Epidural abscess: The Daily PANCE Blueprint

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Epidural abscess: The Daily PANCE Blueprint

A 54-year-old woman presents with a 10-day history of progressively worsening mid-thoracic back pain, fever, and fatigue. She had an epidural catheter placed for postoperative pain control following a hysterectomy two weeks ago, which remained in place for three days. Since the catheter removal, she has experienced severe back pain radiating around her torso and intermittent low-grade fevers. On examination, she is febrile at 38.5°C (101.3°F) with point tenderness over the T7 vertebra and mild bilateral lower extremity weakness. Her WBC count is 14,000/mm³. What is the most appropriate next step in management?

A. MRI of the thoracic spine with gadolinium contrast
B. High-dose intravenous vancomycin plus ceftriaxone
C. Immediate surgical decompression without imaging
D. CT scan of the thoracic spine with intravenous contrast
E. Oral NSAIDs and close outpatient follow-up

Answer and topic summary

The answer is A. MRI of the thoracic spine with gadolinium contrast

A spinal epidural abscess should be highly suspected in any patient with localized spinal tenderness, risk factors for hematogenous spread or direct inoculation (such as a recent epidural catheter), fever, and neurologic deficits. The best initial diagnostic step is MRI of the thoracic spine with gadolinium contrast to pinpoint the location and extent of the abscess and to identify any compression of neural structures. Prompt surgical consultation is crucial once the diagnosis is confirmed, and empiric antibiotic therapy targeting MRSA (eg, vancomycin) plus gram-negative coverage (eg, ceftriaxone) is indicated as soon as possible, ideally after drawing blood cultures. However, obtaining an MRI first helps guide definitive management, including surgical decompression if necessary.

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Covered under ⇒ Neurologic System ⇒ Spinal cord syndromes ⇒ Epidural abscess

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