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.

OBJECTIVES

Acute infectious spinal pathologies (AISP), including discitis, osteomyelitis, spinal epidural abscess, and septic arthritis are rare, carry significant morbidity and mortality, and are difficult to diagnose. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are frequently elevated in AISP, although there are no consensus recommendations on using them. This retrospective study aims to calculate the biomarkers' sensitivity to rule out AISP.

METHODS

We retrospectively reviewed emergency department patients from a national hospital system database over 4 years who presented with spinal pain, had inflammatory biomarkers drawn, and had a spinal magnetic resonance imaging. We collected all International Classification of Diseases, Tenth Revision diagnosis codes in these patients and compared those with and without AISP. For each biomarker, we created a matched propensity analysis and created receiver-operating curves. From these, we calculated the cut points to obtain 90% and 95% sensitivity to rule out AISP. Finally, we calculated the sensitivity when using both biomarkers.

RESULTS

We identified 1963 AISP cases and 3981 controls. The median (interquartile range) for ESR was 18 (30) mm/h in controls vs 56 (54) mm/h in AISP cases, < .001. The median (interquartile range) for CRP was 2.0 (6.7) mg/dL in controls vs 6.4 (11.8) mg/dL in AISP cases, < .001. After matched propensity analysis, we created receiver-operating curves and calculated the sensitivities for both biomarkers at various cut points. The cut point to get 90% sensitivity to rule out AISP was ESR ≤ 20 mm/h or CRP ≤ 1.2 mg/dL. The cut point to get 95% sensitivity to rule out AISP was ESR ≤ 12 mm/h or CRP ≤ 0.7 mg/dL. Applying both biomarkers in parallel, ESR ≤ 20 mm/h and CRP ≤ 1.0 mg/dL, the sensitivity improved to 98.9%, negative predictive value >99%.

CONCLUSION

Low levels of CRP and ESR may help rule out AISP in emergency department patients without confirmatory imaging. Further prospective studies may be indicated to validate these findings.