Spinal Coccidioidomycosis: A Current Review of Diagnosis and Management

Objective: Coccidioidomycosis is an invasive fungal disease that may present with extrathoracic dissemination. Patients with spinal coccidioidomycosis require unique medical and surgical management. We review the risk factors and clinical presentations, discuss the indications for surgical intervention, and evaluate outcomes and complications after medical and surgical management.

Methods: A review of the English-language literature was performed. Eighteen articles included the management of 140 patients with spinal coccidioidomycosis.

Results: For the 140 patients, risk factors included male sex (95%), African American ethnicity (52%), and a recent visit to endemic areas (16%). The most frequent clinical presentation was pain (n = 80, 57%), followed by neurologic compression (52%). One-third of patients had concurrent pulmonary disease. The sensitivity of culture and histology for coccidioidomycosis was 80% and 90%, respectively. Complement fixation titers >1:128 suggest extensive or refractory vertebral infection. The most commonly affected spinal segments were the thoracic and lumbar spine (69%); an additional 40 patients (29%) had epidural and paravertebral abscesses. All patients received therapy with azoles (60%) and/or amphotericin B (43%). Surgical and medical management were used conjunctively to treat 110 patients (79%), with debridement (95% [105/110]) and fusion (64% [70/110]) being the most common surgical procedures. Clinical outcome improved/remained unchanged in 83 patients (59%) and worsened in 4 patients (3%). The mortality was 7%. Infection recurrence and disease progression were the most frequent complications.

Conclusions: Emphasis should be placed on continuous and lifelong appropriate azole therapy. Spinal instability and neurologic compromise are surgical indications for decompression and fusion.