Management of Spinal Infections

Diagnostic Evaluation

The American College of Radiology recommends magnetic resonance imaging (MRI) with and without contrast as the diagnostic modality of choice for spinal infections, with a sensitivity of 96%, specificity of 94%, and accuracy of 92% 1, 2
MRI provides excellent tissue characterization and anatomical detail, making it ideal for visualizing the epidural space and spinal cord 1
The MRI protocol should include T1, T2 with fat suppression or STIR sequences, followed by T1 sequences with contrast in the axial and sagittal planes 2

The American College of Radiology suggests that surgical decompression is indicated in the presence of neurological deficits and documented spinal cord compression 1
Colecting blood cultures and, if possible, image-guided biopsy to identify the etiologic agent is recommended 2, 3

The European Journal of Nuclear Medicine and Molecular Imaging recommends monitoring inflammatory markers (CRP and ESR) to assess treatment response 4
MRI follow-up is useful to evaluate treatment response, although imaging findings may take longer to normalize than clinical and laboratory parameters 2
CT can be useful in pre-surgical planning and follow-up of instrumented spine 2

The European Journal of Nuclear Medicine and Molecular Imaging notes that approximately 10% of cases may have non-contiguous multilevel infections, which should be considered in the diagnostic workup 4
In cases of diagnostic uncertainty, PET-CT with FDG may be useful, especially if MRI is inconclusive or contraindicated 4
The American College of Radiology recommends against delaying treatment while waiting for imaging studies if neurological deficits are present, and notes that CT has low sensitivity (6%) for identifying epidural abscess and should not replace MRI in initial evaluation 1, 2