Diagnosis and Management of Spinal Infections

Diagnostic Approach

The American College of Radiology recommends MRI with and without IV contrast as the diagnostic modality of choice for spinal infections, with sensitivity of 96%, specificity of 94%, and accuracy of 92% 1
The MRI protocol should include T1, T2 with fat suppression or STIR sequences, followed by T1 sequences with contrast in axial and sagittal planes 1
Evaluate for epidural collection or abscess, as paraspinal muscle involvement strongly suggests infectious etiology 1
Consider non-contiguous multilevel infections in approximately 10% of cases 1

Obtain blood cultures immediately before initiating antibiotics 1
Measure inflammatory markers (CRP and ESR) for baseline and treatment monitoring 1
Perform image-guided biopsy if possible to identify the etiologic agent 1

Autoimmune/inflammatory myelitis would show intramedullary cord involvement with enhancement, not isolated paraspinal muscle involvement 3, 4
Neoplastic processes would typically show mass effect and different enhancement patterns 3, 5

Immediate surgical decompression is indicated if neurological deficits are present with documented spinal cord compression 1
Do not delay treatment while waiting for imaging studies if neurological deficits are present 1
Initiate broad-spectrum IV antibiotics after obtaining cultures 1
Monitor inflammatory markers (CRP and ESR) to assess treatment response 1

MRI follow-up is useful to evaluate treatment response, though imaging findings may normalize more slowly than clinical and laboratory parameters 1
If MRI is inconclusive or contraindicated, PET-CT with FDG may be useful 1

Do not rely on CT alone for diagnosis: CT has only 6% sensitivity for identifying epidural abscess and should not replace MRI in initial evaluation 1, 2
Do not overlook multilevel involvement: Approximately 10% of spinal infections are non-contiguous and require total spine imaging 1