Review Question - QID 219595

The patient presents with imaging concerning for cervical spondylodiscitis, epidural abscess, and spinal cord compression, supported by the history of present illness and physical examination findings. Treatment should involve prompt initiation of antibiotic therapy and surgical debridement with spinal stabilization.

Risk factors for the development of spondylodiscitis include intravenous drug use, diabetes, obesity, malignancy, malnutrition, immunodeficiency, and recent systemic infection. Diagnosis is made via an MRI with contrast and can be supported by elevated white blood cell count, ESR, and CRP. Identification of the infecting organism is required to guide antibiotic therapy and can be obtained through blood cultures or biopsy. In cases of cervical spondylodiscitis with associated epidural abscess and evidence of spinal cord compression or neurological deficits, surgical decompression and spinal stabilization, in addition to antibiotic therapy, are indicated.

Patel et al. retrospectively reviewed 128 cases of spinal epidural abscesses and reported the results of medical versus surgical management. Fifty-one patients were treated with antibiotics alone, and 71 were treated with surgery and antibiotics. Twenty-one of the 51 patients initially treated with antibiotics alone failed medical management and required delayed surgical intervention. Diabetes mellitus, CRP greater than 115, white blood cell count greater than 12.5, and positive blood cultures were predictors of medical management failure. More significant neurologic improvement was demonstrated in patients who underwent early surgical intervention compared to delayed surgery after a trial of antibiotic therapy alone. The authors concluded that early surgical intervention should be a mainstay of treatment, and patients treated initially with antibiotics alone should be monitored closely for medical management failure.

Shousha and Boehm retrospectively reported the results of 30 patients with cervical spondylodiscitis treated with surgery and antibiotics. On presentation, 12 patients had neurological deficits, 12 patients had septicemia, and 24 had concomitant epidural abscess. Seven of the 12 patients with neurological deficits had improvement in symptoms after surgery, and three patients died postoperatively due to septicemia. The authors concluded that radical surgical debridement and reconstruction with extended antibiotic therapy is a reliable approach to treat cervical spondylodiscitis.

Figure A is a sagittal MRI slice demonstrating advanced spondylodiscitis at the C3/4 level with associated epidural abscess causing compression and posterior displacement of the spinal cord.

Incorrect Answers:
Answers 1-4: The patient presents with cervical spondylodiscitis, an associated epidural abscess identified on advanced imaging, and symptoms of spinal cord compression. Treatment should involve antibiotic therapy and surgical debridement with reconstruction.