epidural abscess
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Introduction
Localized collection of pus between the dura mater & the overlying skull or adjacent vertebral column. Information here in general refers to spinal epidural abscess.
Etiology
- hematogenous dissemination from infectious foci elsewhere in the body
- continguous extension of an adjacent infection
- infected intervertebral discs
- may be associated with transient bacteremia
- organisms
- Staphylococcus aureus, including MRSA (50%)
- gram negative bacilli (12-17%)
- Streptococci (8-17%)
- primary source of infection not identified in 20-40%
- risk factors
Clinical manifestations
- clinical manifestations due to
- compression on adjacent structures
- ischemia due to thrombophlebitis
- spinal pain followed by nerve root pain
- neurologic manifestations occur late
- long spinal tract signs
- complete paralysis may occur
Red flags suggesting spinal epidural abscess
- unexplained fever
- focal neurologic deficit with progressive/disabling symptoms
- active infection
- immunosuppression
- intravenous drug use
- prolonged glucocorticoid use
- unexplained weight loss
- enduring back pain
- history of cancer
Laboratory
Diagnostic procedures
- CT-guided fine-needle aspiration[1]
- not initial diagnostic test[6]
Radiology
- magnetic resonance imaging (MRI) with gadolinium enhancement
- diagnostic procedure of choice
- preferred over computed tomography (CT) because of better visualization of the spinal cord & epidural space
- identification of associated pathology
- myelogram
- X-ray may add to diagnostic confirmation
Differential diagnosis
Management
- surgical decompression, drainage of the abscess & antibiotics[2]
- empiric coverage for Staphylococcus aureus & gram-negative bacilli
- coverage should include MRSA
- vancomycin & 3rd or 4th generation cephalosporin (cefepime)
- culture of surgical tissue
- decompressive laminectomy
- empiric coverage for Staphylococcus aureus & gram-negative bacilli
- antibiotics alone for patients
- antibiotic alone may be considered for patients without long spinal tract signs
- frequent follow-up neurologic exams & serial MRIs to demonstrate epidural abscess resolution[1]
- independent predictors of failure for non-operative management
- presenting motor deficit
- pathologic or compression fracture in affected levels
- active malignancy
- diabetes mellitus
- sensory changes
- dorsal location of abscess[4]
Notes
- diagnosis initially missed in 75-84% of patients[3]
More general terms
Additional terms
References
- ↑ 1.0 1.1 1.2 1.3 Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 18, 19. 17, 18. American College of Physicians, Philadelphia 1998, 2009, 2018, 2021. 2012, 2015, 2018.
- ↑ 2.0 2.1 Darouiche RO Spinal epidural abscess N Engl J Med 2006, 355:2012 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17093252
- ↑ 3.0 3.1 Bhise V, Meyer AND, Singh H et al. Errors in diagnosis of spinal epidural abscesses in the era of electronic health records. Am J Med 2017 Aug; 130:975 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28366427 <Internet> http://www.amjmed.com/article/S0002-9343(17)30323-6/fulltext
- ↑ 4.0 4.1 Shah AA, Ogink PT, Nelson SB, Harris MB, Schwab JH. Nonoperative management of spinal epidural abscess: Development of a predictive algorithm for failure. J Bone Joint Surg Am 2018 Apr 4; 100:546 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29613923 https://insights.ovid.com/crossref?an=00004623-201804040-00002
- ↑ Chow F Brain and Spinal Epidural Abscess Continuum (Minneap Minn). 2018 Oct;24(5, Neuroinfectious Disease):1327-1348. PMID: https://www.ncbi.nlm.nih.gov/pubmed/30273242 Review.
- ↑ 6.0 6.1 NEJM Knowledge+