Spinal Epidural Abscess


Article Author:
William Gossman
Thomas Knorr


Article Editor:
Fassil Mesfin


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
7/10/2019 2:08:27 PM

Introduction

Spinal epidural abscess is a suppurative infection of the central nervous system. Although classically patients with spinal epidural abscess present with midline back pain, fever, and neurologic deficits, presentations of this disease process can be variable. Spinal epidural abscess is difficult to diagnose if clinical suspicion is not high. When left untreated spinal epidural abscess can cause significant morbidity and mortality. Thus any clinical concern for this diagnosis requires prompt evaluation and treatment.[1][2][3]

Etiology

In patients presenting with spinal epidural abscess, bacteria enter the epidural space resulting in a suppurative infection. Most often, the bacteria enter the epidural space through hematogenous spread. Risk factors for spinal epidural abscess include immunosuppressed state (i.e., diabetes mellitus, alcoholism, cirrhosis, end-stage renal disease, HIV infection), intravenous drug abuse, direct instrumentation (i.e., acupuncture, paraspinal or epidural injection, lumbar puncture, CNS surgery), and bacteremia. Diabetes mellitus is the most common risk factor associated with spinal epidural abscess although intravenous drug use and epidural catheter placement are becoming increasingly important risk factors in the development of this disease process.[4][5]

Epidemiology

Spinal epidural abscess is an uncommon diagnosis. The incidence of this disease process is 1.2 per 10,000 patients. Although spinal epidural abscess is uncommon, its incidence has been increasing in recent years. This increased diagnosis is thought to be because of expanded utilization of invasive spinal procedures, increasing age of the population, and increasing rates of intravenous drug use.[6][7]

In one-third of cases of spinal epidural abscess, there is no identifiable nidus of infection. Diabetes mellitus is the greatest risk factor for a spinal epidural abscess. In total, 33% of patients presenting with spinal epidural abscess have diabetes mellitus. Other important risk factors for the development of spinal epidural abscess include intravenous drug use and instrumentation of the epidural space. In intravenous drug use, hematogenous seeding of the epidural space occurs which leads to spinal epidural abscess. Instrumentation of the epidural space occurring during lumbar puncture or epidural catheter placement can directly inoculate bacteria into the epidural space causing this infectious process. Of note, the incidence of a spinal epidural abscess after epidural catheter placement is approximately 0.5% to 3%.

Staphylococcus aureus accounts for 63% of spinal epidural abscess infections, followed by gram-negative bacilli (16%), streptococcal infections (9%), and other bacteria/mycobacteria/fungi accounting for ~10% of infections.

Pathophysiology

Bacteria enter the epidural space and seed the area between the dura mater and vertebral wall within the spinal canal. This introduction of bacteria into this normally sterile space results in a suppurative infection within this confined area. Most commonly this occurs via hematogenous seeding of the epidural space. Hematogenous spread can occur from soft tissue infections, infected catheters, endocarditis, urinary tract, or respiratory tract infections. Bacteria also can enter the epidural space through the direct extension of infected tissue. This occurs when psoas abscess, vertebral osteomyelitis, or discitis leads to spinal epidural abscess. Additionally, a spinal epidural abscess can be the result of direct inoculation of this tissue. Epidural injections, epidural catheter placements, lumbar punctures, and other central nervous system (CNS) procedures all can result in epidural abscess through direct inoculation.[8][9]

Infection also can be the result of the contiguous spread of an infection such as vertebral osteomyelitis, discitis, retropharyngeal abscess, retroperitoneal abscess or through penetrating injury, epidural injection or catheter placement, lumbar puncture, or recent CNS surgery.

Once bacteria have gained entrance into the epidural space, a resulting pyogenic infection occurs which then results in abscess formation. Damage to the spinal cord may occur through a number of mechanisms including (1) direct compression from expanding abscess, (2) thrombosis and thrombophlebitis of adjacent veins, (3) interruption of arterial blood supply, and (4) bacterial toxins.

Typically, spinal epidural abscess will involve 3 to 5 spinal cord segments. Given that spinal epidural abscesses most commonly are caused by hematogenous spread, 9% of patients presenting with this diagnosis will have two or more noncontiguous areas of pyogenic collections.

History and Physical

The classic triad of a spinal epidural abscess is back pain (75%), fever (48%), and neurologic deficits (33%) due to the direct compressive effects of the abscess. The classic triad presents in as few as 8% of patients, thus if clinical concern exists for this disease prompt diagnostic evaluation must be undertaken.

Pain may be elicited through palpation or percussion of spinous processes overlaying spinal epidural abscess. Pain also may be elicited through straight leg raise from compression of spinal nerve roots. As this disease process progresses patients will develop neurologic deficits consistent with spinal cord or cauda equina compression: urinary retention, bowel incontinence, anesthesia (perianal and saddle anesthesia), motor weakness, or paralysis.

Evaluation

Lab evaluation should include blood cultures, complete blood count, inflammatory markers, and coagulation studies. These studies often will reveal an elevated white blood cell count and elevated inflammatory markers. Although the erythrocyte sedimentation rate is often elevated in these patients, it does not rule out the diagnosis of spinal epidural abscess (85% to 94% sensitivity). [10]

Positive cultures by frequency in specimen type is (1) abscess aspirate: 90%, (2) blood: 62%, and (3) CSF: 19%.

If there is a concern for spinal epidural abscess, patients should undergo immediate MRI of the entire spine. If MRI is unavailable, CT with IV contrast is an alternative although less sensitive.

Lumbar puncture is unnecessary as it lends little diagnostic utility and has potential morbidity in the setting of spinal epidural abscess.

Treatment / Management

Emergent surgical Spineconsultation is the standard of care all patients with radiographic findings epidural abscess and abnormal neurological examinations due to mass effect from an epidural abscess. These patients usually require an emergent surgical evaluation to decompress the spinal cord and nerve roots.[11][12][13]

Overall, the treatment of spinal epidural abscess focuses on elimination of the suppurative mass and eradication of the causative organism. This is accomplished through aspiration, surgical drainage, and antibiotic therapy. The assistance of interventional radiology or spine surgery (orthopedics or neurosurgery) will be required in the management of many if not all of these patients

Death and paralysis are the most feared complications of spinal epidural abscess. Death occurs in 5% of patients typically due to sepsis. Paralysis occurs in 4% to 22% of patients with a spinal epidural abscess. If paralysis occurs, surgery should be performed within 24 to 36 hours of the onset of paralysis. Recovery of neurologic function is unlikely if paralysis occurs greater than 24 hours prior to surgery.

Empiric antibiotic regimens should include vancomycin (30-60 mg/kg) plus a third or fourth-generation cephalosporin (2g cefotaxime Q6H, 2g ceftriaxone Q12H, 2g ceftazidime Q8H, or 2g cefepime Q8H) until speciation and sensitivities of the infecting organism result for more targeted antibiotic therapy. Typically, patients will require a prolonged course of antibiotics (4 to 6 weeks) to treat this infection.

Repeat MRI should be obtained if the patient has worsening symptoms, deteriorating clinical exam, or at 4 to 6 weeks of therapy.

Differential Diagnosis

  • Cervical/lumbar disc stenosis
  • Psoas abscess
  • Transverse myelitis
  • Low back pain
  • Pyelonephritis
  • Spinal cord hematoma

Complications

  • Pressure ulcers
  • Urine retention
  • Supine hypertension
  • Sepsis
  • Deep vein thrombosis

Enhancing Healthcare Team Outcomes

The management of spinal abscess is multidisciplinary and includes a neurosurgeon, neurologist, intensivist, an infectious disease expert, physical therapy and nurse. These patients develop a multitude of complications like urinary retention, DVT, sepsis, pressure ulcers, and supine hypertension. After discharge, most patients require home healthcare and ongoing physical therapy. A home care nurse is often required to monitor these patients for recovery and potential problems. Many of these patients need a long-term indwelling catheter, which also increases the risk of an infection. Gastric aperistalsis is common, and constipation is a recurrent problem. As the infection improves, many patients may benefit from rehabilitation to regain their muscle mass and exercise endurance.  [14][15](Level V)

Outcomes

A spinal abscess is rare in the US, but when it occurs, it does have a significant morbidity. The prognosis depends on the extent of the abscess, neurological deficits present at the time of presentation and response to treatment. Even after treatment, most patients are left with some type of neurological deficit. Many patients require long-term rehabilitation to regain function. During the recovery, pressure ulcers and deep vein thrombosis are also a common occurrence. [4][16][17](Level V)


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Spinal Epidural Abscess - Questions

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Spinal epidural abscesses are commonly caused by which of the following organisms?



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Which is the least likely cause of an abscess in the epidural space?



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A 71-year-old female with a history of diabetes mellitus, hypertension, and hyperlipidemia presents for back pain. She has a remote history of intravenous drug use. She reports one week of progressively worsening lumbar back pain. She endorses shooting sensation down her right leg radiating from her lower back and chills at home. She also endorses difficulty evacuating her bladder and one episode of fecal incontinence earlier this morning. She denies trauma, falls, or prior episodes of similar symptoms. Vital signs show temperature to be 100.8 F, pulse 88 bpm, 130/78 mmHg, respiratory rate18, and oxygen saturation of 99%. Her exam is remarkable for reduced rectal tone, reduced perianal sensation, 5/5 strength in bilateral lower extremities, and midline L2 to L4 tenderness to percussion. Epidural abscess is considered as a possible diagnosis in this patient. What would be this patient's greatest risk factor for the development of spinal epidural abscess?



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A 17-year-old male presents with back pain and fever. He reports stool incontinence for the past day and inability to urinate or walk for the past 12 hours. He reports daily intravenous drug use and fevers for the past week. The patient's back pain is located exclusively in his lower lumbar region. You suspect spinal epidural abscess as the most likely etiology of the patient's symptoms. What is the most appropriate imaging study in this patient's initial evaluation for spinal epidural abscess?



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A 17-year-old female with a history of intravenous drug abuse presents with fever, back pain, and inability to ambulate. She has been experiencing back pain for the past 3 days. She reports that the weakness has been progressively worsening for the past 6 hours, and she is now unable to walk. On exam, the patient has reduced sensation to her umbilicus and 2/5 strength in her lower extremities. An MRI is obtained, and spinal epidural abscess noted at T10-L1 with associated spinal cord compression. What is the most appropriate next intervention?



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A 55-year-old male presented to the emergency room with acute onset back pain and fever. He has a history of intravenous drug use. Which of the following would not be part of the initial workup?



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Spinal Epidural Abscess - References

References

Babu JM,Patel SA,Palumbo MA,Daniels AH, Spinal Emergencies in Primary Care Practice. The American journal of medicine. 2018 Oct 3     [PubMed]
Boody BS,Tarazona DA,Vaccaro AR, Evaluation and Management of Pyogenic and Tubercular Spine Infections. Current reviews in musculoskeletal medicine. 2018 Oct 2     [PubMed]
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Bos EME,Schut ME,de Quelerij M,Kalkman CJ,Hollmann MW,Lirk P, Trends in practice and safety measures of epidural analgesia: Report of a national survey. Acta anaesthesiologica Scandinavica. 2018 Aug 1     [PubMed]
Lener S,Hartmann S,Barbagallo GMV,Certo F,Thomé C,Tschugg A, Management of spinal infection: a review of the literature. Acta neurochirurgica. 2018 Mar     [PubMed]
Pitkänen MT,Aromaa U,Cozanitis DA,Förster JG, Serious complications associated with spinal and epidural anaesthesia in Finland from 2000 to 2009. Acta anaesthesiologica Scandinavica. 2013 May     [PubMed]
Eltorai AEM,Naqvi SS,Seetharam A,Brea BA,Simon C, Recent Developments in the Treatment of Spinal Epidural Abscesses. Orthopedic reviews. 2017 Jun 23     [PubMed]
Colston J,Atkins B, Bone and joint infection. Clinical medicine (London, England). 2018 Mar     [PubMed]
Chaker AN,Bhimani AD,Esfahani DR,Rosinski CL,Geever BW,Patel AS,Hobbs JG,Burch TG,Patel S,Mehta AI, Epidural Abscess: A Propensity Analysis of Surgical Treatment Strategies. Spine. 2018 Jun 18     [PubMed]
Shah AA,Ogink PT,Harris MB,Schwab JH, Development of Predictive Algorithms for Pre-Treatment Motor Deficit and 90-Day Mortality in Spinal Epidural Abscess. The Journal of bone and joint surgery. American volume. 2018 Jun 20     [PubMed]

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