Approach to the Critical Patient

Immediate stabilization

Time-critical recognition triggers

ABCs and resuscitation

Monitoring and targets

Neurologic monitoring bundle

Consult and team activation

Mandatory consultations for all confirmed or strongly suspected SEA

Key decision points

Surgical vs. nonoperative management decision

History

Symptom progression

Classic 4-phase progression (present in minority at diagnosis)

Alarm features

High-risk neurologic symptoms

Risk factors

Injection drug use

Diabetes mellitus

Spinal procedures or instrumentation

Immunocompromise

Concurrent infection or bacteremia

Epidemiologic history

Demographics and social history

Absence of risk factors does not exclude SEA

Physical Exam

Vital signs

Fever

Spinal exam

Focal midline tenderness

Spinal level localization

Neurologic exam

Motor exam

Sensory and reflex exam

Rectal and bladder exam

Skin exam

Source identification

Differential Diagnosis

Infectious mimics

Vertebral osteomyelitis and discitis

Psoas abscess

Spinal subdural abscess

Meningitis

Compressive and structural mimics

Spinal epidural hematoma

Metastatic epidural spinal cord compression

Cauda equina syndrome from disc herniation

Intramedullary spinal cord tumor

Inflammatory mimics

Transverse myelitis

Demyelinating disease

Laboratory Tests

Inflammatory markers

Erythrocyte sedimentation rate (ESR)

C-reactive protein (CRP)

Hematologic and metabolic labs

Complete blood count

Comprehensive metabolic panel

Microbiologic tests

Blood cultures

Image-guided biopsy and culture

Procalcitonin

Diagnostic Tests

Scoring Systems

SEA Risk Stratification (NEJM 2026 algorithm)

Predictors of nonoperative management failure

MRI

MRI spine with and without contrast

Repeat MRI indications

CT

CT spine

Ultrasound

Point-of-care ultrasound (POCUS)

Echocardiography

Disposition

Admission criteria

Hospital admission mandatory for all confirmed SEA

Transfer criteria

Transfer to higher level of care

Discharge criteria

Criteria for outpatient parenteral antibiotic therapy (OPAT) transition

Treatment

Empiric antibiotic therapy

Vancomycin (MRSA and methicillin-sensitive S. aureus coverage)

Ceftriaxone (gram-negative coverage in non-high-risk patients)

Cefepime (high-risk patients or Pseudomonas coverage required)

Antifungal therapy

Antibiotic de-escalation and duration

Culture-directed therapy

Duration of therapy

Surgical management

Urgent surgical decompression

Surgical approaches

Supportive care

Analgesia

Glycemic control

DVT prophylaxis

Special Populations

Pregnancy

Epidemiology and risk in pregnancy

Diagnostic considerations in pregnancy

Treatment in pregnancy

Geriatric

Epidemiology in older adults

Diagnostic challenges

Treatment modifications

Pediatrics

Epidemiology in children

Diagnostic approach in children

Treatment in children

Background

Epidemiology

Incidence

Microbiology

Outcomes

Pathophysiology

Epidural space anatomy

Mechanisms of infection

Neurologic injury mechanisms

Therapeutic Considerations

Evidence base for treatment decisions

Culture yield optimization

Key clinical pearls

Patient Discharge Instructions

copy discharge instructions

Diagnosis and treatment explanation

Wound and PICC care

Activity and physical restrictions

Return to emergency department immediately for

References

Guidelines and key sources

Tande AJ, Currier BL, Osmon DR. Spinal Epidural Abscess. N Engl J Med. 2026

Long B, Carlson J, Montrief T, Koyfman A. High Risk and Low Prevalence Diseases: Spinal Epidural Abscess. Am J Emerg Med. 2022

ACR Appropriateness Criteria: Suspected Spine Infection. JACR. 2021. Expert Panel on Neurological Imaging

ACR Appropriateness Criteria: Cervical Pain or Cervical Radiculopathy. JACR. 2025

Obeda MJ, Dalai AS, Monti EB, et al. Clinical Evaluation for SEA in S. aureus Bacteraemia. Infect Dis. 2026

Budiman L, Abetz JW, Mitra B. Clinical Characteristics of SEA: A Systematic Review and Meta-Analysis. Emerg Med Australas. 2026

Garcia de Santos M, et al. Outcomes and Factors Associated With Medical Treatment Failure in SEA. PLoS One. 2025

Durant EJ, Copos S, Folck BF, et al. Diagnostic Delays Are Common in SEA. West J Emerg Med. 2025

ASRA Pain Medicine Consensus Practice Infection Control Guidelines. Reg Anesth Pain Med. 2025

Miller JM et al. IDSA/ASM Guide to Microbiology Laboratory for Infectious Diseases. Clin Infect Dis. 2024