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Spinal Infection: Discitis, Vertebral Osteomyelitis and Spinal Abscess

Spinemathema picture card for Spinal Infection

By Mr Ahmed-Ramadan Sadek, Neurosurgeon · 8 min read

🎧 Listen to this guideAudio version coming soon. Narrated in Mr Sadek’s voice using AI voice technology, from a script he has reviewed.

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Key points

  • Spinal infection affects the discs, the bones of the spine (vertebrae) or the tissues around them. It is uncommon but serious.
  • It is more likely in older people and in people with diabetes, a weakened immune system, recent spinal surgery or injections, injecting drug use, or an infection in the bloodstream or heart valves.
  • The main symptom is constant back or neck pain that does not settle with rest. Fever is common, but many people do not have one.
  • Diagnosis relies on blood tests (including CRP and blood cultures) and an MRI scan. If you are stable, a needle biopsy is often taken before antibiotics start.
  • Most people are treated with a long course of antibiotics, usually 6 weeks in total, and sometimes up to 12 weeks. Surgery is needed if nerves are under pressure, there is an abscess or the spine is unstable, or if treatment is not working.

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Call 999 or go to A&E if you have back or neck pain together with:

  • New weakness, numbness or tingling in your legs or arms, or difficulty walking.
  • Loss of feeling around your genitals or bottom.
  • Difficulty passing urine, or new loss of bladder or bowel control.
  • Signs of sepsis, such as confusion or slurred speech, uncontrollable shivering, difficulty breathing, blue, grey or blotchy skin, or passing little or no urine.

If you have back pain and feel hot, cold, shivery or generally unwell, ask for an urgent GP appointment or contact NHS 111. Mention it if you have had recent spinal surgery or a spinal injection, have diabetes or a weakened immune system, or inject drugs.

What is spinal infection?

Spinal infection means infection of the vertebrae, the discs between them, or the tissues next to them.[6] You may hear several names:

  • Discitis: infection of a disc.
  • Vertebral osteomyelitis: infection of the bone of a vertebra. Because infection usually spreads from the disc into the bones on either side, the two often occur together, which is called spondylodiscitis.[1]
  • Spinal epidural abscess: a collection of pus inside the spinal canal, in the space around the spinal cord and nerves.[6]

Most often, bacteria travel to the spine in the bloodstream from an infection somewhere else in the body. The disc has no blood supply of its own, so it is a place where bacteria can settle.[1] Infection can also follow spinal surgery or other procedures.[6] The commonest germ is Staphylococcus aureus, found in just over half of cases in a Danish population study.[7] Less often the cause is tuberculosis, a fungus or other organisms.[1]

Spinal infection is uncommon, and estimates differ. A review quotes 0.2 to 2.4 cases of spondylodiscitis per 100,000 people a year in Western countries,[6] while a Danish population study found the yearly rate rose from 2.2 to 5.8 per 100,000 adults between 1995 and 2008.[7] It may be becoming more common as the population ages and more spinal operations are done, although better scanning may also explain part of the rise.[6][7]

Who is at risk?

  • Older age. In the Danish study, rates were highest in older people.[7]
  • Diabetes. Listed in reviews as a common risk factor, and the most common one in a large review of epidural abscess.[6][9][10]
  • A weakened immune system, for example from long-term steroid tablets, chemotherapy or HIV.[3][6]
  • Recent spinal surgery, or an injection or anaesthetic procedure in the spine. Spinal surgery is the most important risk factor that can be influenced.[6] In a review of 915 people with epidural abscess, 5.5% had previously had an epidural anaesthetic or pain relief procedure.[9]
  • Injecting drug use.[6][9]
  • Infection in the bloodstream or heart valves (endocarditis), or a recent skin, urine or other infection that could have seeded the spine.[1][9]

Risk factors matter because symptoms can be vague. In one emergency department study, 98% of people with an epidural abscess had at least one risk factor, compared with 21% of people with ordinary spinal pain.[8]

Symptoms

Back or neck pain is the main symptom, reported by about 85% of people in one review.[6] It is usually felt over the infected area, made worse by activity, and may spread to the tummy, hip, leg or groin.[1] Pain that does not ease with rest or is worse at night is one of the features the NHS says should be checked by a GP.[4]

Fever is often absent. The Infectious Diseases Society of America (IDSA) guideline says fever is present in at most 45% of people with bacterial vertebral osteomyelitis, and a later review gives 48%.[1][6] Painkillers that lower temperature can hide a fever, and infections caused by tuberculosis or fungi rarely cause one.[1] The NHS also notes that a high temperature is less common in older adults with sepsis.[5] Weakness or numbness can develop if the infection presses on nerves or the spinal cord, and this is more common when the neck or upper back is affected.[1]

Spinal infection is often mistaken at first for ordinary wear and tear, and diagnosis can be delayed by months.[1] If your back pain is constant, you are in a risk group or you feel unwell, it is reasonable to ask your doctor whether infection has been considered.

Spinal epidural abscess: an emergency

An abscess inside the spinal canal can press on the spinal cord or nerves and needs urgent assessment by a spinal team, often with emergency surgery.[9] The textbook picture of back pain, fever and nerve symptoms together was present in only 13% of people at their first emergency visit in one study, and 75% had a delay in diagnosis. Lasting weakness affected 45% of those whose diagnosis was delayed, compared with 13% of those diagnosed promptly.[8] A 2026 review found that 40% of people had no nerve symptoms when they first came to hospital, so having no weakness does not rule it out.[10]

Epidural abscess is a serious condition, which is why it is treated urgently. Fast diagnosis and treatment give the best chance of a good recovery. Studies of people with this condition, many of whom had other serious illnesses, report that about 5% to 16% did not survive.[6][10]

Tests

  • Blood tests. Inflammation markers called CRP (C-reactive protein) and ESR are raised in 94% to 100% of people with vertebral osteomyelitis, though they can also be raised for other reasons. The white blood cell count is normal in up to 40%, so a normal count does not rule infection out.[1]
  • Blood cultures. Two sets are recommended for everyone with suspected infection, ideally before antibiotics.[1][6] They identify the germ in up to 59% of cases.[6]
  • MRI scan with contrast. This is the key scan. Its accuracy is reported at 96% to 97% sensitivity,[1][6] and a contrast dye (gadolinium) shows abscesses best.[1] Plain X-rays can look normal early on, because bone damage can take 3 to 6 weeks to show.[1] See our guide to MRI scanning.
  • CT-guided biopsy. A needle is passed into the disc or bone under CT scan guidance to take a sample. The IDSA recommends this when blood tests have not identified the germ.[1]
  • Looking for the source. Doctors will ask about recent infections, procedures and drug use, and check for signs of heart valve infection.[1]

Why antibiotics may wait. If your nerves are working normally and you are otherwise stable, the IDSA suggests holding back antibiotics until a sample has been taken, so the right antibiotic can be chosen for the right germ. If you have sepsis or worsening nerve problems, antibiotics start straight away, and nerve compression may need immediate surgery.[1]

Treatment

Antibiotics

Antibiotics are the main treatment. They usually start through a drip in hospital, and many people later switch to tablets once the infection is under control.[1][6] The choice depends on the germ and is guided by infection specialists and the microbiology laboratory.

For most bacterial vertebral osteomyelitis, the IDSA recommends 6 weeks of antibiotics in total.[1] This is based on a French trial of 359 people published in 2015, which compared 6 weeks with 12 weeks: 90.9% were cured at one year in both groups.[2] Some people need a longer course, up to 12 weeks, depending on the germ and how they respond. This is decided with the local microbiology and infection team, following local policy.[1][6] Always finish the course, even if you feel better.[3]

Rest and bracing

Treatment without surgery often includes a period of rest and/or a brace for at least 6 weeks, depending on how painful it is to get up and about.[6] If pain stops you getting up, many surgeons will consider an operation, because long periods in bed carry their own risks.[6] Your team will advise you on pain relief.

When is surgery needed?

Antibiotics alone work for many people, but surgery is needed in some.[1][6] Reasons include:

  • Nerve damage or pressure on the spinal cord, especially if it is getting worse.[1]
  • An abscess that needs draining.[3][6]
  • A spine that has become unstable or is collapsing into a bent shape.[1]
  • Treatment failure, such as an infection that persists in the bloodstream, or pain that keeps getting worse despite the right antibiotics.[1]

Surgery aims to remove infected tissue, relieve pressure on the nerves, and keep or restore a stable spine, sometimes with screws and rods.[1] Antibiotics continue afterwards.[6] The IDSA advises against operating just because a scan at 4 to 6 weeks looks worse, if you are improving in every other way.[1]

Recovery and outlook

Most people are cured. In the French trial, about 9 in 10 people in each group were cured at one year.[2] Spinal infection is serious, though, especially in people who are already unwell for other reasons, and a small proportion of people do not survive it: modern studies report figures from 0% to 11%.[1][6] Starting treatment early makes a real difference.

  • Progress is checked mainly by how you feel and by blood tests such as CRP, usually after about 4 weeks of treatment.[1]
  • Repeat MRI is not routinely needed if you are improving. Scans can look worse for months even while the infection is healing.[1]
  • As it heals, the infected segment of spine usually fuses solid, with or without surgery.[6]
  • Some back pain often remains even after the infection has gone.[1]
  • Pain that returns or gets worse, or fever coming back, can be a sign the infection has not cleared. Contact your team promptly.[1]

Frequently asked questions

When should I get urgent help for back pain and feeling unwell?

The NHS advises asking for an urgent GP appointment or contacting NHS 111 if you have back pain and feel hot, cold, shivery or generally unwell.[4] Call 999 or go to A&E if back pain comes with weakness, numbness or tingling in both legs, loss of feeling around your genitals or bottom, or bladder or bowel changes.[4] Signs of sepsis, such as confusion or slurred speech, uncontrollable shivering, difficulty breathing or blotchy, blue or grey skin, also need emergency help.[5]

Can you have a spinal infection without a fever?

Yes, and it is common. Fever is present in at most 45% of people with bacterial vertebral osteomyelitis according to the IDSA guideline, and in 48% according to a later review.[1][6] Painkillers that lower temperature can hide a fever.[1] Even with an epidural abscess, the combination of back pain, fever and nerve symptoms was present in only 13% of people at their first emergency visit in one study.[8] Constant pain plus a risk factor is a reason to ask about infection.

Can I get a spinal infection after back surgery or a spinal injection?

It can happen, but it is uncommon. A review describes spinal surgery as the most important risk factor for spinal infection that can be influenced, alongside factors such as older age, diabetes and long-term steroid use.[6] In a large review of epidural abscess, 5.5% of people had previously had an epidural anaesthetic or pain relief procedure.[9] If back pain becomes worse rather than better in the weeks after a procedure, especially with fever or feeling unwell, contact the team who treated you.

Will I need antibiotics through a drip for the whole six weeks?

Not always. Treatment usually starts through a drip, and many people move on to tablets once the infection is under control.[1][6] A UK trial of 1,054 adults with bone and joint infections, which included vertebral osteomyelitis, found that tablets were as effective as drip treatment during the first 6 weeks, with fewer line problems.[11] The NHS notes that some people can take antibiotics at home.[3] The right plan depends on the germ and how you respond, so your infection team will decide.

How long does it take to recover from discitis?

There is no single answer, and good data on recovery time are limited. Antibiotics usually last 6 weeks in total, and sometimes up to 12 weeks if your infection team advises it,[1][2] and treatment without surgery often includes rest or a brace for at least 6 weeks, depending on pain.[6] Pain often improves well before scans do, and some back pain can remain after the infection has cleared.[1]

Can spinal infection come back?

It can, and estimates vary. A review cites observational studies in which infection returned in 10% to 14% of people treated for less than 8 weeks, compared with 3.9% after more than 12 weeks.[6] However, in the only randomised trial, 6 weeks of antibiotics worked as well as 12, with 90.9% cured at one year in both groups.[2] Pain that returns or worsens, or fever coming back, should be reported to your team, who may check blood tests and arrange a scan.[1]

Will I be able to go back to work?

Most people who were working beforehand do return, but it can take time. A Danish study of 112 working-age adults treated for spondylodiscitis found that 73% of those who had been in work a year before the infection were back in the workforce within two years.[12] The same study found that infection reduced people’s ability to work overall.[12] Talk to your team and employer about a phased return.

Further reading

References

  1. Berbari EF, et al. 2015 Infectious Diseases Society of America (IDSA) clinical practice guidelines for the diagnosis and treatment of native vertebral osteomyelitis in adults. Clin Infect Dis. 2015;61(6):e26-46. Link
  2. Bernard L, et al. Antibiotic treatment for 6 weeks versus 12 weeks in patients with pyogenic vertebral osteomyelitis: an open-label, non-inferiority, randomised, controlled trial. Lancet. 2015;385(9971):875-82. Link
  3. NHS. Osteomyelitis. NHS website, page last reviewed 16 August 2023. Link
  4. NHS. Back pain. NHS website, page last reviewed 5 March 2026. Link
  5. NHS. Sepsis. NHS website, page last reviewed 14 May 2026. Link
  6. Lener S, et al. Management of spinal infection: a review of the literature. Acta Neurochir (Wien). 2018;160(3):487-496. Link
  7. Kehrer M, et al. Increasing incidence of pyogenic spondylodiscitis: a 14-year population-based study. J Infect. 2014;68(4):313-20. Link
  8. Davis DP, et al. The clinical presentation and impact of diagnostic delays on emergency department patients with spinal epidural abscess. J Emerg Med. 2004;26(3):285-91. Link
  9. Reihsaus E, et al. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev. 2000;23(4):175-204. Link
  10. Budiman L, et al. Clinical characteristics of patients with spinal epidural abscess: a systematic review and meta-analysis. Emerg Med Australas. 2026;38(1):e70204. Link
  11. Li HK, et al. Oral versus intravenous antibiotics for bone and joint infection. N Engl J Med. 2019;380(5):425-436. Link
  12. Kehrer M, et al. Reduced ability to work both before and after infectious spondylodiscitis in working-age patients. Infect Dis (Lond). 2017;49(2):95-103. Link

This article is general information and is not a substitute for advice about your own situation. Please speak to your GP or specialist before making any change to your treatment.

Last checked: October 2026