What is the appropriate management for a patient with left-sided neck swelling, difficulty walking, and low-grade fever?

Management of Left-Sided Neck Swelling with Difficulty Walking and Low-Grade Fever

This patient requires urgent MRI of the cervical spine with contrast within 24-48 hours and immediate blood cultures to rule out vertebral osteomyelitis or epidural abscess, as the combination of neck swelling, fever, and neurological symptoms (difficulty walking) represents a critical red flag for spinal infection. 1, 2

Immediate Risk Stratification

This presentation is highly concerning for spinal infection with neurological compromise rather than a simple neck mass. The difficulty walking represents a neurological red flag that fundamentally changes management priorities:

• Fever with neck pain/swelling plus neurological symptoms (difficulty walking) should trigger immediate suspicion for vertebral osteomyelitis or epidural abscess 1, 2
• Motor deficits or progressive neurological symptoms require immediate surgical evaluation 2, 3
• The combination of fever and new neurological symptoms has a high probability of representing spinal infection 1, 3

Critical Initial Actions

Immediate Assessment (Within Hours)

• Obtain two sets of blood cultures before any antibiotics 1
• Measure baseline ESR and CRP - elevated inflammatory markers with fever and neck symptoms strongly suggest infection 1, 2
• Perform detailed motor/sensory neurological examination to document the extent of deficits 1
• Assess for bowel/bladder dysfunction - urinary retention has 90% sensitivity for cauda equina syndrome 2
• Check for signs of sepsis or hemodynamic instability 1

Urgent Imaging (Within 24-48 Hours)

• Order MRI of the cervical spine without and with IV contrast - this is the gold standard with 96% sensitivity and 94% specificity for spinal infection 2
• MRI is superior to CT for early detection of vertebral osteomyelitis and epidural abscess 2
• If MRI is unavailable, obtain CT with IV contrast as second-line imaging (79% sensitivity, 100% specificity) 2

Antibiotic Decision Algorithm

The decision to start empiric antibiotics depends on clinical stability:

Start Empiric Antibiotics Immediately If:

• Neurological compromise is present (difficulty walking qualifies) 1, 2
• Patient is septic or hemodynamically unstable 1, 2
• Signs of impending sepsis exist 1

Withhold Antibiotics Until Cultures If:

• Patient is hemodynamically stable without progressive neurological deficits 1
• This allows for better microbiological diagnosis, as NVO is commonly monomicrobial and most frequently due to Staphylococcus aureus 1

Parallel Evaluation for Neck Mass

While spinal infection is the primary concern, simultaneously evaluate the neck swelling itself:

Risk Factors for Malignant Neck Mass

• Mass present ≥2 weeks without infectious etiology 1
• Physical characteristics: fixation, firm consistency, size >1.5 cm, or ulceration 1
• Systemic symptoms beyond fever (weight loss, night sweats) 1, 2

Signs Suggesting Infectious Neck Mass

• Local warmth, erythema, localized swelling, and tenderness 1
• Fever, tachycardia, and symptoms of head/neck infection 1
• Recent upper respiratory infection, dental problem, or trauma 1

However, antibiotics should NOT be used to empirically treat a neck mass unless there is clear evidence of bacterial infection - most adult neck masses are neoplastic, not infectious 1

Surgical Consultation Criteria

Obtain immediate surgical consultation if:

• Neurological compromise exists with or without impending sepsis 1, 2
• MRI demonstrates spinal cord or nerve root compression 1, 2
• Bony destruction with instability is identified 1
• Significant sequestered paraspinal abscess is present 1

Common Pitfalls to Avoid

• Do not attribute fever to a "reactive" neck mass without ruling out spinal infection when neurological symptoms are present 1, 2
• Do not delay imaging while waiting for inflammatory markers - order MRI urgently based on clinical presentation 2
• Do not assume the neck swelling and difficulty walking are unrelated - they may both stem from cervical spine pathology 1, 2
• Do not perform open biopsy of the neck mass before imaging and FNA if malignancy is suspected 1
• Do not start antibiotics empirically for the neck swelling alone unless clear signs of bacterial infection exist 1

Expected Timeline

• Blood cultures and inflammatory markers: Immediate 1
• MRI cervical spine with contrast: Within 24-48 hours 2
• Surgical evaluation: Same day if neurological compromise 1, 2
• Definitive antimicrobial therapy: After cultures if stable, or empiric if unstable 1

Most Likely Diagnosis

Given the triad of neck swelling, fever, and difficulty walking, the most concerning diagnosis is cervical vertebral osteomyelitis with or without epidural abscess, particularly if there are risk factors such as recent Staphylococcus aureus bacteremia, IV drug use, immunosuppression, or diabetes 1, 2, 4