectively, and 8% (2/24) of positive biopsy results deemed contaminants. Management was affected in 36% (113/310) of all biopsies and in 78% (81/104) of biopsies with a positive culture result. No management change occurred in 57% (177/310) of biopsies. Management change was unclear in 6% (20/310). Biopsy results changed antibiotics in 27% (85/310). Management change occurred in 23% (10/44) of cases with prior positive blood culture compared with 41% (93/233) without a prior culture source (P = .024). Negative culture results influenced management in 16% (32/194).
CONCLUSIONS:
Image-guided biopsy for vertebral osteomyelitis-discitis has a meaningful impact on management despite modest yield. Greatest management impact is seen with positive culture results, no prior culture source, and patients not on antibiotics at the time of biopsy. Biopsy culture yield is not affected by preceding antibiotics, and yield is greater with disc sampling and aspiration.
SUMMARY
PREVIOUS LITERATURE:
Image-guided biopsy for diagnosis of VO has been studied to evaluate factors to improve diagnostic yield. Image-guided biopsy has modest yield (27%) and sensitivity (46%-52%). Studies report biopsy influences management of VO in 9%–50% of cases with varying results, especially in the setting of culture-negative cases.
KEY FINDINGS:
Biopsy results changed management in 36% of cases, with 78% of positive cultures impacting antibiotic therapy. Disc sampling and aspiration yielded higher positive culture results. Antibiotics before biopsy did not impact yield, but management change was greater in patients not on antibiotics and with no prior culture source.
KNOWLEDGE ADVANCEMENT:
This study shows that image-guided biopsy meaningfully impacts management of VO, especially when no prior organism is identified and patients are not on antibiotics. We highlight that the biopsy yield is improved with disc sampling and aspiration and that the yield is not significantly affected by prior antibiotic use.
Vertebral osteomyelitis-discitis (VO) is an infection of the intervertebral disc and vertebrae, usually acquired hematogenously. S aureus is the predominant pathogen in Western countries, and M tuberculosis is the most common worldwide.1 Symptoms are vague, most commonly include pain, and progress insidiously over weeks.1,2 Laboratory assays and imaging supplement clinical suspicion to establish the diagnosis. When no organism is identified by blood culture, image-guided biopsy is performed to identify a causative organism.2 In patients with high clinical suspicion, empiric antimicrobial therapy is often initiated before microbiologic diagnosis.2 Regardless of antimicrobial treatment, the yield of a percutaneous biopsy is modest,3-5 with positive microbiology results in 27%5 and biopsy sensitivities of 46%–52%.5,6
The limited yield of image-guided biopsy and the initiation of empiric antibiotics before microbiologic diagnosis raise consideration of the value of biopsy and how to optimize it. A study on image-guided biopsies for suspected osteomyelitis throughout the body found biopsy cultures influencing treatment in 9%.7 In studies evaluating biopsies for VO, reported management impact ranges from 9%–50%.3,8-10
We aim to expand upon prior studies to evaluate the yield and therapeutic impact of image-guided biopsy performed for suspected VO and identify which patients may or may not benefit from biopsy.
MATERIALS AND METHODS
Following Institutional Review Board approval, we performed a multisite retrospective review of adult patients who underwent image-guided biopsy for clinically suspected VO from February 1998 to July 2023.
We searched radiology and pathology reports in the Illuminate InSight software with keywords including spinal levels (“C2,” “T1,” etc), “biopsy,” and “osteomyelitis.” CT and fluoroscopic biopsies for suspected VO were included, while biopsies for noninfectious processes were excluded. Patient demographics, medical history, imaging findings, laboratory values, biopsy details, microbiology and pathology results, antibiotic regimen, clinical course, and management changes were recorded from the medical record. Management change factors assessed included biopsy results’ impact on antibiotic type or course, initiating or stopping antibiotics, surgical decisions, or determining alternate diagnoses.
Over the 25-year period, different tissue processing methods, media, and vendors were used across the sites. All employed routine era-appropriate culture techniques. Biopsies were processed by using a stomacher machine or plastic tube grinder to homogenize along with sterile saline or broth if needed. Generally, aerobic cultures were incubated at 35°C in 5% CO2 for 5 days, aerobic plates (if performed) incubated for at least 4 days, and thioglycollate broth incubated for 14 days. Starting in 2016, some homogenates were inoculated into blood culture bottles (BD BACTEC Plus Aerobic/F medium and BD BACTEC Lytic/10 Anaerobic/F medium) and incubated on the BACTEC 9240/FX instruments (BD Diagnostic Systems) for 14 days. Polymerase chain reaction was not routinely used, though it was available on request.
The χ2 test was used to compare proportions between independent proportions, and the 2-sample t-test was used to compare means. Agreement between prior culture sources and biopsy culture results was evaluated by using Cohen κ. Statistical analysis was performed by using Excel (Microsoft), MedCalc for Windows, Version 19.4 (MedCalc Software), and R Version 4.2.2 by using package irr. All statistical tests were 2-sided, and a P value of < .05 was considered statistically significant. In subgroup analysis of variables, cases with missing data were excluded. This study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines (Supplemental Data).
RESULTS
Three hundred ten image-guided biopsies of disc, vertebra, and/or paraspinal tissue for suspicion of VO were included among 297 unique patients. Twelve patients had multiple biopsies: 9 patients underwent repeat biopsies for the same presentation, 2 patients had 2 separate presentations at different time points, and 1 patient had a repeat biopsy for the same presentation and another separate presentation at a different time point. Among the unique patients were 111 women and 186 men with a mean age of 65.55 years (SD 12.71).
Imaging Findings
Imaging reports before biopsy were available for 94% (290/310): both MR and CT reports were available in 28% (88/290), MR only in 54% (167/290), and CT only in 11% (35/290). Seventy-nine percent (231/290) of reports favored VO, 14% (40/290) were equivocal, and 7% (19/290) favored noninfectious diagnoses. Biopsy was recommended in 5% of reports (14/290). Figure 1 shows imaging of a true-positive VO case.
FIG 1.
Sagittal STIR (A), sagittal postcontrast T1 (B), and axial postcontrast T1 (C) MR sequences demonstrate imaging of L3-L4 vertebral osteomyelitis-discitis with disc-endplate irregularity, T2 hyperintensity centered within the disc (white arrow) extending in the adjacent vertebral bodies, and peripheral enhancement of the irregular disc and endplates (outline arrowhead) with enhancement of the vertebral bodies and the paraspinous tissues (outline arrow). CT-guided biopsy with oblique sagittal (D) and axial (E) images show biopsy needle sampling of the disc-endplate margin.
Lab Values
White blood cell (WBC) count was available for 255 patients, with an average of 8.5 × 109/L (SD 7.69) within normal range (4–11 × 109/L). WBC was abnormal in 22% (55/255), with 39 having elevated WBC and 16 having low WBC. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were available in 226 and 239 cases, respectively. Average ESR was 46.6 mm/h (SD 31.5, normal <20 mm/h), with elevated ESR in 77% (174/226). Average CRP was 49.1 mg/dL (SD 60.2, normal <8 mg/L), with elevated CRP in 78% (187/239). Positive blood cultures were documented in 14% (44/310) before biopsy, and 11% (33/310) had other positive culture/infection sources (urine, joints, wound, sputum, serology, prior biopsy).
Biopsy Procedure Details
Biopsy reports were available in 309 of 310 cases (details summarized in Table 1). CT and fluoroscopic guidance were used for 53% (165/309) and 47% (144/309), respectively. Distribution by level was 7% (21/310) cervical, 33% (102/310) thoracic, and 60% (187/310) lumbar.
Table 1:
Biopsy procedure details
| Procedure Detail | Category | Value |
|---|---|---|
| Technique | CT | 53% (165/309) |
| Fluoroscopy | 47% (144/309) | |
| Level | Cervical | 7% (21/310) |
| Thoracic | 33% (102/310) | |
| Lumbar | 60% (87/310) | |
| Tissue | Disc + bone | 40% (123/309) |
| Bone only | 8% (24/309) | |
| Disc only | 34% (105/309) | |
| Paraspinal + bone/disc | 9% (29/309) | |
| Paraspinal only | 0.3% (1/309) | |
| Unspecified | 9% (27/309) | |
| Sample | Core + aspirate | 32% (98/309) |
| Core only | 62% (193/309) | |
| Aspirate only | 6% (18/309) | |
| Primary needle size | 9–13 g | 14% (42/309) |
| 14 g | 40% (124/309) | |
| 15–17 g | 7% (21/309) | |
| 18–19 g | 13% (42/309) | |
| 20–22 g | 5% (16/309) | |
| Unspecified | 21% (64/309) | |
| Core samples | Average number | 4.00 (SD 2.1) |
| Aspiration | Average volume | 3.125 (SD 3.0) |
Needle sizes were reported in 245 cases ranging from 9–22 g. Many biopsies used multiple needle gauges, including the introducer, to collect samples. The most common (51%, 124/245) needle size was 14 g with 11 g/13 g introducers. Of the core biopsies, 68% (197/291) quantified sample number (range 1–13; mean 4.0 [SD 2.1]), and others reported “multiple” or “several” core samples without quantification. Sample length was not routinely reported. Aspiration volume was reported in 45% (52/116), ranging from 0.5–15 mL and a mean of 3.1 mL (SD 3.0).
Complications were documented in 1.6% (5/310), 3 with CT and 2 with fluoroscopic guidance, including prolonged bleeding (n = 1), nausea (n = 1), pain greater than expected (n = 2), and a linear fracture through the adjacent facet joint (n = 1).
Biopsy Yield
Biopsy yielded a positive culture result in 38% (119/310) of cases, with 13% (15/119) deemed contaminants by the clinical team, resulting in a 34% (104/310) true-positive culture yield. Negative cultures were documented in 58% (179/310). Culture results were unavailable for 4% (12/310) because of lost specimens, nonsubmission, or patient death or discharge. Supplemental Data provides clinical and procedure information in relation to biopsy yield.
As shown in the Supplemental Data, there was no significant difference in biopsy yield with respect to technique, needle size, sample number, and aspirate volume. Biopsy needle sizes (9–13 g, 14 g, 15–17 g, 18–19 g, 20–22 g) showed no significant yield difference, with the lowest yield of 31% (38/124) in the 14 g group and highest yield of 38% (8/21) in the 15–17 g group (P = .6). Core-only biopsies of bone and/or disc had significantly lower yield (29%, 58/193) compared with disc/bone aspirate with or without cores (42%, 39/92) (P = .002). Aspiration only resulted in a yield of 56% (10/18). Bone only samples had significantly lower yield versus disc with or without bone (yield 36%, 82/228) (P = .006). The yield for paraspinal tissue/fluid sampling was 43% (13/30) compared with 33% (84/252) without paraspinal sampling (P = .3).
Thirty percent (94/310) of patients were receiving antibiotics at the time of biopsy. Biopsy yield was 36% (34/94) on antibiotics versus 32% (66/204) not on antibiotics (P = .49). Thirteen patients were on long-term antibiotics for prophylaxis or treatment of other infections, with 16% (2/13) having a positive culture result. Excluding long-term antibiotics (> 6 weeks), mean antibiotic duration before biopsy was 3.69 days (SD 3.01) for positive cultures versus 6.35 days (SD 8.07) for negative cultures (P = .08).
Seventy-seven cases had other positive culture sources, including 44 positive blood cultures. For positive blood cultures, 55% (24/44) had a positive biopsy culture, with 75% (18/24) growing the same organism, 17% (4/24) growing different organisms, and 8% (2/24) growing contaminant organisms. Cohen κ score for agreement between blood and biopsy cultures was 0.34 (95% CI: −0.02, 0.70). With any prior positive culture result (blood, urine, wound, etc), 49% (38/77) had positive biopsy culture, with 68% (26/38) growing the same organism, 18% (7/38) growing different organisms, and 13% (5/38) growing contaminant organisms. The Cohen κ score for all prior cultures compared with biopsy results was 0.39 (95% CI: 0.02, 0.65). Positive biopsy yield was 50% (22/44) with prior positive blood cultures compared with 30% (71/233) with no prior culture source (P = .01). Figure 2 lists the isolated organisms from the biopsy.
FIG 2.
Isolated organisms on biopsy: true-positive (solid black), contaminant (striped).
Management Outcomes and Clinical Diagnosis
Biopsy results changed management (MC) in 36% (113/310) of all cases and did not change management (NMC) in 57% (177/310). Management impact was unclear (UC) in 6% (20/310) due to insufficient documentation or clinical complexity. Figure 3 categorizes management change related to biopsy results. Antibiotics were changed in 27% (85/310) of all cases. In positive biopsy cultures, management changed in 78% (81/104) when antibiotics were started or tailored based on the organism. Table 2 shows management change related to clinical variables.
FIG 3.
Management change categories for all cases.
Table 2:
Clinical information relating to management change
| Management Change (MC) | No Management Change (NMC) | Unclear | P Value (MC vs NMC) | |
|---|---|---|---|---|
| Biopsy | ||||
| All biopsies | 36% (113/310) | 57% (177/310) | 6% (20/310) | |
| Positive culture | 72% (81/113) | 11% (20/177) | 3% (3/104) | P < .0001 |
| Negative culture | 27% (30/113) | 79% (139/177) | 6% (10/179) | P < .0001 |
| Contaminant culture | 2% (2/113) | 9% (11/177) | 13% (2/15) | P = .017 |
| Antibiotics | ||||
| On antibiotics | 19% (21/113) | 40% (70/177) | 3% (3/94) | P = .0002 |
| No antibiotics | 78% (88/113) | 57% (101/177) | 7% (15/204) | P = .0003 |
| Cultures | ||||
| Other culture positive (any source) | 18% (20/113) | 31% (55/177) | 3% (2/77) | P = .014 |
| Blood culture positive | 9% (10/113) | 19% (33/177) | 2% (1/44) | P = .021 |
| No other culture source | 82% (93/113) | 69% (122/177) | 8% (18/233) | P = .014 |
| Laboratory data | ||||
| Abnormal WBC | 13% (15/113) | 23% (40/177) | 0% (0/55) | P = .04 |
| Elevated ESR and/or CRP | 73% (82/113) | 72% (128/177) | 2% (5/215) | P = .85 |
| Imaging | ||||
| Suspicious | 75% (85/113) | 75% (133/177) | 6% (13/231) | P = 1.00 |
| Equivocal | 14% (16/113) | 11% (20/177) | 10% (4/40) | P = .45 |
| Not suspicious | 6% (7/113) | 6% (11/177) | 5% (1/19) | P = 1.00 |
For culture-negative or culture-contaminant cases, management changed in 16% (32/194), or 10% (32/310) of all cases, because of stopping antibiotics, not initiating antibiotics despite high clinical suspicion before biopsy, or determining another diagnosis. One case with negative culture had pathology consistent with acute-on-chronic inflammation, and antibiotics were started as a result of a presumed infection with false-negative culture. In these 32 cases, the sample was core only in 63% (20/32), aspirate only in 6% (2/32), and both core and aspirate in 31% (10/32). Sample location was bone only in 9% (3/32), disc only in 34% (11/32), bone and disc in 38% (12/32), paraspinal and bone/disc in 13% (4/32), and unspecified in 6% (2/32).
Biopsy results did not affect antibiotics in 57% (110/194) of culture-negative or culture-contaminant cases and 44% (134/310) of all cases treated with empiric antibiotics or antibiotics targeted to other culture sources. Antibiotics were not changed in 73% (32/44) of patients with positive blood cultures already on targeted therapy. Antibiotic changes with prior positive blood culture occurred with discordant biopsy results and inadequate antibiotic coverage (7%, 3/44), antibiotics held before biopsy with positive biopsy result (5%, 2/44), and broad-spectrum antibiotics narrowed after concordant or negative biopsy result (11%, 5/44). Excluding patients with no other prior culture source (Fig 4), management changed in 40% (93/233), significantly greater than 23% (10/44) with prior positive blood culture (P = .04). In patients not on antibiotics at biopsy, management changed for 41% (88/216), significantly greater than 22% (21/94) on antibiotics (P = .001).
FIG 4.
Management change categories with no prior culture source.
Culture-negative and culture-contaminant cases were deemed to not contribute to management change if repeat biopsy or surgery was needed (n = 14), in cases with low suspicion for VO before biopsy and no associated treatment (n = 11), and when clinical course was primarily influenced by comorbidities (n = 19) such as other infection, malignancy, and/or cardiac arrest.
A final diagnosis of VO treated with antibiotics was documented in clinical notes of 70% (218/310) of cases, including 104 culture-positive cases and 114 presumed false-negative cultures. VO was excluded based on clinical factors and biopsy results in 20% (62/310) with alternate diagnoses including degenerative (n = 19), trauma/fracture (n = 7), inflammatory/rheumatologic (n = 6), prior treated osteomyelitis (n = 4), postradiation (n = 1), and unspecified (n = 25). The final diagnosis was unclear in 10% (30/310) of culture-negative or culture-contaminant cases in which treatment was also targeted to other pre-existing infections and comorbidities. The concordance rate of initial imaging impression and final clinical diagnosis was 63% (184/290). Management change was not significantly different between the imaging suspicious, equivocal, or not suspicious groups.
DISCUSSION
Diagnosing VO is challenging given its insidious onset, nonspecific symptoms, overlapping clinical features with noninfectious etiologies and low biopsy yield.3-6 Ideal management requires isolation of a causative organism through blood culture or biopsy followed by targeted antibiotic therapy.2 Many patients are started on empiric antibiotics before biopsy. Given these factors, we aimed to assess how image-guided biopsy results influence clinical management in suspected VO.
Similar to prior studies, we observed a suboptimal biopsy yield of 34% (104/310),3-6 with S aureus being the most common isolated pathogen.1,2 We observed a modest overall change in management (36%, 113/310) due to the biopsy results, similar to the 37.5% results from Winkler et al8 but variable from the results from Kuo et al (9%)10 and Ang et al (50%).3 Management was impacted in most (78%, 81/104) culture-positive cases through tailoring of antibiotic regimens. This highlights the importance of optimizing biopsy methods for the greatest biopsy yield to impact management.
Even when an organism cannot be identified with biopsy, many patients are treated empirically if there is high clinical suspicion for VO as was the case in 57% (110/194) of the culture-negative or culture-contaminant biopsies. Despite 30% (94/310) of patients receiving antibiotics before biopsy, there was no significant difference in the biopsy yield based on short-term antibiotic exposure. Our results are in agreement with a recent meta-analysis by Chang et al5 that reported no difference in microbiology sensitivities based on antibiotic exposure, though other studies report antibiotics influence culture yield.11 Longer antibiotic duration (6.35 days) was associated with negative culture results compared with 3.69 days for positive culture results, though this difference did not reach statistical significance, suggesting that antibiotic status should not impact the decision to perform a biopsy but performing the biopsy sooner after initiating antibiotics may improve yield.
Higher biopsy yield (50%; 22/44) occurred in the setting of prior positive blood cultures. However, management change was significantly greater with no positive blood culture (MC 41%, 88/216) versus positive blood cultures (MC 23%, 10/44). This is likely because most patients with positive blood cultures (73%, 32/44) were on appropriate targeted antibiotics at biopsy with subsequent concordant or negative biopsy results that did not change therapy. Similarly, management change was greater in patients not on antibiotics at biopsy (MC 41%, 88/216) versus those on antibiotics (MC 22%, 21/94).
Fluid collection aspiration, disc biopsy (versus bone), withholding antibiotics, elevated CRP, and use of larger-bore needles have been associated with higher diagnostic biopsy yield,3,4,11,12 though other studies question the importance of some of these factors.5 We found disc sampling with or without bone (yield 36%, 82/228) and disc/bone aspiration with or without cores (yield 42%, 39/92) were significantly associated with higher yield than bone only (yield 8%, 2/24) or core only (yield 29%, 56/193). The highest yield (56%, 10/18) was with aspiration only, possibly due to discrete fluid collections rather than solid material. However, variable reporting prevented us from determining if aspiration was from a discrete fluid collection or disc space in most cases. Needle size varied (9 g–22 g), though most used large-bore needles (14 g), with no difference between positive and negative culture groups, contrary to the conclusions from Husseini et al.12
Management change occurred in 16% (32/194) of negative/contaminant culture results or 10% (32/310) of all cases, similar to Winkler et al (11.7%).8 Negative culture results influenced management when an alternate diagnosis was identified histologically. Core samples were crucial for identifying alternate diagnoses and ruling out infection.
With respect to image-guided biopsy for VO, the 2015 Infectious Disease Society of America (IDSA) guidelines2 recommendations include the following: 1) defer image-guided biopsy when blood cultures are positive for S aureus or S Lugdunensis or testing is positive for Brucella species in endemic regions; 2) obtain image-guided biopsy when a microbiologic diagnosis is not established from blood cultures or serology; 3) obtain pathology specimens to guide therapy, which can be informative when cultures are negative; and 4) withhold antimicrobial therapy before biopsy in stable patients to optimize culture sensitivity. These guidelines were not uniformly followed in this heterogeneous multisite retrospective study with a 25-year inclusion period, though our results support the first 3 listed recommendations. We found that short-term antibiotic administration did not impact biopsy yield, suggesting withholding antibiotics before emergent image-guided biopsy may not be necessary.
Biopsy yield is likely impacted by sample handling and laboratory processing. The IDSA recommends using anaerobic transport media and specimen delivery within 2 hours,2 but these protocols could not be verified in our study. The amount of tissue available for microbiology can limit culture recovery, as samples are often shared with pathology. The variability of procedural techniques and sample processing practices in this study is a limitation, but we believe our multicenter design without shared technical policies is reflective of general hospital practices, increasing the external validity of results. The inclusion of cases with variable imaging interpretations, procedural modalities, and target tissue types provides useful information, which may have served as exclusion criteria in prior studies.8,10,11
This study is limited by the subjective nature of deciding management change retrospectively, though we used objective measures related to antibiotic therapy to determine management change. Additionally, we were limited by variable reporting of biopsy technique, including tissue sampled, needle size, and sample number. Laboratory methods were not standardized across time and sites, which could impact biopsy yield, and we could not determine which exact sample led to a positive diagnosis. These factors have been examined in prior studies and emphasize the benefit of standardized procedure reporting to optimize our understanding of impactful procedural practices. Future prospective studies could be performed to contemporaneously evaluate biopsy techniques, laboratory methods, and clinical scenarios resulting in the greatest management changes.
CONCLUSIONS
This study assessed how biopsy results influence the clinical management of VO. Management change is greatest with positive biopsy culture results, no prior culture sources, and among patients not on antibiotics at biopsy. These results support performing a biopsy when a causative organism has not been isolated from another source. Antibiotic therapy at the time of biopsy does not impact yield but may lead to less management change. Disc sampling and aspiration are associated with higher culture yield. Negative culture results also influence management, and core biopsy identifies alternate diagnoses.
Supplementary Material
Acknowledgments
We thank Thomas E. Grys, PhD, Associate Professor and Co-Director of Microbiology at the Mayo Clinic Arizona, for his contribution to the methods and discussion.
ABBREVIATIONS:
- CRP
C-reactive protein
- ESR
erythrocyte sedimentation rate
- IDSA
Infectious Disease Society of America
- MC
management change
- NMC
no management change
- UC
unclear
- VO
vertebral osteomyelitis-discitis
- WBC
white blood cell
Footnotes
Disclosure forms provided by the authors are available with the full text and PDF of this article at www.ajnr.org.
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