A 58-year-old man with a slouched gait and a damp T-shirt clutched to his back sits rigidly on the stretcher, wincing every time the bed rail rattles. He says the pain started as a “pinch” three days ago and has turned into a deep, knife-like ache that shoots down his leg when he coughs. His temperature is 38.6°C, and he keeps asking if it could just be “a bad spasm.” The question is not whether he is uncomfortable — it is whether the clock is already running on cord compromise.

— What’s your move? Read on.

Before you read
  • Which exam finding changes this from “CT later” to “MRI now”?
  • What buys time, and what does not, when neurologic injury is looming?

When to Think of It

Think of it in any patient with severe focal back pain plus fever, bacteremia, IVDU, diabetes, recent spinal procedure, skin/soft tissue infection, or unexplained elevated inflammatory markers. The classic triad is unreliable; back pain is usually the first clue, and neuro deficits may appear late.

Sick or Not Sick

The key fork is neurologic deficit or cord compression signs vs. not. Any weakness, sensory level, saddle anesthesia, urinary retention, fecal incontinence, or progressive radicular pain makes this a spine emergency, not a routine infection.

The First Fifteen Minutes

  • If septic or hypotensive: lactated Ringer’s or normal saline 1–2 L IV bolus, repeat as needed, because perfusion supports spinal cord and organ function.
  • If fever/pain while workup is underway: acetaminophen 1,000 mg PO/IV every 6 hours as needed, because it improves comfort without masking neuro exam the way heavy sedation can.
  • If severe pain: hydromorphone 0.5–1 mg IV every 2–3 hours as needed, or fentanyl 25–50 mcg IV every 15–30 minutes as needed, because uncontrolled pain impairs exam and cooperation.
  • If high suspicion after cultures or if unstable/progressive neuro findings: start empiric IV antibiotics now:
  • Vancomycin 15–20 mg/kg IV every 8–12 hours, because it covers MRSA, the most important pathogen.
  • Ceftriaxone 2 g IV every 24 hours, because it covers many gram-negative organisms.
  • If healthcare-associated, severe sepsis, or concern for Pseudomonas: cefepime 2 g IV every 8 hours instead of ceftriaxone, because it broadens gram-negative coverage.
  • If epidural abscess after instrumentation, penetrating trauma, or bowel source: add metronidazole 500 mg IV every 8 hours if anaerobic coverage is needed, because polymicrobial infection is more likely.
  • If cord compression with evolving deficit: give dexamethasone 10 mg IV now while arranging emergent MRI and surgical consultation, because it may reduce inflammatory edema; practice varies, and this is adjunctive, not definitive.

Definitive Care & Disposition

Get MRI of the entire symptomatic spine with gadolinium urgently; image beyond the local pain level if symptoms or bacteremia suggest skip lesions. Consult neurosurgery/spine surgery and infectious diseases early. Definitive treatment is usually surgical decompression/drainage plus IV antibiotics, especially with neurologic deficit, large abscess, instability, or failure of medical therapy. Admit to a monitored or ICU setting if neuro deficits, sepsis, or rapidly progressive pain are present.

How This One Kills

The killer error is treating it like uncomplicated back pain or sciatica until paralysis appears. The next mistake is delaying MRI because the neurologic exam is “mostly okay” when bladder dysfunction or subtle weakness is already evolving.
The Differential — What Else Looks Like This
  • Lumbar radiculopathy — pain follows a nerve root, but fever, bacteremia risk, and elevated ESR/CRP point away; confusing it delays decompression.
  • Vertebral osteomyelitis/discitis — often less abrupt and more midline, with pain over weeks; missing SEA forfeits urgent surgical timing.
  • Cauda equina syndrome — saddle anesthesia and urinary retention can look similar, but the cause may be disc herniation rather than infection; confusing them delays antibiotics and source control.
  • Psoas abscess — hip pain and pain with hip extension are clues; confusing it with spinal infection delays drainage and misses the primary source.

The Second-Day Story

Older adults, diabetics, and immunocompromised patients may present with little or no fever, vague malaise, or “worsening sciatica” rather than dramatic cord findings. Recent antibiotics can blunt fever and leukocytosis, so ESR/CRP and MRI become the clue when the exam feels underwhelming. A seemingly stable patient can still be hours from neurologic collapse.
Back to Our Patient
Back to our 58-year-old man with fever and deep focal back pain. His exam now reveals mild left foot dorsiflexion weakness and a new complaint of trouble starting urination, so this is suspected spinal epidural abscess with evolving cord compression. He needs urgent blood cultures, immediate MRI of the spine, broad empiric IV antibiotics after cultures if he is stable enough, and emergent spine surgery consultation; because he already has neurologic involvement, he should be admitted at a high level of care for likely operative drainage plus IV therapy.
Patient Presentation to Attending
How you’d present this patient on the floor — tight, pertinent positives and negatives, no rambling
This is a 58-year-old man with diabetes presenting with 3 days of severe focal low back pain and fever, now with new left leg weakness and urinary hesitancy. He denies trauma, but he does report recent skin infection and chills; no chest pain or abdominal pain. On exam he is febrile, has midline lumbar tenderness, and has mild left dorsiflexion weakness with otherwise intact sensation; there is no frank saddle anesthesia yet. Labs are pending, but his presentation is highly concerning for spinal epidural abscess with evolving cord compression. I’ve drawn blood cultures, started analgesia, and I’m arranging emergent MRI and neurosurgery consultation; I’d like to start empiric IV vancomycin plus cefepime after cultures.

Study Directive

  • Draw the SEA progression from bacteremia/risk factor → back pain → radiculopathy → cord compression → paralysis.
  • Memorize the bedside fork: pain only vs. pain plus any deficit/bladder symptom.
  • Practice a 20-second oral MRI request: “Concern for spinal epidural abscess with evolving neurologic deficit; need urgent MRI with gadolinium of the symptomatic spine.”
  • Review empiric antibiotic choices by source and risk for MRSA vs. Pseudomonas.
  • Write out three exam findings that mandate emergent surgery consultation.

Recent Literature

  • Review or guideline Spinal Epidural Abscess
    Tande AJ, Currier BL, Osmon DR · N Engl J Med, 2026 · PMID 42019020 · cited 1×
    A current high-yield reference for ED recognition of spinal epidural abscess—risk factors, back pain plus neurologic or infectious red flags, urgent MRI, blood cultures, antibiotics, and early spine surgery involvement.