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Updated: Apr 18 2023

Spinal Epidural Abscess

  • 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
          • risk factors for failure of nonoperative management: older (>65yrs), diabetics, new-onset neurologic deficits, and MRSA infections
          • 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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