What is the management of a paraspinal abscess?

Management of Paraspinal Abscess

Paraspinal abscess requires immediate surgical consultation combined with broad-spectrum IV antibiotics, with the decision between surgical drainage versus medical management determined by the presence of neurologic deficits, spinal instability, or systemic sepsis. 1

Immediate Diagnostic Workup

• Obtain blood cultures before starting antibiotics, as they are positive in approximately 28% of cases and are critical for pathogen identification 1
• Check inflammatory markers (ESR, CRP, WBC with differential), as elevated ESR is particularly sensitive for spinal abscess 1
• Avoid lumbar puncture in patients with known or suspected epidural abscess, as it is relatively contraindicated due to risk of herniation and has low diagnostic yield 2, 1
• Obtain urgent MRI with contrast of the entire spine to define the full extent of infection, assess for epidural extension, and evaluate for spinal cord compression 2, 1
• Consider imaging the entire spine in IV drug users, tuberculosis cases, or when initial imaging shows multilevel involvement 1

Empiric Antibiotic Therapy

• Start broad-spectrum IV antibiotics immediately, covering Staphylococcus aureus (the most common pathogen in 78% of cases), streptococci, gram-negative bacilli, and anaerobes 1, 3
• The recommended empiric regimen is a third-generation cephalosporin (e.g., ceftriaxone) plus metronidazole 1
• Continue IV antibiotics for 6-8 weeks total, as recommended by the American Society of Anesthesiologists 1
• Antibiotics should be started immediately when spinal abscess is suspected, even before diagnostic confirmation 1

Surgical Decision-Making Algorithm

Immediate surgical consultation is mandatory for:

• Neurologic deficits (spinal cord compression, nerve root compression, radiculopathy, myelopathy, or any progressive neurologic deterioration) 2, 1, 4
• Spinal instability from bony destruction causing mechanical failure 1, 4
• Systemic sepsis or hemodynamic instability 1
• Significant sequestered paraspinal abscess that may not respond to antibiotics alone 2

Medical management may be considered for:

• Patients without neurologic deficits and with stable or normal neurologic examination 3
• Patients with radiculopathy or signs of partial cord compression present for more than 72 hours without deterioration 3
• Absence of systemic sepsis 3
• However, close clinical follow-up with daily neurologic examinations is mandatory, and surgical decompression should be performed immediately if neurologic deterioration or systemic sepsis develops 1, 3

Surgical Options When Indicated

• Obtain surgical consultation promptly to determine whether percutaneous drainage or surgical intervention (e.g., laminectomy) is warranted 2, 1
• Surgical decompression and debridement (laminectomy) remains the traditional treatment for most cases with neurologic involvement 5
• CT-guided percutaneous needle aspiration may be effective for liquid, uniloculated abscesses, particularly in high-risk surgical candidates 2, 6
• Install drainage systems (suction/irrigation systems are statistically superior to simple outflow drains) in all surgical cases 5
• Spinal stabilization may be necessary if bony destruction causes mechanical instability 1
• Multiple operations may be necessary to eradicate infection and restore spinal stability 6

Tissue Diagnosis

• Obtain tissue for both microbiologic and histopathologic examination via CT-guided biopsy when diagnosis is uncertain or to guide definitive therapy 4, 7
• Send specimens for comprehensive cultures: bacterial, mycobacterial, fungal, and Brucella if epidemiologically relevant 4, 7
• Up to 30% of spinal infection cases may have negative routine bacterial cultures, requiring evaluation for atypical organisms 4, 7
• Do not delay biopsy to wait for serologic test results, as tissue diagnosis provides definitive pathogen identification 7

Monitoring and Follow-Up

• Daily neurologic examinations are mandatory during medical treatment to detect any deterioration 1
• Repeat MRI imaging should be performed if clinical deterioration occurs or by 4 weeks to assess treatment response 1
• Serial inflammatory markers (ESR, CRP) help monitor treatment response 1
• Medical treatment resulted in good or excellent early neurologic outcome in 83% of selected patients, but 11% failed medical treatment and required surgery 3

Common Pitfalls to Avoid

• Delaying treatment while awaiting diagnostic confirmation - antibiotics should be started immediately when spinal abscess is suspected 1
• Performing lumbar puncture in patients with known or suspected epidural abscess, as it risks herniation 2, 1
• Failing to image the entire spine in high-risk patients (IV drug users, immunocompromised) who may have multilevel disease 1
• Inadequate duration of antibiotics - a minimum of 6-8 weeks IV therapy is required 1
• Assuming pyogenic bacteria without tissue confirmation - atypical organisms require different treatment approaches 7
• Relying solely on blood cultures - direct tissue sampling has superior yield 7
• Failing to recognize recurrence - paraspinal abscesses can recur with great increase in size, requiring repeat drainage 8