Predicting patients with concurrent noncontiguous spinal epidural abscess lesions

Imaging in spinal infections: Current status and future directions

Imaging plays an important role in the diagnosis of spinal infections. Early diagnosis is paramount in the treatment of spinal infections and leads to improved outcomes. This article reviews the imaging and relevant clinical details of infections of the spine: pyogenic spondylodiscitis, tuberculous spondylodiscitis, septic facet arthritis, epidural abscess, and subdural abscess. Though radiographs can reveal subtle changes with infections, advanced imaging modalities have increased sensitivity to aid in early diagnosis. Magnetic resonance imaging (MRI) is emphasized given it is generally the most sensitive and specific advanced imaging modality. However, nuclear medicine imaging and computer tomography (CT) play a role diagnosis in cases where MRI is not available or contra-indicated. Additionally, CT is also important for image-guided biopsy to guide antimicrobial treatment.

Clinical phenotyping of spondylodiscitis and isolated spinal epidural empyema: a 20-year experience and cohort study

Background

The incidence of spondylodiscitis (SD) and isolated spinal epidural empyema (ISEE) has been increasing in the last decades, but the distinct differences between both entities are poorly understood. We aimed to evaluate the clinical phenotypes and long-term outcomes of SD and ISEE in depth.

Methods

We performed a chart review and analyzed data from our cohorts of consecutive SD and ISEE patients who were treated and assessed in detail for demographic, clinical, imaging, laboratory, and microbiologic characteristics at a university neurosurgical center in Germany from 2002 to 2021. Between-group comparisons were performed to identify meaningful differences in both entities.

Results

We included 208 patients (72 females: age 75 [75 32-90] y vs. 136 males: 65 [23-87] y, median [interquartile range], p < 0.001), of which 142 (68.3%) had SD and 66 (31.7%) had ISEE. Patients with SD were older than ISEE (ISEE: 62 y vs. SD: 70 y, p = 0.001). While SD was more common in males than females (males: n = 101, 71.1% vs. females: n = 41, 28.9%, p < 0.001), there was no sex-related difference in ISEE (males: n = 35, 53.0% vs. females: n = 31, 47.0%, p = 0.71). Obesity was more frequent in ISEE than in SD (ISEE: n = 29, 43.9% vs. SD: n = 37, 26.1%, p = 0.016). However, there were no between-group differences in rates of diabetes and immunodeficiency. In the entire study population, a causative pathogen was identified in 192 (92.3%) patients, with methicillin-susceptible staphylococcus aureus being most frequent (n = 100, 52.1%) and being more frequent in ISEE than SD (ISEE: n = 43, 65.2% vs. SD: n = 57, 40.1%, p = 0.003). SD and ISEE occurred most frequently in the lumbar spine, with no between-group differences (ISEE: n = 25, 37.9% vs. SD: n = 65, 45.8%, p = 0.297). Primary infectious sources were identified in 145 patients (69.7%) and among this skin infection was most common in both entities (ISEE: n = 14, 31.8% vs. SD: n = 25, 24.8%, p = 0.418). Furthermore, epidural administration was more frequent the primary cause of infection in ISEE than SD (ISEE: n = 12, 27.3% vs. SD: n = 5, 4.9%, p < 0.001). The most common surgical procedure in SD was instrumentation (n = 87, 61%) and in ISEE abscess evacuation (n = 63, 95%). Patients with ISEE displayed lower in-hospital complication rates compared to SD for sepsis (ISEE: n = 12, 18.2% vs. SD: n = 94, 66.2%, p < 0.001), septic embolism (ISEE: n = 4/48 cases, 8.3% vs. SD: n = 52/117 cases, 44.4%, p < 0.001), endocarditis (ISEE: n = 1/52 cases, 1.9% vs. SD: n = 23/125 cases, 18.4%, p = 0.003), relapse rate (ISEE: n = 4/46, 8.7% vs. SD: n = 27/92, 29.3%, p = 0.004), and disease-related mortality (ISEE: n = 1, 1.5% vs. SD: n = 11, 7.7%, p = 0.108). Patients with SD showed prolonged length of hospital stay (ISEE: 22 [15, 30] d vs. SD: 38 [29, 53] d, p < 0.001) and extended intensive care unit stay (ISEE: 0 [0, 4] d vs. SD: 3 [0, 12] d, p < 0.002).

Conclusions

Our 20-year experience and cohort analysis on the clinical management of SD and ISEE unveiled distinct clinical phenotypes and outcomes in both entities, with ISEE displaying a more favorable disease course with respect to complications and relapse rates as well as disease-related mortality.

Candida: The Ruthless Opportunist

Spondylodiscitis is a pathology with a devastating potential for functional limitation in patients, which may involve immobilization for months due to the risk of compression or even spinal cord section. It is a rare type of infection occurring in the vertebrae and discs of the spine, and most are bacterial. Fungal cases are rare. We present the clinical case of a 52-year-old female patient with a past medical history of vesicular lithiasis and degenerative disc disease of the cervical spine and no home medication. The patient was hospitalized in the surgery service for about 3.5 months due to necro-hemorrhagic lithiasic pancreatitis that evolved into septic shock and needed organ support in intensive care for 2.5 weeks. Several cycles of antibiotics and endoscopic retrograde cholangiopancreatography (ERCP) with stent placement were performed. She was readmitted for urgent care to the hospital of residence with fever, sweating, and low back pain with sciatica five days after discharge. Lumbar CT and MRI evidence showed the destruction of about two-thirds of the vertebral bodies L3-L4, L5-S1, and adjacent discs, pointing to the diagnosis of infectious spondylodiscitis. Candida albicans was found in blood cultures and lumbar biopsies. The patient was treated with oral fluconazole 400 mg/day for eight months, and the control MRIs showed slow but favorable bone sclerosis over time. She spent a total of 13.5 months in the hospital, including five months in bedbound status. The patient left the hospital walking without any assistance, with an upright mood and disposition. The most likely main fungal infectious factors were the manipulation of the bile ducts, immunosuppression associated with corticosteroid therapy, and multiorgan septic failure. The authors highlight this clinical case for its rarity, complications leading to candidemia, diagnostic and therapeutic delay, complexity, and risk of irreversible injuries to which the patient was subjected. The total recuperation of the patient after such a long physical and emotional struggle was very gratifying.

Does Operative Management of Epidural Abscesses Increase Healthcare Expenditures up to 1 Year After Treatment?

BACKGROUND

The incidence of spinal epidural abscesses is increasing. What is more, they are associated with high rates of morbidity and mortality. Advances in diagnostic imaging and antibiotic therapies have made earlier diagnosis and nonoperative management feasible in appropriately selected patients. Nonoperative treatment also has the advantage of lower immediate healthcare charges; however, it is unknown whether initial nonoperative care leads to higher healthcare charges long term.

QUESTIONS/PURPOSES

(1) Does operative intervention generate higher charges than nonoperative treatment over the course of 1 year after the initial treatment of spinal epidural abscesses? (2) Does the treatment of spinal epidural abscesses in people who actively use intravenous drugs generate higher charges than management in people who do not?

METHODS

This retrospective comparative study at two tertiary academic centers compared adult patients with spinal epidural abscesses treated operatively and nonoperatively from January 2016 through December 2017. Ninety-five patients were identified, with four excluded for lack of billing data and one excluded for concomitant intracranial abscess. Indications for operative management included new or progressive motor deficit, lack of response to nonoperative treatment including persistent or progressive systemic illness, or initial sepsis requiring urgent source control. Of the included patients, 52% (47 of 90) received operative treatment with no differences in age, gender, BMI, and Charlson comorbidity index between groups, nor any difference in 30-day all-cause readmission rate, 1-year reoperation rate, or 2-year mortality. Furthermore, 29% (26 of 90) of patients actively used intravenous drugs and were younger, with a lower BMI and lower Charlson comorbidity index, with no differences in 30-day all-cause readmission rate, 1-year reoperation rate, or 2-year mortality. Cumulative charges at the index hospital discharge and 90 days and 1 year after discharge were compared based on operative or nonoperative management and secondarily by intravenous drug use status. Medical records, laboratory results, and hospital billing data were reviewed for data extraction. Demographic factors including age, gender, region of abscess, intravenous drug use, and comorbidities were extracted, along with clinical factors such as symptoms and ambulatory function at presentation, spinal instability, intensive care unit admission, and complications. The primary outcome was charges associated with care at the index hospital discharge and 90 days and 1 year after discharge. All covariates extracted were included in this analysis using negative binomial regression that accounted for confounders and the nonparametric nature of charge data. Results are presented as an incidence rate ratio with 95% confidence intervals.

RESULTS

After adjusting for demographic and clinical variables such as age, gender, BMI, ambulatory status, presence of mechanical instability, and intensive care unit admission among others, we found higher charges for the group treated with surgery compared with those treated nonoperatively at the index admission (incidence rate ratio [IRR] 1.62 [95% CI 1.35 to 1.94]; p < 0.001) and at 1 year (IRR 1.36 [95% CI 1.10 to 1.68]; p = 0.004). Adjusted analysis also showed that active intravenous drug use was also associated with higher charges at the index admission (IRR 1.57 [95% CI 1.16 to 2.14]; p = 0.004) but no difference at 1 year (IRR 1.11 [95% CI 0.79 to 1.57]; p = 0.55).

CONCLUSION

Multidisciplinary teams caring for patients with spinal epidural abscesses should understand that the decreased charges associated with selecting nonoperative management during the index admission persist at 1 year with no difference in 30-day readmission rates, 1-year reoperation rates, or 2-year mortality. On the other hand, patients with active intravenous drug use have higher index admission charges that do not persist at 1 year, with no difference in 30-day readmission rates, 1-year reoperation rates, or 2-year mortality. These results suggest possible economic benefit to nonoperative management of epidural abscesses without increases in readmission or mortality rates, further tipping the scale in an evolving framework of clinical decision-making. Future studies should investigate if these economic implications are mirrored on the patient-facing side to determine whether any financial burden is shifted onto patients and their families in nonoperative management.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Whole-Spine Magnetic Resonance Imaging: A Review of Suggested Indications

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The spinal column has a propensity for lesions to manifest in a multifocal manner, and identification of the lesions can be difficult.

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When used to image the spine, magnetic resonance imaging (MRI) most accurately identifies the presence and location of lesions, guiding the treatment plan and preventing potentially devastating complications that are known to be associated with unidentified lesions.

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Certain conditions clearly warrant evaluation with whole-spine MRI, whereas the use of whole-spine MRI with other conditions is more controversial.

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We suggest whole-spine MRI when evaluating and treating any spinal infection, lumbar stenosis with upper motor neuron signs, ankylosing disorders of the spine with concern for fracture, congenital scoliosis undergoing surgical correction, and metastatic spinal tumors.

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Use of whole-spine MRI in patients with idiopathic scoliosis and acute spinal trauma remains controversial.

Preclinical models of vertebral osteomyelitis and associated infections: Current models and recommendations for study design

Spine-related infections, such as vertebral osteomyelitis, discitis, or spondylitis, are rare diseases that mostly affect adults, and are usually of hematogenous origin. The incidence of this condition has gradually risen in recent years because of increases in spine-related surgery and hospital-acquired infections, an aging population, and intravenous (IV) drug use. Spine infections are most commonly caused by Staphylococcus aureus, while other systemic infections such as tuberculosis and brucellosis can also cause spondylitis. Various animal models of vertebral osteomyelitis and associated infections have been investigated in mouse, rat, chicken, rabbit, dog, and sheep models by hematogenous and direct inoculation in surgery, each with their strengths and limitations. This review is the first of its kind to concisely analyze the various existing animal models used to reproduce clinically relevant models of infection. Spine-related infection models must address the unique anatomy of the spine, the avascular nature of its structures and tissues and the consequences of tissue destruction such as spinal cord compression. Further investigation is necessary to elucidate the specific mechanisms of host-microbe response to inform antimicrobial therapy and administration techniques in a technically demanding body cavity. Small-animal models are not suitable for large instrumentation, and difficult IV access thwarts antibiotic administration. In contrast, large-animal models can be implanted with clinically relevant instrumentation and are resilient to repeat procedures to study postoperative infection. A canine model of infection offers a unique opportunity to design and investigate antimicrobial treatments through recruitment a rich population of canine patients, presenting with a natural disease that is suitable for randomized trials.

Just the Facts: Risk stratifying non-traumatic back pain for spinal epidural abscess in the emergency department

A 65-year-old male with a history of hypertension presents to the emergency department (ED) with new onset of non-traumatic back pain. The patient is investigated for life-threatening diagnoses and screened for “red flag symptoms,” including fever, neurologic abnormalities, bowel/bladder symptoms, and a history of injectiondrug use (IVDU). The patient is treated symptomatically and discharged home but represents to the ED three additional times, each time with new and progressive symptoms. At the time of admission, he is unable to ambulate, has perineal anesthesia, and 500 cc of urinary retention. Whole spine magnetic resonance imaging (MRI) confirms a thoracic spinal epidural abscess. This case, and many like it, prompts the questions: when should emergency physicians consider the diagnosis of a spinal epidural abscess, and what is the appropriate evaluation of these patients in the ED? (Figure 1).

Spinal Epidural Abscess: Diagnosis, Management, and Outcomes

An infection of the spinal epidural space, spinal epidural abscess (SEA) is a potentially devastating entity that is rising in incidence. Its insidious presentation, variable progression, and potential for precipitous neurologic decline make diagnosis and management of SEA challenging. Prompt diagnosis is key because treatment delay can lead to paralysis or death. Owing to the nonspecific symptoms and signs of SEA, misdiagnosis is alarmingly common. Risk factor assessment to determine the need for definitive MRI reduces diagnostic delays compared with relying on clinical or laboratory findings alone. Although decompression has long been considered the benchmark for SEA, considerable risk associated with spinal surgery is noted in an older cohort with multiple comorbidities. Nonoperative management may represent an alternative in select cases. Failure of nonoperative management is a feared outcome associated with motor deterioration and poor clinical outcomes. Recent studies have identified independent predictors of failure and residual neurologic dysfunction, recurrence, and mortality. Importantly, these studies provide tools that generate probabilities of these outcomes. Future directions of investigation should include external validation of existing algorithms through multi-institutional collaboration, prospective trials, and incorporation of powerful predictive statistics such as machine learning methods.

Keys to diagnosis and management of spinal epidural abscesses: 9 years of institutional experience

OBJECTIVE

Spinal epidural abscesses (SEA's) are a challenge to diagnose, particularly if there are non-contiguous (skip) lesions. There is also limited data to predict which patients can be treated with antibiotics alone and which require surgery. We sought to assess which demographics, clinical and laboratory findings can guide both diagnosis and management of SEA's.

METHODS

All patients with SEA (ICD9 324.1, ICD10 G06.1) between April 2011-May 2019 at a single tertiary center were included. A retrospective EMR review was completed. Patient and disease characteristics were compared using appropriate statistical tests.

RESULTS

108 patients underwent initial surgical treatment versus 105 that were treated medically initially; 22 (21 %) of those failed medical management. Patients who failed medical management had significantly higher CRP, longer symptom duration, and had higher rates of concurrent non-spinal infections. 9% of patients had skip lesions. Patients with skip lesions had significantly higher WBC, ESR, as well as higher rates of bacteremia and concurrent non-spinal infections. Demographic characteristics and proportion with IVDU, smoking, malignancy, and immunosuppression were similar among the three treatment groups.

CONCLUSIONS

21 % of SEA patients failed initial medical management; they had significantly greater CRP, longer symptom duration, more commonly had neurologic deficits, and concurrent non-spinal infections. 9% of patients had skip lesions; they had significantly higher WBC, ESR, rates of bacteremia and infections outside the spine. These variables may guide diagnostic imaging, and identify those at risk of failing of medical management, and therefore require more involved clinical evaluation, and consideration for surgical intervention.

Spinal Epidural Abscess: A Review of Presentation, Management, and Medicolegal Implications

Spinal epidural abscess (SEA) is a rare condition associated with significant morbidity and mortality. Despite advances in diagnostic medicine, early recognition of SEAs remains elusive. The vague presentation of the disease, coupled with its numerous risk factors, the diagnostic requirement for obtaining advanced imaging, and the necessity of specialized care constitute extraordinary challenges to both diagnosis and treatment of SEA. Once diagnosed, SEAs require urgent or emergent medical and/or surgical management. As SEAs are a relatively rare pathology, high-quality data are limited and there is no consensus on their optimal management. This paper focuses on presenting the treatment modalities that have been successful in the management of SEAs and providing a critical assessment of how specific SEA characteristics may render one infection more amenable to primary surgical or medical interventions. This paper reviews the relevant history, epidemiology, clinical presentation, radiology, microbiology, and treatment of SEAs and concludes by addressing the medicolegal implications of delayed treatment of the disease.

Readmission after spinal epidural abscess management in urban populations: a bi-institutional study

OBJECTIVE

The incidence of spinal epidural abscess (SEA) is rising, yet there are few reports discussing readmission rates or predisposing factors for readmission after treatment. The aims of the present study were to determine the rate of 90-day readmission following medical or surgical treatment of SEA in an urban population, identify patients at increased risk for readmission, and delineate the principal causes of readmission.

METHODS

Neurosurgery records from two large urban institutions were reviewed to identify patients who were treated for SEA. Patients who died during admission or were discharged to hospice were excluded. Univariate analysis was performed using chi-square and Student t-tests to identify potential predictors of readmission. A multivariate logistic regression model, controlled for age, body mass index, sex, and institution, was used to determine significant predictors of readmission.

RESULTS

Of 103 patients with identified SEA, 97 met the inclusion criteria. Their mean age was 57.1 years, and 56 patients (57.7%) were male. The all-cause 90-day readmission rate was 37.1%. Infection (sepsis, osteomyelitis, persistent abscess, bacteremia) was the most common cause of readmission, accounting for 36.1% of all readmissions. Neither pretreatment neurological deficit (p = 0.16) nor use of surgical versus medical management (p = 0.33) was significantly associated with readmission. Multivariate analysis identified immunocompromised status (p = 0.036; OR 3.5, 95% CI 1.1-11.5) and hepatic disease (chronic hepatitis or alcohol abuse) (p = 0.033; OR 2.9, 95% CI 1.1-7.7) as positive predictors of 90-day readmission.

CONCLUSIONS

The most common indication for readmission was persistent infection. Readmission was unrelated to baseline neurological status or management strategy. However, both hepatic disease and baseline immunosuppression significantly increased the odds of 90-day readmission after SEA treatment. Patients with these conditions may require closer follow-up upon discharge to reduce overall morbidity and hospital costs associated with SEA.

Risk Management and Avoiding Legal Pitfalls in the Emergency Treatment of High-Risk Orthopedic Injuries

Many orthopedic injuries can have hidden risks that result in increased liability for the emergency medicine practitioner. It is imperative that emergency medicine practitioners consider the diagnoses of compartment syndrome, high-pressure injury, spinal epidural abscess, and tendon lacerations in the right patient. Consideration of the diagnosis and prompt referrals can help to minimize the complications these patients often develop.

Challenges in diagnosis of spinal epidural abscess: A case report

RATIONALE

Spinal epidural abscess (SEA) is a rare condition that shows a high prevalence in immunocompromised patients. The clinical presentation of SEA includes the "classic triad" of pain, fever, and neurological dysfunction. However, these nonspecific features can lead to a high rate of misdiagnosis. SEA may lead to paralysis or even death; thus, prognosis of these patients remains unfavorable.

PATIENT CONCERNS

We report a case of a multilevel (T6-T12) SEA in a 22-year-old woman.

DIAGNOSIS

The patient was initially diagnosed with spinal tuberculosis at a local hospital based on a history of tuberculosis exposure, as well as radiography and computed tomography. Histopathological examination of the tissue resected during laminectomy confirmed the diagnosis of SEA in this patient.

INTERVENTIONS

The patient underwent multilevel laminectomy combined with long-term antibiotic therapy.

OUTCOMES

Physical examination performed 16 months postoperatively revealed that superficial and deep sensation was restored to normal levels in the lower extremities with improvement in the patient's motor function (muscle strength 2/5).

LESSONS

This case report indicates that whole spine magnetic resonance imaging is warranted in patients with SEA and that prompt surgical intervention is important at symptom onset. Long-term antibiotic therapy is also essential postoperatively.

Etiology and Surgical Management of Cervical Spinal Epidural Abscess (SEA):: A Systematic Review

STUDY DESIGN

Systematic analysis and review.

OBJECTIVE

Evaluation of the presentation, etiology, management strategies (including both surgical and nonsurgical options), and neurological functional outcomes in patients with cervical spinal epidural abscess (SEA).

METHODS

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria were used to create a framework based on which articles pertaining to cervical SEA were chosen for review following a search of the Ovid and PubMed databases using the search terms "epidural abscess" and "cervical." Included studies needed to have at least 4 patients aged 18 years or older, and to have been published within the past 20 years.

RESULTS

Database searches yielded 521 potential articles in PubMed and 974 potential articles in Ovid. After review, 11 studies were ultimately identified for inclusion in this systematic review. Surgery appears to be a well-tolerated management strategy with limited complications for patients with cervical SEA. However, the quantity of data comparing medical and surgical treatment of cervical SEA is limited and the bulk of the data is derived from low quality studies.

CONCLUSION

Data reporting was heterogeneous among studies making it difficult to draw discrete conclusions. Early surgical intervention may be appropriate in selected patients with cervical epidural abscess, but it is not clear what distinguishes these patients from those who are successfully managed nonoperatively.

Evaluation and Management of Pyogenic and Tubercular Spine Infections

PURPOSE OF REVIEW

To review the most current diagnostic tools and treatment options for pyogenic and tubercular spine infection.

RECENT FINDINGS

Recent studies have focused on risk factors for failed nonoperative management in order to improve patient selection. Also, spine instrumentation and different grafting options have been safely utilized in the setting of an active infection without increasing the incidence of reoccurrence. However, the optimal surgical technique has yet to be established and instead should be patient specific. Spine infections include a broad spectrum of disorders including discitis, vertebral osteomyelitis, and spinal epidural abscess. It is paramount to recognized spine infections early due to the potential catastrophic consequences of paralysis and sepsis. The management of spine infections continues to evolve as newer diagnostic tools and surgical techniques become available. Magnetic resonance imaging with contrast is the imaging study of choice and computed tomography-guided biopsies are crucial for guiding antibiotic selection. Antibiotics are the mainstay of treatment and surgery is indicated in patients with neurological deficits, sepsis, spinal instability, and those who have failed nonoperative treatment.

Spinal Epidural Abscess: A Series of 101 Cases

BACKGROUND

Spinal epidural abscesses are uncommon but potentially devastating infections that often elude early diagnosis. An increasing incidence has been suggested; however, few contemporary data are available regarding risk factors and epidemiologic trends over time.

METHODS

A retrospective study of spinal epidural abscesses from 2004 to 2014 at a large academic hospital was conducted. Cases were identified using International Classification of Diseases, Ninth Revision (ICD-9) code 324.1, and a review of medical and radiographic records was performed to confirm each case. Data collected included sociodemographics, medical history, suspected route of infection, treatments, and outcome.

RESULTS

The incidence was 5.1 cases for each 10,000 admissions, with no significant changes during the study period. The route of infection was identified in 52% of cases, with bacteremia as the most common (26%), followed by recent surgery/procedure (21%) and spinal injection (6%). An identifiable underlying risk factor was present in 84% of cases, most commonly diabetes and intravenous drug use. A causative organism was identified in 84% of cases, most commonly Staphylococcus aureus; methicillin-resistant isolates accounted for 25% of S. aureus cases. All cases received intravenous antibiotic therapy, and 73% underwent a drainage procedure. Fifteen percent had an adverse outcome (8% paralysis and 7% death).

CONCLUSIONS

The incidence of spinal epidural abscesses may be increasing, with the present study demonstrating a ≥5-fold higher rate compared with historical data. Although the outcome in most cases was favorable, spinal epidural abscesses continue to cause substantial morbidity and mortality and should remain a "not to be missed diagnosis."

Recent Developments in the Treatment of Spinal Epidural Abscesses

Spinal epidural abscess (SEA) is a serious condition that can be challenging to diagnose due to nonspecific symptomology and delayed presentation. Despite this, it requires prompt recognition and management in order to prevent permanent neurologic sequelae. Several recent studies have improved our understanding of SEA. Herein, we summarize the recent literature from the past 10 years relevant to SEA diagnosis, management and outcome. While surgical care remains the mainstay of treatment, a select subset of SEA patients may be managed without operative intervention. Multidisciplinary management involves internal medicine, infectious disease, critical care, and spine surgeons in order to optimize care.

Spinal Epidural Abscess: A Review with Special Emphasis on Earlier Diagnosis

Spinal epidural abscess (SEA) is an uncommon but serious condition with significant morbidity and mortality. The prognosis of SEA is highly dependent on the timeliness of its diagnosis before neurological deficits develop. Unfortunately, often due to its nonspecific presentation, such as back pain, the diagnosis of SEA may be delayed in up to 75% of cases. Although many risk factors for SEA can be found in the published literature, their utility is limited by their frequent lack of objective evidence, numerousness, and absence in a significant proportion of cases. In this review, we call for a more discriminate evidence-based use of the term "risk factor" when discussing SEA and explore several approaches to its earlier diagnosis, including a simple algorithm based on its pathophysiology and serum C-reactive protein or erythrocyte sedimentation rate.