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
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*''[[E. coli]]'' (urine spread)
*''[[E. coli]]'' (urine spread)
*''[[P. aeruginosa]]'' ([[IVDA]])
*''[[P. aeruginosa]]'' ([[IVDA]])
*Rare: [[anaerobes]], [[mycobacteria]], [[fungi]]
*Rare: [[anaerobes]], [[mycobacterium|mycobacteria]], [[fungi]]


===Risk Factors===
===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>
*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 drug use
**Injection [[substance abuse|drug use]]
**Immunocompromised
**Immunocompromised
**Alcohol abuse
**[[Alcohol use disorder]]
**Cancer
**Cancer
**Recent spine procedure
**Recent spine procedure
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**Distant site of infection
**Distant site of infection
**Indwelling catheter
**Indwelling catheter
**Chronic renal failure
**Chronic [[renal failure]]
**Diabetes
**[[Diabetes]]


{{Epidural compression syndromes types}}
{{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


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===Staging===
===Staging===
Progression through stages is highly variable and may evolve rapidly.
Progression through stages is highly variable and may evolve rapidly.
# Back pain at affected site
#Back pain at affected site
# Nerve root pain from affected level
#Nerve root pain from affected level
# Weakness, sensory deficit, bladder/bowel dysfunction
#[[Weakness]], [[numbness|sensory deficit]], [[urinary retention|bladder]]/bowel dysfunction
# Paralysis
#Paralysis


==Differential Diagnosis==
==Differential Diagnosis==
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{{Lower back pain DDX}}
{{Lower back pain DDX}}


==Diagnosis==
==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: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===
===Work-up===
'''Labs'''
'''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>'''
*ESR elevated in >90% of pts
*[[leukocytosis|WBC elevated]] in <45% of patients
*WBC elevated in only 60% of pts
*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)
*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'''
'''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>
*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 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>
*[[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
*CT with IV contrast may provide usual information regarding bony integrity and fluid collections while awaiting MRI


==Management==
==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>
*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  
*Aspiration (for diagnosis) and [[antibiotics]] may be sufficient for patients without neuro deficits  
===[[Antibiotics]]===
===[[Antibiotics]]===
{{Epidural Abscess Treatment}}
{{Epidural Abscess Treatment}}
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*[[Epidural abscess (intracranial)]]
*[[Epidural abscess (intracranial)]]
*[[Epidural compression syndromes]]
*[[Epidural compression syndromes]]
==External Links==
*[http://ddxof.com/spinal-epidural-abscess/ DDxOf: Differential Diagnosis of Spinal Epidural Abscess]


==References==
==References==

Latest revision as of 00:25, 15 December 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]

Risk Factors

Epidural compression syndromes

Sensory dermatome by spinal level.

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]
MRI of an abscess causing cauda equina syndrome.

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
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