Updated: 6/24/2021

Spinal Epidural Abscess

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Cases
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  • summary
    • Spinal Epidural Abscess is a spinal infection caused by a collection of pus or inflammatory granulation tissue between the dura mater and surrounding adipose tissue.
    • Early diagnosis is critical and is made with MRI studies with contrast.
    • Treatment is usually prompt surgical decompression and long-term IV antibiotics.
  • Epidemiology
    • Demographics
      • usually seen in adults > 60 years of age
    • Anatomic location
      • usually dorsal in thoracolumbar spine
    • Risk factors
      • IV drug abuse
      • immunodeficiency
      • malignancy
      • HIV
      • immunosuppressive medications
      • recent spinal procedure
  • Etiology
    • 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
  • 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 the 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
      • entire spine MRI should be performed to rule out skip epidural abscesses
        • concomitant infection outside of the spine
        • delayed presentation (>7 days of symptoms)
        • ESR > 95 mm/hr
  • 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
        • medical treatment failure associated with:
          • neurologic deficits (strongest predictor of medical treatment failure)
          • diabetes
          • CRP >115 mg/L
          • WBC >12 k/mL
          • positive blood cultures
          • age >65 years
          • MRSA
    • Operative
      • surgical decompression +/- spinal stabilization
        • indications
          • 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)
  • 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

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Flashcards (3)
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Questions (9)
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(SBQ18SP.22) An MRI is shown in Figure 1. Which of the following patients with the MRI findings shown would be most likely to require surgical management?

QID: 211344
FIGURES:
1

24-year-old female, neurologically intact, WBC 10k, CRP 20.0mg/dL, MRSA-positive blood culture

4%

(72/1808)

2

47-year old diabetic male, severe midline lower back pain, WBC 14k, CRP 8.0mg/dL, negative blood cultures

6%

(111/1808)

3

55-year-old male, stable bilateral thigh paresthesias, WBC 20k, CRP 15mg/dL, negative blood cultures

8%

(153/1808)

4

67-year-old diabetic female, mild bilateral leg weakness, WBC 12k, CRP 9.0mg/d, MRSA-positive blood culture

79%

(1432/1808)

5

75-year-old diabetic male, neurologically intact, WBC 11k, CRP 10.0mg/d, MRSA-positive blood culture

1%

(22/1808)

L 2 A

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(OBQ18.227) A 56-year-old female with a history of diabetes and urosepsis 2 months ago presents with worsening lower back pain. The patient denies any fevers at home. She presented to an ED several weeks ago with similar complaints where radiographs of the lumbar spine were normal. Physical exam demonstrates 3/5 motor strength in the iliopsoas, quadriceps, and triceps surae muscles. Ankle dorsiflexion causes sustained clonus. An MRI is performed and shown in figure A. What is the next best step in treatment?

QID: 213123
FIGURES:
1

Broad spectrum antibiotics

6%

(78/1369)

2

CT guided aspiration of the L2-3 disc space

16%

(224/1369)

3

L2-3 disc space debridement and anterior interbody fusion

10%

(139/1369)

4

Antibiotics and L4-5 laminectomy and instrumented posterior spinal fusion

5%

(71/1369)

5

MRI imaging of the entire spine

62%

(848/1369)

L 3 A

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(OBQ18.229) A 42-year-old intravenous drug abuser presents with a 1 month history of fevers, chills, and worsening gait instability. Physical exam reveals weakness in the bilateral upper and lower extremities. Her sagittal MRI is depicted in Figure A. Figure B is her axial MRI at the C4-C5 level. What is the most appropriate next step in management?

QID: 213125
FIGURES:
1

Cervical collar with IV methylprednisone

1%

(14/1845)

2

Broad spectrum IV antibiotics

15%

(279/1845)

3

Anterior decompression and fusion

54%

(1002/1845)

4

IR-guided biopsy and culture

20%

(367/1845)

5

Posterior laminectomy and fusion

9%

(163/1845)

L 4 A

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(OBQ15.124) A 47-year-old female presents to the emergency room with 6 weeks of back pain. She underwent aortic valve replacement for acute endocarditis 8 weeks ago. On physical examination, she has progressive bilateral lower extremity weakness and diminished sensation to light touch. Her right ankle demonstrates 8 beats of clonus. Her labs are significant for a white blood cell count of 15,800 as well as an elevated ESR and CRP. Which of the following imaging studies is most consistent with the patient’s clinical presentation?

QID: 5809
FIGURES:
1

Figure A

16%

(230/1413)

2

Figure B

65%

(920/1413)

3

Figure C

5%

(65/1413)

4

Figure D

11%

(157/1413)

5

Figure E

2%

(26/1413)

L 2 B

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(OBQ13.93) A 40-year-old woman with history of intravenous drug abuse and ongoing Staphylococcus aureus septicemia is referred for intractable neck pain with radiation down her arm. She also complains of progressive hand weakness. Examination reveals long tract signs in the lower extremities. Her MRI scan is shown in Figure A. Besides intravenous antibiotics, what is the most appropriate next step in treatment?

QID: 4728
FIGURES:
1

Percutaneous CT guided aspiration, hard cervical orthosis until bony union.

1%

(68/5687)

2

Percutaneous CT guided aspiration, hard cervical orthosis, repeat aspiration at 6-12 weeks followed by anterior corpectomy and fusion if repeat aspiration is sterile.

11%

(636/5687)

3

Anterior cervical debridement and anterior corpectomy without instrumentation

4%

(221/5687)

4

Posterior cervical debridement and instrumented posterior fusion.

1%

(45/5687)

5

Anterior cervical debridement, corpectomy and fusion followed by a posterior instrumented stabilization procedure

82%

(4667/5687)

L 2 B

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(OBQ07.243) A 31-year-old female from the United States who is an active IV drug abuser presents with worsening gait instability for the last four days. She has no history of prior international travel. Physical exam shows diffuse weakness in her upper and lower extremities. A sagittal MRI is shown in Figure A. What is the next most appropriate step in management?

QID: 904
FIGURES:
1

Anterior decompression and fusion

68%

(1825/2693)

2

Posterior decompression and fusion

3%

(86/2693)

3

Methylprednisone loaded at 30 mg/kg followed by drip at 5.4 mg/kg/hr drip for 23 hrs

1%

(28/2693)

4

Broad spectrum IV antibiotics and bracing

12%

(332/2693)

5

CT guided biopsy

15%

(412/2693)

L 3 C

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(OBQ05.182) A 64-year-old female accountant from Oregon is diagnosed with endocarditis 6 months ago underwent a course of IV antibiotic treatment. She now reports 3 months of severe low back pain and progressive lower extremity weakness and paresthesias for the past week. Her leukocyte count is normal and she is afebrile. The ESR and CRP are elevated. Radiographs and MRI scans are shown in Figures A and B, respectively. What is the most appropriate next step in management?

QID: 1068
FIGURES:
1

Intrathecal catheter placement with antibiotic administration for 6 weeks

3%

(92/3441)

2

Irrigation and debridement, corpectomy, and fusion

85%

(2908/3441)

3

Oral prednisone regimen for 4 weeks

0%

(17/3441)

4

Irrigation and debridement via posterior approach

7%

(255/3441)

5

Initiation of multiagent antibiotic regimen for tuberculosis for 6 months

4%

(143/3441)

L 2 B

Select Answer to see Preferred Response

Evidence (15)
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