Epidural abscess (spinal)
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
- S. aureus, strep, pseudomonas, e. coli most common
Risk Factors
- 98% of pts have at least one of the following risk-factors:[2]
- 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%)[3]
- Fever is only present in ~50% of cases
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
Diagnosis
Work-up
- Labs
- ESR elevated in >90% of pts
- WBC elevated in only 60% of pts
- Blood cultures are indicated to identify the source organism (Staph in 2/3 of cases)
- Imaging
- MRI is diagnostic test of choice[4]
- CT with IV contrast may provide usual information regarding bony integrity and fluid collections while awaiting MRI
Management
- Early surgical decompression and drainage[5]
- Aspiration (for diagnosis) and antibiotics may be sufficient for patients without neuro deficits
Antibiotics
- Target Staph, Strep, and Gram-negative bacilli[6]
- 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
References
- ↑ Darouiche RO et al. Bacterial spinal epidural abscess. Review of 43 cases and literature survey. Medicine (Baltimore) 1992; 71:369-85
- ↑ 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
- ↑ 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