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)
QUESTIONS 1 of 3 1 2 3 Previous Next (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? Review Topic QID: 4728 FIGURES: A 1 Percutaneous CT guided aspiration, hard cervical orthosis until bony union. 1% (47/4235) 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% (471/4235) 3 Anterior cervical debridement and anterior corpectomy without instrumentation 4% (163/4235) 4 Posterior cervical debridement and instrumented posterior fusion. 1% (28/4235) 5 Anterior cervical debridement, corpectomy and fusion followed by a posterior instrumented stabilization procedure 82% (3490/4235) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (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? Review Topic QID: 904 FIGURES: A 1 Anterior decompression and fusion 66% (1339/2041) 2 Posterior decompression and fusion 3% (58/2041) 3 Methylprednisone loaded at 30 mg/kg followed by drip at 5.4 mg/kg/hr drip for 23 hrs 1% (20/2041) 4 Broad spectrum IV antibiotics and bracing 14% (278/2041) 5 CT guided biopsy 17% (340/2041) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (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? Review Topic QID: 1068 FIGURES: A B 1 Intrathecal catheter placement with antibiotic administration for 6 weeks 3% (75/2790) 2 Irrigation and debridement, corpectomy, and fusion 85% (2383/2790) 3 Oral prednisone regimen for 4 weeks 0% (13/2790) 4 Irrigation and debridement via posterior approach 7% (197/2790) 5 Initiation of multiagent antibiotic regimen for tuberculosis for 6 months 4% (103/2790) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 2