Upcoming JACEP Open Study Looks at Imaging in Prospective AISP Patients

Low levels of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) may help rule out acute infectious spinal pathology (AISP) in emergency department (ED) patients without confirmatory imaging, according to a study recently published in JACEP Open. In their conclusion, the authors wrote that further prospective studies may be indicated to validate the findings.

“An Assessment of C-Reactive Protein and Erythrocyte Sedimentation Rate in Ruling Out Acute Infectious Spinal Pathology in Emergency Department Patients: A Retrospective Cohort Study” was published in August. In the objectives for the retrospective study, lead author Scott Gutovitz, MD, and the research team pointed out that AISP, including discitis, osteomyelitis, spinal epidural abscess, and septic arthritis are rare, carry significant morbidity and mortality, and are difficult to diagnose.

CRP and ESR, they noted, are frequently elevated in AISP, although there are no consensus recommendations on using them.

This multicenter retrospective cohort study reviewed ED encounters from 2016–2019 across 186 hospitals to assess the sensitivity of ESR and CRP in ruling out AISP. Adult patients presenting with spinal pain who had both biomarkers tested and underwent spinal MRI were included.

After excluding patients with other conditions known to elevate inflammatory markers, the study analyzed 5,944 encounters (1,963 AISP cases and 3,981 controls).

Median ESR was significantly higher in patients with AISP compared to controls (56 vs. 18 mm/h, P<.001), as was CRP (6.4 vs. 2.0 mg/dL, P<.001). Receiver-operating curve analysis identified cutoffs of ESR ≤20 mm/h or CRP ≤1.2 mg/dL for 90 percent sensitivity, and ESR ≤12 mm/h or CRP ≤0.7 mg/dL for 95 percent sensitivity.

Using both biomarkers together (ESR ≤20 mm/h and CRP ≤1.0 mg/dL) achieved 98.9 percent sensitivity and a negative predictive value >99 percent.

The findings suggest that low ESR and CRP values can effectively rule out AISP, potentially reducing the need for MRI in low-risk patients.

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