Spinal Epidural Abscess

Pus in the epidural space compressing the cord. The classic triad of back pain, fever and neurological deficit is present in a minority — waiting for all three is waiting for paralysis. Risk factors are IV drug use, diabetes, a recent spinal…

Back pain + fever + neurology — whole-spine MRI

The pathway

1 · Suspect it on one feature, not three

Back pain plus fever is enough to CONSIDER it and escalate the work-up — it does not diagnose it, and it is not a reason to wait for weakness
New or progressive neurology with back pain, in any risk group
Risk: IV drug use, diabetes, recent epidural or spinal procedure, bacteraemia, indwelling line, immunosuppression
Escalating pain unrelieved by lying still

2 · Examine the cord, not just the back

Power, tone, reflexes and plantars in both legs
Look for a sensory level — a change in sensation at a dermatome
Perineal sensation and anal tone
Bladder — scan it. Retention with overflow is charted as incontinence

3 · Bloods and cultures before antibiotics

Two sets of blood cultures — positive in around half, and the organism guides weeks of therapy
FBC, CRP, ESR — CRP is usually high and is useful to follow
Take cultures before antibiotics provided this does not materially delay treatment. A septic or unstable patient is treated immediately, with cultures alongside

4 · MRI the WHOLE spine, urgently

MRI with gadolinium, WHOLE spine — non-contiguous (skip) disease is well described, so a targeted scan can miss a second collection. Discuss the request with your senior and with radiology rather than arguing it alone
A normal plain X-ray excludes nothing
If MRI is contraindicated or unavailable, discuss CT myelography with neurosurgery
Out of hours is not a reason to wait if there is neurology

5 · Antibiotics

Staphylococcus aureus is the commonest organism; MRSA in IV drug users and healthcare contact
Empirical cover per local policy — typically an anti-staphylococcal agent plus a Gram-negative agent
Add vancomycin where MRSA is plausible
Long course, weeks not days, guided by microbiology

6 · Refer to neurosurgery or spinal surgery NOW

Any neurological deficit — urgent decompression
No deficit — may be managed with antibiotics alone, but only with a surgical team involved and a plan for repeat examination
Recovery tracks the deficit at the time of surgery, so a small deficit today is worth more than a large one tomorrow

7 · Then keep examining

Neurological observations at least four-hourly while at risk, documented, and more often if anything changes
A deficit that appears or worsens is an emergency call, not a ward-round item
Look for the source: endocarditis, a line, a discitis, an injection site

Drugs

Drug	Dose	Route	Notes
Flucloxacillin	2g IV 6-hourly	IV	Typical empirical anti-staphylococcal choice. Local policy wins.
Vancomycin	15–20mg/kg IV, level-adjusted	IV	Add where MRSA is plausible — IV drug use, healthcare contact, known colonisation.
Ceftriaxone	2g IV OD	IV	Gram-negative cover in the empirical combination where local policy uses it.

When to escalate

Any neurological deficit — neurosurgery or spinal surgery immediately,Progressive deficit while awaiting imaging — this is an emergency, escalate again,Septic — sepsis pathway alongside, antibiotics after cultures but within the hour,MRI not available locally — discuss transfer with the regional spinal service tonight

Reference: Infectious Diseases Society of America / British Infection Association guidance on spinal infection; NICE CKS spinal epidural abscess. Local antimicrobial policy takes precedence over any drug named here.

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The app adds what a web page cannot: a VINDICATE differential builder, worked on-call scenarios with full A–E findings, recall practice, and all of it offline.