From the Guidelines
Paraspinal abscesses should be treated with a combination of surgical drainage and antibiotic therapy, with empiric antibiotic coverage including vancomycin and either piperacillin-tazobactam or cefepime, as recommended by the 2015 IDSA guidelines 1.
Diagnosis and Treatment
Paraspinal abscesses are collections of pus that form in the muscles and soft tissues adjacent to the spine. The diagnosis of paraspinal abscesses can be made using MRI, which has a sensitivity of 97%, specificity of 93%, and an accuracy of 94% in diagnosing native vertebral osteomyelitis (NVO) 1.
- The inability to distinguish the margins between the disc space and adjacent vertebral marrow on T1-weighted images associated with increased signal intensity from the disc and the adjacent involved marrow on T2-weighted images is the hallmark of bacterial NVO.
- Extension of the infectious process to the paravertebral space causing an epidural abscess or a paravertebral abscess is best seen on the gadolinium with diethylenetriaminepentacetate (Gd-DTPA)–enhanced MRI.
Antibiotic Therapy
Empiric antibiotic therapy should begin immediately with broad-spectrum coverage, typically including vancomycin 15-20 mg/kg IV every 8-12 hours plus either piperacillin-tazobactam 4.5g IV every 6 hours or cefepime 2g IV every 8 hours 1.
- Once culture results are available, antibiotics should be narrowed accordingly.
- Treatment duration is generally 4-6 weeks, with transition to oral antibiotics when clinically improving.
Surgical Intervention
Surgical intervention is necessary to evacuate the abscess, especially if it is large or causing neurological symptoms, as recommended by the 2016 IDSA guidelines for the treatment of coccidioidomycosis 1.
- Surgical procedures are recommended in addition to anti-fungal drugs for patients with bony lesions that produce spinal instability, spinal cord or nerve root compression, or significant sequestered paraspinal abscess.
Monitoring and Complications
Patients should be monitored for complications such as spinal cord compression, vertebral osteomyelitis, or sepsis.
- Risk factors include diabetes, immunosuppression, intravenous drug use, and recent spinal procedures.
- Early diagnosis and aggressive treatment are essential to prevent serious complications including permanent neurological damage.
From the Research
Paraspinal Abscesses
- Paraspinal abscesses are rare infections affecting the paraspinal muscles and soft tissues 2
- They can pose a threat to the spinal cord via compressive effect, leading to impaired motor or sensory function at the corresponding vertebral level 2
- Paraspinal abscesses often present with non-specific symptoms, resulting in late diagnosis and high morbidity and mortality 2
Diagnosis and Treatment
- Diagnosis should be supported by clinical, laboratory, and imaging findings, with magnetic resonance imaging (MRI) being the most reliable method 3
- Management of spinal infections, including paraspinal abscesses, depends on the location of the infection, disease progression, and patient's general condition 3
- Treatment options include conservative treatment with antimicrobial therapy, or surgical treatment with decompression and drainage, followed by antimicrobial therapy 3, 4
- The optimal duration of antibiotic therapy remains controversial, but should not be less than 6 weeks 3
Specific Considerations
- Penetrating spine trauma can lead to paraspinal and spinal infections, with a low rate of infection reported in some studies 5
- The duration of antibiotics for penetrating spine trauma is controversial, with some studies supporting standard prophylactic antimicrobial treatment for 48 hours, while others recommend extended therapy for one week or greater 5
- The use of vancomycin and cefazolin as standard preoperative antibiotic prophylaxis has been shown to reduce revision surgeries for postoperative infection following instrumented spinal fusion 6