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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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(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:
1

Anterior decompression and fusion

66%

(1259/1916)

2

Posterior decompression and fusion

3%

(51/1916)

3

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

1%

(19/1916)

4

Broad spectrum IV antibiotics and bracing

14%

(267/1916)

5

CT guided biopsy

16%

(316/1916)

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:
1

Intrathecal catheter placement with antibiotic administration for 6 weeks

3%

(68/2569)

2

Irrigation and debridement, corpectomy, and fusion

86%

(2199/2569)

3

Oral prednisone regimen for 4 weeks

0%

(12/2569)

4

Irrigation and debridement via posterior approach

7%

(182/2569)

5

Initiation of multiagent antibiotic regimen for tuberculosis for 6 months

4%

(90/2569)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2
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