The participant should, in order, review the learning objectives, read the article, and complete the CME post-test/evaluation form to receive 1 ACEP Category 1 credit and 1 AMA/PRA Category 1 credit. You will be able to print your CME certificate immediately.

The credit for this CME activity is available through April 30, 2013.

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Risk Factors

Although injection drug use is the most common hematogenous source of SEA, accounting for 52% of cases in some populations, diabetes mellitus is the most common risk factor overall,⁷ followed by trauma, intravenous drug use, and alcoholism. These patient groups are thought to possess cellular and humoral immune system dysfunction.⁷ Less common risk factors are malignancy, end-stage renal disease, epidural anesthetics, vascular access, spinal trauma, and degenerative joint disease, most of which facilitate entry of pathogens by disruption of normal anatomic barriers.⁷

Signs and Symptoms

SEA is a great imitator, making early diagnosis difficult. It is estimated that 51% of patients have more than two emergency department visits prior to diagnosis,²⁵ even though 98% had at least one known risk factor.²⁵ Patients generally seek medical attention at a median of 7 days.²⁶

Back pain is the most common symptom.²⁵ The “classic” triad of SEA (fever, back pain, and neurologic deficits) is uncommon and present in fewer than 20% of patients. Absence of fever is not reassuring, as only a third of patients with SEA report a history of fever. Unrelenting pain, which is exacerbated at night, is very worrisome both for malignancy and infection.²⁷

A history of minor trauma is often offered as an explanation for the pain in 19% of patients, while 14% report a history of chronic back pain.²⁵ This trauma may distract the emergency physician from considering SEA in the differential diagnosis. Symptoms typically progress from back pain and localized tenderness to muscle weakness, sphincter incontinence, sensory deficits, and finally paralysis if untreated.⁷

Physical Exam

The physical exam alone is not sensitive for detecting SEA, and neurologic examination has been documented as normal in more than two-thirds of patients during the initial emergency department visit.²⁵ Either cursory neurological examinations or poor charting is demonstrated by the lack of documentation of a digital rectal examination for roughly half of all patients with SEA.²⁵ Usually some minimal notation as to a “nonfocal” neurologic examination is often documented, but specific details regarding sensation, strength, reflexes, and cerebellar function are often absent.²⁵