Fever in a spinal patient

The major diagnoses to consider are:

• Meningitis
• Infected baclofen pump
• Septicemia from skin infection/cellulitis
• Epidural abscess +/- infected internal metal rods
• Another source of sepsis, such as LRTI, UTI, intra-abdominal sepsis

Handy tips:

• Spinal patients with no sensation below their neurological level of injury will not present in the usual fashion if they have pathology below their level
• Approach to sepsis must be open-minded and rely more heavily on investigations and imaging.
• Spinal patients have altered calcium regulation/excretion and renal calculi are much more common, with their complications. They must always be sought for and excluded.
• look for infected pressure sores!
• Other basic principles apply, i.e. find the source, find the bug, treat empirically and narrow therapy as soon as possible, whilst providing concomitant supportive management.

Investigations:

• Blood tests:
  • Baseline bloods already done, e.g. FBC, UEC, LFTs, lipase, CRP.
• Cultures — see O’Grady et al (2008):
  • Blood cultures are vital:
    ideally 3 sets in 24hrs from different sites collected in a sterile fashion. 10ml of blood per 20ml BC bottle.
  • Sputum
  • Urine (invariably from a suprapubic catheter in these patients, so this means changing the SPC and taking CSU from new SPC)
  • Swabs from excoriated skin
• Chest Xray
• Lumbar puncture:
  • this proved technically impossible as the patient had a fused spine
• Interrogation of and CSF sampling from baclofen pump
• CT abdomen for calculi & intra-abdominal sepsis
• MRI brain & spinal cord

The MRI of the spine is shown below:

A large posterior epidural collection compressing the epidural sac involves the visualised spine, with the superior margin at the C2 level. The inferior margin of the collection is not visualised due to artefact from metal internal fixation at the T2 level.

The CSF from the baclofen pump showed no organisms and a normal WCC. Blood cultures grew a penicillin sensitive Staphyloccus aureus, and high dose IV penicillin was commenced.

The patient was taken urgently to theatre and the extensive epidural abscess was drained. Post op the patient woke from anaesthetic, and taken to ICU for recovery.

• Montgomerie JZ. Infections in patients with spinal cord injuries. Clin Infect Dis. 1997 Dec;25(6):1285-90; quiz 1291-2. 
• O’Grady NP, Barie PS, Bartlett JG, Bleck T, Carroll K, Kalil AC, Linden P, Maki DG, Nierman D, Pasculle W, Masur H; American College of Critical Care Medicine; Infectious Diseases Society of America. Guidelines for evaluation of new fever in critically ill adult patients: 2008 update from the American College of Critical Care Medicine and the Infectious Diseases Society of America. Crit Care Med. 2008 Apr;36(4):1330-49.
• Pradilla G, Ardila GP, Hsu W, Rigamonti D. Epidural abscesses of the CNS. Lancet Neurol. 2009 Mar;8(3):292-300.