epidural abscess.pdf

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Epidural Abscess back pain patients Definitive MRI

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Epidural Abscess back pain patients Definitive MRI

CSC Aug-02 
Epidural Abscess 
 
Key Points: 
• Think of this diagnosis in patients with a predisposing factor (IVDU, immunosuppression) who 
present with fever and back pain 
• On physical exam, check for saddle anesthesia or a sensory level, diminished rectal tone, and any 
evidence of motor weakness 
• Emergent neuroimaging (with an MRI) is the standard of care 
• Definitive therapy almost always involves surgical decompression and a prolonged course of 
antibiotics 
 
 
I. 
Pathogenesis:  May occur as result of either local extension of vertebral osteomyelitis/diskitis 
or hematogenous spread of bacteria from distant site of infection or endocarditis. 
 
II. 
Epidemiology:   
• Common in IV drug users, but may also occur after trauma, spinal surgery, or spontaneously 
• 50% of patients have some form of underlying immunosuppression (DM, HIV)  
 
III. 
Microbiology:  Overwhelmingly S. aureus (2/3 of cases); also gram-negative rods, other 
staph and strep spp.  Less common:  anaerobes, TB. 
 
IV. 
Clinical Manifestations:   
a. Back pain (71%):  may be reproducible on palpation 
b. Fever (66%) 
c. Progresses to neuropathic/radicular pain 
d. With time, may progress to neurologic compromise, including: 
i. Decreased rectal tone 
ii. Saddle anesthesia, or sensory “level” 
iii. Motor weakness and, eventually, paralysis  
 
V. 
Diagnosis:  Once you suspect an epidural abscess, you are obligated to obtain emergent 
neuroimaging – and this is one of the things the MRI team will come in for on a weekend, in 
the middle of the night, whenever.   
• MRI of the spine is the diagnostic test of choice 
• Blood cx should be drawn, and you will probably need to sample the contents of the abscess 
under radiologic guidance to guide therapy 
• LP is contraindicated so as not to spread infection into the CSF 
 
VI.  
Management:  If any evidence of neurologic compromise is present, epidural abscess is a 
neurosurgical emergency!   
•  Prompt surgical drainage is the definitive treatment; rarely, patients can be managed non-
operatively.   
•  Empiric antibiotic coverage, while awaiting culture results, should include staphylococci, 
streptococci, gram-negative bacilli, and anaerobes (i.e., be broad!). 
•  As always, coverage should be narrowed once definitive culture results are available; 
antibiotic duration should be 4-6 weeks. 
 
References 
Reihsaus E, Waldbaur H, Seeling W.  Spinal epidural abscess:  a meta-analysis of 915 patients.  Neurosurg 
Rev 2000 Dec; 23(4):  175-204. 
Roos K.  Nonviral infections.  In Goetz:  Textbook of Clinical Neurology, 1st ed.  Ch. 42, p. 849-851.