What is the treatment for a suspected cervical epidural abscess or phlegmon?

Treatment of Cervical Epidural Abscess or Phlegmon

Immediate surgical consultation is mandatory for cervical epidural abscess with neurologic deficits, and empiric broad-spectrum IV antibiotics covering Staphylococcus aureus must be started urgently—patients treated with early surgery have significantly better outcomes than those receiving delayed intervention. 1, 2

Immediate Diagnostic Workup

• Obtain urgent MRI of the cervical spine without and with IV contrast as the gold standard imaging modality, with 96% sensitivity and 94% specificity for epidural abscess, providing optimal visualization of the epidural space, spinal cord compression, and distinguishing abscess from phlegmon 3, 1

• Draw blood cultures before initiating antibiotics, as they are positive in approximately 28-29% of cases and are critical for pathogen identification 1, 2

• Check inflammatory markers including ESR, CRP, and WBC with differential, as elevated ESR is particularly sensitive for spinal epidural abscess 3, 1

• Avoid lumbar puncture, as it is relatively contraindicated due to risk of herniation and has low diagnostic yield in epidural abscess 3, 1

• Consider imaging the entire spine in IV drug users, immunocompromised patients, or when initial imaging shows multilevel involvement, as ascending infections can occur 1, 4

Empiric Antibiotic Therapy

• Start broad-spectrum IV antibiotics immediately covering Staphylococcus aureus (the most common pathogen), streptococci, gram-negative bacilli, and anaerobes 3, 1, 2

• The recommended empiric regimen is a third-generation cephalosporin (e.g., ceftriaxone) plus metronidazole, though vancomycin plus imipenem/cilastatin has been successfully used for cervical epidural abscess 1, 5

• Continue IV antibiotics for a minimum of 6-8 weeks total, as recommended by the American Society of Anesthesiologists 3, 1

Surgical Decision-Making Algorithm

Immediate surgical consultation is required for:

• Any neurologic deficit including spinal cord compression, radiculopathy, myelopathy, motor weakness, or sensory disturbances 3, 1, 6, 2

• Spinal instability from bony destruction or discitis 1, 4

• Systemic sepsis or clinical deterioration despite antibiotics 3, 1

Medical management alone may be considered only for:

• Patients without any neurologic deficit who are diagnosed and treated promptly with antibiotics 1, 6

• Small phlegmons without significant cord compression on MRI 3, 6

Critical caveat: Patients initially treated with antibiotics alone who deteriorate require urgent delayed surgery, and this group suffers significantly worse outcomes (P < 0.005) than those receiving early surgical intervention 2

Surgical Options When Indicated

• Obtain neurosurgical consultation promptly to determine the optimal surgical approach 3, 1

• Surgical decompression and debridement (laminectomy for posterior abscesses, anterior approach for anterior collections with discitis) remains the treatment of choice for cases with neurologic involvement 1, 7, 4

• CT-guided percutaneous needle aspiration may be effective for liquid abscesses in high-risk surgical candidates 1

• Spinal stabilization may be necessary if bony destruction causes mechanical instability 1, 4

Monitoring and Follow-Up

• Perform daily neurologic examinations during medical treatment to detect any deterioration, as rapid progression can occur 3, 1, 7

• Repeat MRI imaging should be performed if clinical deterioration occurs or by 2-4 weeks to assess treatment response 1, 5

• Serial inflammatory markers (ESR, CRP, WBC) help monitor treatment response and guide duration of therapy 1, 5

• Follow-up imaging at 3 months to confirm complete resolution and rule out relapse 5

Common Pitfalls to Avoid

• Delaying antibiotics while awaiting diagnostic confirmation—start empiric therapy immediately when cervical epidural abscess is suspected 3, 1

• Performing lumbar puncture in patients with known or suspected epidural abscess, which risks herniation 3, 1

• Choosing medical management for patients with neurologic deficits—these patients require urgent surgery, as delayed intervention leads to significantly worse outcomes 1, 2

• Inadequate antibiotic duration—less than 6-8 weeks IV therapy risks relapse 3, 1

• Failing to image the entire spine in IV drug users or immunocompromised patients who may have multilevel disease or ascending infection 1, 4

• Using CT as the primary imaging modality—CT has only 6% sensitivity for epidural abscess detection compared to MRI's 96% 3