Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Neurological compression, sepsis and spinal instability are emergencies
Vertebral infection may extend into the epidural space, collapse an endplate or produce bacteraemia while fever is absent; new weakness, saddle sensory change or bladder dysfunction can mark irreversible neural injury.
Action: Perform immediate neurological and sepsis assessment, obtain blood cultures, arrange urgent whole-region MRI with appropriate spinal coverage, give antibiotics immediately after cultures if septic or neurologically deteriorating, and involve spinal surgery urgently for epidural abscess, compression, instability, deformity or uncontrolled source.
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.
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.
Investigation priorities
01
Two blood-culture setsFirst step
Identify haematogenous organisms before antibiotics.
02
Preferred spinal MRIPreferred
Define disc-endplate infection, epidural compression and paraspinal spread.
Management branches
CompressionProtect neural function now
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.
StableIdentify the organism before treatment
The patient is haemodynamically stable, neurologically intact and has no impending structural emergency.
Key medicines
Empirical intravenous therapy for unstable spinal infectionAfter two rapidly obtainable blood-culture sets, give the full adult regimen in the trust's severe spinal-infection and sepsis protocol immediately when haemodynamic instability, neurological progression or impending compression is present; obtain operative cultures without delaying decompression.
Culture-directed vertebral-osteomyelitis courseFor most bacterial native vertebral osteomyelitis, prescribe the organism-specific parenteral or highly bioavailable oral regimen for about 6 weeks, documenting the exact drug, dose, route, monitoring and stop or review date and extending only for a defined microbiological or source-control reason.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.