What is the appropriate management for a patient with spinal tenderness, chills, gluteal pain, leg pain, decreased sensation in the right lower leg, and leukocytosis (elevated White Blood Cell (WBC) count)?

Suspected Spinal Epidural Abscess with Neurological Compromise

This 26-year-old female requires emergent MRI of the spine and immediate surgical consultation for suspected spinal epidural abscess with neurological compromise. The combination of spinal tenderness, fever/chills, radicular pain, and neurological deficit (decreased sensation in right lower leg) with leukocytosis represents a medical and surgical emergency requiring urgent intervention within hours to prevent permanent neurological damage 1, 2.

Immediate Diagnostic Workup

Urgent Imaging (Within Hours)

• MRI of the entire spine with and without contrast is the imaging modality of choice for suspected spinal infection with neurological symptoms 1.
• MRI can identify epidural abscess, discitis, osteomyelitis, spinal cord compression, and paraspinal soft tissue involvement 1.
• Consider imaging the entire spine rather than just the symptomatic region, as multilevel involvement is possible and the clinical examination may not accurately localize all affected levels 1.

Laboratory Studies Before Antibiotics

• Obtain blood cultures (at least 2 sets) before initiating antimicrobial therapy 1, 3.
• Measure erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) - typically markedly elevated in spinal infection 1.
• The WBC count of 13.3 × 10³/μL represents mild leukocytosis consistent with infection 1, 4.

Immediate Management

Surgical Consultation

• Obtain emergent neurosurgical or spine surgery consultation for all patients with suspected vertebral infection and neurological deficits 1.
• Surgical decompression is indicated for spinal cord or nerve root compression, which this patient likely has given the decreased sensation 1.
• Timing is critical: neurological deficits present for more than a few hours may not be reversible even with surgical intervention 1.

Empiric Antimicrobial Therapy

• Initiate broad-spectrum intravenous antibiotics immediately after blood cultures are obtained 1, 2.
• Empiric coverage should target Staphylococcus aureus (including MRSA), the most common pathogen in spinal epidural abscess, as well as gram-negative organisms 2.
• Typical regimen: vancomycin plus a third- or fourth-generation cephalosporin (or fluoroquinolone) pending culture results 2.

Surgical Indications

This patient meets multiple criteria for surgical intervention 1:

• Nerve root compression (evidenced by radicular pain and sensory deficit)
• Epidural abscess (highly suspected based on clinical presentation)
• Progressive or established neurological deficit requiring emergency decompression

Surgical Options

• Surgical debridement with drainage of abscess 1, 2
• Possible spinal stabilization if bony destruction causes instability 1
• Image-guided needle aspiration may be considered for liquid abscesses, though open surgical drainage is often required 1

Critical Pitfalls to Avoid

Diagnostic Delays

• Do not wait for imaging to initiate antibiotics if there will be any delay - obtain blood cultures first, then start antibiotics 3, 2.
• Epidural abscess is associated with significant diagnostic delay leading to neurological morbidity and mortality 1.
• The classic triad of fever, back pain, and neurological deficit is not always present initially 2.

Risk Factors Present

• Young age does not exclude serious spinal infection 1.
• Elevated ESR (if measured) increases suspicion for epidural abscess 1.

Duration and Follow-up

• Prolonged antimicrobial therapy (4-6 weeks minimum) is typically required for spinal infections, even after surgical drainage 2.
• Therapy duration should be guided by clinical response, normalization of inflammatory markers (CRP), and repeat imaging 2.
• Recurrence is possible even after adequate initial treatment, as demonstrated in case reports of recurrent epidural abscess despite 6 weeks of therapy and surgical drainage 2.
• Serial MRI imaging may be necessary to monitor for recurrence or progression 2.

Additional Considerations

• Consider risk factors for spinal infection: IV drug use, recent spinal procedures, diabetes, immunosuppression 1.
• If initial surgical drainage is performed, maintain high clinical suspicion for recurrence if fever or symptoms return 2.
• Tissue biopsy during surgery should be sent for culture (aerobic, anaerobic, fungal, mycobacterial) and histopathology 1.