Examqo › Examqo library › Neurosurgery › Spine
Spinal epidural abscess and spondylodiscitis
Back pain with fever, or back pain in a patient at risk (injecting drug use, diabetes, bacteraemia, spinal procedure), requires contrast MRI; an epidural abscess with a neurological deficit is a surgical emergency, and spondylodiscitis is treated with targeted antibiotics for 6 weeks.
Why it matters in the exam
The classic triad of epidural abscess — back pain, fever and neurological deficit — is complete in only a minority of patients, so the difficulty is suspecting it early. The commonest organism is Staphylococcus aureus, in about two thirds of cases. CRP and ESR are almost always raised. Gadolinium MRI of the whole spine shows a rim-enhancing epidural collection, sometimes at non-contiguous levels. Treatment: surgical decompression and antibiotics for every patient with a neurological deficit or deterioration; non-operative care only in a patient without deficit, with a known organism and under close neurological monitoring — because deterioration can be rapid.
Spondylodiscitis is usually lumbar, blood-borne, and involves two adjacent endplates and the disc between them. Blood cultures are positive in about half; when they are negative and the patient is stable, CT-guided biopsy is done before antibiotics. The Bernard trial showed that 6 weeks of antibiotics is not inferior to 12. In Israel brucellosis must be remembered — usually lumbar, with an anterosuperior endplate erosion and unpasteurised milk consumption — and tuberculosis (Pott) — usually thoracic, with vertebral destruction, a "cold" paraspinal abscess and relative disc sparing. Surgery for spondylodiscitis is needed for neurological deficit, instability or progressive deformity, a large abscess not amenable to percutaneous drainage, and failure of medical treatment.
Key points
- Risk factor and back pain — gadolinium MRI.
- Staphylococcus aureus — the commonest organism.
- Abscess with deficit — urgent surgery.
- Spondylodiscitis — biopsy when cultures are negative, antibiotics for 6 weeks.
- Brucellosis and tuberculosis in the differential.
Summary table
| Condition | Presentation | Work-up | Treatment |
|---|---|---|---|
| Epidural abscess with deficit | Pain, fever, weakness or sphincters | Gadolinium MRI of the whole spine | Urgent surgery and antibiotics |
| Epidural abscess without deficit | Pain and fever | MRI, blood cultures | Antibiotics and close neurological monitoring |
| Bacterial spondylodiscitis | Back pain, high CRP | Blood cultures; CT-guided biopsy | Antibiotics for 6 weeks |
| Brucellosis | Lumbar pain, unpasteurised milk | Serology, blood culture | Prolonged combination therapy |
| Tuberculosis (Pott) | Thoracic, "cold" abscess, kyphosis | Biopsy, PCR | Antituberculous therapy; surgery for deformity or deficit |
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- Enough for IMLE
The full version is open to subscribers of: Neurosurgery, Orthopedic surgery, Internal medicine, Emergency medicine.
Subscriber? Read the full topic Plans and prices 25 free questions
Sources
- IDSA Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults, 2015 — Diagnosis, biopsy and duration of therapy
- Bernard et al., randomised trial of 6 versus 12 weeks of antibiotics for vertebral osteomyelitis (Lancet), 2015 — Duration of therapy
- Israeli Ministry of Health brucellosis guidance, current — Diagnosis and treatment of brucellosis
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.