53 Chronic ostemyelitis may require surgery in case of a development of biomechanical insta- bility and/or a vertebral collapse with progres- sive deformity. Key words: Vertebral osteomyelitis, Spondylodiscitis, Pyogenic os- teomyelitis, Skeletal tuberculosis. Introduction Haematogenous vertebral osteomyelitis (HVO) is a relatively rare disorder which ac- counts for 2-4% of all cases of infectious bone disease 1 . In recent years, the incidence of spinal infections has seemed to increase according to the growing number of intravenous drug users in young people and in the elderly with the use of intravenous access devices, genitourinary surgery and manipulation. Males are more fre- quently affected than females with an average age of onset in the fifth and sixth decade. The onset of symptoms is typically insidious with neck or back pain often underestimated by the patient. The early diagnosis is also difficult due to the non-specific nature of laboratory and ra- diographic findings. The frequent observation of back pain also makes the diagnosis a chal- lenge in most cases. Several studies in the liter- ature report an average delay in the diagnosis of haematogenous vertebral osteomyelitis from 2 to 6 months after the beginning of the symp- toms 2,3,4 . In this article we review the clinical features and the diagnostic approach to haematogenous vertebral osteomyelitis in or- der to optimise treatment strategies and fol- low-up assessment. Abstract. – This article review the clinical features and the diagnostic approach to haematogenous vertebral osteomyelitis in order to optimise treatment strategies and follow-up assessment. Haematogenous spread is consid- ered to be the most important route: the lumbar spine is the most common site of involvement for pyogenic infection and the thoracic spine for tuberculosis infection. The risk factors for devel- oping haematogenous vertebral osteomyelitis are different among old people, adults and chil- dren: the literature reports that the incidence seems to be increasing in older patients. The source of infection in the elderly has been relat- ed to the use of intravenous access devices and the asymptomatic urinary infections. In young patients the increase has been correlated with the growing number of intravenous drug abusers, with endocarditis and with immigrants from areas where tuberculosis is still endemic. The onset of symptoms is typically insidious with neck or back pain often underestimated by the patient. Fever is present in 10-45% of pa- tients. Spinal infections may cause severe neu- rological compromise in few cases, but mild neurological deficit, limited to one or two nerve roots, was detected in 28-35% of patients. The diagnosis of haematogenous vertebral os- teomyelitis may be very difficult, as the symp- toms can be sometimes not specific, vague or almost absent. The usual delay in diagnosis has been reported to be two to four months, despite the use of imaging techniques: in the early diag- nosis of vertebral ostemyelitis is important the role of bone scintigraphy. The general principles for the management of spine infections are non operative, consisting of external immobilization and intravenous antibiotics, followed by oral an- tibiotics. Indications for surgery should be given in case of absence of clinical improvement after 2-3 weeks of intravenous antibiotics, persistent back pain and systemic effects of chronic infec- tion and with presence or progression of neuro- logical deficit in elderly or in cervical infection. European Review for Medical and Pharmacological Sciences 2005; 9: 53-66 Clinical features, diagnostic and therapeutic approaches to haematogenous vertebral osteomyelitis AL. GASBARRINI, E. BERTOLDI, M. MAZZETTI*, L. FINI***, S. TERZI, F. GONELLA, L. MIRABILE, G. BARBANTI BRÒDANO, A. FURNO**, A. GASBARRINI***, S. BORIANI* Department of Orthopaedics and Traumatology, Maggiore Hospital “C.A. Pizzardi” - Bologna (Italy) *Department of infections disease, Maggiore Hospital “C.A. Pizzardi” - Bologna (Italy) **Nuclear Medicine, Maggiore Hospital “C.A. Pizzardi” - Bologna (Italy) ***Internal Medicine, Catholic University - Rome (Italy)