Epidural abscess (spinal): Difference between revisions
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== Background ==
== Background ==
*Abscess confined to epidural adipose tissue in spine
*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 and usually spans up to 3-5 vertebral spaces
*Usually hematogenous spread from other source of infection
*Usually hematogenous spread from other source of infection
*S. aureus, strep, pseudomonas, e. coli most common  
*S. aureus, strep, pseudomonas, e. coli most common  


==Risk Factors==
==Risk Factors==
*98% of pts have at least one of the following risk-factors:
*98% of pts 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 drug use
#Injection drug use
#Immunocompromised
#Immunocompromised
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==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%)
##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>
##Fever is only present in ~50% of cases
##Fever is only present in ~50% of cases


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##Blood cultures are indicated to identify the source organism (Staph in 2/3 of cases)
##Blood cultures are indicated to identify the source organism (Staph in 2/3 of cases)
#Imaging
#Imaging
##MRI is diagnostic test of choice
##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>
##CT with IV contrast is acceptable (MRI is preferred)
##CT with IV contrast may provide usual information regarding boney integrity and fluid collections while awaiting MRI (MRI is preferred)


==DDX==
==DDX==
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==Treatment ==
==Treatment ==
#Early surgical decompression and drainage
#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 Abx may be sufficient for pts w/o neuro deficits  
#Aspiration (for diagnosis) and antibiotics may be sufficient for patients without neuro deficits  
#Antibiotics
===Antibiotics===
*Antibiotics target [[Staphylococcus_Species|Stap]], [[Strep_Species|Strep]], and [[Gram_Negatives|Gram-negative bacilli]]<ref>Rigamonti D. et al. Spinal epidural abscess: contemporary trends in etiology, evaluation, and management. Surg Neurol 1999; 52:189-96</ref>
##Vanco + metronidazole + (cefotaxime or [[ceftriaxone]] or ceftazadine)
##Vanco + metronidazole + (cefotaxime or [[ceftriaxone]] or ceftazadine)
###Ceftazidine is preferred if pseudomonas is considered likely
###Ceftazidine is preferred if pseudomonas is considered likely
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==Source==
==Source==
*UpToDate
<references/>
*Rosens
*Tintinalli


[[Category:ID]]
[[Category:ID]]
[[Category:Neuro]]
[[Category:Neuro]]

Revision as of 11:22, 1 August 2014

Background

  • Abscess confined to epidural adipose tissue in spine[1]
  • Thoracic and lumbar spine most common; C-spine least common and usually spans up to 3-5 vertebral spaces
  • Usually hematogenous spread from other source of infection
  • S. aureus, strep, pseudomonas, e. coli most common

Risk Factors

  • 98% of pts have at least one of the following risk-factors:[2]
  1. Injection drug use
  2. Immunocompromised
  3. Alcohol abuse
  4. Cancer
  5. Recent spine procedure
  6. Recent spine fracture
  7. Distant site of infection
  8. Indwelling catheter
  9. Chronic renal failure
  10. DM

Clinical Features

  1. Fever + localized back pain is epidural abscess until proven otherwise
    1. Classic triad of fever, back pain, and neuro deficits is rare (13%)[3]
    2. Fever is only present in ~50% of cases

Diagnosis

  1. Labs
    1. ESR elevated in >90% of pts
    2. WBC elevated in only 60% of pts
    3. Blood cultures are indicated to identify the source organism (Staph in 2/3 of cases)
  2. Imaging
    1. MRI is diagnostic test of choice[4]
    2. CT with IV contrast may provide usual information regarding boney integrity and fluid collections while awaiting MRI (MRI is preferred)

DDX

  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[5]
  2. Aspiration (for diagnosis) and antibiotics may be sufficient for patients without neuro deficits

Antibiotics

    1. Vanco + metronidazole + (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

See Also

Source

  1. ↑ Darouiche RO et al. Bacterial spinal epidural abscess. Review of 43 cases and literature survey. Medicine (Baltimore) 1992; 71:369-85
  2. ↑ Sampath P, Rigamonti D. Spinal epidural abscess: a review of epidemiology, diagnosis, and treatment. J Spinal Disord 1999; 12:89-93
  3. ↑ Reihsaus E. et al. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev 2000; 23:175-204
  4. ↑ Angtuaco E. et al. MR imaging of spinal epidural sepsis. Am J Roentgenoli 1987; 149:1249-53
  5. ↑ Bluman E. et al. Spinal epidural abscess in adults. J Am Acad Orthop Surg 2004; 12:155-163
  6. ↑ Rigamonti D. et al. Spinal epidural abscess: contemporary trends in etiology, evaluation, and management. Surg Neurol 1999; 52:189-96
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