Epidural abscess (spinal): Difference between revisions
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== Background == | ==Background== | ||
*Abscess confined to epidural adipose tissue in spine<ref>Darouiche RO et al. Bacterial spinal epidural abscess. Review of 43 cases and literature survey. Medicine (Baltimore) 1992; 71:369-85</ref> | *Abscess confined to epidural adipose tissue in spine<ref>Darouiche RO et al. Bacterial spinal epidural abscess. Review of 43 cases and literature survey. Medicine (Baltimore) 1992; 71:369-85</ref> | ||
*Thoracic and lumbar spine most common; C-spine least common | *Thoracic and lumbar spine most common; C-spine least common | ||
* | *Usually spans up to 3-5 vertebral spaces | ||
*S. aureus, | *Typically hematogenous spread from other source of infection | ||
===Organisms<ref>Darouiche RO. Spinal epidural abscess. N Engl J Med. 2006;355(19):2012–2020. doi:10.1056/NEJMra055111.</ref>=== | |||
*''[[S. aureus]]'' (most common, 2/3 of cases) | |||
*''[[S. epidermidis]]'' (associated with device, instrumentation) | |||
*''[[E. coli]]'' (urine spread) | |||
*''[[P. aeruginosa]]'' ([[IVDA]]) | |||
*Rare: [[anaerobes]], [[mycobacterium|mycobacteria]], [[fungi]] | |||
===Risk Factors=== | ===Risk Factors=== | ||
*98% of | *98% of patients have at least one of the following risk-factors:<ref>Sampath P, Rigamonti D. Spinal epidural abscess: a review of epidemiology, diagnosis, and treatment. J Spinal Disord 1999; 12:89-93</ref> | ||
**Injection [[substance abuse|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 types}} | |||
==Clinical Features == | ==Clinical Features== | ||
*Fever + localized back pain is epidural abscess until proven otherwise | *[[Fever]] + localized [[back pain]] is epidural abscess until proven otherwise | ||
**Classic triad of fever, back pain, and neuro deficits is rare (13%)<ref>Reihsaus E. et al. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev 2000; 23:175-204</ref> | **Classic triad of fever, back pain, and [[focal neuro|neuro deficits]] is rare (13%)<ref>Reihsaus E. et al. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev 2000; 23:175-204</ref> | ||
**Fever is only present in ~50% of cases | **Fever is only present in ~50% of cases | ||
===Prevalence of Clinical Findings <ref>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.</ref>=== | |||
{| class="wikitable" | |||
|- | |||
! 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. | |||
#Back pain at affected site | |||
#Nerve root pain from affected level | |||
#[[Weakness]], [[numbness|sensory deficit]], [[urinary retention|bladder]]/bowel dysfunction | |||
#Paralysis | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Spinal infection types}} | |||
{{Lower back pain DDX}} | {{Lower back pain DDX}} | ||
== | ==Evaluation== | ||
[[File:Sea.png|thumb|A clinical decision algorithm for evaluation of SEA which may decrease diagnostic delay. <ref>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.</ref>]] | |||
* | [[File:MRI of the lumbar spine with abscess in the posterior epidural space, causing cauda equina syndrome.jpg|thumb|MRI of an abscess causing cauda equina syndrome.]] | ||
** | ===Work-up=== | ||
'''Labs<ref>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.</ref>''' | |||
*Imaging | *[[leukocytosis|WBC elevated]] in <45% of patients | ||
**MRI is diagnostic test of choice<ref>Angtuaco E. et al. MR imaging of spinal epidural sepsis. Am J Roentgenoli 1987; 149:1249-53</ref> | *ESR and CRP are almost consistently elevated | ||
**Sensitivity of ESR in pt with SEA risk factors ~100%<ref>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. | |||
</ref> | |||
*Blood cultures are indicated to identify the source organism (Staph in 2/3 of cases) | |||
'''CSF<ref>Darouiche RO. Spinal epidural abscess. N Engl J Med. 2006; 355(19):2012-2020.</ref>''' | |||
*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<ref>Ju, K.L., et al. Predicting Patients with concurrent noncontinguous spinal epidural abscess lesions. Spine J. 2005 15(1):95</ref> | |||
*[[mri|MRI]] with gadolinium is the diagnostic test of choice<ref>Angtuaco E. et al. MR imaging of spinal epidural sepsis. Am J Roentgenoli 1987; 149:1249-53</ref> | |||
*CT with IV contrast may provide usual information regarding bony integrity and fluid collections while awaiting MRI | |||
== | ==Management== | ||
*Early surgical decompression and drainage<ref>Bluman E. et al. Spinal epidural abscess in adults. J Am Acad Orthop Surg 2004; 12:155-163</ref> | |||
*Aspiration (for diagnosis) and [[antibiotics]] may be sufficient for patients without neuro deficits | |||
===[[Antibiotics]]=== | ===[[Antibiotics]]=== | ||
{{Epidural Abscess Treatment}} | {{Epidural Abscess Treatment}} | ||
==Disposition== | |||
*Admit | |||
==See Also== | ==See Also== | ||
*[[Epidural | *[[Epidural abscess (intracranial)]] | ||
*[[Epidural | *[[Epidural compression syndromes]] | ||
==External Links== | |||
*[http://ddxof.com/spinal-epidural-abscess/ DDxOf: Differential Diagnosis of Spinal Epidural Abscess] | |||
== | ==References== | ||
<references/> | <references/> | ||
[[Category:ID]] | [[Category:ID]] | ||
[[Category: | [[Category:Neurology]] |
Revision as of 11:38, 24 October 2020
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]
- S. aureus (most common, 2/3 of cases)
- S. epidermidis (associated with device, instrumentation)
- E. coli (urine spread)
- P. aeruginosa (IVDA)
- Rare: anaerobes, mycobacteria, fungi
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
- Syndromes
- Causes
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.
- Back pain at affected site
- Nerve root pain from affected level
- Weakness, sensory deficit, bladder/bowel dysfunction
- Paralysis
Differential Diagnosis
Spinal infection
Lower Back Pain
- Spine related
- Acute ligamentous injury
- Acute muscle strain
- Disk herniation (Sciatica)
- Degenerative joint disease
- Spondylolithesis
- Epidural compression syndromes
- Thoracic and lumbar fractures and dislocations
- Cancer metastasis
- Spinal stenosis
- Transverse myelitis
- Vertebral osteomyelitis
- Ankylosing spondylitis
- Spondylolisthesis
- Discitis
- Spinal Infarct
- Renal disease
- Intra-abdominal
- Abdominal aortic aneurysm
- Ulcer perforation
- Retrocecal appendicitis
- Large bowel obstruction
- Pancreatitis
- Pelvic disease
- Other
Evaluation
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
- Target Staph, Strep, and Gram-negative bacilli[13]
- Vancomycin 15-20mg/kg BID + metronidazole 500mg (7.5mg/kg) q6 hrs + (Cefotaxime or Ceftriaxone or Ceftazidime)
- Ceftazidime is preferred if pseudomonas is considered likely
- Can substitute Nafcillin or Oxacillin for Vancomycin if not MRSA
Treat for 6-8 weeks
Disposition
- Admit
See Also
External Links
References
- ↑ Darouiche RO et al. Bacterial spinal epidural abscess. Review of 43 cases and literature survey. Medicine (Baltimore) 1992; 71:369-85
- ↑ Darouiche RO. Spinal epidural abscess. N Engl J Med. 2006;355(19):2012–2020. doi:10.1056/NEJMra055111.
- ↑ Sampath P, Rigamonti D. Spinal epidural abscess: a review of epidemiology, diagnosis, and treatment. J Spinal Disord 1999; 12:89-93
- ↑ Reihsaus E. et al. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev 2000; 23:175-204
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Darouiche RO. Spinal epidural abscess. N Engl J Med. 2006; 355(19):2012-2020.
- ↑ Ju, K.L., et al. Predicting Patients with concurrent noncontinguous spinal epidural abscess lesions. Spine J. 2005 15(1):95
- ↑ Angtuaco E. et al. MR imaging of spinal epidural sepsis. Am J Roentgenoli 1987; 149:1249-53
- ↑ Bluman E. et al. Spinal epidural abscess in adults. J Am Acad Orthop Surg 2004; 12:155-163
- ↑ Rigamonti D. et al. Spinal epidural abscess: contemporary trends in etiology, evaluation, and management. Surg Neurol 1999; 52:189-96