Spinal Epidural Abscess

[blackavar]

Had a patient the other night 61, hx of DM, HTN, HL, only complaint was painful midline back pain in the L4-L5 region; in the ED was tachy to low 100s, febrile to 101 and WBC 13.3. No IVDU, no procedures, no neuro findings. tried to find an alternative source for her infection, but the common stuff was all negative (cxr, ua, skin). She was ill appearing, but not toxic appearing. Spinal Epidural Abscess was on our differential, so we tried to get away with a contrast CT; negative. Now, we wanted to push forward with an MRI as this is often quoted as the definitive study. At our institution, we need radiology approval for emergent MRIs, and talked to the radiologist, he saw no reason for it as the CT with contrast was negative which he said was "highly sensitive to epidural abscess." I tried to find some literature, but couldn't find anything specifically comparing anything; only lots of review articles all saying the MRI > CT, some said that CT + myelography = MRI. Anyone know of any studies or literature that had looked at this? Are the new generation CTs considered in this?

This was a nice (free) review article I came across:
http://qjmed.oxfordjournals.org/content/101/1/1.abstract

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[Daiphon]

There was a JAMA review a few years back I routinely use to fight this fight. I'll look for the citation... paper had good references that should address this issue.

-d

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[Daiphon]

Sorry... my phone turned JEM into JAMA. Who knew?

Anyway, it's still a review, but has a solid references list. Paper is from 2010 by Tompkins, et al; goes into why MRI is strongly preferred (greater Se/Sp, better visualization of concomitant osteomyelitis, and better idea of alternative diagnoses). You can get the PubMed reference here: http://www.ncbi.nlm.nih.gov/pubmed/20060254

That being said, there's a decent JAMA article on indications for emergent MRI for other conditions; it's over here: http://www.ncbi.nlm.nih.gov/pubmed?term=10685696

Cheers!
-d

 

[alreadylernd]

Had a patient the other night 61, hx of DM, HTN, HL, only complaint was painful midline back pain in the L4-L5 region; in the ED was tachy to low 100s, febrile to 101 and WBC 13.3. No IVDU, no procedures, no neuro findings. tried to find an alternative source for her infection, but the common stuff was all negative (cxr, ua, skin). She was ill appearing, but not toxic appearing. Spinal Epidural Abscess was on our differential, so we tried to get away with a contrast CT; negative. Now, we wanted to push forward with an MRI as this is often quoted as the definitive study. At our institution, we need radiology approval for emergent MRIs, and talked to the radiologist, he saw no reason for it as the CT with contrast was negative which he said was "highly sensitive to epidural abscess." I tried to find some literature, but couldn't find anything specifically comparing anything; only lots of review articles all saying the MRI > CT, some said that CT + myelography = MRI. Anyone know of any studies or literature that had looked at this? Are the new generation CTs considered in this?

This was a nice (free) review article I came across:
http://qjmed.oxfordjournals.org/content/101/1/1.abstract

What was the outcome for the patient?

 

[8654Marine]

You are limiting your differential.

Besides an abscess, you're looking for discitis, osteomyelitis, & fasciitis as well.

We've also had epidural cellulitis, i.e. tissue inflammation without discrete fluid collection.

Our radiologist can tell us about fluid collection by a CT myelogram, but recommend an MRI to eval the other bad spinal things.

 

[Rendar5]

You can get around it without doing the lit search in the middle of your shift by saying:
"we want to rule out vertebral osteomyelitis"
or you could ask the radiologist to put in his report that MR is not needed to rule out a spinal abscess. Radiologists love to hedge, so if he has to put his money where his mouth is, he may cave.

EDIT:
eh looks like someone else had the same idea about the broader differential of febrile back pain.

 

[Arcan57]

You are limiting your differential.

Besides an abscess, you're looking for discitis, osteomyelitis, & fasciitis as well.

We've also had epidural cellulitis, i.e. tissue inflammation without discrete fluid collection.

Our radiologist can tell us about fluid collection by a CT myelogram, but recommend an MRI to eval the other bad spinal things.

The radiologist will counter that none of the above is an emergency.

 

[neusu]

Had a patient the other night 61, hx of DM, HTN, HL, only complaint was painful midline back pain in the L4-L5 region; in the ED was tachy to low 100s, febrile to 101 and WBC 13.3. No IVDU, no procedures, no neuro findings. tried to find an alternative source for her infection, but the common stuff was all negative (cxr, ua, skin). She was ill appearing, but not toxic appearing. Spinal Epidural Abscess was on our differential, so we tried to get away with a contrast CT; negative. Now, we wanted to push forward with an MRI as this is often quoted as the definitive study. At our institution, we need radiology approval for emergent MRIs, and talked to the radiologist, he saw no reason for it as the CT with contrast was negative which he said was "highly sensitive to epidural abscess." I tried to find some literature, but couldn't find anything specifically comparing anything; only lots of review articles all saying the MRI > CT, some said that CT + myelography = MRI. Anyone know of any studies or literature that had looked at this? Are the new generation CTs considered in this?

This was a nice (free) review article I came across:
http://qjmed.oxfordjournals.org/content/101/1/1.abstract

Patient sounds like she's sick. Draw blood/urine cultures and admit to medicine. She's non-focal on her neuro exam, the MRI is not emergent and can be done electively. Even if there is an epidural abscess it is still, nonetheless, not an operative lesion unless she has focal deficit.

 

[blackavar]

to Daiphon thanks for both those articles! Can't wait to take a look at them.

to 8654Marine, totally agree, I was trying to narrow down the question for the exam to be performed, but your point is well made, we had several of those in our differential as well, but really our decision tree was to perform emergent ED MRI vs. not, and epidural abscess was the question we were posing.

to alreadylernd, ultimately we did not get the emergent ED MRI, we basically did exactly what neusu said: blood cultures, urine cultures, admit to medicine, we discussed with them, no abx while in ED, elective MRI as inpatient.

I switched to a different hospital after that shift, will stop by in the next couple of days to follow up on patient and update you all.

 

[deleted109597]

to alreadylernd, ultimately we did not get the emergent ED MRI, we basically did exactly what neusu said: blood cultures, urine cultures, admit to medicine, we discussed with them, no abx while in ED, elective MRI as inpatient.

So you could see if they got sicker?
Although truly, this patient sounds more like viral syndrome with back pain more than any of the weird **** you all had on your diff.

 

[blackavar]

Follow up for anyone who was eagerly awaiting on the edge of your seats....
Pt was admitted, vancomycin was started on admission day 1 for the treatment of ?
Patient continued to spike fevers to 103 during her first 48 hours.
MRI was obtained on afternoon of admission day #2 which showed..... Enhancement of the paraspinal musculature from L4-S2 extending to involve the dura...possibly due to trauma or infection, no discrete abscess.
ID was consulted; they eventually recommended stopping the vanco on day #4, the patient stopped spiking and her pain medication requirement dissipated. All cultures were negative, and patient was released on hospital day #7, afebrile and pain free with a discharge diagnosis of back pain.

 

[penguinophile]

I'm going to go ahead and apologize for that radiologist. That was a bull**** statement....MRI>>>>>CT for spinal pathology if you're not looking for a fracture.