Prehospital Care

Because the course of this condition is measured in days and not in hours (some patients take several months to present to medical care), patients' arrival by Emergency Medical Services (EMS) transport is unlikely.

If presented with a patient who requires EMS transport, oxygen, analgesia, and a position of comfort are the only treatments needed in the prehospital arena.

In patients in whom meningismus is involved, antiemetics and gentle handling are indicated.

Emergency Department Care

Because this is such a rare entity, making the diagnosis in the ED is likely difficult. The emergency physician should consider the diagnosis when an infectious picture is present along with neurologic deficits originating at the spinal cord level.

Treatment goals include making an accurate diagnosis and starting antibiotics as early as possible.^{[9, 10]}

Determining the extent of the motor and sensory deficit and its levels is important to guide diagnostic modalities later. Examine the cervical, dorsal, and lumbar regions carefully looking for dermal sinuses, suggestive lesions, and signs of local infection.

Plain radiography of the involved spinal levels occasionally can offer a clue when abnormal.

A lumbar puncture always is considered in a patient with a septic picture with neurologic involvement; however, remember that besides cell count, protein, glucose, and bacteriologic studies, manometric maneuvers can establish the diagnosis of CSF block. Again, neuroimaging (especially MRI) of the spine has made CSF manometry largely obsolete for detecting spinal canal block. If a dermal sinus is found in the lumbar region, deferring the lumbar puncture until the absence of a tethered cord syndrome can be ascertained is prudent.

Start antibiotics as soon as the bacteriologic workup samples have been obtained. Concomitant risk factors determine the most optimal antibiotic coverage for each individual patient.

The use of steroids to treat spinal cord swelling should be made in consultation with neurosurgery.

For additional information, see Spinal Cord Abscess and Spinal Cord Tumors - Management of Intradural Intramedullary Neoplasms.

Consultations

The neurosurgeon should be involved early to guide the diagnostic flow toward surgery.

An infectious disease consultant can offer invaluable help regarding the best antimicrobial combination.

Consult a neuroradiologist to read the MRI with gadolinium study.

Medication

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Media Gallery

Graph showing age distribution of 91 patients with intramedullary spinal cord abscess. The age or gender of 14 patients is unknown.

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Author

Andrew K Chang, MD, MS Vincent P Verdile, MD, Endowed Chair in Emergency Medicine, Professor of Emergency Medicine, Vice Chair of Research and Academic Affairs, Albany Medical College; Associate Professor of Clinical Emergency Medicine, Albert Einstein College of Medicine; Attending Physician, Department of Emergency Medicine, Montefiore Medical Center

Andrew K Chang, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American Academy of Pain Medicine, American College of Emergency Physicians, American Geriatrics Society, American Pain Society, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

J Stephen Huff, MD, FACEP Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

J Stephen Huff, MD, FACEP is a member of the following medical societies: American Academy of Neurology, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Liudvikas Jagminas, MD, FACEP Chief of Service, Attending Physician, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Vice-Chair for Network Development, Department of Emergency Medicine, Beth Israel Deaconess and Harvard Medical Faculty Physicians; Adjunct Associate Professor of Emergency Medicine, The Warren Alpert Medical School of Brown University

Liudvikas Jagminas, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, International Trauma Anesthesia and Critical Care Society, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Daniel J Dire, MD, FACEP, FAAP, FAAEM Professor of Pediatrics and Emergency Medicine, University of Texas Health Science Center at San Antonio, Joe R and Teresa Lozano Long School of Medicine

Daniel J Dire, MD, FACEP, FAAP, FAAEM is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, The Society of Federal Health Professionals (AMSUS)

Disclosure: Nothing to disclose.

Robert E O'Connor, MD, MPH Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Heart Association, American Medical Association, National Association of EMS Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.