Treatment
Failure of Therapy
Î IDSA suggests that persistent pain, residual neurologic deficits, elevated
markers of systemic inflammation, or radiographic findings alone, do not
necessarily signify treatment failure in treated NVO patients (W/L).
Î In patients with NVO and suspected treatment failure, IDSA suggests
obtaining markers of systemic inflammation (ESR and CRP). Unchanged or
increasing values after 4 weeks of treatment should increase suspicion for
treatment failure (W/L).
Î IDSA recommends obtaining a follow-up MRI with emphasis on
evolutionary changes in the paraspinal and epidural soft tissue findings in
patients with NVO and suspected treatment failure (S/L).
Î In patients with NVO and clinical and radiographic evidence of
treatment failure, IDSA suggests obtaining additional tissue samples for
microbiologic (bacteria, fungal, and mycobacterial) and histopathologic
examination, either by image-guided aspiration biopsy or through surgical
sampling (W/VL).
Î In patients with NVO and clinical and radiographic evidence of treatment
failure, IDSA suggests consultation with a spine surgeon and an infectious
disease physician (W/VL).
Figure 1. Evaluation
New or worsening
back pain
Fever
↑︎ ESR or
CRP
Bloodstream infection
or endocarditis
New neurological
symptoms
Suspect NVO
Medical and
neurologic exam
Blood cultures
(consider fungal
and Brucella if
at risk)
Spinal MRI
(preferred) or
gallium/Tc99 or
CT or PET scan
TB test if at risk
Image guided biopsy submitted
for cultures and cytolog y
Repeat image-guided
aspiration biopsy,
PEDD or open biopsy
NEG
NEG
