Synopsis
Recognise spinal infection behind persistent back pain, identify sepsis, epidural compression and instability early, preserve microbiological diagnosis, use MRI appropriately, and combine antimicrobial, surgical and rehabilitation decisions.
- Suspect vertebral osteomyelitis when new or worsening focal back or neck pain accompanies fever, raised inflammatory markers, bacteraemia or a relevant exposure; fever may be absent.
- Document power, sensation, reflexes, gait if safe, saddle sensation, anal function and bladder symptoms at presentation and after every clinical change.
- Obtain two sets of blood cultures plus FBC, CRP, ESR, renal and liver profiles; persistent S. aureus bacteraemia warrants spinal assessment even when back pain is understated.
- MRI of the affected spinal region is the preferred diagnostic imaging; include enough coverage to define epidural and paraspinal extension and broaden imaging when multifocal disease is plausible.
- In a stable neurologically intact patient, withhold empirical antibiotics until blood cultures and image-guided or operative biopsy are obtained when microbiology remains unknown.
- In sepsis, haemodynamic instability, neurological progression or impending compression, take rapid blood cultures and start treatment immediately; diagnostic yield never outranks life or neural function.
- Surgery is indicated for neurological compression, instability, progressive deformity, uncontrolled abscess, persistent bacteraemia or failure of correctly directed medical treatment.
- Culture-directed treatment is commonly prolonged; serial symptoms and CRP guide response, while routine follow-up MRI is reserved for poor or discordant clinical progress.
Key red flags
New limb weakness, sensory level, saddle anaesthesia, urinary retention or incontinence, reduced anal tone or rapidly changing radicular pain requires emergency spinal imaging and surgical review.
Shock, confusion, rising lactate, persistent S. aureus bacteraemia or rigors indicates systemic danger and removes any plan to delay treatment for biopsy.
Progressive deformity, severe mechanical pain, vertebral collapse or inability to mobilise raises concern for structural instability and neurological threat.
A new murmur, embolic features, injecting-drug exposure, vascular access or several painful sites suggests endocarditis or multifocal infection and requires source and metastatic-focus assessment.
Investigation priorities
Identify haematogenous organisms before antibiotics.
Define disc-endplate infection, epidural compression and paraspinal spread.
Management branches
New neurological deficit, cauda-equina symptoms, epidural abscess with compression or unstable collapse is present.
- Immobilise and move safely, repeat the neurological record and obtain emergency MRI with relevant spinal coverage.
- Call spinal surgery, anaesthesia and infection teams while obtaining blood cultures and treating sepsis.
- Start immediate intravenous therapy after rapid cultures and proceed to decompression, drainage and operative samples when indicated.
- Manage bladder, pressure areas, thrombosis risk and rehabilitation from the first resuscitative phase.
The patient is haemodynamically stable, neurologically intact and has no impending structural emergency.
- Obtain two blood-culture sets, inflammatory and organ profiles and preferred MRI.
- If blood cultures do not establish microbiology, arrange image-guided biopsy and histology before antibiotics.
- Start culture-directed therapy after sampling and define route, monitoring and duration with infection specialists.
- Assess source, endocarditis risk, abscess drainage, stability, mobilisation and the need for brace or surgery.