Epidural abscess (spinal)

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Background

  • Abscess confined to epidural adipose tissue in spine[1]
  • Thoracic and lumbar spine most common; C-spine least common
  • Usually spans up to 3-5 vertebral spaces
  • Typically hematogenous spread from other source of infection

Organisms[2]

Risk Factors

  • 98% of patients have at least one of the following risk-factors:[3]
    • Injection drug use
    • Immunocompromised
    • Alcohol abuse
    • Cancer
    • Recent spine procedure
    • Recent spine fracture
    • Distant site of infection
    • Indwelling catheter
    • Chronic renal failure
    • Diabetes

Epidural compression syndromes

Clinical Features

  • Fever + localized back pain is epidural abscess until proven otherwise
    • Classic triad of fever, back pain, and neuro deficits is rare (13%)[4]
    • Fever is only present in ~50% of cases

Prevalence of Clinical Findings [5]

Finding Prevalence
Fever (T>38°C) 19-32%
Focal spinal TTP 52-62%
Diffuse spinal TTP 63-65%
Positive SLR 11-13%
Abnormal sensation 17-27%
Weakness 29-40%
Abnormal reflexes 8-17%
Abnormal rectal tone 5-10%
Saddle anesthesia 2%

Staging

Progression through stages is highly variable and may evolve rapidly.

  1. Back pain at affected site
  2. Nerve root pain from affected level
  3. Weakness, sensory deficit, bladder/bowel dysfunction
  4. Paralysis

Differential Diagnosis

Spinal infection

Lower Back Pain

Evaluation

A clinical decision algorithm for evaluation of SEA which may decrease diagnostic delay. [6]

Work-up

Labs[7]

  • WBC elevated in <45% of patients
  • ESR and CRP are almost consistently elevated
    • Sensitivity of ESR in pt with SEA risk factors ~100%[8]
  • Blood cultures are indicated to identify the source organism (Staph in 2/3 of cases)

CSF[9]

  • Gram stain typically negative
  • Cultures are positive in <25% of patients

Imaging

  • Strongly consider imaging the entire spine to assess for non-contiguous epidural abscess[10]
  • MRI with gadolinium is the diagnostic test of choice[11]
  • CT with IV contrast may provide usual information regarding bony integrity and fluid collections while awaiting MRI

Management

  • Early surgical decompression and drainage[12]
  • Aspiration (for diagnosis) and antibiotics may be sufficient for patients without neuro deficits

Antibiotics

Treat for 6-8 weeks

Disposition

  • Admit

See Also

External Links

References

  1. Darouiche RO et al. Bacterial spinal epidural abscess. Review of 43 cases and literature survey. Medicine (Baltimore) 1992; 71:369-85
  2. Darouiche RO. Spinal epidural abscess. N Engl J Med. 2006;355(19):2012–2020. doi:10.1056/NEJMra055111.
  3. Sampath P, Rigamonti D. Spinal epidural abscess: a review of epidemiology, diagnosis, and treatment. J Spinal Disord 1999; 12:89-93
  4. Reihsaus E. et al. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev 2000; 23:175-204
  5. Davis DP, Wold RM, Patel RJ, et al. The clinical presentation and impact of diagnostic delays on emergency department patients with spinal epidural abscess. J Emerg Med. 2004;26(3):285–291. doi:10.1016/j.jemermed.2003.11.013.
  6. Davis DP, Salazar A, Chan TC, Vilke GM. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain. J Neurosurg Spine. 2011;14(6):765–770. doi:10.3171/2011.1.SPINE1091.
  7. Cornett CA, Vincent SA, Crow J, et al. Bacterial spine infections in adults: evaluation and management. Journal of the American Academy of Orthopaedic Surgeons. 2016; 24(1):11-8.
  8. Davis DP, Salazar A, Chan TC, Vilke GM. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain. J Neurosurg Spine. 2011 Jun;14(6):765-70. doi: 10.3171/2011.1.SPINE1091. Epub 2011 Mar 18. PubMed PMID: 21417700.
  9. Darouiche RO. Spinal epidural abscess. N Engl J Med. 2006; 355(19):2012-2020.
  10. Ju, K.L., et al. Predicting Patients with concurrent noncontinguous spinal epidural abscess lesions. Spine J. 2005 15(1):95
  11. Angtuaco E. et al. MR imaging of spinal epidural sepsis. Am J Roentgenoli 1987; 149:1249-53
  12. Bluman E. et al. Spinal epidural abscess in adults. J Am Acad Orthop Surg 2004; 12:155-163
  13. Rigamonti D. et al. Spinal epidural abscess: contemporary trends in etiology, evaluation, and management. Surg Neurol 1999; 52:189-96