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
*Usually hematogenous spread from other source of infection
*Usually spans up to 3-5 vertebral spaces
*S. aureus, strep, pseudomonas, e. coli most common
*Typically hematogenous spread from other source of infection


==Risk Factors==
===Organisms<ref>Darouiche RO. Spinal epidural abscess. N Engl J Med. 2006;355(19):2012–2020. doi:10.1056/NEJMra055111.</ref>===
# Diabetes mellitus
*''[[S. aureus]]'' (most common, 2/3 of cases)
# Alcoholism
*''[[S. epidermidis]]'' (associated with device, instrumentation)
# AIDS
*''[[E. coli]]'' (urine spread)
# Trauma
*''[[P. aeruginosa]]'' ([[IVDA]])
# Tattooing
*Rare: [[anaerobes]], [[mycobacterium|mycobacteria]], [[fungi]]
# Acupuncture
# Contiguous bony or soft tissue infection


==Diagnosis ==
===Risk Factors===
# Fever + localized back pain = epidural abscess until proven otherwise
*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>
##Classic triad of fever, back pain, and neuro deficits is rare  
**Injection [[substance abuse|drug use]]
##Fever is only present in ~50% of cases
**Immunocompromised
# Routine lab tests are rarely helpful
**[[Alcohol use disorder]]
##Only 60% have leukocytosis
**Cancer
#MRI is diagnostic test of choice
**Recent spine procedure
##CT with IV contrast is acceptable (MRI is preferred)
**Recent spine fracture
# Blood cultures are indicated to identify the source organism (Staph in 2/3 of cases)
**Distant site of infection
**Indwelling catheter
**Chronic [[renal failure]]
**[[Diabetes]]
 
{{Epidural compression syndromes types}}
 
==Clinical Features==
*[[Fever]] + localized [[back pain]] is epidural abscess until proven otherwise
**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
 
===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==
# Disc and bony disease
{{Spinal infection types}}
# Vertebral discitis and osteomyelitis 
 
# Metastatic tumors
{{Lower back pain DDX}}
# Meningitis
 
# Herpes zoster, prior to appearance of skin lesions
==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>'''
*[[leukocytosis|WBC elevated]] in <45% of patients
*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]]===
{{Epidural Abscess Treatment}}
 
==Disposition==
*Admit
 
==See Also==
*[[Epidural abscess (intracranial)]]
*[[Epidural compression syndromes]]


==Treatment ==
==External Links==
# Early surgical decompression and drainage
*[http://ddxof.com/spinal-epidural-abscess/ DDxOf: Differential Diagnosis of Spinal Epidural Abscess]
# Aspiration (for diagnosis) and Abx may be sufficient for pts w/o neuro deficits
# Antibiotics
## Vanco + metronidazole + either cefotaxime or ceftriaxone or ceftazadine
### (Ceftazidine is preferred if pseudomonas is considered likely)
### Can substitute nafcillin or oxacillin for vanco if not MRSA
## Treat for 6-8 weeks


==Source==
==References==
UpToDate
<references/>


[[Category:ID]]
[[Category:ID]]
[[Category:Neurology]]

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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