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Spinal epidural abscess with acute spinal cord compromise — MRCEM SBA MCQ

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HardInfection and sepsisSpinal epidural abscess with acute spinal cord compromiseMRCEM SBA

A 62-year-old man with type 2 diabetes presents with ten days of worsening thoracic back pain and fever. During assessment he develops bilateral leg weakness and cannot pass urine. His blood pressure is 124/76 mmHg, pulse 104/min and temperature 38.1°C. Power is 3/5 in both legs, and bladder scanning shows 650 mL of urine. MRI demonstrates a posterior epidural abscess at T8–T10 compressing the spinal cord. Blood cultures have been taken; he has not received antibiotics. Which management plan is most appropriate now?

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Correct answer: C — Start empirical intravenous antibiotics and arrange urgent spinal decompression.

The MRI establishes a spinal epidural abscess, while new bilateral weakness and urinary retention indicate acute spinal cord compromise. Preserved blood pressure does not make it safe to wait for tissue diagnosis or a trial of antibiotics. With blood cultures already obtained, empirical intravenous antibiotics should begin now, alongside urgent spinal surgical assessment for decompression and source control. UK NHS guidance recommends immediate empirical treatment and surgical intervention when spinal infection is accompanied by neurological compromise. ([uhb.nhs.uk](https://www.uhb.nhs.uk/media/513l1wph/antimicrobialprescribingguidelines.pdf)) A is attractive because biopsy can identify the organism, but withholding antibiotics for biopsy is an approach for patients whose neurological examination and haemodynamics are stable—not this patient. B correctly prioritises surgery but unnecessarily delays antimicrobial treatment after blood cultures have been taken. D offers appropriate antibiotics, yet observation risks further neurological injury despite established cord compression. E offers a potential means of sampling or draining a collection, but does not replace urgent surgical assessment and decompression in a patient with an evolving motor deficit and sphincter dysfunction. This patient requires admission under an urgent spinal surgical pathway, with microbiology input to refine treatment. ([uhb.nhs.uk](https://www.uhb.nhs.uk/media/513l1wph/antimicrobialprescribingguidelines.pdf))

Reference: University Hospitals Birmingham NHS Foundation Trust Antimicrobial Prescribing Guidelines: Vertebral Osteomyelitis/Discitis/Spinal Epidural Abscess (Document review June 2026; section review January 2025) — https://www.uhb.nhs.uk/media/513l1wph/antimicrobialprescribingguidelines.pdf Norfolk and Norwich University Hospitals NHS Foundation Trust: Infection of the Spine (Date not stated on page) — https://www.nnuh.nhs.uk/departments/orthopaedic-amp-trauma/spine/infection-of-the-spine/