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Introduction
  • Defined as a collection of pus or inflammatory granulation tissue between the dura mater and surrounding adipose tissue
  • Epidemiology
    • demographics
      • usually seen in adults > 60 years of age
    • location
      • usually dorsal in thoracolumbar spine
    • risk factors
      • IV drug abuse
      • immunodeficiency
      • malignancy
      • HIV
      • immunosuppressive medications
      • recent spinal procedure
  • Pathophysiology
    • origin
      • hematogenous spread ~50%
      • spread from diskitis ~ 33%
    • pathogens
      • staph aureus is most common (50-65%)
      • gram negative infections such as E coli (18%)
      • pseudomonas seen in patients with IV drug use
  • Neurologic deficits
    • 33% of patients with an epidural abscess will have neurologic symptoms
    • 4-22% incidence of permanent paralysis
      • can be caused from direct compression or infarction of spinal cord blood flow.
  • Associated conditions
    • often associated with vertebral osteomyelitis and discitis (spondylodiscitis)
    • present in ~18% of patients with spondylodiscitis
  • Prognosis
    • preoperative degree of neurologic deficits is most important indicator of clinical outcome
    • mortality ~ 5%
    • early diagnosis is most essential factor in preventing devastating outcomes
Presentation
  • Symptoms
    • systemic illness more profound than patients with vertebral osteomyelitis
      • fever present in ~50%
    • pain
      • pain is often severe and insidious in onset an occurs in 87%
  • Physical exam
    • neurologic deficits present in ~33%
      • may present as a radiculopathy or a myelopathy
Labs
  • WBC
    • mean leukocytosis 22,000 cells/mm3
    • elevated in ~42%
  • ESR
    • elevated in > 90% of cases (mean 86.3)
  • CRP
    • elevated in 90% of cases
Imaging
  • Radiographs
    • usually normal
  • CT
    • poor sensitivity for epidural abscess
  • CT myelogram
    • 90% sensitivity but invasive
  • MRI with gadolinium
    • the imaging modality of choice for diagnosis of spinal epidural abscess 
      • shows extent of abscess, presence of vertebral osteomyelitis, and allows evaluation of neurologic compression  
      • gadolinium allows differentiation of pus from CSF
        • a ring enhancing lesion is pathognomonic for abscess 
Treatment
  • Nonoperative
    • bracing and IV antibiotics
      • indications
        • small abscess with minimal compression on neural elements and
          • no neurologic deficits and
          • a patient capable of close clinical followup
        • those who are not candidates for surgery due to medical comorbidities
      • outcomes
        • historically presence of epidural abscess has been considered a surgical emergency
        • there has been a recent trend towards nonoperative management as new studies shows nonoperative treatment effective in patients without neurologic deficit
  • Operative
    • surgical decompression +/- spinal stabilization
      • indications
        • neurologic deficits present  
        • evidence of spinal cord compression on imaging studies
        • persistent infection despite antibiotic therapy
        • progressive deformity or gross spinal instability
      • postoperative antibiotics
        • indicated for 2-4 weeks if no bony involvement of infection
        • indicated for 6 weeks if bony involvement
Techniques
  • Decompressive laminectomy
    • most common form of operative treatment
    • indications
      • indicated when abscess is posterior and there is no contiguous spondylodiscitis
    • avoid wide decompression and facetectomy as it will result in spinal instability
  • Anterior debridement and strut grafting 
    • indications
      • abscess is located anteriorly 
      • anterior vertebral body and discs are involved (presence of spondylodiscitis) 
 

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