Spinal epidural abscess
OVERVIEW
- Spinal epidural abscess is considered a neurosurgical emergency
- morbidity and mortality is worse with delayed diagnosis, and the worse the neurological deficit at the time of surgery the worse the outcome
- surgery within 24 hours of symptom onset is associated with the best prognosis
- Absent fever and absent neurological deficit does not rule out spinal epidural abscess, an MRI may be indicated
PATHOPHYSIOLOGY
- The epidural space is between the dura and the vertebral column
Source of infection
- often unknown
- haematogenous spread
- skin/ soft tissue infections
- infected prostheses e.g. IV catheters
- bacterial endocarditis
- pneumonia
- UTI
- contiguous spread
- Vertebral osteomyelitis
- Retropharyngeal abscess
- Overlying skin infections or pressure sores
- Psoas abscess
- Penetrating injury
- Epidural injections or catheters
- Spinal stimulators
Complications
- death from generalized septicemia/ meningoencephalitis
- Adjacent spread: osteomyelitis, paraspinal abscess
- Spinal cord dysfunction including paralysis: direct compression, spinal ischemia from local thrombosis
CAUSE
Typical causative organisms:
- Staphylococci
- Streptococci
- Gram negative anaerobes
Risk factors
- IV drug abuse
- Immunocompromise, including diabetics, alcoholics and HIV
- Infection of adjacent structures (e.g, vertebral osteomyelitis, infected pressure sores)
- Recent perispinal procedures (e.g. epidurals, lumbar puncture, spinal operations)
CLINICAL FEATURES
Typical progression of symptoms is:
- Localized back pain with or without fever: 50% afebrile, most have local tenderness
- nerve root irritation corresponding to the involved segments
- early neurological deficits: motor weakness, sensory deficits, bowel or bladder dysfunction
- late neurological deficits: paralysis (very poor prognosis if complete paralysis >24 hours)
- other complications (see above)
The diagnosis is often missed at first presentation, when neurological deficits may be absent
INVESTIGATIONS
Laboratory tests
- FBC: WBC increased with neutrophilia
- CRP can be elevated before abnormalities in WBC are seen (suspect SEA if raised CRP and point tenderness in back)
- Blood cultures
Imaging
- Spine XR usually unhelpful
- CT scan: high false negative rate but may be diagnositc; can be used for CT-guided diagnostic aspirate for cultures
- MRI: gold standard for diagnosis; ideally perform before the onset of neurological symptoms; routinely scanning the entire spine is the safest approach although some radiologists prefer to image the preseumed affected segment and adjacent segments
MANAGEMENT
- IV antibiotics (typically prolonged for 4-6 weeks, due to associated osteomyelitis)
- cefotaxime
- flucoxacillin, or vancomycin if MRSA is suspected
- Urgent neurosurgical referral for consideration of early decompressive laminectomy and drainage
- Selected cases may be managed by aspiration and/ or medical management alone
- Supportive care and monitoring including analgesia, attention to bowel and bladder cares, pressure injury prophylaxis and other issue relevant to spinal cord compromise
References and Links
CCC Neurocritical Care Series
Emergencies: Brain Herniation, Eclampsia, Elevated ICP, Status Epilepticus, Status Epilepticus in Paeds
DDx: Acute Non-Traumatic Weakness, Bulbar Dysfunction, Coma, Coma-like Syndromes, Delayed Awakening, Hearing Loss in ICU, ICU acquired Weakness, Post-Op Confusion, Pseudocoma, Pupillary Abnormalities
Neurology: Anti-NMDA Encephalitis, Basilar Artery Occlusion, Central Diabetes Insipidus, Cerebral Oedema, Cerebral Venous Sinus Thrombosis, Cervical (Carotid / Vertebral) Artery Dissections, Delirium, GBS vs CIP, GBS vs MG vs MND, Guillain-Barre Syndrome, Horner’s Syndrome, Hypoxic Brain Injury, Intracerebral Haemorrhage (ICH), Myasthenia Gravis, Non-convulsive Status Epilepticus, Post-Hypoxic Myoclonus, PRES, Stroke Thrombolysis, Transverse Myelitis, Watershed Infarcts, Wernicke’s Encephalopathy
Neurosurgery: Cerebral Salt Wasting, Decompressive Craniectomy, Decompressive Craniectomy for Malignant MCA Syndrome, Intracerebral Haemorrhage (ICH)
— SCI: Anatomy and Syndromes, Acute Traumatic Spinal Cord Injury, C-Spine Assessment, C-Spine Fractures, Spinal Cord Infarction, Syndomes,
— SAH: Acute management, Coiling vs Clipping, Complications, Grading Systems, Literature Summaries, ICU Management, Monitoring, Overview, Prognostication, Vasospasm
— TBI: Assessment, Base of skull fracture, Brain Impact Apnoea, Cerebral Perfusion Pressure (CPP), DI in TBI, Elevated ICP, Limitations of CT, Lund Concept, Management, Moderate Head Injury, Monitoring, Overview, Paediatric TBI, Polyuria incl. CSW, Prognosis, Seizures, Temperature
ID in NeuroCrit. Care: Aseptic Meningitis, Bacterial Meningitis, Botulism, Cryptococcosis, Encephalitis, HSV Encephalitis, Meningococcaemia, Spinal Epidural Abscess
Equipment/Investigations: BIS Monitoring, Codman ICP Monitor, Continuous EEG, CSF Analysis, CT Head, CT Head Interpretation, EEG, Extradural ICP Monitors, External Ventricular Drain (EVD), Evoked Potentials, Jugular Bulb Oxygen Saturation, MRI Head, MRI and the Critically Ill, Train of Four (TOF), Transcranial Doppler
Pharmacology: Desmopressin, Hypertonic Saline, Levetiracetam (Keppra), Mannitol, Midazolam, Sedation in ICU, Thiopentone
MISC: Brainstem Rules of 4, Cognitive Impairment in Critically Ill, Eye Movements in Coma, Examination of the Unconscious Patient, Glasgow Coma Scale (GCS), Hiccoughs, Myopathy vs Neuropathy, Neurology Literature Summaries, NSx Literature Summaries, Occulocephalic and occulovestibular reflexes, Prognosis after Cardiac Arrest, SIADH vs Cerebral Salt Wasting, Sleep in ICU
Journal articles
- Darouiche RO. Spinal epidural abscess. N Engl J Med. 2006 Nov 9;355(19):2012-20. PMID: 17093252.
- Sendi P, Bregenzer T, Zimmerli W. Spinal epidural abscess in clinical practice. QJM. 2008 Jan;101(1):1-12. PMID: 17982180.
- Shah NH, Roos KL. Spinal epidural abscess and paralytic mechanisms. Curr Opin Neurol. 2013 Jun;26(3):314-7. PMID: 23511442.
- Tompkins M, Panuncialman I, Lucas P, Palumbo M. Spinal epidural abscess. J Emerg Med. 2010 Sep;39(3):384-90. PMID: 20060254.
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
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