����JFIFXX�����    $.' ",#(7),01444'9=82<.342  2!!22222222222222222222222222222222222222222222222222����"��4�� ���,�PG"Z_�4�˷����kjز�Z�,F+��_z�,�© �����zh6�٨�ic�fu���#ډb���_�N�?��wQ���5-�~�I���8����TK<5o�Iv-�����k�_U_�����~b�M��d����Ӝ�U�Hh��?]��E�w��Q���k�{��_}qFW7HTՑ��Y��F�?_�'ϔ��_�Ջt��=||I ��6�έ"�����D���/[�k�9���Y�8ds|\���Ҿp6�Ҵ���]��.����6�z<�v��@]�i%��$j��~�g��J>��no����pM[me�i$[����s�o�ᘨ�˸ nɜG-�ĨU�ycP�3.DB�li�;��hj���x7Z^�N�h������N3u{�:j�x�힞��#M&��jL P@_���� P��&��o8������9�����@Sz6�t7#O�ߋ �s}Yf�T���lmr����Z)'N��k�۞p����w\�Tȯ?�8`�O��i{wﭹW�[�r�� ��Q4F�׊���3m&L�=��h3����z~��#�\�l :�F,j@�� ʱ�wQT����8�"kJO���6�֚l����}���R�>ډK���]��y����&����p�}b��;N�1�m�r$�|��7�>e�@B�TM*-iH��g�D�)� E�m�|�ؘbҗ�a��Ҿ����t4���o���G��*oCN�rP���Q��@z,|?W[0�����:�n,jWiE��W��$~/�hp\��?��{(�0���+�Y8rΟ�+����>S-S����VN;�}�s?.����� w�9��˟<���Mq4�Wv'��{)0�1mB��V����W[�����8�/<� �%���wT^�5���b��)iM� pg�N�&ݝ��VO~�q���u���9� ����!��J27����$O-���! �:�%H��� ـ����y�ΠM=t{!S�� oK8������t<����è:a������[�����ա�H���~��w��Qz`�po�^ ����Q��n� �,uu�C�$ ^���,������8�#��:�6��e�|~���!�3�3.�\0��q��o�4`.|� ����y�Q�`~;�d�ׯ,��O�Zw�������`73�v�܋�<���Ȏ�� ـ4k��5�K�a�u�=9Yd��$>x�A�&�� j0� ���vF��� Y�|�y��� ~�6�@c��1vOp�Ig����4��l�OD���L����� R���c���j�_�uX6��3?nk��Wy�f;^*B� ��@�~a�`��Eu������+���6�L��.ü>��}y���}_�O�6�͐�:�YrG�X��kG�����l^w���~㒶sy��Iu�!� W ��X��N�7BV��O��!X�2����wvG�R�f�T#�����t�/?���%8�^�W�aT��G�cL�M���I��(J����1~�8�?aT ���]����AS�E��(��*E}� 2��#I/�׍qz��^t�̔���b�Yz4x���t�){ OH��+(E��A&�N�������XT��o��"�XC��'���)}�J�z�p� ��~5�}�^����+�6����w��c��Q�|Lp�d�H��}�(�.|����k��c4^�"�����Z?ȕ ��a<�L�!039C� �Eu�C�F�Ew�ç ;�n?�*o���B�8�bʝ���'#Rqf���M}7����]����s2tcS{�\icTx;�\��7K���P���ʇ Z O-��~��c>"��?�������P��E��O�8��@�8��G��Q�g�a�Վ���󁶠�䧘��_%#r�>�1�z�a��eb��qcPѵ��n���#L��� =��׀t� L�7�`��V���A{�C:�g���e@�w1 Xp3�c3�ġ����p��M"'-�@n4���fG��B3�DJ�8[Jo�ߐ���gK)ƛ��$���� ���8�3�����+���� �����6�ʻ���� ���S�kI�*KZlT _`���?��K����QK�d����B`�s}�>���`��*�>��,*@J�d�oF*����弝��O}�k��s��]��y�ߘ��c1G�V���<=�7��7����6�q�PT��tXԀ�!9*4�4Tހ3XΛex�46���Y��D ����� �BdemDa����\�_l,��G�/���֌7���Y�](�xTt^%�GE�����4�}bT���ڹ�����;Y)���B�Q��u��>J/J �⮶.�XԄ��j�ݳ�+E��d ��r�5�_D�1 ��o�� �B�x�΢�#���<��W�����8���R6�@g�M�.��� dr�D��>(otU��@x=��~v���2� ӣ�d�oBd��3�eO�6�㣷�����ݜ6��6Y��Qz`��S��{���\P�~z m5{J/L��1������<�e�ͅPu�b�]�ϔ���'������f�b� Zpw��c`"��i���BD@:)ִ�:�]��hv�E�w���T�l��P���"Ju�}��وV J��G6��. J/�Qgl߭�e�����@�z�Zev2u�)]կ�����7x���s�M�-<ɯ�c��r�v�����@��$�ޮ}lk���a���'����>x��O\�ZFu>�����ck#��&:��`�$�ai�>2Δ����l���oF[h��lE�ܺ�Πk:)���`�� $[6�����9�����kOw�\|���8}������ބ:��񶐕��I�A1/�=�2[�,�!��.}gN#�u����b��� ~��݊��}34q����d�E��Lc��$��"�[q�U�硬g^��%B �z���r�pJ�ru%v\h1Y�ne`ǥ:g���pQM~�^�Xi� ��`S�:V29.�P���V�?B�k�� AEvw%�_�9C�Q����wKekPؠ�\�;Io d�{ ߞo�c1eP����\� `����E=���@K<�Y���eڼ�J���w����{av�F�'�M�@/J��+9p���|]�����Iw &`��8���&M�hg��[�{��Xj��%��Ӓ�$��(����ʹN���<>�I���RY���K2�NPlL�ɀ)��&e����B+ь����( � �JTx���_?EZ� }@ 6�U���뙢ط�z��dWI�n` D����噥�[��uV��"�G&Ú����2g�}&m��?ċ�"����Om#��������� ��{�ON��"S�X��Ne��ysQ���@Fn��Vg���dX�~nj�]J�<�K]:��FW��b�������62�=��5f����JKw��bf�X�55��~J �%^����:�-�QIE��P��v�nZum� z � ~ə ���� ���ة����;�f��\v���g�8�1��f24;�V���ǔ�)����9���1\��c��v�/'Ƞ�w�������$�4�R-��t���� e�6�/�ġ �̕Ecy�J���u�B���<�W�ַ~�w[B1L۲�-JS΂�{���΃������A��20�c#��@ 0!1@AP"#2Q`$3V�%45a6�FRUq��� ����^7ׅ,$n�������+��F�`��2X'��0vM��p�L=������5��8������u�p~���.�`r�����\���O��,ư�0oS ��_�M�����l���4�kv\JSd���x���SW�<��Ae�IX����������$I���w�:S���y���›R��9�Q[���,�5�;�@]�%���u�@ *ro�lbI �� ��+���%m:�͇ZV�����u�̉����θau<�fc�.����{�4Ա� �Q����*�Sm��8\ujqs]{kN���)qO�y�_*dJ�b�7���yQqI&9�ԌK!�M}�R�;������S�T���1���i[U�ɵz�]��U)V�S6���3$K{�ߊ<�(� E]Զ[ǼENg�����'�\?#)Dkf��J���o��v���'�%ƞ�&K�u�!��b�35LX�Ϸ��63$K�a�;�9>,R��W��3�3� d�JeTYE.Mϧ��-�o�j3+y��y^�c�������VO�9NV\nd�1 ��!͕_)a�v;����թ�M�lWR1��)El��P;��yوÏ�u 3�k�5Pr6<�⒲l�!˞*��u־�n�!�l:����UNW ��%��Chx8vL'��X�@��*��)���̮��ˍ��� ���D-M�+J�U�kvK����+�x8��cY������?�Ԡ��~3mo��|�u@[XeY�C�\Kp�x8�oC�C�&����N�~3-H���� ��MX�s�u<`���~"WL��$8ξ��3���a�)|:@�m�\���^�`�@ҷ)�5p+��6���p�%i)P M���ngc�����#0Aruz���RL+xSS?���ʮ}()#�t��mˇ!��0}}y����<�e� �-ή�Ԩ��X������ MF���ԙ~l L.3���}�V뽺�v�����멬��Nl�)�2����^�Iq��a��M��qG��T�����c3#������3U�Ǎ���}��לS�|qa��ڃ�+���-��2�f����/��bz��ڐ�� �ݼ[2�ç����k�X�2�* �Z�d���J�G����M*9W���s{��w���T��x��y,�in�O�v��]���n����P�$�JB@=4�OTI�n��e�22a\����q�d���%�$��(���:���: /*�K[PR�fr\nڙdN���F�n�$�4�[�� U�zƶ����� �mʋ���,�ao�u 3�z� �x��Kn����\[��VFmbE;�_U��&V�Gg�]L�۪&#n%�$ɯ�dG���D�TI=�%+AB�Ru#��b4�1�»x�cs�YzڙJG��f��Il��d�eF'T� iA��T���uC�$����Y��H?����[!G`}���ͪ� �纤Hv\������j�Ex�K���!���OiƸ�Yj�+u-<���'q����uN�*�r\��+�]���<�wOZ.fp�ێ��,-*)V?j-kÊ#�`�r��dV����(�ݽBk�����G�ƛk�QmUڗe��Z���f}|����8�8��a���i��3'J�����~G_�^���d�8w������ R�`(�~�.��u���l�s+g�bv���W���lGc}��u���afE~1�Ue������Z�0�8�=e�� f@/�jqEKQQ�J��oN��J���W5~M>$6�Lt�;$ʳ{���^��6�{����v6���ķܰg�V�cnn �~z�x�«�,2�u�?cE+Ș�H؎�%�Za�)���X>uW�Tz�Nyo����s���FQƤ��$��*�&�LLXL)�1�" L��eO��ɟ�9=���:t��Z���c��Ž���Y?�ӭV�wv�~,Y��r�ۗ�|�y��GaF�����C�����.�+� ���v1���fήJ�����]�S��T��B��n5sW}y�$��~z�'�c ��8 ��� ,! �p��VN�S��N�N�q��y8z˱�A��4��*��'������2n<�s���^ǧ˭P�Jޮɏ�U�G�L�J�*#��<�V��t7�8����TĜ>��i}K%,���)[��z�21z ?�N�i�n1?T�I�R#��m-�����������������1����lA�`��fT5+��ܐ�c�q՝��ʐ��,���3�f2U�եmab��#ŠdQ�y>\��)�SLY����w#��.���ʑ�f��� ,"+�w�~�N�'�c�O�3F�������N<���)j��&��,-� �љ���֊�_�zS���TǦ����w�>��?�������n��U仆�V���e�����0���$�C�d���rP �m�׈e�Xm�Vu� �L��.�bֹ��� �[Դaզ���*��\y�8�Է:�Ez\�0�Kq�C b��̘��cө���Q��=0Y��s�N��S.���3.���O�o:���#���v7�[#߫ ��5�܎�L���Er4���9n��COWlG�^��0k�%<���ZB���aB_���������'=��{i�v�l�$�uC���mƎҝ{�c㱼�y]���W�i ��ߧc��m�H� m�"�"�����;Y�ߝ�Z�Ǔ�����:S#��|}�y�,/k�Ld� TA�(�AI$+I3��;Y*���Z��}|��ӧO��d�v��..#:n��f>�>���ȶI�TX��� 8��y����"d�R�|�)0���=���n4��6ⲑ�+��r<�O�܂~zh�z����7ܓ�HH�Ga롏���nCo�>������a ���~]���R���̲c?�6(�q�;5%� |�uj�~z8R=X��I�V=�|{v�Gj\gc��q����z�؋%M�ߍ����1y��#��@f^���^�>N�����#x#۹��6�Y~�?�dfPO��{��P�4��V��u1E1J �*|���%���JN��`eWu�zk M6���q t[�� ��g�G���v��WIG��u_ft����5�j�"�Y�:T��ɐ���*�;� e5���4����q$C��2d�}���� _S�L#m�Yp��O�.�C�;��c����Hi#֩%+) �Ӎ��ƲV���SYź��g |���tj��3�8���r|���V��1#;.SQ�A[���S������#���`n�+���$��$I �P\[�@�s��(�ED�z���P��])8�G#��0B��[ى��X�II�q<��9�~[Z멜�Z�⊔IWU&A>�P~�#��dp<�?����7���c��'~���5 ��+$���lx@�M�dm��n<=e�dyX��?{�|Aef ,|n3�<~z�ƃ�uۧ�����P��Y,�ӥQ�*g�#먙R�\���;T��i,��[9Qi歉����c>]9�� ��"�c��P�� �Md?٥��If�ت�u��k��/����F��9�c*9��Ǎ:�ØF���z�n*�@|I�ށ9����N3{'��[�'ͬ�Ҳ4��#}��!�V� Fu��,�,mTIk���v C�7v���B�6k�T9��1�*l� '~��ƞF��lU��'�M ����][ΩũJ_�{�i�I�n��$���L�� j��O�dx�����kza۪��#�E��Cl����x˘�o�����V���ɞ�ljr��)�/,�߬h�L��#��^��L�ф�,íMƁe�̩�NB�L�����iL����q�}��(��q��6IçJ$�W�E$��:������=#����(�K�B����zђ <��K(�N�۫K�w��^O{!����)�H���>x�������lx�?>Պ�+�>�W���,Ly!_�D���Ō�l���Q�!�[ �S����J��1��Ɛ�Y}��b,+�Lo�x�ɓ)����=�y�oh�@�꥟/��I��ѭ=��P�y9��� �ۍYӘ�e+�p�Jnϱ?V\SO%�(�t� ���=?MR�[Ș�����d�/ ��n�l��B�7j� ��!�;ӥ�/�[-���A�>�dN�sLj ��,ɪv��=1c�.SQ�O3�U���ƀ�ܽ�E����������̻��9G�ϷD�7(�}��Ävӌ\�y�_0[w ���<΍>����a_��[0+�L��F.�޺��f�>oN�T����q;���y\��bՃ��y�jH�<|q-eɏ�_?_9+P���Hp$�����[ux�K w�Mw��N�ی'$Y2�=��q���KB��P��~������Yul:�[<����F1�2�O���5=d����]Y�sw:���Ϯ���E��j,_Q��X��z`H1,#II ��d�wr��P˂@�ZJV����y$�\y�{}��^~���[:N����ߌ�U�������O��d�����ؾe��${p>G��3c���Ė�lʌ�� ת��[��`ϱ�-W����dg�I��ig2��� ��}s ��ؤ(%#sS@���~���3�X�nRG�~\jc3�v��ӍL��M[JB�T��s3}��j�Nʖ��W����;7��ç?=X�F=-�=����q�ߚ���#���='�c��7���ڑW�I(O+=:uxq�������������e2�zi+�kuG�R��������0�&e�n���iT^J����~\jy���p'dtG��s����O��3����9* �b#Ɋ�� p������[Bws�T�>d4�ۧs���nv�n���U���_�~,�v����ƜJ1��s�� �QIz��)�(lv8M���U=�;����56��G���s#�K���MP�=��LvyGd��}�VwWBF�'�à �?MH�U�g2�� ����!�p�7Q��j��ڴ����=��j�u��� Jn�A s���uM������e��Ɔ�Ҕ�!)'��8Ϣ�ٔ��ޝ(��Vp���צ֖d=�IC�J�Ǡ{q������kԭ�߸���i��@K����u�|�p=..�*+����x�����z[Aqġ#s2a�Ɗ���RR�)*HRsi�~�a &f��M��P����-K�L@��Z��Xy�'x�{}��Zm+���:�)�) IJ�-i�u���� ���ܒH��'�L(7�y�GӜq���� j��� 6ߌg1�g�o���,kر���tY�?W,���p���e���f�OQS��!K�۟cҒA�|ս�j�>��=⬒��˧L[�� �߿2JaB~R��u�:��Q�] �0H~���]�7��Ƽ�I���(}��cq '�ήET���q�?f�ab���ӥvr� �)o��-Q��_'����ᴎo��K������;��V���o��%���~OK ����*��b�f:���-ťIR��`B�5!RB@���ï�� �u �̯e\�_U�_������� g�ES��3�������QT��a����x����U<~�c?�*�#]�MW,[8O�a�x��]�1bC|踤�P��lw5V%�)�{t�<��d��5���0i�XSU��m:��Z�┵�i�"��1�^B�-��P�hJ��&)O��*�D��c�W��vM��)����}���P��ܗ-q����\mmζZ-l@�}��a��E�6��F�@��&Sg@���ݚ�M����� ȹ 4����#p�\H����dYDo�H���"��\��..R�B�H�z_�/5˘����6��KhJR��P�mƶi�m���3�,#c�co��q�a)*Pt����R�m�k�7x�D�E�\Y�閣_X�<���~�)���c[[�BP����6�Yq���S��0����%_����;��Àv�~�| VS؇ ��'O0��F0��\���U�-�d@�����7�SJ*z��3n��y��P����O���������m�~�P�3|Y��ʉr#�C�<�G~�.,! ���bqx���h~0=��!ǫ�jy����l�O,�[B��~��|9��ٱ����Xly�#�i�B��g%�S��������tˋ���e���ې��\[d�t)��.+u�|1 ������#�~Oj����hS�%��i.�~X���I�H�m��0n���c�1uE�q��cF�RF�o���7� �O�ꮧ� ���ۛ{��ʛi5�rw?׌#Qn�TW��~?y$��m\�\o����%W� ?=>S�N@�� �Ʈ���R����N�)�r"C�:��:����� �����#��qb��Y�. �6[��2K����2u�Ǧ�HYR��Q�MV��� �G�$��Q+.>�����nNH��q�^��� ����q��mM��V��D�+�-�#*�U�̒ ���p욳��u:�������IB���m���PV@O���r[b= �� ��1U�E��_Nm�yKbN�O���U�}�the�`�|6֮P>�\2�P�V���I�D�i�P�O;�9�r�mAHG�W�S]��J*�_�G��+kP�2����Ka�Z���H�'K�x�W�MZ%�O�YD�Rc+o��?�q��Ghm��d�S�oh�\�D�|:W������UA�Qc yT�q������~^�H��/��#p�CZ���T�I�1�ӏT����4��"�ČZ�����}��`w�#�*,ʹ�� ��0�i��課�Om�*�da��^gJ݅{���l�e9uF#T�ֲ��̲�ٞC"�q���ߍ ոޑ�o#�XZTp����@ o�8��(jd��xw�]�,f���`~�|,s��^����f�1���t��|��m�򸄭/ctr��5s��7�9Q�4�H1꠲BB@l9@���C�����+�wp�xu�£Yc�9��?`@#�o�mH�s2��)�=��2�.�l����jg�9$�Y�S�%*L������R�Y������7Z���,*=�䷘$�������arm�o�ϰ���UW.|�r�uf����IGw�t����Zwo��~5 ��YյhO+=8fF�)�W�7�L9lM�̘·Y���֘YLf�큹�pRF���99.A �"wz��=E\Z���'a� 2��Ǚ�#;�'}�G���*��l��^"q��+2FQ� hj��kŦ��${���ޮ-�T�٭cf�|�3#~�RJ����t��$b�(R��(����r���dx� >U b�&9,>���%E\� Ά�e�$��'�q't��*�א���ެ�b��-|d���SB�O�O��$�R+�H�)�܎�K��1m`;�J�2�Y~9��O�g8=vqD`K[�F)k�[���1m޼c��n���]s�k�z$@��)!I �x՝"v��9=�ZA=`Ɠi �:�E��)`7��vI��}d�YI�_ �o�:ob���o ���3Q��&D&�2=�� �Ά��;>�h����y.*ⅥS������Ӭ�+q&����j|UƧ����}���J0��WW< ۋS�)jQR�j���Ư��rN)�Gű�4Ѷ(�S)Ǣ�8��i��W52���No˓� ۍ%�5brOn�L�;�n��\G����=�^U�dI���8$�&���h��'���+�(������cȁ߫k�l��S^���cƗjԌE�ꭔ��gF���Ȓ��@���}O���*;e�v�WV���YJ\�]X'5��ղ�k�F��b 6R�o՜m��i N�i����>J����?��lPm�U��}>_Z&�KK��q�r��I�D�Չ~�q�3fL�:S�e>���E���-G���{L�6p�e,8��������QI��h��a�Xa��U�A'���ʂ���s�+טIjP�-��y�8ۈZ?J$��W�P� ��R�s�]��|�l(�ԓ��sƊi��o(��S0��Y� 8�T97.�����WiL��c�~�dxc�E|�2!�X�K�Ƙਫ਼�$((�6�~|d9u+�qd�^3�89��Y�6L�.I�����?���iI�q���9�)O/뚅����O���X��X�V��ZF[�یgQ�L��K1���RҖr@v�#��X�l��F���Нy�S�8�7�kF!A��sM���^rkp�jP�DyS$N���q��nxҍ!U�f�!eh�i�2�m���`�Y�I�9r�6� �TF���C}/�y�^���Η���5d�'��9A-��J��>{�_l+�`��A���[�'��յ�ϛ#w:݅�%��X�}�&�PSt�Q�"�-��\縵�/����$Ɨh�Xb�*�y��BS����;W�ջ_mc�����vt?2}1�;qS�d�d~u:2k5�2�R�~�z+|HE!)�Ǟl��7`��0�<�,�2*���Hl-��x�^����'_TV�gZA�'j� ^�2Ϊ��N7t�����?w�� �x1��f��Iz�C-Ȗ��K�^q�;���-W�DvT�7��8�Z�������� hK�(P:��Q- �8�n�Z���܃e貾�<�1�YT<�,�����"�6{/ �?�͟��|1�:�#g��W�>$����d��J��d�B��=��jf[��%rE^��il:��B���x���Sּ�1հ��,�=��*�7 fcG��#q� �eh?��2�7�����,�!7x��6�n�LC�4x��},Geǝ�tC.��vS �F�43��zz\��;QYC,6����~;RYS/6���|2���5���v��T��i����������mlv��������&� �nRh^ejR�LG�f���? �ۉҬܦƩ��|��Ȱ����>3����!v��i�ʯ�>�v��オ�X3e���_1z�Kȗ\<������!�8���V��]��?b�k41�Re��T�q��mz��TiOʦ�Z��Xq���L������q"+���2ۨ��8}�&N7XU7Ap�d�X��~�׿��&4e�o�F��� �H����O���č�c�� 懴�6���͉��+)��v;j��ݷ�� �UV�� i��� j���Y9GdÒJ1��詞�����V?h��l����l�cGs�ځ�������y�Ac�����\V3�? �� ܙg�>qH�S,�E�W�[�㺨�uch�⍸�O�}���a��>�q�6�n6����N6�q������N ! 1AQaq�0@����"2BRb�#Pr���3C`��Scst���$4D���%Td�� ?���N����a��3��m���C���w��������xA�m�q�m���m������$����4n淿t'��C"w��zU=D�\R+w�p+Y�T�&�պ@��ƃ��3ޯ?�Aﶂ��aŘ���@-�����Q�=���9D��ռ�ѻ@��M�V��P��܅�G5�f�Y<�u=,EC)�<�Fy'�"�&�չ�X~f��l�KԆV��?�� �W�N����=(� �;���{�r����ٌ�Y���h{�١������jW����P���Tc�����X�K�r��}���w�R��%��?���E��m�� �Y�q|����\lEE4���r���}�lsI�Y������f�$�=�d�yO����p�����yBj8jU�o�/�S��?�U��*������ˍ�0������u�q�m [�?f����a�� )Q�>����6#������� ?����0UQ����,IX���(6ڵ[�DI�MNލ�c&���υ�j\��X�R|,4��� j������T�hA�e��^���d���b<����n�� �즇�=!���3�^�`j�h�ȓr��jẕ�c�,ٞX����-����a�ﶔ���#�$��]w�O��Ӫ�1y%��L�Y<�wg#�ǝ�̗`�x�xa�t�w��»1���o7o5��>�m뭛C���Uƃߜ}�C���y1Xνm�F8�jI���]����H���ۺиE@I�i;r�8ӭ����V�F�Շ| ��&?�3|x�B�MuS�Ge�=Ӕ�#BE5G�����Y!z��_e��q�р/W>|-�Ci߇�t�1ޯќd�R3�u��g�=0 5��[?�#͏��q�cf���H��{ ?u�=?�?ǯ���}Z��z���hmΔ�BFTW�����<�q�(v� ��!��z���iW]*�J�V�z��gX֧A�q�&��/w���u�gYӘa���; �i=����g:��?2�dž6�ى�k�4�>�Pxs����}������G�9��3 ���)gG�R<>r h�$��'nc�h�P��Bj��J�ҧH� -��N1���N��?��~��}-q!=��_2hc�M��l�vY%UE�@|�v����M2�.Y[|y�"Eï��K�ZF,�ɯ?,q�?v�M 80jx�"�;�9vk�����+ ֧�� �ȺU��?�%�vcV��mA�6��Qg^M����A}�3�nl� QRN�l8�kkn�'�����(��M�7m9و�q���%ޟ���*h$Zk"��$�9��: �?U8�Sl��,,|ɒ��xH(ѷ����Gn�/Q�4�P��G�%��Ա8�N��!� �&�7�;���eKM7�4��9R/%����l�c>�x;������>��C�:�����t��h?aKX�bhe�ᜋ^�$�Iհ �hr7%F$�E��Fd���t��5���+�(M6�t����Ü�UU|zW�=a�Ts�Tg������dqP�Q����b'�m���1{|Y����X�N��b �P~��F^F:����k6�"�j!�� �I�r�`��1&�-$�Bevk:y���#yw��I0��x��=D�4��tU���P�ZH��ڠ底taP��6����b>�xa����Q�#� WeF��ŮNj�p�J* mQ�N����*I�-*�ȩ�F�g�3 �5��V�ʊ�ɮ�a��5F���O@{���NX��?����H�]3��1�Ri_u��������ѕ�� ����0��� F��~��:60�p�͈�S��qX#a�5>���`�o&+�<2�D����: �������ڝ�$�nP���*)�N�|y�Ej�F�5ټ�e���ihy�Z �>���k�bH�a�v��h�-#���!�Po=@k̆IEN��@��}Ll?j�O������߭�ʞ���Q|A07x���wt!xf���I2?Z��<ץ�T���cU�j��]��陎Ltl �}5�ϓ��$�,��O�mˊ�;�@O��jE��j(�ا,��LX���LO���Ц�90�O �.����a��nA���7������j4 ��W��_ٓ���zW�jcB������y՗+EM�)d���N�g6�y1_x��p�$Lv:��9�"z��p���ʙ$��^��JԼ*�ϭ����o���=x�Lj�6�J��u82�A�H�3$�ٕ@�=Vv�]�'�qEz�;I˼��)��=��ɯ���x �/�W(V���p�����$ �m�������u�����񶤑Oqˎ�T����r��㠚x�sr�GC��byp�G��1ߠ�w e�8�$⿄����/�M{*}��W�]˷.�CK\�ުx���/$�WPw���r� |i���&�}�{�X� �>��$-��l���?-z���g����lΆ���(F���h�vS*���b���߲ڡn,|)mrH[���a�3�ר�[1��3o_�U�3�TC�$��(�=�)0�kgP���� ��u�^=��4 �WYCҸ:��vQ�ר�X�à��tk�m,�t*��^�,�}D*� �"(�I��9R����>`�`��[~Q]�#af��i6l��8���6�:,s�s�N6�j"�A4���IuQ��6E,�GnH��zS�HO�uk�5$�I�4��ؤ�Q9�@��C����wp�BGv[]�u�Ov���0I4���\��y�����Q�Ѹ��~>Z��8�T��a��q�ޣ;z��a���/��S��I:�ܫ_�|������>=Z����8:�S��U�I�J��"IY���8%b8���H��:�QO�6�;7�I�S��J��ҌAά3��>c���E+&jf$eC+�z�;��V����� �r���ʺ������my�e���aQ�f&��6�ND��.:��NT�vm�<- u���ǝ\MvZY�N�NT��-A�>jr!S��n�O 1�3�Ns�%�3D@���`������ܟ 1�^c<���� �a�ɽ�̲�Xë#�w�|y�cW�=�9I*H8�p�^(4���՗�k��arOcW�tO�\�ƍR��8����'�K���I�Q�����?5�>[�}��yU�ײ -h��=��% q�ThG�2�)���"ו3]�!kB��*p�FDl�A���,�eEi�H�f�Ps�����5�H:�Փ~�H�0Dت�D�I����h�F3�������c��2���E��9�H��5�zԑ�ʚ�i�X�=:m�xg�hd(�v����׊�9iS��O��d@0ڽ���:�p�5�h-��t�&���X�q�ӕ,��ie�|���7A�2���O%P��E��htj��Y1��w�Ѓ!����  ���� ࢽ��My�7�\�a�@�ţ�J �4�Ȼ�F�@o�̒?4�wx��)��]�P��~�����u�����5�����7X ��9��^ܩ�U;Iꭆ 5 �������eK2�7(�{|��Y׎ �V��\"���Z�1� Z�����}��(�Ǝ"�1S���_�vE30>���p;� ΝD��%x�W�?W?v����o�^V�i�d��r[��/&>�~`�9Wh��y�;���R��� ;;ɮT��?����r$�g1�K����A��C��c��K��l:�'��3 c�ﳯ*"t8�~l��)���m��+U,z��`(�>yJ�?����h>��]��v��ЍG*�{`��;y]��I�T� ;c��NU�fo¾h���/$���|NS���1�S�"�H��V���T���4��uhǜ�]�v;���5�͠x��'C\�SBpl���h}�N����� A�Bx���%��ޭ�l��/����T��w�ʽ]D�=����K���ž�r㻠l4�S�O?=�k �M:� ��c�C�a�#ha���)�ѐxc�s���gP�iG��{+���x���Q���I= �� z��ԫ+ �8"�k�ñ�j=|����c ��y��CF��/��*9ж�h{ �?4�o� ��k�m�Q�N�x��;�Y��4膚�a�w?�6�>e]�����Q�r�:����g�,i"�����ԩA�*M�<�G��b�if��l^M��5� �Ҩ�{����6J��ZJ�����P�*�����Y���ݛu�_4�9�I8�7���������,^ToR���m4�H��?�N�S�ѕw��/S��甍�@�9H�S�T��t�ƻ���ʒU��*{Xs�@����f�����֒Li�K{H�w^���������Ϥm�tq���s� ���ք��f:��o~s��g�r��ט� �S�ѱC�e]�x���a��) ���(b-$(�j>�7q�B?ӕ�F��hV25r[7 Y� }L�R��}����*sg+��x�r�2�U=�*'WS��ZDW]�WǞ�<��叓���{�$�9Ou4��y�90-�1�'*D`�c�^o?(�9��u���ݐ��'PI&� f�Jݮ�������:wS����jfP1F:X �H�9dԯ���˝[�_54 �}*;@�ܨ�� ð�yn�T���?�ןd�#���4rG�ͨ��H�1�|-#���Mr�S3��G�3�����)�.᧏3v�z֑��r����$G"�`j �1t��x0<Ɔ�Wh6�y�6��,œ�Ga��gA����y��b��)��h�D��ß�_�m��ü �gG;��e�v��ݝ�nQ� ��C����-�*��o���y�a��M��I�>�<���]obD��"�:���G�A��-\%LT�8���c�)��+y76���o�Q�#*{�(F�⽕�y����=���rW�\p���۩�c���A���^e6��K������ʐ�cVf5$�'->���ՉN"���F�"�UQ@�f��Gb~��#�&�M=��8�ט�JNu9��D��[̤�s�o�~������ G��9T�tW^g5y$b��Y'��س�Ǵ�=��U-2 #�MC�t(�i� �lj�@Q 5�̣i�*�O����s�x�K�f��}\��M{E�V�{�υ��Ƈ�����);�H����I��fe�Lȣr�2��>��W�I�Ȃ6������i��k�� �5�YOxȺ����>��Y�f5'��|��H+��98pj�n�.O�y�������jY��~��i�w'������l�;�s�2��Y��:'lg�ꥴ)o#'Sa�a�K��Z� �m��}�`169�n���"���x��I ��*+� }F<��cГ���F�P�������ֹ*�PqX�x۩��,� ��N�� �4<-����%����:��7����W���u�`����� $�?�I��&����o��o��`v�>��P��"��l���4��5'�Z�gE���8���?��[�X�7(��.Q�-��*���ތL@̲����v��.5���[��=�t\+�CNܛ��,g�SQnH����}*F�G16���&:�t��4ُ"A��̣��$�b �|����#rs��a�����T�� ]�<�j��BS�('$�ɻ� �wP;�/�n��?�ݜ��x�F��yUn�~mL*-�������Xf�wd^�a�}��f�,=t�׵i�.2/wpN�Ep8�OР���•��R�FJ� 55TZ��T �ɭ�<��]��/�0�r�@�f��V��V����Nz�G��^���7hZi����k��3�,kN�e|�vg�1{9]_i��X5y7� 8e]�U����'�-2,���e"����]ot�I��Y_��n�(JҼ��1�O ]bXc���Nu�No��pS���Q_���_�?i�~�x h5d'�(qw52] ��'ޤ�q��o1�R!���`ywy�A4u���h<קy���\[~�4�\ X�Wt/� 6�����n�F�a8��f���z �3$�t(���q��q�x��^�XWeN'p<-v�!�{�(>ӽDP7��ո0�y)�e$ٕv�Ih'Q�EA�m*�H��RI��=:��� ���4牢) �%_iN�ݧ�l]� �Nt���G��H�L��� ɱ�g<���1V�,�J~�ٹ�"K��Q�� 9�HS�9�?@��k����r�;we݁�]I�!{ �@�G�[�"��`���J:�n]�{�cA�E����V��ʆ���#��U9�6����j�#Y�m\��q�e4h�B�7��C�������d<�?J����1g:ٳ���=Y���D�p�ц� ׈ǔ��1�]26؜oS�'��9�V�FVu�P�h�9�xc�oq�X��p�o�5��Ա5$�9W�V(�[Ak�aY錎qf;�'�[�|���b�6�Ck��)��#a#a˙��8���=äh�4��2��C��4tm^ �n'c���]GQ$[Wҿ��i���vN�{Fu ��1�gx��1┷���N�m��{j-,��x�� Ūm�ЧS�[�s���Gna���䑴�� x�p 8<������97�Q���ϴ�v�aϚG��Rt�Һ׈�f^\r��WH�JU�7Z���y)�vg=����n��4�_)y��D'y�6�]�c�5̪�\� �PF�k����&�c;��cq�$~T�7j ���nç]�<�g ":�to�t}�159�<�/�8������m�b�K#g'I'.W�����6��I/��>v��\�MN��g���m�A�yQL�4u�Lj�j9��#44�t��l^�}L����n��R��!��t��±]��r��h6ٍ>�yҏ�N��fU�� ���� Fm@�8}�/u��jb9������he:A�y�ծw��GpΧh�5����l}�3p468��)U��d��c����;Us/�֔�YX�1�O2��uq�s��`hwg�r~�{ R��mhN��؎*q 42�*th��>�#���E����#��Hv�O����q�}�����6�e��\�,Wk�#���X��b>��p}�դ��3���T5��†��6��[��@�P�y*n��|'f�֧>�lư΂�̺����SU�'*�q�p�_S�����M�� '��c�6�����m�� ySʨ;M��r���Ƌ�m�Kxo,���Gm�P��A�G�:��i��w�9�}M(�^�V��$ǒ�ѽ�9���|���� �a����J�SQ�a���r�B;����}���ٻ֢�2�%U���c�#�g���N�a�ݕ�'�v�[�OY'��3L�3�;,p�]@�S��{ls��X�'���c�jw�k'a�.��}�}&�� �dP�*�bK=ɍ!����;3n�gΊU�ߴmt�'*{,=SzfD� A��ko~�G�aoq�_mi}#�m�������P�Xhύ����mxǍ�΂���巿zf��Q���c���|kc�����?���W��Y�$���_Lv����l߶��c���`?����l�j�ݲˏ!V��6����U�Ђ(A���4y)H���p�Z_�x��>���e��R��$�/�`^'3qˏ�-&Q�=?��CFVR �D�fV�9��{�8g�������n�h�(P"��6�[�D���< E�����~0<@�`�G�6����Hг�cc�� �c�K.5��D��d�B���`?�XQ��2��ٿyqo&+�1^� DW�0�ꊩ���G�#��Q�nL3��c���������/��x ��1�1[y�x�პCW��C�c�UĨ80�m�e�4.{�m��u���I=��f�����0QRls9���f���������9���~f�����Ǩ��a�"@�8���ȁ�Q����#c�ic������G��$���G���r/$W�(��W���V�"��m�7�[m�A�m����bo��D� j����۳� l���^�k�h׽����� ��#� iXn�v��eT�k�a�^Y�4�BN��ĕ��0 !01@Q"2AaPq3BR������?���@4�Q�����T3,���㺠�W�[=JK�Ϟ���2�r^7��vc�:�9 �E�ߴ�w�S#d���Ix��u��:��Hp��9E!�� V 2;73|F��9Y���*ʬ�F��D����u&���y؟��^EA��A��(ɩ���^��GV:ݜDy�`��Jr29ܾ�㝉��[���E;Fzx��YG��U�e�Y�C���� ����v-tx����I�sם�Ę�q��Eb�+P\ :>�i�C'�;�����k|z�رn�y]�#ǿb��Q��������w�����(�r|ӹs��[�D��2v-%��@;�8<a���[\o[ϧw��I!��*0�krs)�[�J9^��ʜ��p1)� "��/_>��o��<1����A�E�y^�C��`�x1'ܣn�p��s`l���fQ��):�l����b>�Me�jH^?�kl3(�z:���1ŠK&?Q�~�{�ٺ�h�y���/�[��V�|6��}�KbX����mn[-��7�5q�94�������dm���c^���h� X��5��<�eޘ>G���-�}�دB�ޟ� ��|�rt�M��V+�]�c?�-#ڛ��^ǂ}���Lkr���O��u�>�-D�ry� D?:ޞ�U��ǜ�7�V��?瓮�"�#���r��չģVR;�n���/_� ؉v�ݶe5d�b9��/O��009�G���5n�W����JpA�*�r9�>�1��.[t���s�F���nQ� V 77R�]�ɫ8����_0<՜�IF�u(v��4��F�k�3��E)��N:��yڮe��P�`�1}�$WS��J�SQ�N�j�ٺ��޵�#l���ј(�5=��5�lǏmoW�v-�1����v,W�mn��߀$x�<����v�j(����c]��@#��1������Ǔ���o'��u+����;G�#�޸��v-lη��/(`i⣍Pm^���ԯ̾9Z��F��������n��1��� ��]�[��)�'������:�֪�W��FC����� �B9،!?���]��V��A�Վ�M��b�w��G F>_DȬ0¤�#�QR�[V��kz���m�w�"��9ZG�7'[��=�Q����j8R?�zf�\a�=��O�U����*oB�A�|G���2�54 �p��.w7� �� ��&������ξxGHp� B%��$g�����t�Џ򤵍z���HN�u�Я�-�'4��0��;_��3 !01"@AQa2Pq#3BR������?��ʩca��en��^��8���<�u#��m*08r��y�N"�<�Ѳ0��@\�p��� �����Kv�D��J8�Fҽ� �f�Y��-m�ybX�NP����}�!*8t(�OqѢ��Q�wW�K��ZD��Δ^e��!� ��B�K��p~�����e*l}z#9ң�k���q#�Ft�o��S�R����-�w�!�S���Ӥß|M�l޶V��!eˈ�8Y���c�ЮM2��tk���� ������J�fS����Ö*i/2�����n]�k�\���|4yX�8��U�P.���Ы[���l��@"�t�<������5�lF���vU�����W��W��;�b�cД^6[#7@vU�xgZv��F�6��Q,K�v��� �+Ъ��n��Ǣ��Ft���8��0��c�@�!�Zq s�v�t�;#](B��-�nῃ~���3g������5�J�%���O������n�kB�ĺ�.r��+���#�N$?�q�/�s�6��p��a����a��J/��M�8��6�ܰ"�*������ɗud"\w���aT(����[��F��U՛����RT�b���n�*��6���O��SJ�.�ij<�v�MT��R\c��5l�sZB>F��<7�;EA��{��E���Ö��1U/�#��d1�a�n.1ě����0�ʾR�h��|�R��Ao�3�m3 ��%�� ���28Q� ��y��φ���H�To�7�lW>����#i`�q���c����a��� �m,B�-j����݋�'mR1Ήt�>��V��p���s�0IbI�C.���1R�ea�����]H�6����������4B>��o��](��$B���m�����a�!=��?�B� K�Ǿ+�Ծ"�n���K��*��+��[T#�{E�J�S����Q�����s�5�:�U�\wĐ�f�3����܆&�)����I���Ԇw��E T�lrTf6Q|R�h:��[K�� �z��c֧�G�C��%\��_�a�84��HcO�bi��ؖV��7H �)*ģK~Xhչ0��4?�0��� �E<���}3���#���u�?�� ��|g�S�6ꊤ�|�I#Hڛ� �ա��w�X��9��7���Ŀ%�SL��y6č��|�F�a 8���b��$�sק�h���b9RAu7�˨p�Č�_\*w��묦��F ����4D~�f����|(�"m���NK��i�S�>�$d7SlA��/�²����SL��|6N�}���S�˯���g��]6��; �#�.��<���q'Q�1|KQ$�����񛩶"�$r�b:���N8�w@��8$�� �AjfG|~�9F ���Y��ʺ��Bwؒ������M:I岎�G��`s�YV5����6��A �b:�W���G�q%l�����F��H���7�������Fsv7��k�� 403WebShell
403Webshell
Server IP : 172.67.215.126  /  Your IP : 172.69.130.107
Web Server : Apache/2.4.52 (Ubuntu)
System : Linux ip-172-31-19-221 6.8.0-1029-aws #31~22.04.1-Ubuntu SMP Thu Apr 24 21:16:18 UTC 2025 x86_64
User : www-data ( 33)
PHP Version : 8.1.28
Disable Function : NONE
MySQL : OFF  |  cURL : ON  |  WGET : ON  |  Perl : ON  |  Python : OFF  |  Sudo : ON  |  Pkexec : ON
Directory :  /efsdata/scitechnol.com/httpdocs/submission/uploads/

Upload File :
current_dir [ Writeable ] document_root [ Writeable ]

 

Command :

[ Back ]     

Current File : /efsdata/scitechnol.com/httpdocs/submission/uploads/283-0-Manuscript-2013-01-04.doc
��ࡱ�>��	������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������	��d*bjbj���	;|����"Q�������HH������������8��k��lC��%%%CCCCCCC^E�HhC�$$$C��%%�&C[4[4[4$
�%�%o>�[4$C[4[4:�9,;:%�����~����+12�9
[><C0lC�9RhH]3�hH;:;:�hH��:��� [4�� KCC'44lC$$$$��������������������������������������������������������������������hHH	Q:	

Ryan Garcia, MD
Department of Orthopaedic Surgery
University Hospitals Case Medical Center
Case Western Reserve University School of Medicine
Cleveland, Ohio 44106
Phone: 216-970-3816
Fax: 216-844-8181
Email:  ryangarcia78@gmail.com
	
January 4, 2013


Dear Editorial Board,

	Enclosed for review is a new and original manuscript entitled: Spinal Discitis and Vertebral Body Osteomyelitis: Following Treatment Guidelines?  

Institutional Review Board (IRB) approval was requested and obtained prior to beginning this study.  All authors participated in the production of this manuscript by design development, data collection and analysis, manuscript preparation, and final editing.  All authors agree to have this manuscript published in Journal of Spine.  All authors report to have no conflicts of interest associated with this manuscript.
 
	Thank you in advance for the consideration and review of our manuscript. 


Sincerely,







Ryan M. Garcia, MD








Spinal Discitis and Vertebral Body Osteomyelitis: 
Following Treatment Guidelines?

Ryan M. Garcia, MD1
James E Murphy, MD1
Sheeraz A. Qureshi, MD/MBA2
Christopher G. Furey, MD1
Henry H. Bohlman, MD1
Ezequiel H. Cassinelli, MD3


	Department of Orthopaedic Surgery 
	University Hospitals Case Medical Center 
	Case Western Reserve University School of Medicine
	11100 Euclid Avenue
	Cleveland, Ohio 44106

2.		Department of Orthopaedic Surgery
		Mount Sinai School of Medicine

3.		Peachtree Orthopaedic Clinic
	5505 Peachtree Dunwoody Rd.
	Atlanta, GA 30342


Please address all correspondence to: 

Ryan M Garcia, MD
Department of Orthopaedic Surgery
University Hospitals Case Medical Center
Case Western Reserve School of Medicine
Cleveland, Ohio 44106
Phone:  216-970-3816   
Fax:  216-844-8181
Email:   HYPERLINK "mailto:ryangarcia78@gmail.com" ryangarcia78@gmail.com





Key Words � Discitis, Vertebral Osteomyelitis, Infection, Diagnosis, Biopsy, Culture, Bacteria, Antibiotic 


Disclosure of Funding - None
Abstract

Background:  Treatment of spinal discitis and vertebral osteomyelitis is pathogen specific antibiotics based on biopsy and culture.  We aim to evaluate whether tissue biopsy and culture are routinely obtained prior to empiric antibiotics.
Methods:  We retrospectively reviewed patients admitted for spinal discitis or vertebral osteomyelitis.  Isolated bacterial pathogens were reviewed in addition to the timing of antibiotic administration in relation to admission, advanced imaging, and biopsy.Results:  39 patients were reviewed.  Antibiotics were started an average of 26 hours after admission with 11 patients (28%) receiving antibiotics within 1 hour.  Antibiotics were started prior to MRI in 9 patients (23%) and within 1 hour of the completed MRI in 4 patients (10%).  Biopsy and culture was performed in only 20 patients (51%) with 11 of these (55%) performed after antibiotics.  Specific bacterial pathogens were cultured in 9 biopsies (45%).  Six of the 9 biopsies (67%) performed prior to antibiotics identified a bacterial pathogen.  Biopsies performed after antibiotics identified pathogens in only 3 of 11 (27%).  
Conclusions:  In our review, 26 patients (67%) were not treated according to current guidelines.  For 15 patients, a biopsy and culture was never obtained and for 11 patients biopsy and culture was performed after antibiotics.  

Key Words � Discitis, Vertebral Osteomyelitis, Infection, Diagnosis, Biopsy, Culture, Bacteria, Antibiotic 

Introduction
	Pyogenic spinal discitis and vertebral osteomyelitis is an uncommon clinical scenario. ADDIN EN.CITE <EndNote><Cite><Author>Ambrose</Author><Year>1966</Year><RecNum>1</RecNum><record><rec-number>1</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ambrose, G. B.</author><author>Alpert, M.</author><author>Neer, C. S.</author></authors></contributors><titles><title>Vertebral osteomyelitis. A diagnostic problem</title><secondary-title>JAMA</secondary-title></titles><periodical><full-title>JAMA</full-title></periodical><pages>619-22</pages><volume>197</volume><number>8</number><edition>1966/08/22</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Anti-Bacterial Agents/therapeutic use</keyword><keyword>Arthrodesis</keyword><keyword>Biopsy</keyword><keyword>Blood Sedimentation</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>Diagnosis, Differential</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Humans</keyword><keyword>Immunity</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Osteomyelitis/*diagnosis</keyword><keyword>Spinal Diseases/*diagnosis</keyword><keyword>Spine/radiography</keyword></keywords><dates><year>1966</year><pub-dates><date>Aug 22</date></pub-dates></dates><isbn>0098-7484 (Print)</isbn><accession-num>5953091</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=5953091</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Bonfiglio</Author><Year>2006</Year><RecNum>2</RecNum><record><rec-number>2</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Bonfiglio, M.</author><author>Lange, T. A.</author><author>Kim, Y. M.</author></authors></contributors><titles><title>The Classic: Pyogenic vertebral osteomyelitis: disk space infections. 1973</title><secondary-title>Clin Orthop Relat Res</secondary-title></titles><periodical><full-title>Clin Orthop Relat Res</full-title></periodical><pages>4-8</pages><volume>444</volume><edition>2006/03/09</edition><keywords><keyword>Bacterial Infections/diagnosis/*history/therapy</keyword><keyword>Discitis/*history/microbiology</keyword><keyword>History, 20th Century</keyword><keyword>Humans</keyword><keyword>Osteomyelitis/*history/microbiology</keyword></keywords><dates><year>2006</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>0009-921X (Print)</isbn><accession-num>16523120</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=16523120</url></related-urls></urls><electronic-resource-num>10.1097/01.blo.0000201172.64764.bb&#xD;00003086-200603000-00002 [pii]</electronic-resource-num><language>eng</language></record></Cite><Cite><Author>Stone</Author><Year>1963</Year><RecNum>10</RecNum><record><rec-number>10</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Stone, D. B.</author><author>Bonfiglio, M.</author></authors></contributors><titles><title>Pyogenic Vertebral Osteomyelitis. A Diagnostic Pitfall for the Internist</title><secondary-title>Arch Intern Med</secondary-title></titles><periodical><full-title>Arch Intern Med</full-title></periodical><pages>491-500</pages><volume>112</volume><edition>1963/10/01</edition><keywords><keyword>*Anti-Bacterial Agents</keyword><keyword>*Back Pain</keyword><keyword>*Bacteriology</keyword><keyword>*Blood Sedimentation</keyword><keyword>*Diagnosis</keyword><keyword>*Drainage</keyword><keyword>*Geriatrics</keyword><keyword>*Osteomyelitis</keyword><keyword>*Radiography</keyword><keyword>*Serum Globulins</keyword><keyword>*Spine</keyword><keyword>*Staphylococcal Infections</keyword></keywords><dates><year>1963</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>0003-9926 (Print)</isbn><accession-num>14051367</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=14051367</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Guri</Author><Year>1947</Year><RecNum>20</RecNum><record><rec-number>20</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Guri, J. P.</author></authors></contributors><titles><title>Differential diagnosis and treatment of pyogenic osteomyelitis of the vertebral column</title><secondary-title>Med Press</secondary-title></titles><periodical><full-title>Med Press</full-title></periodical><pages>569-72</pages><volume>218</volume><number>26</number><edition>1947/12/24</edition><dates><year>1947</year><pub-dates><date>Dec 24</date></pub-dates></dates><accession-num>18911307</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=18911307</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Wilensky</Author><Year>1926</Year><RecNum>35</RecNum><record><rec-number>35</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Wilensky, WO</author></authors></contributors><titles><title>Osteomyelitis of the vertebrae</title><secondary-title>Ann Surg</secondary-title></titles><periodical><full-title>Ann Surg</full-title></periodical><pages>561-70</pages><volume>89</volume><dates><year>1926</year></dates><urls></urls></record></Cite><Cite><Author>Waldvogel</Author><Year>1970</Year><RecNum>38</RecNum><record><rec-number>38</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Waldvogel, F. A.</author><author>Medoff, G.</author><author>Swartz, M. N.</author></authors></contributors><titles><title>Osteomyelitis: a review of clinical features, therapeutic considerations and unusual aspects</title><secondary-title>N Engl J Med</secondary-title></titles><periodical><full-title>N Engl J Med</full-title></periodical><pages>198-206</pages><volume>282</volume><number>4</number><edition>1970/01/22</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Age Factors</keyword><keyword>Aged</keyword><keyword>Anti-Bacterial Agents/therapeutic use</keyword><keyword>Bone and Bones/pathology</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>Chronic Disease</keyword><keyword>Female</keyword><keyword>Focal Infection/complications</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>*Osteomyelitis/classification/diagnosis/drug</keyword><keyword>therapy/epidemiology/etiology/microbiology/pathology/physiopathology/radio</keyword><keyword>graphy</keyword><keyword>Prognosis</keyword></keywords><dates><year>1970</year><pub-dates><date>Jan 22</date></pub-dates></dates><isbn>0028-4793 (Print)&#xD;0028-4793 (Linking)</isbn><accession-num>4902833</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=4902833</url></related-urls></urls><language>eng</language></record></Cite></EndNote>1-6  Prior to advancements in magnetic resonance imaging (MRI), ADDIN EN.CITE <EndNote><Cite><Author>Sharif</Author><Year>1992</Year><RecNum>40</RecNum><record><rec-number>40</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Sharif, H. S.</author></authors></contributors><auth-address>Department of Radiology, Riyadh Armed Forces Hospital, Kingdom of Saudi Arabia.</auth-address><titles><title>Role of MR imaging in the management of spinal infections</title><secondary-title>AJR Am J Roentgenol</secondary-title></titles><periodical><full-title>AJR Am J Roentgenol</full-title></periodical><pages>1333-45</pages><volume>158</volume><number>6</number><edition>1992/06/01</edition><keywords><keyword>Adult</keyword><keyword>Child, Preschool</keyword><keyword>Diagnosis, Differential</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Infection/*diagnosis</keyword><keyword>*Magnetic Resonance Imaging</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Spinal Cord Diseases/*diagnosis</keyword><keyword>Spondylitis/*diagnosis</keyword></keywords><dates><year>1992</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>0361-803X (Print)&#xD;0361-803X (Linking)</isbn><accession-num>1590137</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=1590137</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Maiuri</Author><Year>1997</Year><RecNum>15</RecNum><record><rec-number>15</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Maiuri, F.</author><author>Iaconetta, G.</author><author>Gallicchio, B.</author><author>Manto, A.</author><author>Briganti, F.</author></authors></contributors><auth-address>Institute of Neurosurgery, School of Medicine, University, Federico II, Naples, Italy.</auth-address><titles><title>Spondylodiscitis. Clinical and magnetic resonance diagnosis</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>1741-6</pages><volume>22</volume><number>15</number><edition>1997/08/01</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Discitis/*radiography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Magnetic Resonance Imaging/*standards</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Reference Standards</keyword><keyword>Retrospective Studies</keyword><keyword>Tomography, X-Ray Computed</keyword></keywords><dates><year>1997</year><pub-dates><date>Aug 1</date></pub-dates></dates><isbn>0362-2436 (Print)</isbn><accession-num>9259785</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=9259785</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Modic</Author><Year>1985</Year><RecNum>29</RecNum><record><rec-number>29</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Modic, M. T.</author><author>Feiglin, D. H.</author><author>Piraino, D. W.</author><author>Boumphrey, F.</author><author>Weinstein, M. A.</author><author>Duchesneau, P. M.</author><author>Rehm, S.</author></authors></contributors><titles><title>Vertebral osteomyelitis: assessment using MR</title><secondary-title>Radiology</secondary-title></titles><periodical><full-title>Radiology</full-title></periodical><pages>157-66</pages><volume>157</volume><number>1</number><edition>1985/10/01</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Diphosphonates/diagnostic use</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Gallium Radioisotopes/diagnostic use</keyword><keyword>Humans</keyword><keyword>Magnetic Resonance Spectroscopy/*diagnostic use</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Osteomyelitis/*diagnosis/radiography/radionuclide imaging</keyword><keyword>Prospective Studies</keyword><keyword>Spinal Diseases/*diagnosis/radiography/radionuclide imaging</keyword><keyword>Technetium/diagnostic use</keyword><keyword>*Technetium Tc 99m Medronate/*analogs &amp; derivatives</keyword><keyword>Tomography, Emission-Computed</keyword></keywords><dates><year>1985</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>0033-8419 (Print)&#xD;0033-8419 (Linking)</isbn><accession-num>3875878</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=3875878</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Dagirmanjian</Author><Year>1996</Year><RecNum>28</RecNum><record><rec-number>28</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dagirmanjian, A.</author><author>Schils, J.</author><author>McHenry, M.</author><author>Modic, M. T.</author></authors></contributors><auth-address>Department of Radiology, Cleveland Clinic Foundation, OH 44195, USA.</auth-address><titles><title>MR imaging of vertebral osteomyelitis revisited</title><secondary-title>AJR Am J Roentgenol</secondary-title></titles><periodical><full-title>AJR Am J Roentgenol</full-title></periodical><pages>1539-43</pages><volume>167</volume><number>6</number><edition>1996/12/01</edition><keywords><keyword>Humans</keyword><keyword>*Magnetic Resonance Imaging</keyword><keyword>Osteomyelitis/*diagnosis/microbiology</keyword><keyword>Retrospective Studies</keyword><keyword>Spinal Diseases/*diagnosis/microbiology</keyword></keywords><dates><year>1996</year><pub-dates><date>Dec</date></pub-dates></dates><isbn>0361-803X (Print)&#xD;0361-803X (Linking)</isbn><accession-num>8956593</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=8956593</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Szypryt</Author><Year>1988</Year><RecNum>33</RecNum><record><rec-number>33</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Szypryt, E. P.</author><author>Hardy, J. G.</author><author>Hinton, C. E.</author><author>Worthington, B. S.</author><author>Mulholland, R. C.</author></authors></contributors><auth-address>Department of Orthopaedic Surgery, Harlow Wood Orthopaedic Hospital, Nottingham, England.</auth-address><titles><title>A comparison between magnetic resonance imaging and scintigraphic bone imaging in the diagnosis of disc space infection in an animal model</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>1042-8</pages><volume>13</volume><number>9</number><edition>1988/09/01</edition><keywords><keyword>Animals</keyword><keyword>Infection/*diagnosis/radiography/radionuclide imaging</keyword><keyword>Inflammation/diagnosis/radiography/radionuclide imaging</keyword><keyword>*Intervertebral Disk/pathology/radiography/radionuclide imaging</keyword><keyword>Lumbosacral Region</keyword><keyword>*Magnetic Resonance Imaging</keyword><keyword>Male</keyword><keyword>Rabbits</keyword><keyword>Spinal Diseases/*diagnosis/radiography/radionuclide imaging</keyword><keyword>Staphylococcal Infections/diagnosis/radiography/radionuclide imaging</keyword></keywords><dates><year>1988</year><pub-dates><date>Sep</date></pub-dates></dates><isbn>0362-2436 (Print)&#xD;0362-2436 (Linking)</isbn><accession-num>3206298</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=3206298</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>An</Author><Year>1991</Year><RecNum>39</RecNum><record><rec-number>39</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>An, H. S.</author><author>Vaccaro, A. R.</author><author>Dolinskas, C. A.</author><author>Cotler, J. M.</author><author>Balderston, R. A.</author><author>Bauerle, W. B.</author></authors></contributors><auth-address>Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee.</auth-address><titles><title>Differentiation between spinal tumors and infections with magnetic resonance imaging</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>S334-8</pages><volume>16</volume><number>8 Suppl</number><edition>1991/08/01</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Bacterial Infections/*diagnosis</keyword><keyword>Diagnosis, Differential</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>*Magnetic Resonance Imaging</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Spinal Diseases/*diagnosis</keyword><keyword>Spinal Neoplasms/*diagnosis/secondary</keyword></keywords><dates><year>1991</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>0362-2436 (Print)&#xD;0362-2436 (Linking)</isbn><accession-num>1785083</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=1785083</url></related-urls></urls><language>eng</language></record></Cite></EndNote>7-12 confirming the diagnosis of spondylodiscitis was challenging and often delayed. ADDIN EN.CITE <EndNote><Cite><Author>Garcia</Author><Year>1960</Year><RecNum>37</RecNum><record><rec-number>37</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Garcia, A., Jr.</author><author>Grantham, S. A.</author></authors></contributors><titles><title>Hematogenous pyogenic vertebral osteomyelitis</title><secondary-title>J Bone Joint Surg Am</secondary-title></titles><periodical><full-title>J Bone Joint Surg Am</full-title></periodical><pages>429-36</pages><volume>42-A</volume><edition>1960/04/01</edition><keywords><keyword>Osteomyelitis/*etiology</keyword></keywords><dates><year>1960</year><pub-dates><date>Apr</date></pub-dates></dates><isbn>0021-9355 (Print)&#xD;0021-9355 (Linking)</isbn><accession-num>13849901</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=13849901</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Eismont</Author><Year>1983</Year><RecNum>36</RecNum><record><rec-number>36</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Eismont, F. J.</author><author>Bohlman, H. H.</author><author>Soni, P. L.</author><author>Goldberg, V. M.</author><author>Freehafer, A. A.</author></authors></contributors><titles><title>Pyogenic and fungal vertebral osteomyelitis with paralysis</title><secondary-title>J Bone Joint Surg Am</secondary-title></titles><periodical><full-title>J Bone Joint Surg Am</full-title></periodical><pages>19-29</pages><volume>65</volume><number>1</number><edition>1983/01/01</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Bacterial Infections/*complications/therapy</keyword><keyword>Candidiasis/complications/therapy</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Osteomyelitis/*complications/therapy</keyword><keyword>Paralysis/*etiology</keyword><keyword>Spinal Diseases/*complications/therapy</keyword><keyword>Suppuration</keyword></keywords><dates><year>1983</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>0021-9355 (Print)&#xD;0021-9355 (Linking)</isbn><accession-num>6849675</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=6849675</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Bonfiglio</Author><Year>2006</Year><RecNum>2</RecNum><record><rec-number>2</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Bonfiglio, M.</author><author>Lange, T. A.</author><author>Kim, Y. M.</author></authors></contributors><titles><title>The Classic: Pyogenic vertebral osteomyelitis: disk space infections. 1973</title><secondary-title>Clin Orthop Relat Res</secondary-title></titles><periodical><full-title>Clin Orthop Relat Res</full-title></periodical><pages>4-8</pages><volume>444</volume><edition>2006/03/09</edition><keywords><keyword>Bacterial Infections/diagnosis/*history/therapy</keyword><keyword>Discitis/*history/microbiology</keyword><keyword>History, 20th Century</keyword><keyword>Humans</keyword><keyword>Osteomyelitis/*history/microbiology</keyword></keywords><dates><year>2006</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>0009-921X (Print)</isbn><accession-num>16523120</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=16523120</url></related-urls></urls><electronic-resource-num>10.1097/01.blo.0000201172.64764.bb&#xD;00003086-200603000-00002 [pii]</electronic-resource-num><language>eng</language></record></Cite><Cite><Author>Guri</Author><Year>1947</Year><RecNum>20</RecNum><record><rec-number>20</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Guri, J. P.</author></authors></contributors><titles><title>Differential diagnosis and treatment of pyogenic osteomyelitis of the vertebral column</title><secondary-title>Med Press</secondary-title></titles><periodical><full-title>Med Press</full-title></periodical><pages>569-72</pages><volume>218</volume><number>26</number><edition>1947/12/24</edition><dates><year>1947</year><pub-dates><date>Dec 24</date></pub-dates></dates><accession-num>18911307</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=18911307</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Puig Guri</Author><Year>1946</Year><RecNum>32</RecNum><record><rec-number>32</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Puig Guri, J</author></authors></contributors><titles><title>Pyogenic osteomyelitis of the spine: differential diagnosis through clinical and roentgenographic observations</title><secondary-title>J Bone Joint Surg Am</secondary-title></titles><periodical><full-title>J Bone Joint Surg Am</full-title></periodical><pages>29-39</pages><volume>28</volume><dates><year>1946</year></dates><urls></urls></record></Cite><Cite><Author>Digby</Author><Year>1979</Year><RecNum>23</RecNum><record><rec-number>23</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Digby, J. M.</author><author>Kersley, J. B.</author></authors></contributors><titles><title>Pyogenic non-tuberculous spinal infection: an analysis of thirty cases</title><secondary-title>J Bone Joint Surg Br</secondary-title></titles><periodical><full-title>J Bone Joint Surg Br</full-title></periodical><pages>47-55</pages><volume>61</volume><number>1</number><edition>1979/02/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Anti-Bacterial Agents/therapeutic use</keyword><keyword>Child</keyword><keyword>Diagnosis, Differential</keyword><keyword>Escherichia coli Infections</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Osteomyelitis/*diagnosis/etiology/radiography</keyword><keyword>Proteus Infections</keyword><keyword>Spinal Diseases/*diagnosis/etiology</keyword><keyword>Staphylococcal Infections</keyword><keyword>Suppuration/etiology</keyword><keyword>Tuberculosis, Spinal/diagnosis</keyword></keywords><dates><year>1979</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>0301-620X (Print)&#xD;0301-620X (Linking)</isbn><accession-num>370121</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=370121</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Griffiths</Author><Year>1971</Year><RecNum>21</RecNum><record><rec-number>21</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Griffiths, H. E.</author><author>Jones, D. M.</author></authors></contributors><titles><title>Pyogenic infection of the spine. A review of twenty-eight cases</title><secondary-title>J Bone Joint Surg Br</secondary-title></titles><periodical><full-title>J Bone Joint Surg Br</full-title></periodical><pages>383-91</pages><volume>53</volume><number>3</number><edition>1971/08/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Anti-Bacterial Agents/therapeutic use</keyword><keyword>Cervical Vertebrae</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Hemophilia A/etiology</keyword><keyword>Humans</keyword><keyword>Lumbar Vertebrae</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>*Osteomyelitis/complications/drug therapy/etiology/radiography</keyword><keyword>Paraplegia/etiology</keyword><keyword>*Spinal Diseases/drug therapy/etiology/radiography</keyword><keyword>Spinal Injuries/complications</keyword><keyword>*Staphylococcal Infections/drug therapy</keyword><keyword>Thoracic Vertebrae</keyword><keyword>Urinary Tract Infections/etiology</keyword></keywords><dates><year>1971</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>0301-620X (Print)&#xD;0301-620X (Linking)</isbn><accession-num>5562365</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=5562365</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Stone</Author><Year>1963</Year><RecNum>10</RecNum><record><rec-number>10</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Stone, D. B.</author><author>Bonfiglio, M.</author></authors></contributors><titles><title>Pyogenic Vertebral Osteomyelitis. A Diagnostic Pitfall for the Internist</title><secondary-title>Arch Intern Med</secondary-title></titles><periodical><full-title>Arch Intern Med</full-title></periodical><pages>491-500</pages><volume>112</volume><edition>1963/10/01</edition><keywords><keyword>*Anti-Bacterial Agents</keyword><keyword>*Back Pain</keyword><keyword>*Bacteriology</keyword><keyword>*Blood Sedimentation</keyword><keyword>*Diagnosis</keyword><keyword>*Drainage</keyword><keyword>*Geriatrics</keyword><keyword>*Osteomyelitis</keyword><keyword>*Radiography</keyword><keyword>*Serum Globulins</keyword><keyword>*Spine</keyword><keyword>*Staphylococcal Infections</keyword></keywords><dates><year>1963</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>0003-9926 (Print)</isbn><accession-num>14051367</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=14051367</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Waldvogel</Author><Year>1970</Year><RecNum>38</RecNum><record><rec-number>38</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Waldvogel, F. A.</author><author>Medoff, G.</author><author>Swartz, M. N.</author></authors></contributors><titles><title>Osteomyelitis: a review of clinical features, therapeutic considerations and unusual aspects</title><secondary-title>N Engl J Med</secondary-title></titles><periodical><full-title>N Engl J Med</full-title></periodical><pages>198-206</pages><volume>282</volume><number>4</number><edition>1970/01/22</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Age Factors</keyword><keyword>Aged</keyword><keyword>Anti-Bacterial Agents/therapeutic use</keyword><keyword>Bone and Bones/pathology</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>Chronic Disease</keyword><keyword>Female</keyword><keyword>Focal Infection/complications</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>*Osteomyelitis/classification/diagnosis/drug</keyword><keyword>therapy/epidemiology/etiology/microbiology/pathology/physiopathology/radio</keyword><keyword>graphy</keyword><keyword>Prognosis</keyword></keywords><dates><year>1970</year><pub-dates><date>Jan 22</date></pub-dates></dates><isbn>0028-4793 (Print)&#xD;0028-4793 (Linking)</isbn><accession-num>4902833</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=4902833</url></related-urls></urls><language>eng</language></record></Cite></EndNote>2-4, 6, 13-17  Although age predilection for spinal discitis and vertebral osteomyelitis remains unclear, current series have reported patient demographics with a poorer health and immune status. ADDIN EN.CITE <EndNote><Cite><Author>Carragee</Author><Year>1997</Year><RecNum>14</RecNum><record><rec-number>14</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Carragee, E. J.</author></authors></contributors><auth-address>Stanford University Medical Center, California 94305, USA. carragee@leland.stanford.edu</auth-address><titles><title>Pyogenic vertebral osteomyelitis</title><secondary-title>J Bone Joint Surg Am</secondary-title></titles><periodical><full-title>J Bone Joint Surg Am</full-title></periodical><pages>874-80</pages><volume>79</volume><number>6</number><edition>1997/06/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adrenal Cortex Hormones/therapeutic use</keyword><keyword>Adult</keyword><keyword>Age Factors</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Antineoplastic Agents/therapeutic use</keyword><keyword>Bacterial Infections/*diagnosis/surgery</keyword><keyword>Corynebacterium Infections/diagnosis/surgery</keyword><keyword>Debridement</keyword><keyword>Diabetes Complications</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Gram-Positive Bacterial Infections/diagnosis/surgery</keyword><keyword>Humans</keyword><keyword>Immune System Diseases/complications</keyword><keyword>Immunocompromised Host</keyword><keyword>Kidney Failure/complications</keyword><keyword>Liver Failure/complications</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Neoplasms/drug therapy</keyword><keyword>Nutrition Disorders/complications</keyword><keyword>Osteomyelitis/diagnosis/*microbiology/surgery</keyword><keyword>Propionibacterium acnes</keyword><keyword>Retrospective Studies</keyword><keyword>Rheumatic Diseases/complications</keyword><keyword>Spinal Diseases/diagnosis/*microbiology/surgery</keyword><keyword>Spinal Fusion</keyword><keyword>Staphylococcal Infections/diagnosis/surgery</keyword><keyword>Staphylococcus epidermidis</keyword><keyword>Survival Rate</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>1997</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>0021-9355 (Print)</isbn><accession-num>9199385</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=9199385</url></related-urls></urls><language>eng</language></record></Cite></EndNote>18  The most common presenting symptom reported is pain (back or neck) followed by fever and malaise ADDIN EN.CITE <EndNote><Cite><Author>Carragee</Author><Year>1997</Year><RecNum>14</RecNum><record><rec-number>14</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Carragee, E. J.</author></authors></contributors><auth-address>Stanford University Medical Center, California 94305, USA. carragee@leland.stanford.edu</auth-address><titles><title>Pyogenic vertebral osteomyelitis</title><secondary-title>J Bone Joint Surg Am</secondary-title></titles><periodical><full-title>J Bone Joint Surg Am</full-title></periodical><pages>874-80</pages><volume>79</volume><number>6</number><edition>1997/06/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adrenal Cortex Hormones/therapeutic use</keyword><keyword>Adult</keyword><keyword>Age Factors</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Antineoplastic Agents/therapeutic use</keyword><keyword>Bacterial Infections/*diagnosis/surgery</keyword><keyword>Corynebacterium Infections/diagnosis/surgery</keyword><keyword>Debridement</keyword><keyword>Diabetes Complications</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Gram-Positive Bacterial Infections/diagnosis/surgery</keyword><keyword>Humans</keyword><keyword>Immune System Diseases/complications</keyword><keyword>Immunocompromised Host</keyword><keyword>Kidney Failure/complications</keyword><keyword>Liver Failure/complications</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Neoplasms/drug therapy</keyword><keyword>Nutrition Disorders/complications</keyword><keyword>Osteomyelitis/diagnosis/*microbiology/surgery</keyword><keyword>Propionibacterium acnes</keyword><keyword>Retrospective Studies</keyword><keyword>Rheumatic Diseases/complications</keyword><keyword>Spinal Diseases/diagnosis/*microbiology/surgery</keyword><keyword>Spinal Fusion</keyword><keyword>Staphylococcal Infections/diagnosis/surgery</keyword><keyword>Staphylococcus epidermidis</keyword><keyword>Survival Rate</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>1997</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>0021-9355 (Print)</isbn><accession-num>9199385</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=9199385</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Bonfiglio</Author><Year>2006</Year><RecNum>2</RecNum><record><rec-number>2</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Bonfiglio, M.</author><author>Lange, T. A.</author><author>Kim, Y. M.</author></authors></contributors><titles><title>The Classic: Pyogenic vertebral osteomyelitis: disk space infections. 1973</title><secondary-title>Clin Orthop Relat Res</secondary-title></titles><periodical><full-title>Clin Orthop Relat Res</full-title></periodical><pages>4-8</pages><volume>444</volume><edition>2006/03/09</edition><keywords><keyword>Bacterial Infections/diagnosis/*history/therapy</keyword><keyword>Discitis/*history/microbiology</keyword><keyword>History, 20th Century</keyword><keyword>Humans</keyword><keyword>Osteomyelitis/*history/microbiology</keyword></keywords><dates><year>2006</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>0009-921X (Print)</isbn><accession-num>16523120</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=16523120</url></related-urls></urls><electronic-resource-num>10.1097/01.blo.0000201172.64764.bb&#xD;00003086-200603000-00002 [pii]</electronic-resource-num><language>eng</language></record></Cite><Cite><Author>Digby</Author><Year>1979</Year><RecNum>23</RecNum><record><rec-number>23</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Digby, J. M.</author><author>Kersley, J. B.</author></authors></contributors><titles><title>Pyogenic non-tuberculous spinal infection: an analysis of thirty cases</title><secondary-title>J Bone Joint Surg Br</secondary-title></titles><periodical><full-title>J Bone Joint Surg Br</full-title></periodical><pages>47-55</pages><volume>61</volume><number>1</number><edition>1979/02/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Anti-Bacterial Agents/therapeutic use</keyword><keyword>Child</keyword><keyword>Diagnosis, Differential</keyword><keyword>Escherichia coli Infections</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Osteomyelitis/*diagnosis/etiology/radiography</keyword><keyword>Proteus Infections</keyword><keyword>Spinal Diseases/*diagnosis/etiology</keyword><keyword>Staphylococcal Infections</keyword><keyword>Suppuration/etiology</keyword><keyword>Tuberculosis, Spinal/diagnosis</keyword></keywords><dates><year>1979</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>0301-620X (Print)&#xD;0301-620X (Linking)</isbn><accession-num>370121</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=370121</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Griffiths</Author><Year>1971</Year><RecNum>21</RecNum><record><rec-number>21</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Griffiths, H. E.</author><author>Jones, D. M.</author></authors></contributors><titles><title>Pyogenic infection of the spine. A review of twenty-eight cases</title><secondary-title>J Bone Joint Surg Br</secondary-title></titles><periodical><full-title>J Bone Joint Surg Br</full-title></periodical><pages>383-91</pages><volume>53</volume><number>3</number><edition>1971/08/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Anti-Bacterial Agents/therapeutic use</keyword><keyword>Cervical Vertebrae</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Hemophilia A/etiology</keyword><keyword>Humans</keyword><keyword>Lumbar Vertebrae</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>*Osteomyelitis/complications/drug therapy/etiology/radiography</keyword><keyword>Paraplegia/etiology</keyword><keyword>*Spinal Diseases/drug therapy/etiology/radiography</keyword><keyword>Spinal Injuries/complications</keyword><keyword>*Staphylococcal Infections/drug therapy</keyword><keyword>Thoracic Vertebrae</keyword><keyword>Urinary Tract Infections/etiology</keyword></keywords><dates><year>1971</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>0301-620X (Print)&#xD;0301-620X (Linking)</isbn><accession-num>5562365</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=5562365</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Kemp</Author><Year>1973</Year><RecNum>24</RecNum><record><rec-number>24</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kemp, H. B.</author><author>Jackson, J. W.</author><author>Jeremiah, J. D.</author><author>Hall, A. J.</author></authors></contributors><titles><title>Pyogenic infections occurring primarily in intervertebral discs</title><secondary-title>J Bone Joint Surg Br</secondary-title></titles><periodical><full-title>J Bone Joint Surg Br</full-title></periodical><pages>698-714</pages><volume>55</volume><number>4</number><edition>1973/11/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Bacteria/isolation &amp; purification</keyword><keyword>*Bacterial Infections/complications/pathology</keyword><keyword>Diagnosis, Differential</keyword><keyword>Humans</keyword><keyword>*Intervertebral Disk/microbiology/pathology/radiography</keyword><keyword>Myelography</keyword><keyword>Osteomyelitis/complications/diagnosis/radiography</keyword><keyword>*Spinal Diseases/complications/microbiology/pathology/radiography</keyword><keyword>Staphylococcal Infections/diagnosis</keyword><keyword>Suppuration</keyword><keyword>Tomography</keyword></keywords><dates><year>1973</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>0301-620X (Print)&#xD;0301-620X (Linking)</isbn><accession-num>4766176</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=4766176</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Pritchard</Author><Year>1960</Year><RecNum>31</RecNum><record><rec-number>31</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pritchard, A. E.</author><author>Thompson, W. A.</author></authors></contributors><titles><title>Acute pyogenic infections of the spine in children</title><secondary-title>J Bone Joint Surg Br</secondary-title></titles><periodical><full-title>J Bone Joint Surg Br</full-title></periodical><pages>86-9</pages><volume>42-B</volume><edition>1960/02/01</edition><keywords><keyword>*Child</keyword><keyword>*Infant</keyword><keyword>*Osteomyelitis</keyword></keywords><dates><year>1960</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>0301-620X (Print)&#xD;0301-620X (Linking)</isbn><accession-num>13854410</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=13854410</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Puig Guri</Author><Year>1946</Year><RecNum>32</RecNum><record><rec-number>32</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Puig Guri, J</author></authors></contributors><titles><title>Pyogenic osteomyelitis of the spine: differential diagnosis through clinical and roentgenographic observations</title><secondary-title>J Bone Joint Surg Am</secondary-title></titles><periodical><full-title>J Bone Joint Surg Am</full-title></periodical><pages>29-39</pages><volume>28</volume><dates><year>1946</year></dates><urls></urls></record></Cite><Cite><Author>Tampieri</Author><Year>1991</Year><RecNum>9</RecNum><record><rec-number>9</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Tampieri, D.</author><author>Weill, A.</author><author>Melanson, D.</author><author>Ethier, R.</author></authors></contributors><auth-address>Department of Neuroradiology, Montreal Neurological Institute and Hospital, Quebec, Canada.</auth-address><titles><title>Percutaneous aspiration biopsy in cervical spine lytic lesions. Indications and technique</title><secondary-title>Neuroradiology</secondary-title></titles><periodical><full-title>Neuroradiology</full-title></periodical><pages>43-7</pages><volume>33</volume><number>1</number><edition>1991/01/01</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>*Biopsy, Needle/instrumentation/methods</keyword><keyword>Cervical Vertebrae/*pathology/radiography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Osteolysis/*pathology/radiography</keyword><keyword>Osteomyelitis/diagnosis/radiography</keyword><keyword>Spinal Diseases/diagnosis/radiography</keyword><keyword>Spinal Neoplasms/diagnosis/radiography</keyword><keyword>Tomography, X-Ray Computed</keyword></keywords><dates><year>1991</year></dates><isbn>0028-3940 (Print)</isbn><accession-num>2027444</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=2027444</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Perronne</Author><Year>1994</Year><RecNum>19</RecNum><record><rec-number>19</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Perronne, C.</author><author>Saba, J.</author><author>Behloul, Z.</author><author>Salmon-Ceron, D.</author><author>Leport, C.</author><author>Vilde, J. L.</author><author>Kahn, M. F.</author></authors></contributors><auth-address>Department of Infectious and Tropical Diseases, Hopital Bichat-Claude Bernard, Paris, France.</auth-address><titles><title>Pyogenic and tuberculous spondylodiskitis (vertebral osteomyelitis) in 80 adult patients</title><secondary-title>Clin Infect Dis</secondary-title></titles><periodical><full-title>Clin Infect Dis</full-title></periodical><pages>746-50</pages><volume>19</volume><number>4</number><edition>1994/10/01</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Bacteriological Techniques</keyword><keyword>Biopsy, Needle</keyword><keyword>Discitis/diagnosis/*microbiology/pathology</keyword><keyword>Female</keyword><keyword>*Gram-Negative Bacterial Infections/diagnosis</keyword><keyword>Humans</keyword><keyword>Intervertebral Disk/microbiology/pathology</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Osteomyelitis/diagnosis/*microbiology/pathology</keyword><keyword>Retrospective Studies</keyword><keyword>*Staphylococcal Infections/diagnosis</keyword><keyword>*Streptococcal Infections/diagnosis</keyword><keyword>*Tuberculosis, Spinal/diagnosis/pathology</keyword></keywords><dates><year>1994</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>1058-4838 (Print)</isbn><accession-num>7803642</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=7803642</url></related-urls></urls><language>eng</language></record></Cite></EndNote>2, 15-22 and an elevated erythrocyte sedimentation rate is the most sensitive serologic test. ADDIN EN.CITE <EndNote><Cite><Author>Carragee</Author><Year>1997</Year><RecNum>14</RecNum><record><rec-number>14</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Carragee, E. J.</author></authors></contributors><auth-address>Stanford University Medical Center, California 94305, USA. carragee@leland.stanford.edu</auth-address><titles><title>Pyogenic vertebral osteomyelitis</title><secondary-title>J Bone Joint Surg Am</secondary-title></titles><periodical><full-title>J Bone Joint Surg Am</full-title></periodical><pages>874-80</pages><volume>79</volume><number>6</number><edition>1997/06/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adrenal Cortex Hormones/therapeutic use</keyword><keyword>Adult</keyword><keyword>Age Factors</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Antineoplastic Agents/therapeutic use</keyword><keyword>Bacterial Infections/*diagnosis/surgery</keyword><keyword>Corynebacterium Infections/diagnosis/surgery</keyword><keyword>Debridement</keyword><keyword>Diabetes Complications</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Gram-Positive Bacterial Infections/diagnosis/surgery</keyword><keyword>Humans</keyword><keyword>Immune System Diseases/complications</keyword><keyword>Immunocompromised Host</keyword><keyword>Kidney Failure/complications</keyword><keyword>Liver Failure/complications</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Neoplasms/drug therapy</keyword><keyword>Nutrition Disorders/complications</keyword><keyword>Osteomyelitis/diagnosis/*microbiology/surgery</keyword><keyword>Propionibacterium acnes</keyword><keyword>Retrospective Studies</keyword><keyword>Rheumatic Diseases/complications</keyword><keyword>Spinal Diseases/diagnosis/*microbiology/surgery</keyword><keyword>Spinal Fusion</keyword><keyword>Staphylococcal Infections/diagnosis/surgery</keyword><keyword>Staphylococcus epidermidis</keyword><keyword>Survival Rate</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>1997</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>0021-9355 (Print)</isbn><accession-num>9199385</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=9199385</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Digby</Author><Year>1979</Year><RecNum>23</RecNum><record><rec-number>23</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Digby, J. M.</author><author>Kersley, J. B.</author></authors></contributors><titles><title>Pyogenic non-tuberculous spinal infection: an analysis of thirty cases</title><secondary-title>J Bone Joint Surg Br</secondary-title></titles><periodical><full-title>J Bone Joint Surg Br</full-title></periodical><pages>47-55</pages><volume>61</volume><number>1</number><edition>1979/02/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Anti-Bacterial Agents/therapeutic use</keyword><keyword>Child</keyword><keyword>Diagnosis, Differential</keyword><keyword>Escherichia coli Infections</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Osteomyelitis/*diagnosis/etiology/radiography</keyword><keyword>Proteus Infections</keyword><keyword>Spinal Diseases/*diagnosis/etiology</keyword><keyword>Staphylococcal Infections</keyword><keyword>Suppuration/etiology</keyword><keyword>Tuberculosis, Spinal/diagnosis</keyword></keywords><dates><year>1979</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>0301-620X (Print)&#xD;0301-620X (Linking)</isbn><accession-num>370121</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=370121</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Griffiths</Author><Year>1971</Year><RecNum>21</RecNum><record><rec-number>21</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Griffiths, H. E.</author><author>Jones, D. M.</author></authors></contributors><titles><title>Pyogenic infection of the spine. A review of twenty-eight cases</title><secondary-title>J Bone Joint Surg Br</secondary-title></titles><periodical><full-title>J Bone Joint Surg Br</full-title></periodical><pages>383-91</pages><volume>53</volume><number>3</number><edition>1971/08/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Anti-Bacterial Agents/therapeutic use</keyword><keyword>Cervical Vertebrae</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Hemophilia A/etiology</keyword><keyword>Humans</keyword><keyword>Lumbar Vertebrae</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>*Osteomyelitis/complications/drug therapy/etiology/radiography</keyword><keyword>Paraplegia/etiology</keyword><keyword>*Spinal Diseases/drug therapy/etiology/radiography</keyword><keyword>Spinal Injuries/complications</keyword><keyword>*Staphylococcal Infections/drug therapy</keyword><keyword>Thoracic Vertebrae</keyword><keyword>Urinary Tract Infections/etiology</keyword></keywords><dates><year>1971</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>0301-620X (Print)&#xD;0301-620X (Linking)</isbn><accession-num>5562365</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=5562365</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Pritchard</Author><Year>1960</Year><RecNum>31</RecNum><record><rec-number>31</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pritchard, A. E.</author><author>Thompson, W. A.</author></authors></contributors><titles><title>Acute pyogenic infections of the spine in children</title><secondary-title>J Bone Joint Surg Br</secondary-title></titles><periodical><full-title>J Bone Joint Surg Br</full-title></periodical><pages>86-9</pages><volume>42-B</volume><edition>1960/02/01</edition><keywords><keyword>*Child</keyword><keyword>*Infant</keyword><keyword>*Osteomyelitis</keyword></keywords><dates><year>1960</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>0301-620X (Print)&#xD;0301-620X (Linking)</isbn><accession-num>13854410</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=13854410</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Frederickson</Author><Year>1978</Year><RecNum>41</RecNum><record><rec-number>41</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Frederickson, B.</author><author>Yuan, H.</author><author>Olans, R.</author></authors></contributors><titles><title>Management and outcome of pyogenic vertebral osteomyelitis</title><secondary-title>Clin Orthop Relat Res</secondary-title></titles><periodical><full-title>Clin Orthop Relat Res</full-title></periodical><pages>160-7</pages><number>131</number><edition>1978/03/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Anti-Bacterial Agents/therapeutic use</keyword><keyword>*Cervical Vertebrae/radiography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>*Lumbar Vertebrae/radiography</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Osteomyelitis/radiography/*therapy</keyword><keyword>Suppuration</keyword><keyword>*Thoracic Vertebrae/radiography</keyword></keywords><dates><year>1978</year><pub-dates><date>Mar-Apr</date></pub-dates></dates><isbn>0009-921X (Print)&#xD;0009-921X (Linking)</isbn><accession-num>657614</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=657614</url></related-urls></urls><language>eng</language></record></Cite></EndNote>16-18, 20, 23  Patient symptoms are often poorly defined and the course of the disease can be slow and indolent leading to a delay in diagnosis.  Carragee reported that the diagnosis of pyogenic discitis and osteomyelitis was made within 28 days of the onset of symptoms in the majority of patients while in a smaller number of patients the diagnosis was delayed for more than 3 months. ADDIN EN.CITE <EndNote><Cite><Author>Carragee</Author><Year>1997</Year><RecNum>14</RecNum><record><rec-number>14</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Carragee, E. J.</author></authors></contributors><auth-address>Stanford University Medical Center, California 94305, USA. carragee@leland.stanford.edu</auth-address><titles><title>Pyogenic vertebral osteomyelitis</title><secondary-title>J Bone Joint Surg Am</secondary-title></titles><periodical><full-title>J Bone Joint Surg Am</full-title></periodical><pages>874-80</pages><volume>79</volume><number>6</number><edition>1997/06/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adrenal Cortex Hormones/therapeutic use</keyword><keyword>Adult</keyword><keyword>Age Factors</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Antineoplastic Agents/therapeutic use</keyword><keyword>Bacterial Infections/*diagnosis/surgery</keyword><keyword>Corynebacterium Infections/diagnosis/surgery</keyword><keyword>Debridement</keyword><keyword>Diabetes Complications</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Gram-Positive Bacterial Infections/diagnosis/surgery</keyword><keyword>Humans</keyword><keyword>Immune System Diseases/complications</keyword><keyword>Immunocompromised Host</keyword><keyword>Kidney Failure/complications</keyword><keyword>Liver Failure/complications</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Neoplasms/drug therapy</keyword><keyword>Nutrition Disorders/complications</keyword><keyword>Osteomyelitis/diagnosis/*microbiology/surgery</keyword><keyword>Propionibacterium acnes</keyword><keyword>Retrospective Studies</keyword><keyword>Rheumatic Diseases/complications</keyword><keyword>Spinal Diseases/diagnosis/*microbiology/surgery</keyword><keyword>Spinal Fusion</keyword><keyword>Staphylococcal Infections/diagnosis/surgery</keyword><keyword>Staphylococcus epidermidis</keyword><keyword>Survival Rate</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>1997</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>0021-9355 (Print)</isbn><accession-num>9199385</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=9199385</url></related-urls></urls><language>eng</language></record></Cite></EndNote>18 
	Historically, the infectious organism isolated from 60 to 80 percent of patients diagnosed with spinal discitis and vertebral osteomyelitis was Staphlococcus aureus. ADDIN EN.CITE <EndNote><Cite><Author>Bonfiglio</Author><Year>2006</Year><RecNum>2</RecNum><record><rec-number>2</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Bonfiglio, M.</author><author>Lange, T. A.</author><author>Kim, Y. M.</author></authors></contributors><titles><title>The Classic: Pyogenic vertebral osteomyelitis: disk space infections. 1973</title><secondary-title>Clin Orthop Relat Res</secondary-title></titles><periodical><full-title>Clin Orthop Relat Res</full-title></periodical><pages>4-8</pages><volume>444</volume><edition>2006/03/09</edition><keywords><keyword>Bacterial Infections/diagnosis/*history/therapy</keyword><keyword>Discitis/*history/microbiology</keyword><keyword>History, 20th Century</keyword><keyword>Humans</keyword><keyword>Osteomyelitis/*history/microbiology</keyword></keywords><dates><year>2006</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>0009-921X (Print)</isbn><accession-num>16523120</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=16523120</url></related-urls></urls><electronic-resource-num>10.1097/01.blo.0000201172.64764.bb&#xD;00003086-200603000-00002 [pii]</electronic-resource-num><language>eng</language></record></Cite><Cite><Author>Stone</Author><Year>1963</Year><RecNum>10</RecNum><record><rec-number>10</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Stone, D. B.</author><author>Bonfiglio, M.</author></authors></contributors><titles><title>Pyogenic Vertebral Osteomyelitis. A Diagnostic Pitfall for the Internist</title><secondary-title>Arch Intern Med</secondary-title></titles><periodical><full-title>Arch Intern Med</full-title></periodical><pages>491-500</pages><volume>112</volume><edition>1963/10/01</edition><keywords><keyword>*Anti-Bacterial Agents</keyword><keyword>*Back Pain</keyword><keyword>*Bacteriology</keyword><keyword>*Blood Sedimentation</keyword><keyword>*Diagnosis</keyword><keyword>*Drainage</keyword><keyword>*Geriatrics</keyword><keyword>*Osteomyelitis</keyword><keyword>*Radiography</keyword><keyword>*Serum Globulins</keyword><keyword>*Spine</keyword><keyword>*Staphylococcal Infections</keyword></keywords><dates><year>1963</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>0003-9926 (Print)</isbn><accession-num>14051367</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=14051367</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Guri</Author><Year>1947</Year><RecNum>20</RecNum><record><rec-number>20</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Guri, J. P.</author></authors></contributors><titles><title>Differential diagnosis and treatment of pyogenic osteomyelitis of the vertebral column</title><secondary-title>Med Press</secondary-title></titles><periodical><full-title>Med Press</full-title></periodical><pages>569-72</pages><volume>218</volume><number>26</number><edition>1947/12/24</edition><dates><year>1947</year><pub-dates><date>Dec 24</date></pub-dates></dates><accession-num>18911307</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=18911307</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Kulowski</Author><Year>1936</Year><RecNum>26</RecNum><record><rec-number>26</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kulowski, J</author></authors></contributors><titles><title>Pyogenic osteomyelitis of the spine: an analysis and discussion of 102 cases</title><secondary-title>J Bone Joint Surg Am</secondary-title></titles><periodical><full-title>J Bone Joint Surg Am</full-title></periodical><pages>343-364</pages><volume>18</volume><dates><year>1936</year></dates><urls></urls></record></Cite><Cite><Author>Malawski</Author><Year>1991</Year><RecNum>27</RecNum><record><rec-number>27</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Malawski, S. K.</author><author>Lukawski, S.</author></authors></contributors><auth-address>Orthopaedic Department, Postgraduate Medical Education Academy, Warsaw, Poland.</auth-address><titles><title>Pyogenic infection of the spine</title><secondary-title>Clin Orthop Relat Res</secondary-title></titles><periodical><full-title>Clin Orthop Relat Res</full-title></periodical><pages>58-66</pages><number>272</number><edition>1991/11/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Bacterial Infections/complications/diagnosis/*therapy</keyword><keyword>*Cervical Vertebrae</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>*Lumbar Vertebrae</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Reoperation</keyword><keyword>Sacrum</keyword><keyword>Spinal Diseases/complications/diagnosis/therapy</keyword><keyword>Spondylitis/complications/diagnosis/therapy</keyword><keyword>*Thoracic Vertebrae</keyword></keywords><dates><year>1991</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>0009-921X (Print)&#xD;0009-921X (Linking)</isbn><accession-num>1934752</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=1934752</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Ambrose</Author><Year>1966</Year><RecNum>1</RecNum><record><rec-number>1</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ambrose, G. B.</author><author>Alpert, M.</author><author>Neer, C. S.</author></authors></contributors><titles><title>Vertebral osteomyelitis. A diagnostic problem</title><secondary-title>JAMA</secondary-title></titles><periodical><full-title>JAMA</full-title></periodical><pages>619-22</pages><volume>197</volume><number>8</number><edition>1966/08/22</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Anti-Bacterial Agents/therapeutic use</keyword><keyword>Arthrodesis</keyword><keyword>Biopsy</keyword><keyword>Blood Sedimentation</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>Diagnosis, Differential</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Humans</keyword><keyword>Immunity</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Osteomyelitis/*diagnosis</keyword><keyword>Spinal Diseases/*diagnosis</keyword><keyword>Spine/radiography</keyword></keywords><dates><year>1966</year><pub-dates><date>Aug 22</date></pub-dates></dates><isbn>0098-7484 (Print)</isbn><accession-num>5953091</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=5953091</url></related-urls></urls><language>eng</language></record></Cite></EndNote>1-4, 24, 25  More recent reports have confirmed that Staphlococcus aureus remains the most common infectious organism, but have demonstrated a much lower incidence (approximately 35 percent). ADDIN EN.CITE <EndNote><Cite><Author>Carragee</Author><Year>1997</Year><RecNum>14</RecNum><record><rec-number>14</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Carragee, E. J.</author></authors></contributors><auth-address>Stanford University Medical Center, California 94305, USA. carragee@leland.stanford.edu</auth-address><titles><title>Pyogenic vertebral osteomyelitis</title><secondary-title>J Bone Joint Surg Am</secondary-title></titles><periodical><full-title>J Bone Joint Surg Am</full-title></periodical><pages>874-80</pages><volume>79</volume><number>6</number><edition>1997/06/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adrenal Cortex Hormones/therapeutic use</keyword><keyword>Adult</keyword><keyword>Age Factors</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Antineoplastic Agents/therapeutic use</keyword><keyword>Bacterial Infections/*diagnosis/surgery</keyword><keyword>Corynebacterium Infections/diagnosis/surgery</keyword><keyword>Debridement</keyword><keyword>Diabetes Complications</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Gram-Positive Bacterial Infections/diagnosis/surgery</keyword><keyword>Humans</keyword><keyword>Immune System Diseases/complications</keyword><keyword>Immunocompromised Host</keyword><keyword>Kidney Failure/complications</keyword><keyword>Liver Failure/complications</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Neoplasms/drug therapy</keyword><keyword>Nutrition Disorders/complications</keyword><keyword>Osteomyelitis/diagnosis/*microbiology/surgery</keyword><keyword>Propionibacterium acnes</keyword><keyword>Retrospective Studies</keyword><keyword>Rheumatic Diseases/complications</keyword><keyword>Spinal Diseases/diagnosis/*microbiology/surgery</keyword><keyword>Spinal Fusion</keyword><keyword>Staphylococcal Infections/diagnosis/surgery</keyword><keyword>Staphylococcus epidermidis</keyword><keyword>Survival Rate</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>1997</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>0021-9355 (Print)</isbn><accession-num>9199385</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=9199385</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Lucio</Author><Year>2000</Year><RecNum>17</RecNum><record><rec-number>17</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lucio, E.</author><author>Adesokan, A.</author><author>Hadjipavlou, A. G.</author><author>Crow, W. N.</author><author>Adegboyega, P. A.</author></authors></contributors><auth-address>Department of Pathology, University of Texas Medical Branch, Galveston, TX 77555-0588, USA.</auth-address><titles><title>Pyogenic spondylodiskitis: a radiologic/pathologic and culture correlation study</title><secondary-title>Arch Pathol Lab Med</secondary-title></titles><periodical><full-title>Arch Pathol Lab Med</full-title></periodical><pages>712-6</pages><volume>124</volume><number>5</number><edition>2000/04/27</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Biopsy</keyword><keyword>Blastomyces/isolation &amp; purification</keyword><keyword>Blastomycosis/*microbiology/*pathology/radionuclide imaging</keyword><keyword>Cervical Vertebrae/microbiology/pathology/radionuclide imaging</keyword><keyword>Discitis/*microbiology/*pathology/radionuclide imaging</keyword><keyword>Female</keyword><keyword>Fever/*etiology</keyword><keyword>Gadolinium/diagnostic use</keyword><keyword>Gallium Radioisotopes/diagnostic use</keyword><keyword>Gram-Positive Bacterial Infections/*microbiology/*pathology</keyword><keyword>Gram-Positive Cocci/isolation &amp; purification</keyword><keyword>Humans</keyword><keyword>Lumbar Vertebrae/*microbiology/*pathology/radionuclide imaging</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Thoracic Vertebrae/microbiology/pathology/radionuclide imaging</keyword></keywords><dates><year>2000</year><pub-dates><date>May</date></pub-dates></dates><isbn>0003-9985 (Print)</isbn><accession-num>10782153</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=10782153</url></related-urls></urls><language>eng</language></record></Cite></EndNote>18, 26  Polymicrobial, fungal, bacterial organisms with low-virulence, antibiotic resistant bacteria, and atypical bacteria have been isolated more recently with an increased frequency particularly in patients with an impaired immune response or a history of prior intravenous drug use. ADDIN EN.CITE <EndNote><Cite><Author>Carragee</Author><Year>1997</Year><RecNum>14</RecNum><record><rec-number>14</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Carragee, E. J.</author></authors></contributors><auth-address>Stanford University Medical Center, California 94305, USA. carragee@leland.stanford.edu</auth-address><titles><title>Pyogenic vertebral osteomyelitis</title><secondary-title>J Bone Joint Surg Am</secondary-title></titles><periodical><full-title>J Bone Joint Surg Am</full-title></periodical><pages>874-80</pages><volume>79</volume><number>6</number><edition>1997/06/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adrenal Cortex Hormones/therapeutic use</keyword><keyword>Adult</keyword><keyword>Age Factors</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Antineoplastic Agents/therapeutic use</keyword><keyword>Bacterial Infections/*diagnosis/surgery</keyword><keyword>Corynebacterium Infections/diagnosis/surgery</keyword><keyword>Debridement</keyword><keyword>Diabetes Complications</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Gram-Positive Bacterial Infections/diagnosis/surgery</keyword><keyword>Humans</keyword><keyword>Immune System Diseases/complications</keyword><keyword>Immunocompromised Host</keyword><keyword>Kidney Failure/complications</keyword><keyword>Liver Failure/complications</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Neoplasms/drug therapy</keyword><keyword>Nutrition Disorders/complications</keyword><keyword>Osteomyelitis/diagnosis/*microbiology/surgery</keyword><keyword>Propionibacterium acnes</keyword><keyword>Retrospective Studies</keyword><keyword>Rheumatic Diseases/complications</keyword><keyword>Spinal Diseases/diagnosis/*microbiology/surgery</keyword><keyword>Spinal Fusion</keyword><keyword>Staphylococcal Infections/diagnosis/surgery</keyword><keyword>Staphylococcus epidermidis</keyword><keyword>Survival Rate</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>1997</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>0021-9355 (Print)</isbn><accession-num>9199385</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=9199385</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Lucio</Author><Year>2000</Year><RecNum>17</RecNum><record><rec-number>17</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lucio, E.</author><author>Adesokan, A.</author><author>Hadjipavlou, A. G.</author><author>Crow, W. N.</author><author>Adegboyega, P. A.</author></authors></contributors><auth-address>Department of Pathology, University of Texas Medical Branch, Galveston, TX 77555-0588, USA.</auth-address><titles><title>Pyogenic spondylodiskitis: a radiologic/pathologic and culture correlation study</title><secondary-title>Arch Pathol Lab Med</secondary-title></titles><periodical><full-title>Arch Pathol Lab Med</full-title></periodical><pages>712-6</pages><volume>124</volume><number>5</number><edition>2000/04/27</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Biopsy</keyword><keyword>Blastomyces/isolation &amp; purification</keyword><keyword>Blastomycosis/*microbiology/*pathology/radionuclide imaging</keyword><keyword>Cervical Vertebrae/microbiology/pathology/radionuclide imaging</keyword><keyword>Discitis/*microbiology/*pathology/radionuclide imaging</keyword><keyword>Female</keyword><keyword>Fever/*etiology</keyword><keyword>Gadolinium/diagnostic use</keyword><keyword>Gallium Radioisotopes/diagnostic use</keyword><keyword>Gram-Positive Bacterial Infections/*microbiology/*pathology</keyword><keyword>Gram-Positive Cocci/isolation &amp; purification</keyword><keyword>Humans</keyword><keyword>Lumbar Vertebrae/*microbiology/*pathology/radionuclide imaging</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Thoracic Vertebrae/microbiology/pathology/radionuclide imaging</keyword></keywords><dates><year>2000</year><pub-dates><date>May</date></pub-dates></dates><isbn>0003-9985 (Print)</isbn><accession-num>10782153</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=10782153</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Maiuri</Author><Year>1997</Year><RecNum>15</RecNum><record><rec-number>15</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Maiuri, F.</author><author>Iaconetta, G.</author><author>Gallicchio, B.</author><author>Manto, A.</author><author>Briganti, F.</author></authors></contributors><auth-address>Institute of Neurosurgery, School of Medicine, University, Federico II, Naples, Italy.</auth-address><titles><title>Spondylodiscitis. Clinical and magnetic resonance diagnosis</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>1741-6</pages><volume>22</volume><number>15</number><edition>1997/08/01</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Discitis/*radiography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Magnetic Resonance Imaging/*standards</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Reference Standards</keyword><keyword>Retrospective Studies</keyword><keyword>Tomography, X-Ray Computed</keyword></keywords><dates><year>1997</year><pub-dates><date>Aug 1</date></pub-dates></dates><isbn>0362-2436 (Print)</isbn><accession-num>9259785</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=9259785</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Chew</Author><Year>2001</Year><RecNum>34</RecNum><record><rec-number>34</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Chew, F. S.</author><author>Kline, M. J.</author></authors></contributors><auth-address>Department of Radiology, Wake Forest University School of Medicine, Medical Center Dr, Winston-Salem, NC 27157-1088, USA. fchew@wfubmc.edu</auth-address><titles><title>Diagnostic yield of CT-guided percutaneous aspiration procedures in suspected spontaneous infectious diskitis</title><secondary-title>Radiology</secondary-title></titles><periodical><full-title>Radiology</full-title></periodical><pages>211-4</pages><volume>218</volume><number>1</number><edition>2001/01/12</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Discitis/*microbiology/*radiography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Retrospective Studies</keyword><keyword>Sensitivity and Specificity</keyword><keyword>Suction</keyword><keyword>*Tomography, X-Ray Computed</keyword></keywords><dates><year>2001</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>0033-8419 (Print)&#xD;0033-8419 (Linking)</isbn><accession-num>11152804</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=11152804</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Tampieri</Author><Year>1991</Year><RecNum>9</RecNum><record><rec-number>9</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Tampieri, D.</author><author>Weill, A.</author><author>Melanson, D.</author><author>Ethier, R.</author></authors></contributors><auth-address>Department of Neuroradiology, Montreal Neurological Institute and Hospital, Quebec, Canada.</auth-address><titles><title>Percutaneous aspiration biopsy in cervical spine lytic lesions. Indications and technique</title><secondary-title>Neuroradiology</secondary-title></titles><periodical><full-title>Neuroradiology</full-title></periodical><pages>43-7</pages><volume>33</volume><number>1</number><edition>1991/01/01</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>*Biopsy, Needle/instrumentation/methods</keyword><keyword>Cervical Vertebrae/*pathology/radiography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Osteolysis/*pathology/radiography</keyword><keyword>Osteomyelitis/diagnosis/radiography</keyword><keyword>Spinal Diseases/diagnosis/radiography</keyword><keyword>Spinal Neoplasms/diagnosis/radiography</keyword><keyword>Tomography, X-Ray Computed</keyword></keywords><dates><year>1991</year></dates><isbn>0028-3940 (Print)</isbn><accession-num>2027444</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=2027444</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Perronne</Author><Year>1994</Year><RecNum>19</RecNum><record><rec-number>19</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Perronne, C.</author><author>Saba, J.</author><author>Behloul, Z.</author><author>Salmon-Ceron, D.</author><author>Leport, C.</author><author>Vilde, J. L.</author><author>Kahn, M. F.</author></authors></contributors><auth-address>Department of Infectious and Tropical Diseases, Hopital Bichat-Claude Bernard, Paris, France.</auth-address><titles><title>Pyogenic and tuberculous spondylodiskitis (vertebral osteomyelitis) in 80 adult patients</title><secondary-title>Clin Infect Dis</secondary-title></titles><periodical><full-title>Clin Infect Dis</full-title></periodical><pages>746-50</pages><volume>19</volume><number>4</number><edition>1994/10/01</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Bacteriological Techniques</keyword><keyword>Biopsy, Needle</keyword><keyword>Discitis/diagnosis/*microbiology/pathology</keyword><keyword>Female</keyword><keyword>*Gram-Negative Bacterial Infections/diagnosis</keyword><keyword>Humans</keyword><keyword>Intervertebral Disk/microbiology/pathology</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Osteomyelitis/diagnosis/*microbiology/pathology</keyword><keyword>Retrospective Studies</keyword><keyword>*Staphylococcal Infections/diagnosis</keyword><keyword>*Streptococcal Infections/diagnosis</keyword><keyword>*Tuberculosis, Spinal/diagnosis/pathology</keyword></keywords><dates><year>1994</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>1058-4838 (Print)</isbn><accession-num>7803642</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=7803642</url></related-urls></urls><language>eng</language></record></Cite></EndNote>8, 18, 21, 22, 26, 27    
	Biopsy and culture of the infectious spinal lesion is necessary to make the diagnosis, isolate the specific infectious pathogen, and tailor antibiotic therapy for the treatment of spinal discitis and vertebral osteomyelitis. ADDIN EN.CITE  ADDIN EN.CITE.DATA 1, 2, 16, 18, 19, 22, 23, 27-32.  Minimizing negative culture results can be accomplished by adequate tissue sampling and withholding all pretreatment empiric antibiotic therapy prior to obtaining the biopsy and culture. ADDIN EN.CITE <EndNote><Cite><Author>Lucio</Author><Year>2000</Year><RecNum>17</RecNum><record><rec-number>17</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lucio, E.</author><author>Adesokan, A.</author><author>Hadjipavlou, A. G.</author><author>Crow, W. N.</author><author>Adegboyega, P. A.</author></authors></contributors><auth-address>Department of Pathology, University of Texas Medical Branch, Galveston, TX 77555-0588, USA.</auth-address><titles><title>Pyogenic spondylodiskitis: a radiologic/pathologic and culture correlation study</title><secondary-title>Arch Pathol Lab Med</secondary-title></titles><periodical><full-title>Arch Pathol Lab Med</full-title></periodical><pages>712-6</pages><volume>124</volume><number>5</number><edition>2000/04/27</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Biopsy</keyword><keyword>Blastomyces/isolation &amp; purification</keyword><keyword>Blastomycosis/*microbiology/*pathology/radionuclide imaging</keyword><keyword>Cervical Vertebrae/microbiology/pathology/radionuclide imaging</keyword><keyword>Discitis/*microbiology/*pathology/radionuclide imaging</keyword><keyword>Female</keyword><keyword>Fever/*etiology</keyword><keyword>Gadolinium/diagnostic use</keyword><keyword>Gallium Radioisotopes/diagnostic use</keyword><keyword>Gram-Positive Bacterial Infections/*microbiology/*pathology</keyword><keyword>Gram-Positive Cocci/isolation &amp; purification</keyword><keyword>Humans</keyword><keyword>Lumbar Vertebrae/*microbiology/*pathology/radionuclide imaging</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Thoracic Vertebrae/microbiology/pathology/radionuclide imaging</keyword></keywords><dates><year>2000</year><pub-dates><date>May</date></pub-dates></dates><isbn>0003-9985 (Print)</isbn><accession-num>10782153</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=10782153</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Osti</Author><Year>1990</Year><RecNum>22</RecNum><record><rec-number>22</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Osti, O. L.</author><author>Fraser, R. D.</author><author>Vernon-Roberts, B.</author></authors></contributors><auth-address>Spinal Service and Spinal Injuries Unit, Royal Adelaide Hospital, South Australia.</auth-address><titles><title>Discitis after discography. The role of prophylactic antibiotics</title><secondary-title>J Bone Joint Surg Br</secondary-title></titles><periodical><full-title>J Bone Joint Surg Br</full-title></periodical><pages>271-4</pages><volume>72</volume><number>2</number><edition>1990/03/01</edition><keywords><keyword>Animals</keyword><keyword>Cefazolin/*administration &amp; dosage/pharmacology/therapeutic use</keyword><keyword>Contrast Media/administration &amp; dosage</keyword><keyword>Discitis/*etiology/pathology/prevention &amp; control</keyword><keyword>Humans</keyword><keyword>Injections, Intravenous</keyword><keyword>Intervertebral Disk/pathology/*radiography</keyword><keyword>Lumbar Vertebrae</keyword><keyword>Prospective Studies</keyword><keyword>Radiography/*adverse effects</keyword><keyword>Sheep</keyword><keyword>Staphylococcal Infections/etiology/pathology/*prevention &amp; control</keyword><keyword>Staphylococcus epidermidis/drug effects</keyword></keywords><dates><year>1990</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>0301-620X (Print)&#xD;0301-620X (Linking)</isbn><accession-num>2312567</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=2312567</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Ambrose</Author><Year>1966</Year><RecNum>1</RecNum><record><rec-number>1</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ambrose, G. B.</author><author>Alpert, M.</author><author>Neer, C. S.</author></authors></contributors><titles><title>Vertebral osteomyelitis. A diagnostic problem</title><secondary-title>JAMA</secondary-title></titles><periodical><full-title>JAMA</full-title></periodical><pages>619-22</pages><volume>197</volume><number>8</number><edition>1966/08/22</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Anti-Bacterial Agents/therapeutic use</keyword><keyword>Arthrodesis</keyword><keyword>Biopsy</keyword><keyword>Blood Sedimentation</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>Diagnosis, Differential</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Humans</keyword><keyword>Immunity</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Osteomyelitis/*diagnosis</keyword><keyword>Spinal Diseases/*diagnosis</keyword><keyword>Spine/radiography</keyword></keywords><dates><year>1966</year><pub-dates><date>Aug 22</date></pub-dates></dates><isbn>0098-7484 (Print)</isbn><accession-num>5953091</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=5953091</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Chew</Author><Year>2001</Year><RecNum>34</RecNum><record><rec-number>34</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Chew, F. S.</author><author>Kline, M. J.</author></authors></contributors><auth-address>Department of Radiology, Wake Forest University School of Medicine, Medical Center Dr, Winston-Salem, NC 27157-1088, USA. fchew@wfubmc.edu</auth-address><titles><title>Diagnostic yield of CT-guided percutaneous aspiration procedures in suspected spontaneous infectious diskitis</title><secondary-title>Radiology</secondary-title></titles><periodical><full-title>Radiology</full-title></periodical><pages>211-4</pages><volume>218</volume><number>1</number><edition>2001/01/12</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Discitis/*microbiology/*radiography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Retrospective Studies</keyword><keyword>Sensitivity and Specificity</keyword><keyword>Suction</keyword><keyword>*Tomography, X-Ray Computed</keyword></keywords><dates><year>2001</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>0033-8419 (Print)&#xD;0033-8419 (Linking)</isbn><accession-num>11152804</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=11152804</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Tampieri</Author><Year>1991</Year><RecNum>9</RecNum><record><rec-number>9</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Tampieri, D.</author><author>Weill, A.</author><author>Melanson, D.</author><author>Ethier, R.</author></authors></contributors><auth-address>Department of Neuroradiology, Montreal Neurological Institute and Hospital, Quebec, Canada.</auth-address><titles><title>Percutaneous aspiration biopsy in cervical spine lytic lesions. Indications and technique</title><secondary-title>Neuroradiology</secondary-title></titles><periodical><full-title>Neuroradiology</full-title></periodical><pages>43-7</pages><volume>33</volume><number>1</number><edition>1991/01/01</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>*Biopsy, Needle/instrumentation/methods</keyword><keyword>Cervical Vertebrae/*pathology/radiography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Osteolysis/*pathology/radiography</keyword><keyword>Osteomyelitis/diagnosis/radiography</keyword><keyword>Spinal Diseases/diagnosis/radiography</keyword><keyword>Spinal Neoplasms/diagnosis/radiography</keyword><keyword>Tomography, X-Ray Computed</keyword></keywords><dates><year>1991</year></dates><isbn>0028-3940 (Print)</isbn><accession-num>2027444</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=2027444</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Cotty</Author><Year>1988</Year><RecNum>7</RecNum><record><rec-number>7</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cotty, P.</author><author>Fouquet, B.</author><author>Pleskof, L.</author><author>Audurier, A.</author><author>Cotty, F.</author><author>Goupille, P.</author><author>Valat, J. P.</author><author>Alison, D.</author><author>Laffont, J.</author></authors></contributors><titles><title>Vertebral osteomyelitis: value of percutaneous biopsy. 30 cases</title><secondary-title>J Neuroradiol</secondary-title></titles><periodical><full-title>J Neuroradiol</full-title></periodical><pages>13-21</pages><volume>15</volume><number>1</number><edition>1988/01/01</edition><keywords><keyword>Biopsy, Needle</keyword><keyword>Humans</keyword><keyword>Osteomyelitis/*pathology</keyword><keyword>Spinal Diseases/*pathology</keyword><keyword>Spine/*pathology</keyword></keywords><dates><year>1988</year></dates><isbn>0150-9861 (Print)</isbn><accession-num>3397771</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=3397771</url></related-urls></urls><language>eng&#xD;fre</language></record></Cite></EndNote>1, 21, 26, 27, 31, 33
	The purpose of this study is to retrospectively evaluate whether previously published treatment algorithms are being followed regarding biopsy and tissue culture and the timing of antibiotic treatment in patients with spinal discitis and vertebral osteomyelitis.  We also investigated the timing of antibiotic therapy in relation to timing of patient hospital admission, diagnostic MRI of the spine, and biopsy and tissue culture of the suspicious lesion.

Materials and Methods
	The hospital records of all patients diagnosed and treated at our institution for spinal discitis and vertebral osteomyelitis from January 2002 to December 2007 were retrospectively reviewed.  Patient records were identified by International Statistical Classification of Diseases and Related Health Problems codes (ICD-9) 722.90 to 722.93.  This ICD-9 classification code specifies patients diagnosed with an unspecified disc disorder of the spine in various regions.  Institutional review board approval was obtained prior to the collection of any data and authors did not have any associated conflict of interest.  
Each patient�s medical history and overall immune status were evaluated based on the classification of Cierny. ADDIN EN.CITE <EndNote><Cite><Author>Cierny</Author><Year>1990</Year><RecNum>47</RecNum><record><rec-number>47</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cierny, G., 3rd</author></authors></contributors><titles><title>Chronic osteomyelitis: results of treatment</title><secondary-title>Instr Course Lect</secondary-title></titles><periodical><full-title>Instr Course Lect</full-title></periodical><pages>495-508</pages><volume>39</volume><edition>1990/01/01</edition><keywords><keyword>Chronic Disease</keyword><keyword>Humans</keyword><keyword>Osteomyelitis/*therapy</keyword><keyword>Prognosis</keyword></keywords><dates><year>1990</year></dates><isbn>0065-6895 (Print)&#xD;0065-6895 (Linking)</isbn><accession-num>2186142</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=2186142</url></related-urls></urls><language>eng</language></record></Cite></EndNote>34  Patients with a normal immune system were classified A-hosts, patients with an impaired immune status were classified B-hosts, and patients for whom the morbidity of treatment is greater than the morbidity of the disease were classified C-hosts. 
We aimed to identify and evaluate only patients in which holding antibiotic therapy prior to obtaining a biopsy and culture would be considered medically safe and appropriate.  In other words, strict exclusion criteria were established prior initiating this study in order to eliminate the analysis of patients where immediate empiric antibiotic therapy would be considered the standard of care.  For example, patients that presented to our institution with an abnormal neurologic examination and evidence of neurologic compression by MRI secondary to an epidural abscess or other fluid collection were excluded.  In these patients, urgent or emergent surgical debridement as well as the use of empiric antibiotic therapy could be considered the necessary standard of care.  Additionally, patients with clinical evidence of bacteremic shock as evidenced by high grade fevers, hypotension, tachycardia, and positive blood cultures were excluded.  Similarly, avoiding immediate empiric antibiotic therapy in patients with evidence of bacteremic shock could be considered potentially life threatening.  We also excluded any patient that may have developed discitis or vertebral osteomyelitis after a spinal procedure.
The start of antibiotic therapy was identified using the pharmacology date and time that was recorded in the medical record.  Time of admission and time of MRI was similarly identified using the admitting and radiology department documentation. 
	
Results
Of the total 62 patients were initially identified by ICD-9 codes 722.90 to 722.93.  Of these, 39 patients were included in this study.  Twenty-two were men and 17 were women.  The average age (and standard deviation) at the time of hospital admission was 59.1 + 14.0 years (range, 31.7 to 90.8 years).  Spinal discitis and vertebral osteomyelitis was localized to the lumbar and sacral spine in 28 patients, the thoracic spine in 6 patients, and the cervical spine in 5 patients.  Twenty-three patients were excluded from analysis based on our aforementioned exclusion criteria.  Of these, 13 patients were excluded secondary to presenting with signs and symptoms of bacteremic shock and 10 patients were excluded secondary to MRI evidence of an epidural abscess causing neurologic compression which necessitated urgent surgical decompression.  
Patient co-morbidities were each reviewed and analyzed for potential risk factors associated for developing discitis and vertebral osteomyelitis.  Using the classification of Cierny, ADDIN EN.CITE <EndNote><Cite><Author>Cierny</Author><Year>1990</Year><RecNum>47</RecNum><record><rec-number>47</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cierny, G., 3rd</author></authors></contributors><titles><title>Chronic osteomyelitis: results of treatment</title><secondary-title>Instr Course Lect</secondary-title></titles><periodical><full-title>Instr Course Lect</full-title></periodical><pages>495-508</pages><volume>39</volume><edition>1990/01/01</edition><keywords><keyword>Chronic Disease</keyword><keyword>Humans</keyword><keyword>Osteomyelitis/*therapy</keyword><keyword>Prognosis</keyword></keywords><dates><year>1990</year></dates><isbn>0065-6895 (Print)&#xD;0065-6895 (Linking)</isbn><accession-num>2186142</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=2186142</url></related-urls></urls><language>eng</language></record></Cite></EndNote>34 29 patients (74%) were classified as B-hosts, 8 patients (20%) were classified as A-hosts, and 2 patients (5%) were classified as C-hosts.  The most common medical co-morbidities identified were diabetes mellitus (15 patients), end-stage renal disease (7 patients), and hepatitis C (6 patients).  Additionally, 8 patients reported a remote history of intravenous drug use.
All patients reviewed reported to have pain at or near the site of infection.  The mean reported duration of symptoms prior to admission was 27.3 + 27.4 days (range, 2 to 120 days).  Twenty-seven patients were admitted to a general internal medicine service, 6 patients were admitted to the orthopaedic spine service, and 6 patients were admitted to the neurosurgical service (Table 1).  Patients admitted to the orthopedic spine service were more likely to obtain a biopsy before the use of antibiotics when compared to those admitted to the general medical service or the neurosurgical service (Table 1).  
The mean time to antibiotic therapy after admission was 26.3 + 35.7 hours (range, 0 to 198 hours).  Eleven patients (28%) were identified to have received antibiotic therapy within 1 hour of being admitted to the hospital.  Four of these 11 patients had received intravenous antibiotics prior to being transferred to our institution and were therefore considered to have received antibiotics at the time of admission.  Of these 4 patients, a biopsy and culture was not performed prior to being transferred to our institution.  MRI was performed or available for review in all patients following admission.  The mean time to MRI after admission was 16.1 + 29.1 hours (range, 0 to 132 hours).  MRI was performed and reviewed within one hour of admission in 16 patients (41%) including 6 patients that were transferred to our institution with a completed MRI.  Antibiotic therapy was started at our institution prior to obtaining a diagnostic spinal MRI in 9 patients (23%).  For 4 additional patients (10%), antibiotics were noted to have been initiated within 1 hour following the spinal MRI.  The diagnosis of spinal discitis and/or vertebral osteomyelitis was confirmed by MRI in all patients.
Computerized tomography (CT) guided biopsy and culture of the suspicious site of infection was performed in 20 patients (51%) (Table 1). Fourteen biopsies were performed in the lumbar spine, 5 in the thoracic spine, and 1 in the cervical spine.  Eleven of the 20 biopsies performed (55%) were identified to have been performed after the initiation of antibiotic therapy while only 9 biopsies (45%) were performed prior to starting antibiotics (Table 1).  Biopsy and culture was not performed in 4 patients at the discretion of the treating service secondary to having a confirmatory blood culture pathogen.  For 5 patients, a decision was made by an attending radiologist to forego a biopsy and culture as these patients had received numerous doses of a variety of empiric antibiotic prior to consultation.  For the remaining 10 patients, a clear explanation for not obtaining a biopsy could not be identified within the medical record.
Specific bacterial pathogens were cultured from 9 of 20 biopsy specimens (45%).  Six of the 9 biopsies (67%) that were performed prior to antibiotics administration were positive while only 3 of 11 biopsies (27%) that were performed after the initiation of antibiotic therapy was a bacterial pathogen cultured.  Bacterial organisms cultured from the biopsy specimen included methacillin-resistant Staphlococcus aureus (MRSA) in 3 patients, Escherichia coli (E. coli) in 3 patients, methacillin-sensitive Staphlococcus aureus (MSSA) in 2 patients, and Burkholderia pickettii in 1 patient.  Organisms cultured from patients that did not undergo a biopsy secondary to culture positive blood included MRSA in 1 patient, Enterococcus in 1 patient, MSSA in 1 patient, and Pseudomonas aeruginosa in 1 patient.  Antibiotics selected for long-term administration were ultimately changed from those selected following admission to the hospital in 9 of 13 patients (69%) based on the specific bacterial pathogen that was isolated (Table 2).  For 4 patients with MRSA culture results (3 biopsies, 1 blood culture) the final antibiotic chosen for long-term administration was not altered.

Discussion
	In our review of patients diagnosed with spinal discitis or vertebral osteomyelitis, 26 of the 39 patients (67%) were recognized as not being treated according to prior published recommendations.  Treatment algorithms for spinal discitis and vertebral osteomyelitis include obtaining a biopsy and culture of the infectious lesion prior to the initiation of antibiotic therapy.  For 15 patients, a biopsy and culture was never obtained and for 11 patients a biopsy and culture was performed after the initiation of antibiotic therapy.  Furthermore, obtaining a biopsy specimen after the initiation of antibiotics appears to have a negative effect on the final culture result.  A specific bacterial pathogen was isolated in 6 of 9 biopsies (67%) that were performed prior to the initiation of antibiotic therapy and only 3 of 11 biopsies (27%) when antibiotics were started prior to biopsy.  Similarly, Cotty et al. reported the results of 30 biopsies that were performed for vertebral osteomyelitis and was only able to isolate a causative organism in 27% of biopsies performed after the initiation of antibiotics compared to 75% of biopsies performed prior to antibiotics. ADDIN EN.CITE <EndNote><Cite><Author>Cotty</Author><Year>1988</Year><RecNum>7</RecNum><record><rec-number>7</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cotty, P.</author><author>Fouquet, B.</author><author>Pleskof, L.</author><author>Audurier, A.</author><author>Cotty, F.</author><author>Goupille, P.</author><author>Valat, J. P.</author><author>Alison, D.</author><author>Laffont, J.</author></authors></contributors><titles><title>Vertebral osteomyelitis: value of percutaneous biopsy. 30 cases</title><secondary-title>J Neuroradiol</secondary-title></titles><periodical><full-title>J Neuroradiol</full-title></periodical><pages>13-21</pages><volume>15</volume><number>1</number><edition>1988/01/01</edition><keywords><keyword>Biopsy, Needle</keyword><keyword>Humans</keyword><keyword>Osteomyelitis/*pathology</keyword><keyword>Spinal Diseases/*pathology</keyword><keyword>Spine/*pathology</keyword></keywords><dates><year>1988</year></dates><isbn>0150-9861 (Print)</isbn><accession-num>3397771</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=3397771</url></related-urls></urls><language>eng&#xD;fre</language></record></Cite></EndNote>31 
	Using our exclusion criteria, we attempted to isolate the ideal patient where withholding antibiotic therapy would have been considered medically safe and not life threatening.  The duration of patient symptoms described further suggests a more chronic and indolent inflammatory course.  We believe that withholding antibiotic therapy in these patients until a biopsy and culture can be performed is a safe clinical practice that allows the highest yield of isolating the offending bacterial pathogen. ADDIN EN.CITE <EndNote><Cite><Author>Cotty</Author><Year>1988</Year><RecNum>7</RecNum><record><rec-number>7</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cotty, P.</author><author>Fouquet, B.</author><author>Pleskof, L.</author><author>Audurier, A.</author><author>Cotty, F.</author><author>Goupille, P.</author><author>Valat, J. P.</author><author>Alison, D.</author><author>Laffont, J.</author></authors></contributors><titles><title>Vertebral osteomyelitis: value of percutaneous biopsy. 30 cases</title><secondary-title>J Neuroradiol</secondary-title></titles><periodical><full-title>J Neuroradiol</full-title></periodical><pages>13-21</pages><volume>15</volume><number>1</number><edition>1988/01/01</edition><keywords><keyword>Biopsy, Needle</keyword><keyword>Humans</keyword><keyword>Osteomyelitis/*pathology</keyword><keyword>Spinal Diseases/*pathology</keyword><keyword>Spine/*pathology</keyword></keywords><dates><year>1988</year></dates><isbn>0150-9861 (Print)</isbn><accession-num>3397771</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=3397771</url></related-urls></urls><language>eng&#xD;fre</language></record></Cite></EndNote>31  The use of antibiotics in this series also appears to be a reflexive practice by many physicians who encounter patients with back pain and elevated inflammatory markers.  For example, 11 patients (28%) had antibiotic initiated within 1 hour of admission, 9 patients (23%) had antibiotics initiated before a diagnostic spinal MRI, and 4 patients (10%) had antibiotics initiated within 1 hour of MRI completion.   
	The poorer health and immune status of patients represented in our series and those reported by Carragee ADDIN EN.CITE <EndNote><Cite><Author>Carragee</Author><Year>1997</Year><RecNum>14</RecNum><record><rec-number>14</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Carragee, E. J.</author></authors></contributors><auth-address>Stanford University Medical Center, California 94305, USA. carragee@leland.stanford.edu</auth-address><titles><title>Pyogenic vertebral osteomyelitis</title><secondary-title>J Bone Joint Surg Am</secondary-title></titles><periodical><full-title>J Bone Joint Surg Am</full-title></periodical><pages>874-80</pages><volume>79</volume><number>6</number><edition>1997/06/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adrenal Cortex Hormones/therapeutic use</keyword><keyword>Adult</keyword><keyword>Age Factors</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Antineoplastic Agents/therapeutic use</keyword><keyword>Bacterial Infections/*diagnosis/surgery</keyword><keyword>Corynebacterium Infections/diagnosis/surgery</keyword><keyword>Debridement</keyword><keyword>Diabetes Complications</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Gram-Positive Bacterial Infections/diagnosis/surgery</keyword><keyword>Humans</keyword><keyword>Immune System Diseases/complications</keyword><keyword>Immunocompromised Host</keyword><keyword>Kidney Failure/complications</keyword><keyword>Liver Failure/complications</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Neoplasms/drug therapy</keyword><keyword>Nutrition Disorders/complications</keyword><keyword>Osteomyelitis/diagnosis/*microbiology/surgery</keyword><keyword>Propionibacterium acnes</keyword><keyword>Retrospective Studies</keyword><keyword>Rheumatic Diseases/complications</keyword><keyword>Spinal Diseases/diagnosis/*microbiology/surgery</keyword><keyword>Spinal Fusion</keyword><keyword>Staphylococcal Infections/diagnosis/surgery</keyword><keyword>Staphylococcus epidermidis</keyword><keyword>Survival Rate</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>1997</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>0021-9355 (Print)</isbn><accession-num>9199385</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=9199385</url></related-urls></urls><language>eng</language></record></Cite></EndNote>18 further substantiates the utility of obtaining a biopsy and culture for the treatment of spinal discitis and vertebral osteomyelitis.  Historically, the most commonly isolated organisms were staphlococci and streptococci, ADDIN EN.CITE <EndNote><Cite><Author>Bonfiglio</Author><Year>2006</Year><RecNum>2</RecNum><record><rec-number>2</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Bonfiglio, M.</author><author>Lange, T. A.</author><author>Kim, Y. M.</author></authors></contributors><titles><title>The Classic: Pyogenic vertebral osteomyelitis: disk space infections. 1973</title><secondary-title>Clin Orthop Relat Res</secondary-title></titles><periodical><full-title>Clin Orthop Relat Res</full-title></periodical><pages>4-8</pages><volume>444</volume><edition>2006/03/09</edition><keywords><keyword>Bacterial Infections/diagnosis/*history/therapy</keyword><keyword>Discitis/*history/microbiology</keyword><keyword>History, 20th Century</keyword><keyword>Humans</keyword><keyword>Osteomyelitis/*history/microbiology</keyword></keywords><dates><year>2006</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>0009-921X (Print)</isbn><accession-num>16523120</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=16523120</url></related-urls></urls><electronic-resource-num>10.1097/01.blo.0000201172.64764.bb&#xD;00003086-200603000-00002 [pii]</electronic-resource-num><language>eng</language></record></Cite><Cite><Author>Stone</Author><Year>1963</Year><RecNum>10</RecNum><record><rec-number>10</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Stone, D. B.</author><author>Bonfiglio, M.</author></authors></contributors><titles><title>Pyogenic Vertebral Osteomyelitis. A Diagnostic Pitfall for the Internist</title><secondary-title>Arch Intern Med</secondary-title></titles><periodical><full-title>Arch Intern Med</full-title></periodical><pages>491-500</pages><volume>112</volume><edition>1963/10/01</edition><keywords><keyword>*Anti-Bacterial Agents</keyword><keyword>*Back Pain</keyword><keyword>*Bacteriology</keyword><keyword>*Blood Sedimentation</keyword><keyword>*Diagnosis</keyword><keyword>*Drainage</keyword><keyword>*Geriatrics</keyword><keyword>*Osteomyelitis</keyword><keyword>*Radiography</keyword><keyword>*Serum Globulins</keyword><keyword>*Spine</keyword><keyword>*Staphylococcal Infections</keyword></keywords><dates><year>1963</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>0003-9926 (Print)</isbn><accession-num>14051367</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=14051367</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Guri</Author><Year>1947</Year><RecNum>20</RecNum><record><rec-number>20</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Guri, J. P.</author></authors></contributors><titles><title>Differential diagnosis and treatment of pyogenic osteomyelitis of the vertebral column</title><secondary-title>Med Press</secondary-title></titles><periodical><full-title>Med Press</full-title></periodical><pages>569-72</pages><volume>218</volume><number>26</number><edition>1947/12/24</edition><dates><year>1947</year><pub-dates><date>Dec 24</date></pub-dates></dates><accession-num>18911307</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=18911307</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Kulowski</Author><Year>1936</Year><RecNum>26</RecNum><record><rec-number>26</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kulowski, J</author></authors></contributors><titles><title>Pyogenic osteomyelitis of the spine: an analysis and discussion of 102 cases</title><secondary-title>J Bone Joint Surg Am</secondary-title></titles><periodical><full-title>J Bone Joint Surg Am</full-title></periodical><pages>343-364</pages><volume>18</volume><dates><year>1936</year></dates><urls></urls></record></Cite><Cite><Author>Malawski</Author><Year>1991</Year><RecNum>27</RecNum><record><rec-number>27</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Malawski, S. K.</author><author>Lukawski, S.</author></authors></contributors><auth-address>Orthopaedic Department, Postgraduate Medical Education Academy, Warsaw, Poland.</auth-address><titles><title>Pyogenic infection of the spine</title><secondary-title>Clin Orthop Relat Res</secondary-title></titles><periodical><full-title>Clin Orthop Relat Res</full-title></periodical><pages>58-66</pages><number>272</number><edition>1991/11/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Bacterial Infections/complications/diagnosis/*therapy</keyword><keyword>*Cervical Vertebrae</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>*Lumbar Vertebrae</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Reoperation</keyword><keyword>Sacrum</keyword><keyword>Spinal Diseases/complications/diagnosis/therapy</keyword><keyword>Spondylitis/complications/diagnosis/therapy</keyword><keyword>*Thoracic Vertebrae</keyword></keywords><dates><year>1991</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>0009-921X (Print)&#xD;0009-921X (Linking)</isbn><accession-num>1934752</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=1934752</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Ambrose</Author><Year>1966</Year><RecNum>1</RecNum><record><rec-number>1</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ambrose, G. B.</author><author>Alpert, M.</author><author>Neer, C. S.</author></authors></contributors><titles><title>Vertebral osteomyelitis. A diagnostic problem</title><secondary-title>JAMA</secondary-title></titles><periodical><full-title>JAMA</full-title></periodical><pages>619-22</pages><volume>197</volume><number>8</number><edition>1966/08/22</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Anti-Bacterial Agents/therapeutic use</keyword><keyword>Arthrodesis</keyword><keyword>Biopsy</keyword><keyword>Blood Sedimentation</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>Diagnosis, Differential</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Humans</keyword><keyword>Immunity</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Osteomyelitis/*diagnosis</keyword><keyword>Spinal Diseases/*diagnosis</keyword><keyword>Spine/radiography</keyword></keywords><dates><year>1966</year><pub-dates><date>Aug 22</date></pub-dates></dates><isbn>0098-7484 (Print)</isbn><accession-num>5953091</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=5953091</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Stone</Author><Year>1963</Year><RecNum>10</RecNum><record><rec-number>10</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Stone, D. B.</author><author>Bonfiglio, M.</author></authors></contributors><titles><title>Pyogenic Vertebral Osteomyelitis. A Diagnostic Pitfall for the Internist</title><secondary-title>Arch Intern Med</secondary-title></titles><periodical><full-title>Arch Intern Med</full-title></periodical><pages>491-500</pages><volume>112</volume><edition>1963/10/01</edition><keywords><keyword>*Anti-Bacterial Agents</keyword><keyword>*Back Pain</keyword><keyword>*Bacteriology</keyword><keyword>*Blood Sedimentation</keyword><keyword>*Diagnosis</keyword><keyword>*Drainage</keyword><keyword>*Geriatrics</keyword><keyword>*Osteomyelitis</keyword><keyword>*Radiography</keyword><keyword>*Serum Globulins</keyword><keyword>*Spine</keyword><keyword>*Staphylococcal Infections</keyword></keywords><dates><year>1963</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>0003-9926 (Print)</isbn><accession-num>14051367</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=14051367</url></related-urls></urls><language>eng</language></record></Cite></EndNote>1-4, 24, 25 however, more recent reports have documented the isolation of gram-negative organisms, fungal organisms, low-virulent organisms, and organisms that are antibiotic-resistant. ADDIN EN.CITE  ADDIN EN.CITE.DATA 8, 18, 19, 21, 23, 25-27, 31, 35, 36  Long-term pathogen specific antibiotic therapy with or without bracing is the recommended treatment of choice for spinal discitis and vertebral osteomyelitis, therefore, isolation of the specific bacterial pathogen is crucial.  In our series, antibiotics were changed based on the isolated bacterial pathogen in 9 of 13 patients (69%).  The majority of patients without a biopsy or those with a negative biopsy result were treated with long-term intravenous antibiotics (most commonly, Vancomycin and Ciprofloxacin) that target a broad spectrum of bacterial pathogens and those with potential antibiotic resistance.  The judicious use of such antibiotics raises further concern of increased risks of nosocomial infections while also potentially creating a wider antibiotic resistance for which future solutions may not exist. ADDIN EN.CITE <EndNote><Cite><Author>Chastre</Author><Year>2008</Year><RecNum>44</RecNum><record><rec-number>44</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Chastre, J.</author></authors></contributors><auth-address>Universite Paris 6 Pierre et Marie Curie, Service de Reanimation Medicale, Institut de Cardiologie, Hopital Pitie-Salpetriere, AP-HP, Paris, France. jean.chastre@psl.ap-hop-paris.fr</auth-address><titles><title>Evolving problems with resistant pathogens</title><secondary-title>Clin Microbiol Infect</secondary-title></titles><periodical><full-title>Clin Microbiol Infect</full-title></periodical><pages>3-14</pages><volume>14 Suppl 3</volume><edition>2008/05/03</edition><keywords><keyword>Anti-Bacterial Agents/pharmacology</keyword><keyword>Cross Infection/epidemiology/microbiology</keyword><keyword>*Drug Resistance, Bacterial</keyword><keyword>Europe/epidemiology</keyword><keyword>Gram-Negative Bacteria/*drug effects</keyword><keyword>Gram-Negative Bacterial Infections/epidemiology/microbiology</keyword><keyword>Humans</keyword><keyword>Intensive Care Units</keyword><keyword>Methicillin Resistance</keyword><keyword>Microbial Sensitivity Tests</keyword><keyword>Pneumonia, Ventilator-Associated/epidemiology/microbiology</keyword><keyword>Staphylococcal Infections/epidemiology/microbiology</keyword><keyword>Staphylococcus aureus/*drug effects</keyword><keyword>United States/epidemiology</keyword></keywords><dates><year>2008</year><pub-dates><date>Apr</date></pub-dates></dates><isbn>1198-743X (Print)&#xD;1198-743X (Linking)</isbn><accession-num>18318874</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=18318874</url></related-urls></urls><electronic-resource-num>CLM1958 [pii]&#xD;10.1111/j.1469-0691.2008.01958.x</electronic-resource-num><language>eng</language></record></Cite></EndNote>37  
	A number of potential options exist for obtaining a biopsy and culture of the infectious spinal lesion.  Needle biopsy techniques of the vertebral body and disc space were first described in 1935 by Robertson and Ball. ADDIN EN.CITE <EndNote><Cite><Author>Robertson</Author><Year>1935</Year><RecNum>46</RecNum><record><rec-number>46</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Robertson, R. C.</author><author>Ball, R. P.</author></authors></contributors><titles><title>Destructive Spine Lesions.  Diagnosis by needle biopsy.</title><secondary-title>J Bone Joint Surg Am</secondary-title></titles><periodical><full-title>J Bone Joint Surg Am</full-title></periodical><pages>749-758</pages><volume>17</volume><dates><year>1935</year></dates><urls></urls></record></Cite></EndNote>38  Current advancements with computerized tomography (CT) guidance have refined these early techniques and improved the diagnostic yield of the procedure. ADDIN EN.CITE <EndNote><Cite><Author>Chew</Author><Year>2001</Year><RecNum>34</RecNum><record><rec-number>34</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Chew, F. S.</author><author>Kline, M. J.</author></authors></contributors><auth-address>Department of Radiology, Wake Forest University School of Medicine, Medical Center Dr, Winston-Salem, NC 27157-1088, USA. fchew@wfubmc.edu</auth-address><titles><title>Diagnostic yield of CT-guided percutaneous aspiration procedures in suspected spontaneous infectious diskitis</title><secondary-title>Radiology</secondary-title></titles><periodical><full-title>Radiology</full-title></periodical><pages>211-4</pages><volume>218</volume><number>1</number><edition>2001/01/12</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Discitis/*microbiology/*radiography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Retrospective Studies</keyword><keyword>Sensitivity and Specificity</keyword><keyword>Suction</keyword><keyword>*Tomography, X-Ray Computed</keyword></keywords><dates><year>2001</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>0033-8419 (Print)&#xD;0033-8419 (Linking)</isbn><accession-num>11152804</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=11152804</url></related-urls></urls><language>eng</language></record></Cite></EndNote>27  Chew and Kline demonstrated a high sensitivity and specificity of isolating bacterial pathogens following CT guided aspirations but a lower yield in detecting fungal infections. ADDIN EN.CITE <EndNote><Cite><Author>Chew</Author><Year>2001</Year><RecNum>34</RecNum><record><rec-number>34</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Chew, F. S.</author><author>Kline, M. J.</author></authors></contributors><auth-address>Department of Radiology, Wake Forest University School of Medicine, Medical Center Dr, Winston-Salem, NC 27157-1088, USA. fchew@wfubmc.edu</auth-address><titles><title>Diagnostic yield of CT-guided percutaneous aspiration procedures in suspected spontaneous infectious diskitis</title><secondary-title>Radiology</secondary-title></titles><periodical><full-title>Radiology</full-title></periodical><pages>211-4</pages><volume>218</volume><number>1</number><edition>2001/01/12</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Discitis/*microbiology/*radiography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Retrospective Studies</keyword><keyword>Sensitivity and Specificity</keyword><keyword>Suction</keyword><keyword>*Tomography, X-Ray Computed</keyword></keywords><dates><year>2001</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>0033-8419 (Print)&#xD;0033-8419 (Linking)</isbn><accession-num>11152804</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=11152804</url></related-urls></urls><language>eng</language></record></Cite></EndNote>27  Biopsies of cervical spine lesions, despite close proximity to vital structures, have also been described as a safe and effective method to verify bacterial pathogen. ADDIN EN.CITE <EndNote><Cite><Author>Tampieri</Author><Year>1991</Year><RecNum>9</RecNum><record><rec-number>9</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Tampieri, D.</author><author>Weill, A.</author><author>Melanson, D.</author><author>Ethier, R.</author></authors></contributors><auth-address>Department of Neuroradiology, Montreal Neurological Institute and Hospital, Quebec, Canada.</auth-address><titles><title>Percutaneous aspiration biopsy in cervical spine lytic lesions. Indications and technique</title><secondary-title>Neuroradiology</secondary-title></titles><periodical><full-title>Neuroradiology</full-title></periodical><pages>43-7</pages><volume>33</volume><number>1</number><edition>1991/01/01</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>*Biopsy, Needle/instrumentation/methods</keyword><keyword>Cervical Vertebrae/*pathology/radiography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Osteolysis/*pathology/radiography</keyword><keyword>Osteomyelitis/diagnosis/radiography</keyword><keyword>Spinal Diseases/diagnosis/radiography</keyword><keyword>Spinal Neoplasms/diagnosis/radiography</keyword><keyword>Tomography, X-Ray Computed</keyword></keywords><dates><year>1991</year></dates><isbn>0028-3940 (Print)</isbn><accession-num>2027444</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=2027444</url></related-urls></urls><language>eng</language></record></Cite></EndNote>21    Only 1 cervical lesion in our series had a biopsy performed which ultimately resulted in the isolation of a low virulent pathogen Burkholderia pickettii. Finally, Hoffer further described obtaining biopsies in children without complications. ADDIN EN.CITE <EndNote><Cite><Author>Hoffer</Author><Year>1988</Year><RecNum>6</RecNum><record><rec-number>6</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hoffer, F. A.</author><author>Strand, R. D.</author><author>Gebhardt, M. C.</author></authors></contributors><auth-address>Department of Radiology, Children&apos;s Hospital, Boston, MA 02115.</auth-address><titles><title>Percutaneous biopsy of pyogenic infection of the spine in children</title><secondary-title>J Pediatr Orthop</secondary-title></titles><periodical><full-title>J Pediatr Orthop</full-title></periodical><pages>442-4</pages><volume>8</volume><number>4</number><edition>1988/07/01</edition><keywords><keyword>Adolescent</keyword><keyword>Anti-Bacterial Agents/therapeutic use</keyword><keyword>Biopsy/*methods</keyword><keyword>Braces</keyword><keyword>Child</keyword><keyword>Chronic Disease</keyword><keyword>Combined Modality Therapy</keyword><keyword>Evaluation Studies as Topic</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Osteomyelitis/*pathology/radiography/therapy</keyword><keyword>Retrospective Studies</keyword><keyword>Salmonella Infections/*pathology/radiography/therapy</keyword><keyword>Spinal Diseases/*pathology/radiography/therapy</keyword><keyword>Staphylococcal Infections/*pathology/radiography/therapy</keyword><keyword>*Tomography, X-Ray Computed</keyword></keywords><dates><year>1988</year><pub-dates><date>Jul-Aug</date></pub-dates></dates><isbn>0271-6798 (Print)</isbn><accession-num>3392196</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=3392196</url></related-urls></urls><language>eng</language></record></Cite></EndNote>29
	We recognize some limitations with this study.  It is a retrospective analysis of a nonrandomized patient population.  Patients were identified based on ICD-9 coding which may have led to a number of missed patients with spinal discitis or vertebral osteomyelitis.  Patients were admitted and treated by a number of different physicians with varied medical educations and backgrounds.  By analyzing the medical records only, we were unable to verify the exact reason and decision that a biopsy and culture was not performed for 15 patients.  Similarly, we were unable to completely discern the decision-making process that was employed when antibiotics were started without a confirmatory tissue diagnosis.
	The results of this study indicate that a significant number of patients treated at our institution for spinal discitis and vertebral osteomyelitis did not have a biopsy and culture performed of the spinal lesion.  When a biopsy was obtained, the majority were performed after antibiotics had been initiated.  Antibiotic therapy appears to have been initiated immediately after the diagnosis is made or suspected in the majority of patients.  We believe that withholding antibiotics in patients without evidence of septicemia or neurologic compromise is a safe clinical practice until a biopsy and culture can be performed.  Physicians treating this disease should be educated regarding the ideal management of these patients.  
References
1.	Ambrose GB, Alpert M, Neer CS. Vertebral osteomyelitis. A diagnostic problem. JAMA 1966; 197(8):619-22.
2.	Bonfiglio M, Lange TA, Kim YM. The Classic: Pyogenic vertebral osteomyelitis: disk space infections. 1973. Clin Orthop Relat Res 2006; 444:4-8.
3.	Stone DB, Bonfiglio M. Pyogenic Vertebral Osteomyelitis. A Diagnostic Pitfall for the Internist. Arch Intern Med 1963; 112:491-500.
4.	Guri JP. Differential diagnosis and treatment of pyogenic osteomyelitis of the vertebral column. Med Press 1947; 218(26):569-72.
5.	Wilensky W. Osteomyelitis of the vertebrae. Ann Surg 1926; 89:561-70.
6.	Waldvogel FA, Medoff G, Swartz MN. Osteomyelitis: a review of clinical features, therapeutic considerations and unusual aspects. N Engl J Med 1970; 282(4):198-206.
7.	Sharif HS. Role of MR imaging in the management of spinal infections. AJR Am J Roentgenol 1992; 158(6):1333-45.
8.	Maiuri F, Iaconetta G, Gallicchio B, et al. Spondylodiscitis. Clinical and magnetic resonance diagnosis. Spine (Phila Pa 1976) 1997; 22(15):1741-6.
9.	Modic MT, Feiglin DH, Piraino DW, et al. Vertebral osteomyelitis: assessment using MR. Radiology 1985; 157(1):157-66.
10.	Dagirmanjian A, Schils J, McHenry M, Modic MT. MR imaging of vertebral osteomyelitis revisited. AJR Am J Roentgenol 1996; 167(6):1539-43.
11.	Szypryt EP, Hardy JG, Hinton CE, et al. A comparison between magnetic resonance imaging and scintigraphic bone imaging in the diagnosis of disc space infection in an animal model. Spine (Phila Pa 1976) 1988; 13(9):1042-8.
12.	An HS, Vaccaro AR, Dolinskas CA, et al. Differentiation between spinal tumors and infections with magnetic resonance imaging. Spine (Phila Pa 1976) 1991; 16(8 Suppl):S334-8.
13.	Garcia A, Jr., Grantham SA. Hematogenous pyogenic vertebral osteomyelitis. J Bone Joint Surg Am 1960; 42-A:429-36.
14.	Eismont FJ, Bohlman HH, Soni PL, et al. Pyogenic and fungal vertebral osteomyelitis with paralysis. J Bone Joint Surg Am 1983; 65(1):19-29.
15.	Puig Guri J. Pyogenic osteomyelitis of the spine: differential diagnosis through clinical and roentgenographic observations. J Bone Joint Surg Am 1946; 28:29-39.
16.	Digby JM, Kersley JB. Pyogenic non-tuberculous spinal infection: an analysis of thirty cases. J Bone Joint Surg Br 1979; 61(1):47-55.
17.	Griffiths HE, Jones DM. Pyogenic infection of the spine. A review of twenty-eight cases. J Bone Joint Surg Br 1971; 53(3):383-91.
18.	Carragee EJ. Pyogenic vertebral osteomyelitis. J Bone Joint Surg Am 1997; 79(6):874-80.
19.	Kemp HB, Jackson JW, Jeremiah JD, Hall AJ. Pyogenic infections occurring primarily in intervertebral discs. J Bone Joint Surg Br 1973; 55(4):698-714.
20.	Pritchard AE, Thompson WA. Acute pyogenic infections of the spine in children. J Bone Joint Surg Br 1960; 42-B:86-9.
21.	Tampieri D, Weill A, Melanson D, Ethier R. Percutaneous aspiration biopsy in cervical spine lytic lesions. Indications and technique. Neuroradiology 1991; 33(1):43-7.
22.	Perronne C, Saba J, Behloul Z, et al. Pyogenic and tuberculous spondylodiskitis (vertebral osteomyelitis) in 80 adult patients. Clin Infect Dis 1994; 19(4):746-50.
23.	Frederickson B, Yuan H, Olans R. Management and outcome of pyogenic vertebral osteomyelitis. Clin Orthop Relat Res 1978(131):160-7.
24.	Kulowski J. Pyogenic osteomyelitis of the spine: an analysis and discussion of 102 cases. J Bone Joint Surg Am 1936; 18:343-364.
25.	Malawski SK, Lukawski S. Pyogenic infection of the spine. Clin Orthop Relat Res 1991(272):58-66.
26.	Lucio E, Adesokan A, Hadjipavlou AG, et al. Pyogenic spondylodiskitis: a radiologic/pathologic and culture correlation study. Arch Pathol Lab Med 2000; 124(5):712-6.
27.	Chew FS, Kline MJ. Diagnostic yield of CT-guided percutaneous aspiration procedures in suspected spontaneous infectious diskitis. Radiology 2001; 218(1):211-4.
28.	Milone FP, Bianco AJ, Jr., Ivins JC. Infections of the intervertebral disk in children. JAMA 1962; 181:1029-33.
29.	Hoffer FA, Strand RD, Gebhardt MC. Percutaneous biopsy of pyogenic infection of the spine in children. J Pediatr Orthop 1988; 8(4):442-4.
30.	Nagel DA, Albright JA, Keggi KJ, Southwick WO. Closer Look at Spinal Lesions: Open Biopsy of Vertebral Lesions. JAMA 1965; 191:975-8.
31.	Cotty P, Fouquet B, Pleskof L, et al. Vertebral osteomyelitis: value of percutaneous biopsy. 30 cases. J Neuroradiol 1988; 15(1):13-21.
32.	McGahan JP, Dublin AB. Evaluation of spinal infections by plain radiographs, computed tomography, intrathecal metrizamide, and CT-guided biopsy. Diagn Imaging Clin Med 1985; 54(1):11-20.
33.	Osti OL, Fraser RD, Vernon-Roberts B. Discitis after discography. The role of prophylactic antibiotics. J Bone Joint Surg Br 1990; 72(2):271-4.
34.	Cierny G, 3rd. Chronic osteomyelitis: results of treatment. Instr Course Lect 1990; 39:495-508.
35.	Gepstein R, Folman Y, Lidor C, et al. Management of pyogenic vertebral osteomyelitis with spinal cord compression in the elderly. Paraplegia 1992; 30(11):795-8.
36.	Patzakis MJ, Rao S, Wilkins J, et al. Analysis of 61 cases of vertebral osteomyelitis. Clin Orthop Relat Res 1991(264):178-83.
37.	Chastre J. Evolving problems with resistant pathogens. Clin Microbiol Infect 2008; 14 Suppl 3:3-14.
38.	Robertson RC, Ball RP. Destructive Spine Lesions.  Diagnosis by needle biopsy. J Bone Joint Surg Am 1935; 17:749-758.









Legends and Tables


Treating Medical ServiceNumber of Patients (N=39)Biopsies Performed (N=20)Biopsies Performed Prior to the Initiation of Antibiotics (N=9)General Internal Medicine27134Orthopaedic Spine644Neurologic Surgery631
 
Table 1 � 	The number of patients admitted to various treating medical services and the number of biopsies that were obtained are depicted.



PatientEmpiric Antibiotic SelectedSpecific Bacterial Pathogen IsolatedSource of Bacterial PathogenAntibiotic Selected for Long-term Administration Based on Bacterial Specific Pathogen1Vancomycin / ZosynMSSABiopsy and CultureCephazolin2Vancomycin / ZosynMSSABiopsy and CultureCephazolin3Vancomycin / CeftazidimeE. ColiBiopsy and CultureCiprofloxacin / Ceftriaxone4VancomycinE. ColiBiopsy and CultureCeftriaxone / Ertapenem5Vancomycin / CiprofloxacinE. ColiBiopsy and CultureCiprofloxacin / Bactrim6Vancomycin / Ciprofloxacin / CeftriaxoneBurkholderia pickettii Biopsy and CultureCefepime / Bactrim7Vancomycin / CiprofloxacinPseudomonas aeruginosa Blood CultureCiprofloxacin / Cefepime8 Vancomycin / Ampicillin / CiprofloxacinEnterococcusBlood CultureAmpicillin / Gentamycin9Vancomycin / CeftriaxoneMSSABlood CultureCephazolin / Rifampin

Table 2	Final long-term antibiotics chosen for treatment were changed in 9 patients with a cultured bacterial pathogen.  
(MSSA = Methicillin-sensitive Staphlococcus aureus, E. Coli = Escherichia coli)
	










Spinal Discitis Treatment Guidelines

 PAGE   \* MERGEFORMAT 1




�V	�	�	�
�
OP�������01DE`abz{������"#����������ż�����������|��|�|��|����t�m�hf.�hE)TjhE)TUh.�hE)TH*mHsHh.�hE)TmHsHh.�hE)TH*h.�hE)T	hE)T5�h.�hE)T5�CJaJhQz5�CJaJhE)T5�CJaJhKbphE)TmHsHhE)TmHsHh�hE)T5�h�hE)T6�B*phh�hE)ThE)TB*phhE)T(4]���������		�	�	NP������������������������������������`��gdE)T$a$gdE)TgdE)T���������������2Fb|������������������������������
&FgdE)T$a$gdE)TgdE)T��3
H
_
`
�
�
�
�
�
�
�
�
"#5W�����78������������������������d�gdE)T$a$gdE)TgdE)T�h`�hgdE)T���h^��`�hgdE)T567�����������(.KL=>L"#0��������22222���������������ɻɻɴɭ�ɦ͗͟���wswkwh�"�h�"�H*h�"�jh�{+Uh�{+h�{+h�{+	h�{+5�h1X�h�O�5�h1X�h1X�5�h�=PhU<Fh�hU<Fh,khU<Fh�zhU<Fh�+�hU<Fh�{hU<FhU<F	hU<F5�h	EhE)T5�	hE)T5�hE)Th1hE)T0JjhE)TU�jhE)TU(89:;<�������>#$���
��M�v{x|x�x�zT����������������������������d�`��gd�9�d�gd"Eqd�gdU<FgdE)T2'2B2G2H2I2WWWW-WAWEWQWdWeWi�j�w�x�z���.�/�َڎ܎ݎߎ���
��!�?�@�W�X�`�a�b�s��������������������=���Y�������������������Ž����ܵ�����୦ئئ؛��ؗ�h�p�h*jh#Fzh#FzUh#Fzh#Fzjh�X�Uh�Qh�X�jh�EUh�Eh#Fzh�Ejh�Uh#Fzh�Sth�"�h�"�H*h�"�jh�H�Uh�r�h�{+h�eS7Y�Z�����	�
�(�0�1�>�[�k�z���������������'(34NX^rs����������� � � � !.!7!8!W!d!m!�!�!�!�!�!�!�����������������Ž�����̸�۴۰���۠��ۜ۰���ۜۘ��hH�h�8Hh��jh��Uh�Sth�l�h�Qh��	h�6�jh�Uh�h�h�h�6�h�h��h��h�h*h�p�h�"�h�"�H*h�"�jh#FzU9�!�!�!"""�M�M�M�M�M�M�MN!N2N;NCNQN^NgN�N�N�N�NOOOO#O$O'OO�O�O�O�O�O�O�O�v�v�v�v�v�v�vw	wTw{ww�w��������������������豼��ĭ���̩̩�����������h(-�h�Eh
Y�h"Eq	h"Eq5�jh\W(Uh�[&h\W(h�E��j�h�"�Ujh�"�Ujh/%�Uh�*�hi�	h�St5�h�h�h�"�h�"�H*h�"�jhH�Uh��h�Sth�K
4�w�w�w�w�w�wxxxx$xMxaxyxzx{x|x�x�x�x�xy3y�yHz�z�z�zK{j{k{l{m{WXZ[w�������Q�T�h�u�{���������؀�����������������������������Ͽ������������������������������h�eh�vFh^t�h,Dqh�"�h�"�H*h�"�jh��Uh��h=?7hn�hSJh�{-h�h�W�	h�5�h1X�h1X�5�	hE)T5�h1X�h"Eq5�h"Eqh"Eqh�E�huh�p�:�������E�[�r�����Ɂ́�����P�T�g�k�n�{�����Â˂͂�
�$�&�9�=�`�����̃؃�����?�P�X�\�l�m�n�s�u������������������օ���	�
��������������������������������������������������������������칱h1X�h1X�5�h�h�{-h1X�h�(ch�Qh�X�h%h1uh
Y�h(-�h�9�h�eh^hh�W�h3?h�vFh^t�hrA�DT��	���b�}�ޑ��2�ʞ˞֞t�����	�ny������������������������0�d�^��`�0�gd
Vad�gd
Va��d�`��gd"y���d�`��gd�v���d�`��gd1O�d�gd"Eq��d�`��gd�W���,�;�F�q�r�t�������������������������‡Ç͇�����4�C�X�d�������������ƈɈ׈���.�@�a�b������������
��4�6�7�Z�a�g�h�s�������������������������������������������������ʾ�޺޺޶޺޶޺�haW�heIh��h�"�h�"�H*h�"�jh��Uh=?7h�_�h]a�h�r�hqm�h1O�>*h1O�h7Q�h�ehrA�	hrA�5�D��ގ���#�$�?�@�|�}������������������ݑޑ��Q�W�������̒Β��_�����������&�:�f�k�l���єӔܔ�������$�1�5�6�V�i������������������������������������ؼ�ĸ�̼��̼������̨������������h=th�]�h�]�>*h�]�h�=h�v�h�R0h�?ThT+h7Q�h�]�h�>*h�hQ�h-!hn�h]a�h]a�>*h]a�h1O�heIhU8A����ĕʕݕ������"�����ǖі֖��������}����������������������������&�.�7�C�D�K�L�M�����ޘ���ÙřΙϙЙ�0�1�2�d�j�������������������ǚ���������������������������������������������������������������Լ�Լh0]�h"y�h%4�h�E�h�.�h�h�5h!A�hZh-!h�t:h�heIh�+�h�h�h7Q�hT+h�)�Hǚ֚ך���h�������������ӛ���*�>�Y�o���ۜ��
���0�F���������ǝם�����	�#�,�4�5�6�7�ɞʞ՞֞מ����E�z��Q�T�W��������������������������������������������������������hd�hfZ�h �hd�h �hfZ�	hfZ�5�	h�*5�h1X�h1X�5�h�E�h�t:h�h�&�hH.ehn�h�d[6�h�=h�d[6�hXq�h�d[h�=h0]�h�h�h"y�h!A�<W�`����������������
�B�M�U�y��� �!�N�Q�k�l�n�o�q�r�s�t�������¨������%��)�*�<�>�V�i�j�k�m�n�p�q�������*���
����;�����������������������������������������������ͥť������	h��5�jh�lXUh��hHH�h�Qh��hsL�h�{uh�"�h�"�H*h�"�jhn�Uhn�h6chEE^hEE^hjohEE^h �h}A!hd�hfZ�?;�y�z�$�%�'�(�)������������*�H�R�S�b�c�w�x�y�z�����������>�{����������U�_�k�m�w�x������������������'�F�J�����������������������������������������������౵൭���������������������h7�h�M�h|�h�<7hj
thDHh��h �hH��j�Qh�"�Ujh�"�UjhH�Uh�"h�y�h�"�h�"�H*h�"�jh�y�Uh�&r?������������������%�Q�g�h�i��������������c�d�e�������������
��)�Z�[�\������������������������
��"�F�G�H�������������������������������ü�������묨ä�àà���������똨jh6cUh6ch�Qh
 �jhg9�Uhg9�hA�hA�h��h��jh|�UjhFuUhn&�hFuh|�h"Eqhj
th�"�h�"�H*h�"�jh�s�U<���Jbcyz���	�	�	�	�	�
�
!��j����)
,
T
i
j
�
�
�
�
$1a����':Cklmny�������������������ÿû÷÷������������������������à����hjU�h
VamHsHh
Va	h
Va5�hg9�hg9�hdh#FzhK�hsL�hEE^h��h �h�B	h%4�h�"h�"�h�"�H*h�"�jh�m�Uh�m�	hg9�6�h�=h6c6�h�Hdh�Qh6c7�w���r�|��e��N�0�C����V�������������������������������0�d�^��`�0�gd
Va�5�%"O".$/$0$1$8$K$L$M$�$�$�$�$%%0%1%4%;%?%�%�%�%&�&�����������Ư��������z�s�\K hR]/h�'�CJPJaJnH	tH	,hR]/h�'�CJOJPJQJ^JaJnH	tH	h>yh�'�	h�'�5�h�5h�'�5�,h�5h�'�CJOJPJQJ^JaJnH	tH	 h�5h�'�CJPJaJnH	tH	,h�5h�'�CJOJPJQJ^JaJnH	tH	h�'�h�'�h+&�h�'�5�h�"�h�vXhA�h�5h�"�h
VamHsHh
VahjU�h
VamHsH�X�n -!�!%"�"M#�#/$0$1$2$3$4$5$6$7$8$K$L$M$����������������������d�gd�'����0�^��`�0�gdA����0�d�^��`�0����0�d�^��`�0�gd
VaM$f$�$�$�$�$�$�$�$�$����\�����kd�$$If�l���\�a
e=�F��F����������F�F�	����
t��L6�������������������������������4�4�
lB�a�]p�(��������yt��$$Ifa$gd��	�$�$%%%%h\\\\$$Ifa$gd���kdH�$$If�l���\�a
e=�F����������F������������������F���������F�	������������
t��L6�������������������������������������������������������4�4�
lB�a�]p�(��������yt��%%*%,%.%0%h\\\\$$Ifa$gd���kd��$$If�l���\�a
e=�F����������F������������������F���������F�	������������
t��L6�������������������������������������������������������4�4�
lB�a�]p�(��������yt��0%1%2%4%�%�%�%�%h[[NFFFd�gd�'����`�^��`�`�gd�'����0�^��`�0�gd�'��kd�$$If�l��\�a
e=�F������F��������������F�����F�	��������
t��L6�������������������������������������������4�4�
lB�a�]p�(��������yt���%�%�%&)&&�&�&�����D��kd'�$$If�l���r�$l\%�FD�Fh�����FH�����F����������F�
t���$6��������������������������������������4�4�
lB�a�]p�2����������yt��$$Ifa$gd���&�&�&�&�&�&�&�&����D���kdz�$$If�l���r�$l\%gD��������gh������������gH������������g�����������������g���������
t���$6��������������������������������������������������������������������4�4�
lB�a�]p�2����������yt��$$Ifa$gd���&�&�&�&�&D'E'�'�'�'�'((((@(A(^(t(�(�(�(�(A)B)D)K)L)�)�)�)�)�)�)*
**************��������������������غ�������������������h�djh�dUh�"�h�m�h�'�hn�h�'�6�h�=h�'�6�h4(h�'�	h�'�5�h�5h�'�5�h�'�2hR]/h�'�6�CJOJPJQJ]�^JaJnH	tH	 hR]/h�'�CJPJaJnH	tH	,hR]/h�'�CJOJPJQJ^JaJnH	tH	0�&�&�&�&�&�&
''���D����kd�$$If�l���r�$l\%gD��������gh������������gH������������g�����������������g���������
t���$6��������������������������������������������������������������������4�4�
lB�a�]p�2����������yt��$$Ifa$gd��'('D'E'G'R'Z'm'��D�����kdH�$$If�l���r�$l\%gD��������gh������������gH������������g�����������������g���������
t���$6��������������������������������������������������������������������4�4�
lB�a�]p�2����������yt��$$Ifa$gd��m'�'�'�'�'�'�'�'�D������kd��$$If�l���r�$l\%gD��������gh������������gH������������g�����������������g���������
t���$6��������������������������������������������������������������������4�4�
lB�a�]p�2����������yt��$$Ifa$gd���'�'�'((-(@(PDDDDD$$Ifa$gd���kd�$$If�l���r�$l\%gD��������gh������������gH������������g�����������������g���������
t���$6��������������������������������������������������������������������4�4�
lB�a�]p�2����������yt��@(A(C(^(v(�(�(PDDDDD$$Ifa$gd���kd}�$$If�l���r�$l\%gD��������gh������������gH������������g�����������������g���������
t���$6��������������������������������������������������������������������4�4�
lB�a�]p�2����������yt���(�(�(�(�(�(�(PDDDDD$$Ifa$gd���kd�$$If�l���r�$l\%gD��������gh������������gH������������g�����������������g���������
t���$6��������������������������������������������������������������������4�4�
lB�a�]p�2����������yt���(�(�())+)A)PDDDDD$$Ifa$gd���kdK�$$If�l���r�$l\%gD��������gh������������gH������������g�����������������g���������
t���$6��������������������������������������������������������������������4�4�
lB�a�]p�2����������yt��A)B)C)D)�)*PCC6-��^��gd�'����`�^��`�`�gd�'����0�^��`�0�gd�'��kd��$$If�l��r�$l\%gD����gh��������gH��������g�������������g�����
t���$6�����������������������������������������������������4�4�
lB�a�]p�2����������yt��************C*D*`*a*b*c*d*������������������$a$$a$gd�"�gd1X����0�d�^��`�0�gd�'�d�gd�'�gd�'�*%*7*B*D*E*\*]*^*_*b*c*d*���������h�dhQzmHnHujh�"�Uh�"�h�'�90P1�h:pnN��/ ��=!�"�#��$��%��������D���y������K�ryangarcia78@gmail.com���y������K�<mailto:ryangarcia78@gmail.com�PD<EndNote><Cite><Author>Milone</Author><Year>1962</Year><RecNum>25</RecNum><record><rec-number>25</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Milone, F. P.</author><author>Bianco, A. J., Jr.</author><author>Ivins, J. C.</author></authors></contributors><titles><title>Infections of the intervertebral disk in children</title><secondary-title>JAMA</secondary-title></titles><periodical><full-title>JAMA</full-title></periodical><pages>1029-33</pages><volume>181</volume><edition>1962/09/22</edition><keywords><keyword>*Child</keyword><keyword>*Infant</keyword><keyword>*Staphylococcal Infections</keyword></keywords><dates><year>1962</year><pub-dates><date>Sep 22</date></pub-dates></dates><isbn>0098-7484 (Print)&#xD;0098-7484 (Linking)</isbn><accession-num>14474216</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=14474216</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Bonfiglio</Author><Year>2006</Year><RecNum>2</RecNum><record><rec-number>2</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Bonfiglio, M.</author><author>Lange, T. A.</author><author>Kim, Y. M.</author></authors></contributors><titles><title>The Classic: Pyogenic vertebral osteomyelitis: disk space infections. 1973</title><secondary-title>Clin Orthop Relat Res</secondary-title></titles><periodical><full-title>Clin Orthop Relat Res</full-title></periodical><pages>4-8</pages><volume>444</volume><edition>2006/03/09</edition><keywords><keyword>Bacterial Infections/diagnosis/*history/therapy</keyword><keyword>Discitis/*history/microbiology</keyword><keyword>History, 20th Century</keyword><keyword>Humans</keyword><keyword>Osteomyelitis/*history/microbiology</keyword></keywords><dates><year>2006</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>0009-921X (Print)</isbn><accession-num>16523120</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=16523120</url></related-urls></urls><electronic-resource-num>10.1097/01.blo.0000201172.64764.bb&#xD;00003086-200603000-00002 [pii]</electronic-resource-num><language>eng</language></record></Cite><Cite><Author>Hoffer</Author><Year>1988</Year><RecNum>6</RecNum><record><rec-number>6</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hoffer, F. A.</author><author>Strand, R. D.</author><author>Gebhardt, M. C.</author></authors></contributors><auth-address>Department of Radiology, Children&apos;s Hospital, Boston, MA 02115.</auth-address><titles><title>Percutaneous biopsy of pyogenic infection of the spine in children</title><secondary-title>J Pediatr Orthop</secondary-title></titles><periodical><full-title>J Pediatr Orthop</full-title></periodical><pages>442-4</pages><volume>8</volume><number>4</number><edition>1988/07/01</edition><keywords><keyword>Adolescent</keyword><keyword>Anti-Bacterial Agents/therapeutic use</keyword><keyword>Biopsy/*methods</keyword><keyword>Braces</keyword><keyword>Child</keyword><keyword>Chronic Disease</keyword><keyword>Combined Modality Therapy</keyword><keyword>Evaluation Studies as Topic</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Osteomyelitis/*pathology/radiography/therapy</keyword><keyword>Retrospective Studies</keyword><keyword>Salmonella Infections/*pathology/radiography/therapy</keyword><keyword>Spinal Diseases/*pathology/radiography/therapy</keyword><keyword>Staphylococcal Infections/*pathology/radiography/therapy</keyword><keyword>*Tomography, X-Ray Computed</keyword></keywords><dates><year>1988</year><pub-dates><date>Jul-Aug</date></pub-dates></dates><isbn>0271-6798 (Print)</isbn><accession-num>3392196</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=3392196</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Digby</Author><Year>1979</Year><RecNum>23</RecNum><record><rec-number>23</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Digby, J. M.</author><author>Kersley, J. B.</author></authors></contributors><titles><title>Pyogenic non-tuberculous spinal infection: an analysis of thirty cases</title><secondary-title>J Bone Joint Surg Br</secondary-title></titles><periodical><full-title>J Bone Joint Surg Br</full-title></periodical><pages>47-55</pages><volume>61</volume><number>1</number><edition>1979/02/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Anti-Bacterial Agents/therapeutic use</keyword><keyword>Child</keyword><keyword>Diagnosis, Differential</keyword><keyword>Escherichia coli Infections</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Osteomyelitis/*diagnosis/etiology/radiography</keyword><keyword>Proteus Infections</keyword><keyword>Spinal Diseases/*diagnosis/etiology</keyword><keyword>Staphylococcal Infections</keyword><keyword>Suppuration/etiology</keyword><keyword>Tuberculosis, Spinal/diagnosis</keyword></keywords><dates><year>1979</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>0301-620X (Print)&#xD;0301-620X (Linking)</isbn><accession-num>370121</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=370121</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Carragee</Author><Year>1997</Year><RecNum>14</RecNum><record><rec-number>14</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Carragee, E. J.</author></authors></contributors><auth-address>Stanford University Medical Center, California 94305, USA. carragee@leland.stanford.edu</auth-address><titles><title>Pyogenic vertebral osteomyelitis</title><secondary-title>J Bone Joint Surg Am</secondary-title></titles><periodical><full-title>J Bone Joint Surg Am</full-title></periodical><pages>874-80</pages><volume>79</volume><number>6</number><edition>1997/06/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adrenal Cortex Hormones/therapeutic use</keyword><keyword>Adult</keyword><keyword>Age Factors</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Antineoplastic Agents/therapeutic use</keyword><keyword>Bacterial Infections/*diagnosis/surgery</keyword><keyword>Corynebacterium Infections/diagnosis/surgery</keyword><keyword>Debridement</keyword><keyword>Diabetes Complications</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Gram-Positive Bacterial Infections/diagnosis/surgery</keyword><keyword>Humans</keyword><keyword>Immune System Diseases/complications</keyword><keyword>Immunocompromised Host</keyword><keyword>Kidney Failure/complications</keyword><keyword>Liver Failure/complications</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Neoplasms/drug therapy</keyword><keyword>Nutrition Disorders/complications</keyword><keyword>Osteomyelitis/diagnosis/*microbiology/surgery</keyword><keyword>Propionibacterium acnes</keyword><keyword>Retrospective Studies</keyword><keyword>Rheumatic Diseases/complications</keyword><keyword>Spinal Diseases/diagnosis/*microbiology/surgery</keyword><keyword>Spinal Fusion</keyword><keyword>Staphylococcal Infections/diagnosis/surgery</keyword><keyword>Staphylococcus epidermidis</keyword><keyword>Survival Rate</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>1997</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>0021-9355 (Print)</isbn><accession-num>9199385</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=9199385</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Ambrose</Author><Year>1966</Year><RecNum>1</RecNum><record><rec-number>1</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ambrose, G. B.</author><author>Alpert, M.</author><author>Neer, C. S.</author></authors></contributors><titles><title>Vertebral osteomyelitis. A diagnostic problem</title><secondary-title>JAMA</secondary-title></titles><periodical><full-title>JAMA</full-title></periodical><pages>619-22</pages><volume>197</volume><number>8</number><edition>1966/08/22</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Anti-Bacterial Agents/therapeutic use</keyword><keyword>Arthrodesis</keyword><keyword>Biopsy</keyword><keyword>Blood Sedimentation</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>Diagnosis, Differential</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Humans</keyword><keyword>Immunity</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Osteomyelitis/*diagnosis</keyword><keyword>Spinal Diseases/*diagnosis</keyword><keyword>Spine/radiography</keyword></keywords><dates><year>1966</year><pub-dates><date>Aug 22</date></pub-dates></dates><isbn>0098-7484 (Print)</isbn><accession-num>5953091</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=5953091</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Kemp</Author><Year>1973</Year><RecNum>24</RecNum><record><rec-number>24</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kemp, H. B.</author><author>Jackson, J. W.</author><author>Jeremiah, J. D.</author><author>Hall, A. J.</author></authors></contributors><titles><title>Pyogenic infections occurring primarily in intervertebral discs</title><secondary-title>J Bone Joint Surg Br</secondary-title></titles><periodical><full-title>J Bone Joint Surg Br</full-title></periodical><pages>698-714</pages><volume>55</volume><number>4</number><edition>1973/11/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Bacteria/isolation &amp; purification</keyword><keyword>*Bacterial Infections/complications/pathology</keyword><keyword>Diagnosis, Differential</keyword><keyword>Humans</keyword><keyword>*Intervertebral Disk/microbiology/pathology/radiography</keyword><keyword>Myelography</keyword><keyword>Osteomyelitis/complications/diagnosis/radiography</keyword><keyword>*Spinal Diseases/complications/microbiology/pathology/radiography</keyword><keyword>Staphylococcal Infections/diagnosis</keyword><keyword>Suppuration</keyword><keyword>Tomography</keyword></keywords><dates><year>1973</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>0301-620X (Print)&#xD;0301-620X (Linking)</isbn><accession-num>4766176</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=4766176</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Nagel</Author><Year>1965</Year><RecNum>30</RecNum><record><rec-number>30</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Nagel, D. A.</author><author>Albright, J. A.</author><author>Keggi, K. J.</author><author>Southwick, W. O.</author></authors></contributors><titles><title>Closer Look at Spinal Lesions: Open Biopsy of Vertebral Lesions</title><secondary-title>JAMA</secondary-title></titles><periodical><full-title>JAMA</full-title></periodical><pages>975-8</pages><volume>191</volume><edition>1965/03/22</edition><keywords><keyword>*Adenocarcinoma</keyword><keyword>*Axis</keyword><keyword>*Back Pain</keyword><keyword>*Biopsy</keyword><keyword>*Drug Therapy</keyword><keyword>*Fractures, Bone</keyword><keyword>*Geriatrics</keyword><keyword>*Klebsiella</keyword><keyword>*Osteitis</keyword><keyword>*Osteitis Deformans</keyword><keyword>*Postoperative Complications</keyword><keyword>*Radiography</keyword><keyword>*Spinal Diseases</keyword><keyword>*Spinal Fusion</keyword><keyword>*Spinal Injuries</keyword><keyword>*Spinal Neoplasms</keyword><keyword>*Staphylococcal Infections</keyword><keyword>*Surgical Procedures, Operative</keyword><keyword>*Tuberculosis, Spinal</keyword></keywords><dates><year>1965</year><pub-dates><date>Mar 22</date></pub-dates></dates><isbn>0098-7484 (Print)&#xD;0098-7484 (Linking)</isbn><accession-num>14257739</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=14257739</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Chew</Author><Year>2001</Year><RecNum>34</RecNum><record><rec-number>34</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Chew, F. S.</author><author>Kline, M. J.</author></authors></contributors><auth-address>Department of Radiology, Wake Forest University School of Medicine, Medical Center Dr, Winston-Salem, NC 27157-1088, USA. fchew@wfubmc.edu</auth-address><titles><title>Diagnostic yield of CT-guided percutaneous aspiration procedures in suspected spontaneous infectious diskitis</title><secondary-title>Radiology</secondary-title></titles><periodical><full-title>Radiology</full-title></periodical><pages>211-4</pages><volume>218</volume><number>1</number><edition>2001/01/12</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Discitis/*microbiology/*radiography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Retrospective Studies</keyword><keyword>Sensitivity and Specificity</keyword><keyword>Suction</keyword><keyword>*Tomography, X-Ray Computed</keyword></keywords><dates><year>2001</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>0033-8419 (Print)&#xD;0033-8419 (Linking)</isbn><accession-num>11152804</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=11152804</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Frederickson</Author><Year>1978</Year><RecNum>41</RecNum><record><rec-number>41</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Frederickson, B.</author><author>Yuan, H.</author><author>Olans, R.</author></authors></contributors><titles><title>Management and outcome of pyogenic vertebral osteomyelitis</title><secondary-title>Clin Orthop Relat Res</secondary-title></titles><periodical><full-title>Clin Orthop Relat Res</full-title></periodical><pages>160-7</pages><number>131</number><edition>1978/03/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Anti-Bacterial Agents/therapeutic use</keyword><keyword>*Cervical Vertebrae/radiography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>*Lumbar Vertebrae/radiography</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Osteomyelitis/radiography/*therapy</keyword><keyword>Suppuration</keyword><keyword>*Thoracic Vertebrae/radiography</keyword></keywords><dates><year>1978</year><pub-dates><date>Mar-Apr</date></pub-dates></dates><isbn>0009-921X (Print)&#xD;0009-921X (Linking)</isbn><accession-num>657614</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=657614</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Cotty</Author><Year>1988</Year><RecNum>7</RecNum><record><rec-number>7</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cotty, P.</author><author>Fouquet, B.</author><author>Pleskof, L.</author><author>Audurier, A.</author><author>Cotty, F.</author><author>Goupille, P.</author><author>Valat, J. P.</author><author>Alison, D.</author><author>Laffont, J.</author></authors></contributors><titles><title>Vertebral osteomyelitis: value of percutaneous biopsy. 30 cases</title><secondary-title>J Neuroradiol</secondary-title></titles><periodical><full-title>J Neuroradiol</full-title></periodical><pages>13-21</pages><volume>15</volume><number>1</number><edition>1988/01/01</edition><keywords><keyword>Biopsy, Needle</keyword><keyword>Humans</keyword><keyword>Osteomyelitis/*pathology</keyword><keyword>Spinal Diseases/*pathology</keyword><keyword>Spine/*pathology</keyword></keywords><dates><year>1988</year></dates><isbn>0150-9861 (Print)</isbn><accession-num>3397771</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=3397771</url></related-urls></urls><language>eng&#xD;fre</language></record></Cite><Cite><Author>Perronne</Author><Year>1994</Year><RecNum>19</RecNum><record><rec-number>19</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Perronne, C.</author><author>Saba, J.</author><author>Behloul, Z.</author><author>Salmon-Ceron, D.</author><author>Leport, C.</author><author>Vilde, J. L.</author><author>Kahn, M. F.</author></authors></contributors><auth-address>Department of Infectious and Tropical Diseases, Hopital Bichat-Claude Bernard, Paris, France.</auth-address><titles><title>Pyogenic and tuberculous spondylodiskitis (vertebral osteomyelitis) in 80 adult patients</title><secondary-title>Clin Infect Dis</secondary-title></titles><periodical><full-title>Clin Infect Dis</full-title></periodical><pages>746-50</pages><volume>19</volume><number>4</number><edition>1994/10/01</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Bacteriological Techniques</keyword><keyword>Biopsy, Needle</keyword><keyword>Discitis/diagnosis/*microbiology/pathology</keyword><keyword>Female</keyword><keyword>*Gram-Negative Bacterial Infections/diagnosis</keyword><keyword>Humans</keyword><keyword>Intervertebral Disk/microbiology/pathology</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Osteomyelitis/diagnosis/*microbiology/pathology</keyword><keyword>Retrospective Studies</keyword><keyword>*Staphylococcal Infections/diagnosis</keyword><keyword>*Streptococcal Infections/diagnosis</keyword><keyword>*Tuberculosis, Spinal/diagnosis/pathology</keyword></keywords><dates><year>1994</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>1058-4838 (Print)</isbn><accession-num>7803642</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=7803642</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>McGahan</Author><Year>1985</Year><RecNum>8</RecNum><record><rec-number>8</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>McGahan, J. P.</author><author>Dublin, A. B.</author></authors></contributors><titles><title>Evaluation of spinal infections by plain radiographs, computed tomography, intrathecal metrizamide, and CT-guided biopsy</title><secondary-title>Diagn Imaging Clin Med</secondary-title></titles><periodical><full-title>Diagn Imaging Clin Med</full-title></periodical><pages>11-20</pages><volume>54</volume><number>1</number><edition>1985/01/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Bacterial Infections/*radiography</keyword><keyword>Biopsy, Needle</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Metrizamide/diagnostic use</keyword><keyword>Middle Aged</keyword><keyword>Mycoses/*radiography</keyword><keyword>*Myelography</keyword><keyword>Osteomyelitis/etiology/pathology/radiography</keyword><keyword>Radiographic Image Enhancement</keyword><keyword>Spine/pathology/radiography</keyword><keyword>Spondylitis/pathology/*radiography</keyword><keyword>*Tomography, X-Ray Computed</keyword><keyword>Tuberculosis, Spinal/complications</keyword></keywords><dates><year>1985</year></dates><isbn>0254-881X (Print)</isbn><accession-num>3844326</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=3844326</url></related-urls></urls><language>eng</language></record></Cite></EndNote>DHD<EndNote><Cite><Author>Malawski</Author><Year>1991</Year><RecNum>27</RecNum><record><rec-number>27</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Malawski, S. K.</author><author>Lukawski, S.</author></authors></contributors><auth-address>Orthopaedic Department, Postgraduate Medical Education Academy, Warsaw, Poland.</auth-address><titles><title>Pyogenic infection of the spine</title><secondary-title>Clin Orthop Relat Res</secondary-title></titles><periodical><full-title>Clin Orthop Relat Res</full-title></periodical><pages>58-66</pages><number>272</number><edition>1991/11/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Bacterial Infections/complications/diagnosis/*therapy</keyword><keyword>*Cervical Vertebrae</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>*Lumbar Vertebrae</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Reoperation</keyword><keyword>Sacrum</keyword><keyword>Spinal Diseases/complications/diagnosis/therapy</keyword><keyword>Spondylitis/complications/diagnosis/therapy</keyword><keyword>*Thoracic Vertebrae</keyword></keywords><dates><year>1991</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>0009-921X (Print)&#xD;0009-921X (Linking)</isbn><accession-num>1934752</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=1934752</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Gepstein</Author><Year>1992</Year><RecNum>42</RecNum><record><rec-number>42</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Gepstein, R.</author><author>Folman, Y.</author><author>Lidor, C.</author><author>Barchilon, V.</author><author>Catz, A.</author><author>Hallel, T.</author></authors></contributors><auth-address>Department of Orthopaedics, Meir Hospital, Kfar Saba, Israel.</auth-address><titles><title>Management of pyogenic vertebral osteomyelitis with spinal cord compression in the elderly</title><secondary-title>Paraplegia</secondary-title></titles><periodical><full-title>Paraplegia</full-title></periodical><pages>795-8</pages><volume>30</volume><number>11</number><edition>1992/11/01</edition><keywords><keyword>Aged</keyword><keyword>Bacterial Infections/*complications/drug therapy</keyword><keyword>Escherichia coli Infections/complications/drug therapy</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Klebsiella Infections/complications/drug therapy</keyword><keyword>Male</keyword><keyword>Osteomyelitis/complications/drug therapy/*surgery</keyword><keyword>Spinal Cord Compression/complications/drug therapy/*surgery</keyword><keyword>Staphylococcal Infections/complications/drug therapy</keyword></keywords><dates><year>1992</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>0031-1758 (Print)&#xD;0031-1758 (Linking)</isbn><accession-num>1484732</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=1484732</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Carragee</Author><Year>1997</Year><RecNum>14</RecNum><record><rec-number>14</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Carragee, E. J.</author></authors></contributors><auth-address>Stanford University Medical Center, California 94305, USA. carragee@leland.stanford.edu</auth-address><titles><title>Pyogenic vertebral osteomyelitis</title><secondary-title>J Bone Joint Surg Am</secondary-title></titles><periodical><full-title>J Bone Joint Surg Am</full-title></periodical><pages>874-80</pages><volume>79</volume><number>6</number><edition>1997/06/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adrenal Cortex Hormones/therapeutic use</keyword><keyword>Adult</keyword><keyword>Age Factors</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Antineoplastic Agents/therapeutic use</keyword><keyword>Bacterial Infections/*diagnosis/surgery</keyword><keyword>Corynebacterium Infections/diagnosis/surgery</keyword><keyword>Debridement</keyword><keyword>Diabetes Complications</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Gram-Positive Bacterial Infections/diagnosis/surgery</keyword><keyword>Humans</keyword><keyword>Immune System Diseases/complications</keyword><keyword>Immunocompromised Host</keyword><keyword>Kidney Failure/complications</keyword><keyword>Liver Failure/complications</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Neoplasms/drug therapy</keyword><keyword>Nutrition Disorders/complications</keyword><keyword>Osteomyelitis/diagnosis/*microbiology/surgery</keyword><keyword>Propionibacterium acnes</keyword><keyword>Retrospective Studies</keyword><keyword>Rheumatic Diseases/complications</keyword><keyword>Spinal Diseases/diagnosis/*microbiology/surgery</keyword><keyword>Spinal Fusion</keyword><keyword>Staphylococcal Infections/diagnosis/surgery</keyword><keyword>Staphylococcus epidermidis</keyword><keyword>Survival Rate</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>1997</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>0021-9355 (Print)</isbn><accession-num>9199385</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=9199385</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Maiuri</Author><Year>1997</Year><RecNum>15</RecNum><record><rec-number>15</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Maiuri, F.</author><author>Iaconetta, G.</author><author>Gallicchio, B.</author><author>Manto, A.</author><author>Briganti, F.</author></authors></contributors><auth-address>Institute of Neurosurgery, School of Medicine, University, Federico II, Naples, Italy.</auth-address><titles><title>Spondylodiscitis. Clinical and magnetic resonance diagnosis</title><secondary-title>Spine (Phila Pa 1976)</secondary-title></titles><periodical><full-title>Spine (Phila Pa 1976)</full-title></periodical><pages>1741-6</pages><volume>22</volume><number>15</number><edition>1997/08/01</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Discitis/*radiography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Magnetic Resonance Imaging/*standards</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Reference Standards</keyword><keyword>Retrospective Studies</keyword><keyword>Tomography, X-Ray Computed</keyword></keywords><dates><year>1997</year><pub-dates><date>Aug 1</date></pub-dates></dates><isbn>0362-2436 (Print)</isbn><accession-num>9259785</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=9259785</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Lucio</Author><Year>2000</Year><RecNum>17</RecNum><record><rec-number>17</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lucio, E.</author><author>Adesokan, A.</author><author>Hadjipavlou, A. G.</author><author>Crow, W. N.</author><author>Adegboyega, P. A.</author></authors></contributors><auth-address>Department of Pathology, University of Texas Medical Branch, Galveston, TX 77555-0588, USA.</auth-address><titles><title>Pyogenic spondylodiskitis: a radiologic/pathologic and culture correlation study</title><secondary-title>Arch Pathol Lab Med</secondary-title></titles><periodical><full-title>Arch Pathol Lab Med</full-title></periodical><pages>712-6</pages><volume>124</volume><number>5</number><edition>2000/04/27</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Biopsy</keyword><keyword>Blastomyces/isolation &amp; purification</keyword><keyword>Blastomycosis/*microbiology/*pathology/radionuclide imaging</keyword><keyword>Cervical Vertebrae/microbiology/pathology/radionuclide imaging</keyword><keyword>Discitis/*microbiology/*pathology/radionuclide imaging</keyword><keyword>Female</keyword><keyword>Fever/*etiology</keyword><keyword>Gadolinium/diagnostic use</keyword><keyword>Gallium Radioisotopes/diagnostic use</keyword><keyword>Gram-Positive Bacterial Infections/*microbiology/*pathology</keyword><keyword>Gram-Positive Cocci/isolation &amp; purification</keyword><keyword>Humans</keyword><keyword>Lumbar Vertebrae/*microbiology/*pathology/radionuclide imaging</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Thoracic Vertebrae/microbiology/pathology/radionuclide imaging</keyword></keywords><dates><year>2000</year><pub-dates><date>May</date></pub-dates></dates><isbn>0003-9985 (Print)</isbn><accession-num>10782153</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=10782153</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Chew</Author><Year>2001</Year><RecNum>34</RecNum><record><rec-number>34</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Chew, F. S.</author><author>Kline, M. J.</author></authors></contributors><auth-address>Department of Radiology, Wake Forest University School of Medicine, Medical Center Dr, Winston-Salem, NC 27157-1088, USA. fchew@wfubmc.edu</auth-address><titles><title>Diagnostic yield of CT-guided percutaneous aspiration procedures in suspected spontaneous infectious diskitis</title><secondary-title>Radiology</secondary-title></titles><periodical><full-title>Radiology</full-title></periodical><pages>211-4</pages><volume>218</volume><number>1</number><edition>2001/01/12</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Discitis/*microbiology/*radiography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Retrospective Studies</keyword><keyword>Sensitivity and Specificity</keyword><keyword>Suction</keyword><keyword>*Tomography, X-Ray Computed</keyword></keywords><dates><year>2001</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>0033-8419 (Print)&#xD;0033-8419 (Linking)</isbn><accession-num>11152804</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=11152804</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Frederickson</Author><Year>1978</Year><RecNum>41</RecNum><record><rec-number>41</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Frederickson, B.</author><author>Yuan, H.</author><author>Olans, R.</author></authors></contributors><titles><title>Management and outcome of pyogenic vertebral osteomyelitis</title><secondary-title>Clin Orthop Relat Res</secondary-title></titles><periodical><full-title>Clin Orthop Relat Res</full-title></periodical><pages>160-7</pages><number>131</number><edition>1978/03/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Anti-Bacterial Agents/therapeutic use</keyword><keyword>*Cervical Vertebrae/radiography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>*Lumbar Vertebrae/radiography</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Osteomyelitis/radiography/*therapy</keyword><keyword>Suppuration</keyword><keyword>*Thoracic Vertebrae/radiography</keyword></keywords><dates><year>1978</year><pub-dates><date>Mar-Apr</date></pub-dates></dates><isbn>0009-921X (Print)&#xD;0009-921X (Linking)</isbn><accession-num>657614</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=657614</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Kemp</Author><Year>1973</Year><RecNum>24</RecNum><record><rec-number>24</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kemp, H. B.</author><author>Jackson, J. W.</author><author>Jeremiah, J. D.</author><author>Hall, A. J.</author></authors></contributors><titles><title>Pyogenic infections occurring primarily in intervertebral discs</title><secondary-title>J Bone Joint Surg Br</secondary-title></titles><periodical><full-title>J Bone Joint Surg Br</full-title></periodical><pages>698-714</pages><volume>55</volume><number>4</number><edition>1973/11/01</edition><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Bacteria/isolation &amp; purification</keyword><keyword>*Bacterial Infections/complications/pathology</keyword><keyword>Diagnosis, Differential</keyword><keyword>Humans</keyword><keyword>*Intervertebral Disk/microbiology/pathology/radiography</keyword><keyword>Myelography</keyword><keyword>Osteomyelitis/complications/diagnosis/radiography</keyword><keyword>*Spinal Diseases/complications/microbiology/pathology/radiography</keyword><keyword>Staphylococcal Infections/diagnosis</keyword><keyword>Suppuration</keyword><keyword>Tomography</keyword></keywords><dates><year>1973</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>0301-620X (Print)&#xD;0301-620X (Linking)</isbn><accession-num>4766176</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=4766176</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Patzakis</Author><Year>1991</Year><RecNum>43</RecNum><record><rec-number>43</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Patzakis, M. J.</author><author>Rao, S.</author><author>Wilkins, J.</author><author>Moore, T. M.</author><author>Harvey, P. J.</author></authors></contributors><auth-address>Department of Orthopaedics, University of Southern California School of Medicine, Los Angeles.</auth-address><titles><title>Analysis of 61 cases of vertebral osteomyelitis</title><secondary-title>Clin Orthop Relat Res</secondary-title></titles><periodical><full-title>Clin Orthop Relat Res</full-title></periodical><pages>178-83</pages><number>264</number><edition>1991/03/01</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Osteomyelitis/*diagnosis/drug therapy/microbiology</keyword><keyword>Prognosis</keyword><keyword>Spinal Diseases/*diagnosis/drug therapy/microbiology</keyword></keywords><dates><year>1991</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>0009-921X (Print)&#xD;0009-921X (Linking)</isbn><accession-num>1997233</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=1997233</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Tampieri</Author><Year>1991</Year><RecNum>9</RecNum><record><rec-number>9</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Tampieri, D.</author><author>Weill, A.</author><author>Melanson, D.</author><author>Ethier, R.</author></authors></contributors><auth-address>Department of Neuroradiology, Montreal Neurological Institute and Hospital, Quebec, Canada.</auth-address><titles><title>Percutaneous aspiration biopsy in cervical spine lytic lesions. Indications and technique</title><secondary-title>Neuroradiology</secondary-title></titles><periodical><full-title>Neuroradiology</full-title></periodical><pages>43-7</pages><volume>33</volume><number>1</number><edition>1991/01/01</edition><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>*Biopsy, Needle/instrumentation/methods</keyword><keyword>Cervical Vertebrae/*pathology/radiography</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Osteolysis/*pathology/radiography</keyword><keyword>Osteomyelitis/diagnosis/radiography</keyword><keyword>Spinal Diseases/diagnosis/radiography</keyword><keyword>Spinal Neoplasms/diagnosis/radiography</keyword><keyword>Tomography, X-Ray Computed</keyword></keywords><dates><year>1991</year></dates><isbn>0028-3940 (Print)</isbn><accession-num>2027444</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=2027444</url></related-urls></urls><language>eng</language></record></Cite><Cite><Author>Cotty</Author><Year>1988</Year><RecNum>7</RecNum><record><rec-number>7</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cotty, P.</author><author>Fouquet, B.</author><author>Pleskof, L.</author><author>Audurier, A.</author><author>Cotty, F.</author><author>Goupille, P.</author><author>Valat, J. P.</author><author>Alison, D.</author><author>Laffont, J.</author></authors></contributors><titles><title>Vertebral osteomyelitis: value of percutaneous biopsy. 30 cases</title><secondary-title>J Neuroradiol</secondary-title></titles><periodical><full-title>J Neuroradiol</full-title></periodical><pages>13-21</pages><volume>15</volume><number>1</number><edition>1988/01/01</edition><keywords><keyword>Biopsy, Needle</keyword><keyword>Humans</keyword><keyword>Osteomyelitis/*pathology</keyword><keyword>Spinal Diseases/*pathology</keyword><keyword>Spine/*pathology</keyword></keywords><dates><year>1988</year></dates><isbn>0150-9861 (Print)</isbn><accession-num>3397771</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;dopt=Citation&amp;list_uids=3397771</url></related-urls></urls><language>eng&#xD;fre</language></record></Cite></EndNote>1$$If�]!vh5��5��5�5��	#v�#v�#v#v�	:V�l��
t��L6�,�5��5��5�5��	/��/�
�������/��/��/��/�
�/��������B�a�]p�(��������yt��M$$If�]!vh5��5��5�5��	#v�#v�#v#v�	:V�l��
t��L6�,�5��5��5�5��	/�
�/��������/��������/��������/�
�/��������/��������/��������/��B�a�]p�(��������yt��M$$If�]!vh5��5��5�5��	#v�#v�#v#v�	:V�l��
t��L6�,�5��5��5�5��	/�
�/��������/��������/��������/�
�/��������/��������/��������/��B�a�]p�(��������yt��?$$If�]!vh5��5��5�5��	#v�#v�#v#v�	:V�l�
t��L6�,�5��5��5�5��	/��/��������/��������/��/��/��������/��������/��B�a�]p�(��������yt��Q$$If�]!vh5��5�h5�H5��5��#v�#vh#vH#v�#v�:V�l��
t���$6�,�5�D5�h5�H5��5��/��/�
�/�
�������/��������/��/��/��B�a�]p�2����������yt��e$$If�]!vh5��5�h5�H5��5��#v�#vh#vH#v�#v�:V�l��
t���$6�,�5�D5�h5�H5��5��9�/�
�/��/��������/��������/��������/��������/��������/�
�B�a�]p�2����������yt��e$$If�]!vh5��5�h5�H5��5��#v�#vh#vH#v�#v�:V�l��
t���$6�,�5�D5�h5�H5��5��9�/�
�/��/��������/��������/��������/��������/��������/�
�B�a�]p�2����������yt��e$$If�]!vh5��5�h5�H5��5��#v�#vh#vH#v�#v�:V�l��
t���$6�,�5�D5�h5�H5��5��9�/�
�/��/��������/��������/��������/��������/��������/�
�B�a�]p�2����������yt��e$$If�]!vh5��5�h5�H5��5��#v�#vh#vH#v�#v�:V�l��
t���$6�,�5�D5�h5�H5��5��9�/�
�/��/��������/��������/��������/��������/��������/�
�B�a�]p�2����������yt��e$$If�]!vh5��5�h5�H5��5��#v�#vh#vH#v�#v�:V�l��
t���$6�,�5�D5�h5�H5��5��9�/�
�/��/��������/��������/��������/��������/��������/�
�B�a�]p�2����������yt��e$$If�]!vh5��5�h5�H5��5��#v�#vh#vH#v�#v�:V�l��
t���$6�,�5�D5�h5�H5��5��9�/�
�/��/��������/��������/��������/��������/��������/�
�B�a�]p�2����������yt��e$$If�]!vh5��5�h5�H5��5��#v�#vh#vH#v�#v�:V�l��
t���$6�,�5�D5�h5�H5��5��9�/�
�/��/��������/��������/��������/��������/��������/�
�B�a�]p�2����������yt��e$$If�]!vh5��5�h5�H5��5��#v�#vh#vH#v�#v�:V�l��
t���$6�,�5�D5�h5�H5��5��9�/�
�/��/��������/��������/��������/��������/��������/�
�B�a�]p�2����������yt��e$$If�]!vh5��5�h5�H5��5��#v�#vh#vH#v�#v�:V�l�
t���$6�,�5�D5�h5�H5��5��9�/��/��/��������/��������/��������/��������/��/��B�a�]p�2����������yt��^002���� 0@P`p������2(�� 0@P`p������ 0@P`p������ 0@P`p������ 0@P`p������ 0@P`p������ 0@P`p��8X�V~_HmH	nH	sH	tH	H`�H�*Normal CJPJ_HaJmH	nHsH	tHDA`�DDefault Paragraph FontRi@�RTable Normal�4�
l4�a�(k �(No List>>�>�*Title$a$5�>*PJ\�tH	@�@�O� List Paragraph
��^��4@41X�0Header

�H�$B��!B1X�0Header CharCJPJaJnHtH4 @241X�0Footer

�H�$B��AB1X�0Footer CharCJPJaJnHtHH�RH1X�Balloon TextCJOJQJ^JaJZ��aZ1X�Balloon Text Char CJOJPJQJ^JaJnHtH6U@�q6L	Hyperlink>*B*ph�>���>�QW
Title Char5>*CJ\aJ.(��.nNLine NumberPK!����[Content_Types].xml���j�0E����ж�r�(��΢Iw},��-j��4	��w�P�-t#bΙ{U�����T�U^h�d}㨫��)��*1P�'��	�^��W��0)��T�9<�l�#��$yi}��;�~@��(��H����u�*Dנz��/0�ǰ��$��X��3aZ����,�D0j~�3߶�b��~i>���3�\`�?�/�[���G��\�!�-�Rk.�s�Ի�..���a濭?��PK!�֧�6_rels/.rels���j�0���}Q��%v/��C/�}�(h"���O�
����=������ ����C?�h�v=��Ʌ��%[xp��{۵_�Pѣ<�1�H�0���O�R�Bd���JE�4b$��q_����6L�R�7`������0̞O��,�En7�Li�b��/�S���e��е�����PK!ky���theme/theme/themeManager.xml�M
� @�}�w��7c�(Eb�ˮ��C�AǠҟ����7��՛K
Y,�
�e�.���|,���H�,l����xɴ��I�sQ}#Ր���� ֵ+�!�,�^�$j=�GW��)�E�+&
8���PK!����Ptheme/theme/theme1.xml�YOo�6��w toc'vu�ر�-M�n�i���P�@�I}��úa��m�a[�إ�4�:lЯ�GR��X^�6؊�>$�������!)O�^�r�C$�y@�����/�yH*��񄴽)�޵��߻��UDb�`}"�qۋ�Jח���X^�)I`n�E���p)���li�V[]�1M<������O�P��6r�=���z�gb�Ig��u��S�eb��O������R�D۫����qu	�g��Z����o~ٺlAp�lx�pT0���+[}`j���zA��V�2�F���i�@�q�v�֬5\|��ʜ̭N��le�X�ds���jcs���7���f����
��W��+�Ն�7����`���g�Ș��J���j|��h(�K��D-����
dX��iJ�؇(��x$(��:��;�˹!�I_�T��S1�����?E��?�����?ZBΪm���U/������?�~����xY���'���y5�g&΋/����ɋ�>���G�M�Ge���D�����3Vq%'#q�����$�8��K�����)f�w9:ĵ��
x}r�x����w���r�:\TZaG�*�y8I�j�bR��c|XŻ�ǿ�I
u3KG�nD1�NIB�s���
��R��u���K>V�.EL+M2�#'�f��i~�V��vl�{u8��z��H�
�*���:�(W�☕
~��J�T�e\O*�tHG��HY��}KN�P�*ݾ˦���TѼ�9/#��A7�qZ��$*c?���qU��n��w�N��%��O��i�4=3ڗP��
����1�P�m\\9���������Mؓ�2a�D�]�;Yt�\��[x����]�}Wr��|�]��g-���
eW�
�)6-r��CS�j��
i�d	�DЇA�ΜIqbJ#x�꺃6k���#��A�Sh��&ʌt(Q�%��p%m��&]�caSl=�X�����\P�1�Mh�9�M��V�dDA��aV�B��[݈fJ�íP|8�քA�V^��f
�H��n���-��"�d>�z��n��NJ�	�ة�>�b���&����2��v����Kyϼ��D:����,AGm��\nz��i�Ù��.uχYC�6�OMf��3o�r��$��5�����NH�T[XF64�T,ќ���M0�E)`#�5�XY�`�פ;��%�1�U�٥m;���R>QD����D�cp�U�'��&LE�/p���m���%]�����8fi��r�S4�d7y\�`�J�n���ί�I�R��3U�~7+���׸#��m�q�BiD���������i*�L6�9�m�Y&���i���HE��=(K&�N!V�.K�e�LD�ĕ�{D	����vEꦚde��NƟ��e�(�MN9ߜR�6����&3(��a���/D��U�z�<�{ˊ�Y��ȳ����V���)�9�Z[��4^n��5���!J��?��Q�3�eBo�C����M����m<�.�vp�����IY�f���Z�Y_p�[�=al-�Y�}Nc͙���ŋ4vfa��vl����'S��A�8�|�*u�{��-�ߟ0%M0�7%����<���ҍ���PK!
ѐ��'theme/theme/_rels/themeManager.xml.rels��M
�0���wooӺ�&݈Э���5
6?$Q��
�,.�a��i����c2�1h�:�q��m��@RN��;d�`��o7�g�K(M&$R(.1�r'J��ЊT���8��V�"��AȻ�H�u}��|�$�b{��P����8�g/]�QAsم(����#��L�[������PK-!����[Content_Types].xmlPK-!�֧�6+_rels/.relsPK-!ky���theme/theme/themeManager.xmlPK-!����P�theme/theme/theme1.xmlPK-!
ѐ��'�	theme/theme/_rels/themeManager.xml.relsPK]�
<?xml version="1.0" encoding="UTF-8" standalone="yes"?>
<a:clrMap xmlns:a="http://schemas.openxmlformats.org/drawingml/2006/main" bg1="lt1" tx1="dk1" bg2="lt2" tx2="dk2" accent1="accent1" accent2="accent2" accent3="accent3" accent4="accent4" accent5="accent5" accent6="accent6" hlink="hlink" folHlink="folHlink"/>d"|����	22PPPS2Y��!�w�������ǚW�;������&*d* "#$%&'()+3=��8T���M$�$%0%�%�&�&'m'�'@(�(�(A)*d*!*,-./012456789:;<�5�
**H*OOdOi|w|.}ن܆?�W�`�������Y�����'3����E�E�F�FGG#G�G�n�nlsWwZw���k�n�q�j�m�p�y�$�'������R�b�x�y���������h�����d�����[�����G������d"X��Q���Q���Q���Q���Q���Q���Q���Q���Q���Q���QQ�@���Q���Q���Q���Q���Q���Q���Q���QQ�@���Q���Q���Q���Q���Q���Q���2JLS!����8�@�����������0�(	�
��B
�S����	?���6e����f����g��d��h����i��d��j����k����l��$��m����n����o��d��p��$��q��d��r��$��s��$��t��d��u�����v�����w����x�����y��$��z��d��{����|����}��$��~��������43
����43
���L:3
���:3
����93
����93
���L93
���93
����83
����83
���83
���L83
����73
����73
����:3
����;3
���L73
����63
����:3
����63
���73
��������\�����������������������\������� 44IITY���������WWblqy��������XX^B
B
H
�
�
�
�����e"	

 "!#&$%'()*+,-./012345������&&GGRX^^���������akpx��������]``G
J
J
�
�
�
�����e"	

 "!#%&$'()*+,-./012345:**�urn:schemas-microsoft-com:office:smarttags�Street�;+
*�urn:schemas-microsoft-com:office:smarttags�address�>&*�urn:schemas-microsoft-com:office:smarttags
�PostalCode�9'*�urn:schemas-microsoft-com:office:smarttags�State�8)*�urn:schemas-microsoft-com:office:smarttags�City�=6*�urn:schemas-microsoft-com:office:smarttags	�PlaceType�=3*�urn:schemas-microsoft-com:office:smarttags	�PlaceName�95*�urn:schemas-microsoft-com:office:smarttags�place�8��65633635366+*)5'&536+*)5'&65633635365)'&)5')5')5')5'+* +]ey�������2DF`qvz{��������r}��CNHP\i��				&	0
8
D
Q
�
�
�
�
�
�
1OAO�|�|�|�|i�q�������������r�z���������^klr��F�F�o�o�o�o�p�pqq�{�{\|f|�|�|�|�|JRan����΁ց������;�C�U�b�������͓̓ӓ��*�7�8�>�Y�e�f�o���
�<�F����*���ėӗ�\�a����������������"�1�>�����]�g�c�o�p�y���������(������&3RVW]^c������		2	:	;	H	�	�	�	�	�	�	�	�	�	Q
U
�
$X]��������	#@Mbl����B
G
p
w
|
�
�
�

7CDLWdsw����������"&'+/78E������������37jr�������_g������*.GO\dhnr~������
 %01AMZrv~����������"*.67D��������������!,8@AQ����.6Z`ekuz��������5����#.:OZry����15W_������%O]ep}����#%)*016QX�������	��������������8CGQmx{��������     - 5 8 ? C M j t � � � � � � � � � � � � � 	!!!+!5!8!@!�!�!�!�!�!�!"""""""""%"-"b"e"��2EFa������������
	a	�	�	�	�	�
�
�
�
�
%&P���:
7e�����_����<?�����5WX���CLs���$%O�M�����!�!"""""""""b"e"33333333333333333333333333333333�
�
,$�/�FGG'G|p�p�pb�y�%@@K"""""""""""B"b"e"�
|p�p@@K"e"�y+8�������������>,Y��y���������h�������^��`���OJQJo(�h�H���h�������^��`���OJQJ^Jo(�h�Ho�h�p����p^�p`���OJQJo(�h�H���h�@����@^�@`���OJQJo(�h�H���h�����^�`���OJQJ^Jo(�h�Ho�h�������^��`���OJQJo(�h�H���h�������^��`���OJQJo(�h�H���h�������^��`���OJQJ^Jo(�h�Ho�h�P����P^�P`���OJQJo(�h�H���8�0��8^�8`�0�o(.
�������^��`����h�H.�
�p�L��p^�p`�L��h�H.�
�@����@^�@`����h�H.�
�����^�`����h�H.�
���L���^��`�L��h�H.�
�������^��`����h�H.�
�������^��`����h�H.�
�P�L��P^�P`�L��h�H.�y+8>,Y������������									��������������������������������������P�-8�B�D�C4�\�,-icBvz���F/�Z=t�B	�N	C
�K
d�*�Aw���M�d-!��e�hu#N��6c�y<jo*�=�oL3?3P\T\%�EU8}A!�"�[&�'�A(�B(\W(NN)�+T+�{+�{-R]/�R0s32�5�g6�q6�<7=?7l8�t:�>�?�\EU<F�vFDH�8HeISJ�2JnN�QP�Q�eSE)T�?T�QWf]W�lX�vXM)YpYZ^Z	<[�d[�\]EE^
Va�(c�HdH.ef^h�DjI"kalo,Dq"Eq�&rTlsj
t�StFu5$u1u�hu�{u#FzQz�{X!|�b|8r�HH��	�o�!A�n�]a��*�Gl���8Z�Al��p�|��O��d��"�/%�jU��X��h��v���2�
 �%4��X��.��/��s�fZ�d�"y��y� ��W��M�x����;��;�qm��)�(-��"�A�sL�;Z�E7��>��E�w'��Y�Xq��_�����n&�A�H��'�#d��r�
Y��&�g9����m�7��'������r��s�Q����b�0]��s��l�n��E��_�1O�B,��h��8�K��]�^t��_�p��+�cW�1X��9�1����aW���i�7Q�rA�0u�k��)��H��W��;�0]�""��EN.InstantFormat�	EN.Layout�U�EN.Libraries ��w<ENInstantFormat><Enabled>1</Enabled><ScanUnformatted>1</ScanUnformatted><ScanChanges>1</ScanChanges></ENInstantFormat>Z<ENLayout><Style>Annals Surgery</Style><LeftDelim>{</LeftDelim><RightDelim>}</RightDelim><FontName>Times New Roman</FontName><FontSize>12</FontSize><ReflistTitle></ReflistTitle><StartingRefnum>1</StartingRefnum><FirstLineIndent>0</FirstLineIndent><HangingIndent>720</HangingIndent><LineSpacing>0</LineSpacing><SpaceAfter>0</SpaceAfter></ENLayout>K<ENLibraries><Libraries><item>Discitis.enl</item></Libraries></ENLibraries>�@d"p@��Unknown������������G��*�Ax�	�Times New Roman5��Symbol3.��*�Cx�	�ArialG5��
	���j�MS Mincho-�3� fg5.��*�[`�)�Tahoma?=�	�*�Cx�	�Courier New;��WingdingsA���� B�Cambria Math"q���h�"��"��Q����Q���!��x���24d� � 2�q���HX	�?�����������������������s�2!xx���
Key Points
vhacletestRyan Garcia����Oh��+'��0<x����	��
�
$,4�Key PointsvhacletestNormalRyan Garcia2Microsoft Office Word@��G@����@�����Q������՜.��+,��D��՜.��+,��8�hp|�������
����� Key PointsTitle� 8@_PID_HLINKS�At?mailto:ryangarcia78@gmail.com	

 !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~��������������������������������������������������������������������������������������������������������������������������������	

 !"#$%&'()*+,-./0123456789:;<=>����@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~���������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������Root Entry��������	�F�������Data
������������?�1Table�����|HWordDocument����;|SummaryInformation(�������������DocumentSummaryInformation8���������CompObj������������y������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
����	�F'Microsoft Office Word 97-2003 Document
MSWordDocWord.Document.8�9�q

Youez - 2016 - github.com/yon3zu
LinuXploit