Cervical Spinal Infections
Vertebral osteomyelitis, discitis, and spinal epidural abscess are rare in developed countries. Most cases stem from hematogenous seeding, skin abscesses, and urinary tract infections but can also originate from a host of other sites, including penetrating trauma and invasive spinal procedures (eg, lumbar punctures, epidural injections). 46,47 Cervical spine infections are associated with immune-compromising situations or conditions (eg, IV drug use, diabetes mellitus, malignancy, acquired immunodeficiency syndrome, renal insufficiency, long-term use of systemic corticosteroids).
All three of these conditions present similarly, often as localized neck pain that grows more intense over a period of days to weeks and worsens with neck movement. Neurological signs ordinarily appear late in the course of the illness. Fever is a classic symptom but is not always present.48 There is usually tenderness over the involved spinous process. The development of motor or sensory loss suggests formation of an abscess,49 which can rapidly lead to further compressive symptoms and sepsis.
Leukocytosis may be absent but erythrocyte sedimentation rate and C-reactive protein are often elevated. A CT scan with contrast is frequently required for diagnosis, though when available, MRI with IV gadolinium is the test of choice (Figure 6). Most cases are caused by S aureus, but antibiotic coverage for gram-positive organisms (including MRSA), gram-negative organisms, and anaerobes should be started as soon as blood cultures are drawn. Neurosurgery should be consulted emergently since, with cervical epidural abscess, neurological deterioration—even to the point of total paralysis—can develop in a matter of hours.50
Conclusion
Although most patients presenting to the ED with neck pain are musculoskeletal and associated with a traumatic event, other infrequent but potentially serious atraumatic causes may be present. Based on a patient’s symptoms, emergency physicians should also consider these conditions in the differential diagnosis to ensure rapid treatment to prevent further complications.