Epidural abscess (spinal)

Background

• Abscess confined to epidural adipose tissue in spine
• Thoracic and lumbar spine most common, C-spine least common
• Usually hematogenous spread from other source of infection
• S. aureus, strep, pseudomonas, e. coli most common

Risk Factors

1. Diabetes mellitus
2. Alcoholism
3. AIDS
4. Trauma
5. Tattooing
6. Acupuncture
7. Contiguous bony or soft tissue infection

Diagnosis

1. Classic triad of fever, back pain, and neuro deficits is rare
2. Fever is only present in ~50% of cases
3. Fever + localized back pain = epidural abscess until proven otherwise
4. Routine lab tests are rarely helpful
5. Only 60% have leukocytosis
6. CT with IV contrast is acceptable (MRI is preferred)
7. Blood cultures are indicated to identify the source organism (Staph in 2/3 of cases)
8. CSF studies are rarely useful (only positive in 20% of cases)

Differential Diagnosis

1. Disc and bony disease
2. Vertebral discitis and osteomyelitis
3. Metastatic tumors
4. Meningitis
5. Herpes zoster, prior to appearance of skin lesions

Treatment

1. Early surgical decompression and drainage
2. Aspiration (for diagnosis) and Abx may be sufficient for pts w/o neuro deficits
3. Antibiotics
   1. Vanco + metronidazole + either cefotaxime or ceftriaxone or ceftazadine
      1. (Ceftazidine is preferred if pseudomonas is considered likely)
      2. Can substitute nafcillin or oxacillin for vanco if not MRSA
   2. Treat for 6-8 weeks

Source

UpToDate