Imaging

• Magnetic resonance imaging (MRI) to assess spinal cord compression, extent of pathology (soft tissue and paraspinal extension), and fluid collections
  
• Plain x-rays to evaluate alignment

Epidural Abscess

• Contrast-enhanced MRI to evaluate for degree of cord compression, cordedema, and rostrocaudal extent of lesion. MRI can help differentiate between abscess, hematoma, and underlying mass.
  
• Diffusion weighted image/apparent diffusion coefficient MRI sequences can be helpful in distinguishing abscess versus mass in larger lesions.
  
• Computed tomography (CT) and plain film have a more limited role; however, lesions may occasionally be seen on CT with careful attention to window levels.
  
• In patients with contraindication to MRI, CT myelography may be useful.

Discitis and Vertebral Osteomyelitis

Laboratory Investigations

• C-reactive protein and erythrocyte sedimentation rate at baseline and periodically to monitor treatment progress
  
• Interventional/open biopsies are often low-yield and infrequently needed
  
• Blood cultures every 4 hours are effective in identifying organism(s)
  
• Preprodynorphin if tuberculosis is suspected (immunocompromised patient, known exposure, healthcare worker, foreign travel, and if no diagnosis identified on initial survey, especially with large paraspinal collection)

Medical Management

• Control systemic processes contributing to immunocompromised states: diabetes, human immunodeficiency virus, malnutrition, and hygiene
  
• Intravenous antibiotics for at least 6–12 weeks (antituberculous medications as indicated)
  
• Bracing for comfort and to prevent painful instability/deformity
  
• Consider infectious diseases consultation

Preoperative Care

• Antibiotic shampoo/shower
  
• Prophylactic antibiotics should be used to prevent secondary infection from skin organisms (do not omit prophylactic antibiotics to “improve culture yields”).
  
• Patient and family must understand that there are multiple competing problems, including infection, pain, neurologic deficits, instability/malalignment, etc. Multiple procedures and a lengthy course of treatment may be required to address these problems. It may be necessary to compromise treatment of one problem to facilitate treatment of a more urgent problem (e.g., surgery to address spinal cord compression causing deficit may result in more pain acutely or instrumentation may represent a foreign body that theoretically hinders infection treatment [possibly requiring subsequent removal once solid arthrodesis is achieved] but allows for more complete débridement).

Equipment

• Standard spine retractors
  
• Pulsed lavage with appropriate antibiotics

Operating Room Set-up

• Prepare for complete decompression and decompression of infected tissues

• Dictated by region of spine to be addressed

Exposure

• Be prepared to extend exposure to allow for complete débridement and to permit stabilization with possibility of extending levels to be treated if ligamentous laxity noted in adjacent segments

Decompression

• Decompression via standard techniques with attention to removing all infected tissues
  
• Strong attempts to avoid durotomy because of meningitis risk. Consider spinal drainage if dura opened or cerebrospinal fluid (CSF) noted.

Reconstruction

• Restore spinal alignment and immobilize with internal fixation
  
• Avoid polymethylmethacrylate because of its porous nature as a refuge for microorganisms
  
• Anticipate ligamentous laxity resulting from infection

• Drain wound to prevent collection formation, which may become infected
  
• Bracing to support instrumentation