Daily Clinical Briefing · Educational reading for healthcare professionals
Spinal epidural abscess can be advanced before fever or neurological deficits appear.
A normal neurological examination does not exclude early spinal epidural abscess when severe progressive spinal pain and infection risk are present.
Spinal epidural abscess becomes much harder to treat once neurological deficits appear. The difficulty is that waiting for weakness, sphincter disturbance or paralysis can mean waiting until the disease is already advanced.
The familiar combination of back pain, fever and neurological deficit is present in fewer than 20% of patients at diagnosis. Localised back or neck pain is much more common, occurring in more than 80%, while fever is reported far less consistently. A normal neurological examination therefore does not make early disease disappear.
The character and trajectory of the pain matter. Severe progressive pain, constant pain, pain at rest or at night, focal midline tenderness and repeat attendance because symptoms are worsening should all increase concern. Infection risks add weight, including diabetes, intravenous drug use, chronic renal failure or dialysis, immunosuppression, malignancy, recent spinal procedures and nearby infection.
Inflammatory markers can help decide who needs further investigation, but they are nonspecific. Raised C-reactive protein or erythrocyte sedimentation rate supports concern rather than making the diagnosis.
MRI of the spine with and without contrast is the key investigation described, with reported sensitivity around 96% and specificity around 94% for spinal infection. Most epidural abscesses span two or three vertebral segments, although non-contiguous skip lesions occur. Imaging therefore needs to reflect the clinical pattern rather than automatically stopping at one painful level when the findings do not fit neatly.
The clinical progression moves from localised spinal pain to radicular pain, then weakness, sensory change or sphincter dysfunction, and finally paralysis. Neurological status at diagnosis strongly predicts outcome, and injury at the later stages may be difficult or impossible to reverse.
That makes the repeat attendance particularly important. A previous diagnosis of lumbar strain should not downgrade worsening pain on the next visit. Re-examine strength, sensation, gait and bowel or bladder function, reassess infection risk and use the whole pattern to decide whether MRI is needed before weakness develops.
After out-of-hospital cardiac arrest, stable patients without STEMI or other high-risk features can follow delayed or selective angiography, while serial ECGs, lateral or posterior views, arrest characteristics and prognosis help identify those who still warrant earlier invasive assessment.
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Normal serum vitamin B12 does not exclude functional deficiency when homocysteine and methylmalonic acid are raised, while a relapsing neurological syndrome that later develops fever, cytopenias and transaminitis should prompt reconsideration of systemic immune dysregulation including HLH.
Spinal epidural abscess may present with severe back or neck pain despite absent fever and a normal neurological examination, making pain progression, repeat attendance, infection risks and inflammatory markers important triggers for early contrast-enhanced MRI.
Reassess severe or worsening spinal pain carefully when a patient returns after an earlier benign diagnosis. Check strength, sensation, gait and bowel or bladder function even when fever is absent. Use infection risks, pain characteristics and inflammatory markers together to decide when MRI with and without contrast is needed.
An adult receiving long-term dialysis returns with increasingly severe constant back pain that is worse at night. There is no fever, strength and sensation remain normal, and inflammatory markers are raised. What investigation should be prioritised?
MRI of the spine with and without contrast should be prioritised when spinal epidural abscess is suspected. A normal neurological examination and absent fever do not exclude early disease.
A comatose patient remains electrically and haemodynamically stable after resuscitation from out-of-hospital cardiac arrest. The ECG shows no STEMI and there are no other high-risk features. What coronary angiography strategy is supported?
A delayed or selective angiography strategy with further risk assessment is appropriate rather than routine immediate angiography. Coma alone should not determine the decision, and evolving ECG findings or other concerning features can still prompt earlier investigation.
A patient develops progressive blurred vision and peripheral neurological symptoms despite a normal serum vitamin B12 concentration. Homocysteine and methylmalonic acid are both raised. How should the normal vitamin B12 result be interpreted?
It does not exclude functional vitamin B12 deficiency. Raised homocysteine and methylmalonic acid provide additional evidence that vitamin B12 function may be inadequate despite a normal serum concentration.
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