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Spinal Epidural Abscess

A spinal epidural abscess is a potentially life-threatening bacterial infection of the epidural space, due to its insidious onset and nonspecific symptoms of fever, back pain and malaise. The diagnosis is often delayed, and radiculopathy accompanied by severe disability or even paralysis are seen in severe stages of the disease. Laboratory, imaging, and microbiological studies are mandatory during workup.


Presentation

The development of a spinal epidural abscess (SEA) is commonly a result of a bacterial infection occurring in other sites, most notably the heart (endocarditis), skin (abscesses and furuncles), throat (pharyngitis, retropharyngeal abscess), or dental infections, and the pathogenesis of bacterial dissemination in the epidural space remains incompletely understood [1] [2] [3]. Contiguous infections of the adjacent tissues, such as osteomyelitis, spondylitis, and/or discitis, on the other hand, are important sources of infection as well, whereas medical procedures involving the epidural space (administration of anesthesia) has been reported prior to its appearance in a minority of patients [3]. Several risk factors have been identified - diabetes mellitus, underlying immunosuppression (for eg. acquired immunodeficiency syndrome, or AIDS), intravenous drug abuse, alcoholism, but also trauma, which precede signs and symptoms in up to 35% of cases [1] [2] [3] [4]. SEA most frequently develops in the thoracic and lumbar spine, and the two principal complaints are nonspecific back pain and fever [1] [3]. Radiculopathy, muscle weakness, sphincter incontinence and various sensory and motor deficits are encountered in many individuals, as the diagnosis is often delayed [1] [3]. In up to a third of patients, paralysis may ensue, whereas a fatal onset of sepsis has been documented, strengthening the need for early recognition [1] [4].

Fever
  • Acupuncture and wet-cupping therapy should be taken into consideration as a cause of spinal epidural abscesses in patients who present with neck pain and fever.[ncbi.nlm.nih.gov]
  • A case is reported here of a 33-year-old woman with symptoms of night sweats, fever and low back pain. Rose-Bengal test for brucellosis was positive and Brucella standard tube agglutination test was positive at a titre of 1/160.[ncbi.nlm.nih.gov]
  • While the classic triad consists of back pain, fever, and neurologic deficits (D) , only a small proportion of patients actually have all three components at presentation.[foamcast.org]
  • The classical triad of symptoms includes back pain, fever and neurological deterioration.[ncbi.nlm.nih.gov]
  • Infection should be suspected in patients presenting with axial pain, fever, or elevated inflammatory markers.[ncbi.nlm.nih.gov]
Malaise
  • A spinal epidural abscess is a potentially life-threatening bacterial infection of the epidural space, due to its insidious onset and nonspecific symptoms of fever, back pain and malaise.[symptoma.com]
  • Fever with rigors, malaise and profuse night sweating were added to the symptoms, two days before admission. Magnetic Resonance imaging clearly showed the lesion and blood and tissue cultures were positive for Brucella melitensis .[casesjournal.biomedcentral.com]
  • Three days before admission at the outside hospital, the patient developed a low grade fever and malaise, and 1 day before admission the patient developed right hip pain. Because of the pain, the child refused to bear weight.[pediatrics.aappublications.org]
  • Fever, malaise, and back pain are the most consistent early symptoms ( Table 2 ) . Local tenderness, with or without neurologic deficit, is the usual physical finding, and leukocytosis may be the only abnormal laboratory finding.[aafp.org]
  • […] emotional as well as physical distress about the increasing (as opposed to persistent) pain complains of weakness or numbness in the legs, even if one believes the patient to be malingering has increasing difficulty walking complains of associated fatigue, malaise[pilchermd.com]
Lower Extremity Pain
  • In spite of appropriate coverage of his bacteremia, the patient’s back and bilateral lower extremity pain intensified, and he eventually developed urinary retention for which he required catheterization.[jss.amegroups.com]
Unable to Stand
  • She reported being unable to stand for more than brief periods. On the morning of the fourth hospital day, the patient reported weakness of her arms and legs and numbness of the soles of her feet. She experienced a loss of bladder control.[cmpa-acpm.ca]
Fecal Incontinence
  • No urine or fecal incontinence. No numbness or tingling. Triage Vital Signs: Physical Exam: The physician noted: “Vital signs are normal.” The patient was morbidly obese. Musculoskeletal: Normal ROM. No tenderness.[blog.thesullivangroup.com]
  • He had no complaints of urinary retention or fecal incontinence. Laboratory tests disclosed elevated inflammatory status (C-reactive protein 3.68 mg/L, white blood cell count 11,780/μL).[surgicalcasereports.springeropen.com]
  • Sixty-seven percent complained of localized back pain, and 78% developed neurologic disturbances such as lower-limb paraplegia, urinary or fecal incontinence, or irradiating pain ( table 1 ).[anesthesiology.pubs.asahq.org]
  • Incontinence Urinary Retention: due to detrusor muscle weakness Urinary Incontinence Low Back Pain/Sciatica: sciatica may be unilateral or bilateral Variable Lower Extremity Sensory/Motor Dysfunction Lower Extremity Weakness: bilateral or unilateral[mdnxs.com]
  • Clinical manifestations include local and radicular pain, weakness, sensory loss, URINARY INCONTINENCE, and FECAL INCONTINENCE. Cranial epidural abscesses are usually associated with OSTEOMYELITIS of a cranial bone, SINUSITIS, or OTITIS MEDIA.[fpnotebook.com]
Tachycardia
  • The patient presented to the emergency department with tachycardia; there was no repeat set of vital signs, and the patient went home with tachycardia. This is a common finding in emergency department medical care.[blog.thesullivangroup.com]
  • Examination findings included resting tachycardia and melenic stool. Blood pressure was 95/50 mm Hg. Multiple raised, soft, bluish 0.3 to 1 cm lesions were noted on the trunk and extremities.[consultant360.com]
  • Objectively, vital signs were notable for tachycardia and elevated core temperature. The patient was ill-appearing, disoriented and unable to provide detailed history.[ddxof.com]
  • Her vitals include a fever of 100.4 and tachycardia of 110. She refuses to provide other history. Back pain is a common presentation to the ED, accounting for approximately 3% of all visits.[epmonthly.com]
Back Pain
  • Patients present with localized back pain with tenderness to percussion. Fevers are common (reported in up to 75% of patients).[foamcast.org]
  • The process of ascertaining patients with grave diseases from the vast majority of patients with uncomplicated back pain can be tough.[emdidactic.blogspot.com]
  • We present the case of a previously well man with a one month history of back pain resulting from an epidural abscess.[ncbi.nlm.nih.gov]
  • We herein report the case of a 54-year-old woman who presented with progressive low back pain and fever with a root sign. She underwent surgical decompression, with an immediate improvement of the low back pain.[ncbi.nlm.nih.gov]
  • A case is reported here of a 33-year-old woman with symptoms of night sweats, fever and low back pain. Rose-Bengal test for brucellosis was positive and Brucella standard tube agglutination test was positive at a titre of 1/160.[ncbi.nlm.nih.gov]
Low Back Pain
  • We herein report the case of a 54-year-old woman who presented with progressive low back pain and fever with a root sign. She underwent surgical decompression, with an immediate improvement of the low back pain.[ncbi.nlm.nih.gov]
  • A case is reported here of a 33-year-old woman with symptoms of night sweats, fever and low back pain. Rose-Bengal test for brucellosis was positive and Brucella standard tube agglutination test was positive at a titre of 1/160.[ncbi.nlm.nih.gov]
  • The patient remained neurologically stable and continued to be clinically in good condition without any low back pain after 1 year. Surgical drainage, together with systemic antibiotics, is the main treatment choice for extensive SEAs.[ncbi.nlm.nih.gov]
  • She now reports 3 months of severe low back pain and progressive lower extremity weakness and paresthesias for the past week. Her leukocyte count is normal and she is afebrile. The ESR and CRP are elevated.[orthobullets.com]
  • Sacroiliac joint injections are frequently performed procedures in the management of acute and chronic low-back pain, including patients with various immunocompromised states.[ncbi.nlm.nih.gov]
Spine Pain
  • A 9-month substudy was performed in all patients who presented to the ED with spine pain so that the diagnostic test characteristics of the ESR and CRP level could be defined.[ncbi.nlm.nih.gov]
  • Prospective Evaluation of a Clinical Decision Guideline to Diagnose Spinal Epidural Abscess in Patients who Present to the Emergency Department with Spine Pain. J Neurosurg Spine. 2011 Jun;14(6):765-70. PMID: 21417700 Della-Guistina, D.[coreem.net]
  • Within Just a few days, he developed increasingly severe midthoracic spine pain. He soon developed rigors, chills, and vomiting. His symptoms rapidly worsened over the subsequent 12-24 hours.[aibolita.com]
  • Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain. J Neurosurg Spine 2011;14:765-770. SOURCE J.[ahcmedia.com]
Mid Back Pain
  • “Pt. reports mid back pain X 3 days, right left, increasing with cough and laying down. Clear sputum. History of same pain, diagnosed with pneumonia at that time, 3 years ago. She denies shortness of breath and chest pain.”[blog.thesullivangroup.com]
  • Ortho, 33; NS, 33 Other consultation, % a 50 33 Table 2 Complete List of Reviewed Cases Paitient Sex/Age, y Initial Presentation a Initial Setting Region Postop b Time to Rectal Exam c Specialty Outcome Complaint Verdict ( ) Surgery Consult Imaging M/# Mid-back[healio.com]
Right Shoulder Pain
  • This 15-year-old patient presented with right shoulder pain in the absence of the fever, back pain, or long-tract signs; therefore, the diagnosis of the spinal pathology was delayed.[ncbi.nlm.nih.gov]
Hyperreflexia
  • When evaluating back pain, order an emergency MRI if: Suspected spinal infection (fever, raised ESR or other risk factors for SEA) Cord compression (progressive neuro deficits, hyperreflexia, h/o cancer, bony lesions on X-Ray).[emdidactic.blogspot.com]
  • A patient’s reflexes may vary from being absent to hyperreflexia with clonus (rhythmic muscle spasms or contractions) and extensor plantar responses (a/k/a Babinski responses).[matzuslaw.com]
  • Complete transverse spinal cord syndrome with paraplegia and sphincter dysfunction Incomplete spinal cord syndromes Unilateral motor or sensory deficits [ 10 ] Gait ataxia [10] Reflexes may vary from absent to hyperreflexia with clonus and extensor plantar[emedicine.medscape.com]
  • WikEM: Epidural abscess (spinal) Motor Neuron Signs Upper Motor Neuron: Spasticity Hyperreflexia Pronator drift Babinski Lower Motor Neuron: Flaccidity Hyporeflexia Fasciculation Atrophy Causes of Weakness Lesion Critical Emergent Non-neurological Shock[ddxof.com]
  • Reflex abnormalities (Early hyperreflexia may give way to diminished or absent reflexes). Respiratory compromise (with cervical lesions). Spinal epidural abscess: Bowel and bladder incontinence. Difficulty urinating (urinary retention).[epainassist.com]
Clonus
  • A patient’s reflexes may vary from being absent to hyperreflexia with clonus (rhythmic muscle spasms or contractions) and extensor plantar responses (a/k/a Babinski responses).[matzuslaw.com]
  • Complete transverse spinal cord syndrome with paraplegia and sphincter dysfunction Incomplete spinal cord syndromes Unilateral motor or sensory deficits [ 10 ] Gait ataxia [10] Reflexes may vary from absent to hyperreflexia with clonus and extensor plantar[emedicine.medscape.com]
  • Patellar clonus was present, with hypoesthesia below D 9 level. The chest x-ray was within normal limits.[atmph.org]
Unable to Walk
  • By this point he was unable to walk, had severe tenderness in the back around the midline and paraspinal region, and severely limited motion of the spine. He also presented with pararesthesia below the inguinal ligaments in both lower limbs.[spinalnewsinternational.com]
  • At a 1-yr follow-up examination, the patient was unable to walk without crutches and suffered severe lumbar back pain.[anesthesiology.pubs.asahq.org]
Long Tract Signs
  • This 15-year-old patient presented with right shoulder pain in the absence of the fever, back pain, or long-tract signs; therefore, the diagnosis of the spinal pathology was delayed.[ncbi.nlm.nih.gov]
Long Tract Signs
  • This 15-year-old patient presented with right shoulder pain in the absence of the fever, back pain, or long-tract signs; therefore, the diagnosis of the spinal pathology was delayed.[ncbi.nlm.nih.gov]
Urinary Retention
  • Back pain (83%, 10/12) was the most common clinical presentation, followed by paraparesis (50%, 6/12), radiating pain (33%, 4/12), and urinary retention (25%, 3/12).[ncbi.nlm.nih.gov]
  • retention is constipated Fortunately SEA progresses in a relatively linear pattern.[pilchermd.com]
  • retention GBS: If no signs of cauda equina and sensory disturbances paralleling ascending weakness (with hyporeflexia) Bilateral weakness of upper extremities Lesion: Central cord syndrome Causes: Syringomyelia, hyperextension injury Findings: Pain and[ddxof.com]
  • Symptoms A spinal epidural abscess may cause the following symptoms: Loss of control of bowel or bladder function Difficulty urinating (urinary retention) Fever Weakness in the legs Back pain Mental status changes (if infection is in the blood) Causes[columbiaspine.org]
  • He had no complaints of urinary retention or fecal incontinence. Laboratory tests disclosed elevated inflammatory status (C-reactive protein 3.68 mg/L, white blood cell count 11,780/μL).[surgicalcasereports.springeropen.com]
Urinary Incontinence
  • The most common presenting symptoms were neck or back pain, motor deficits, and urinary incontinence. The most common underlying medical condition was diabetes mellitus.[ncbi.nlm.nih.gov]
  • The patient suffered from urinary incontinence and constipation. Two months after surgery the patient had full lower limb motor recovery (grade 5), except for grade 4 knee flexion, nocturnal incontinence, and constipation.[spinalnewsinternational.com]
  • Findings such as urinary incontinence and perineal parasthesias can significantly increase the likelihood of the patient having a SEA, however lack of these findings does not reliably rule out the disease.[aliem.com]
  • incontinence Stage 4 : paralysis Typical Clinical Symptoms/Signs Abdominal Pain (see Abdominal Pain , [[Abdominal Pain]]): may occur in thoracic spine epidural abscess Fever (see Fever , [[Fever]]) Back (75% of cases) (see Back Pain , [[Back Pain]])[mdnxs.com]

Workup

Workup of patients in whom SEAs are the cause of symptoms should start with a thorough patient history that will evaluate the course of illness and assess whether risk factors for a SEA are present. Exclusion of previous trauma, recent dental treatment, drug or alcohol abuse, as well as confirmation of diabetes mellitus or other immunosuppressive diseases is imperative during patient history. The role of the physical examination must be emphasized, as percussion of the back may reveal local tenderness and pain, which can be an important clue in making a presumptive diagnosis, especially if accompanying signs of fever, malaise or neurological deficits are present [3]. A complete blood count (CBC) often reveal anemia, leukocytosis, and a high erythrocyte sedimentation rate (ESR) [1]. Blood cultures are positive in about 60% of patients, and staphylococcus aureus is identified as the principal causative agent, followed by actinomyces spp., various anaerobic bacteria and mycobacterium tuberculosis (known as Pott disease) [1] [3]. Imaging studies, however, are the cornerstone of SEA diagnosis [2]. Magnetic resonance imaging (MRI) of the thoracolumbar spine will reveal an abscess in the posterior epidural space in more than two-thirds of cases and is depicted as a homogenous enhancement [3]. Gadolinium-enhanced MRI is frequently implemented in order to obtain an even better view of the epidural space [3] [4]. When the lesion is identified, biopsy, either open or needle aspiration (guided by computed tomography), is usually performed to solidify the diagnosis, as it provides a viable sample for cultivation and confirmation of the causative agent [3].

Treatment

  • Traditionally the treatment of choice has involved emergency surgical evacuation and a prolonged course of antibiotics tailored to the offending pathogen.[ncbi.nlm.nih.gov]
  • No complications of treatment were noted.[ncbi.nlm.nih.gov]
  • Spinal epidural abscess (SEA) is a rare condition that requires prompt diagnosis and initiation of treatment for optimal outcome. Treatment generally consists of surgical intervention and systemic antibiotics.[ncbi.nlm.nih.gov]
  • This study reviews these published reports and compares pooled data with historical treatment data.[ncbi.nlm.nih.gov]

Prognosis

  • After therapy, 21 patients had a good prognosis and 8 had a poor prognosis. Significant prognostic factors included older age ( 70years), presence of diabetes mellitus, adrenal insufficiency, and MRSA infection.[ncbi.nlm.nih.gov]
  • The therapeutic results showed that 28 patients had a good prognosis and 17 had a poor prognosis.[ncbi.nlm.nih.gov]
  • The prognosis of SEA is highly dependent on the timeliness of its diagnosis before neurological deficits develop. Unfortunately, often due to its nonspecific presentation, such as back pain, the diagnosis of SEA may be delayed in up to 75% of cases.[ncbi.nlm.nih.gov]
  • It is quite unfortunate for this patient to have a poor prognosis due to a delayed diagnosis and an improper management. A number of lessons can be learnt from this case.[ncbi.nlm.nih.gov]
  • The medical literature regarding spinal epidural abscess has two common threads: reports of poor prognosis and appeals for rapid treatment.[jamanetwork.com]

Etiology

  • The etiological agent S. moniliformis was identified by 16S rRNA-based polymerase chain reaction and sequencing as well as by culture and mass spectrometry.[ncbi.nlm.nih.gov]
  • It is all-too-easy to attribute to degenerative joint etiology. Symptoms may even be masked by NSAID or steroid use. Symptoms to look for are not necessarily present.[emdocs.net]
  • Spinal epidural abscess: contemporary trends in etiology, evaluation, and management. Surg Neurol . 1999;52:189-96. [ PubMed ] Tompkins M, Panuncialman I, Lucas P, et al. Spinal epidural abscess.[westjem.com]
  • X rays and CTs of spine do not reveal infectious etiologies. Use MRI to scan the entire spine with contrast because lesions often occur at multiple levels.[emdidactic.blogspot.com]
  • We thought the source of infection was her urine; however, the infectious disease physicians deemed the etiology to be her neck infection despite the rarity of K. pneumoniae in soft tissue infections.[omicsonline.org]

Epidemiology

  • The epidemiological data in southern Taiwan is still lacking.[ncbi.nlm.nih.gov]
  • The authors present 2 cases of pyomyositis with an SEA and review the epidemiology, pathophysiology, diagnostic workup, and management of this disorder.[ncbi.nlm.nih.gov]
  • The two groups did not differ significantly in epidemiological, clinical or laboratory characteristics, or in the causative bacteria isolated.[ncbi.nlm.nih.gov]
  • An increasing incidence has been suggested; however, few contemporary data are available regarding risk factors and epidemiologic trends over time.[ncbi.nlm.nih.gov]
  • Spinal Epidural Abscess (aafp.org) Definition: Suppurative infection enclosed within the epidural space Epidemiology Incidence: 2-12.5 cases per 10,000 hospitalized patients ( Sendi 2008 , Arko 2014 ).[coreem.net]
Sex distribution
Age distribution

Pathophysiology

  • The incidence of spinal epidural abscess is increasing, and the understanding of the pathophysiology is evolving. Better understanding of the pathophysiology, specifically the role of ischemia, warrants a change in therapy.[ncbi.nlm.nih.gov]
  • In this review, we call for a more discriminate evidence-based use of the term "risk factor" when discussing SEA and explore several approaches to its earlier diagnosis, including a simple algorithm based on its pathophysiology and serum C-reactive protein[ncbi.nlm.nih.gov]
  • The authors present 2 cases of pyomyositis with an SEA and review the epidemiology, pathophysiology, diagnostic workup, and management of this disorder.[ncbi.nlm.nih.gov]
  • […] 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[lifeinthefastlane.com]
  • Pathophysiology The spinal epidural space is not a uniform space. Posteriorly, the epidural space contains fat, small arteries, and the venous plexus. Infections in this space may spread over several vertebral levels.[emedicine.medscape.com]

Prevention

  • The characteristics of spinal epidural abscess that develop after acupuncture and how to prevent such complications are also discussed.[ncbi.nlm.nih.gov]
  • Spinal epidural abscess is a rare complication with potential severe morbidity, and continued vigilance is needed as timely intervention may prevent severe morbidity and potentially fatal outcome.[ncbi.nlm.nih.gov]
  • Spinal injury may be prevented if surgical and medical interventions are implemented early. The diagnosis is difficult, because clinical symptoms are not specific and can mimic many benign conditions.[ncbi.nlm.nih.gov]
  • Early recognition at the point of initial clinical presentation may prevent irreversible neurologic injury or other serious, adverse outcomes. To facilitate early recognition of SEA, we developed a predictive scoring model.[ncbi.nlm.nih.gov]
  • Infection control and the prevention of further neurological deterioration in time are paramount in the treatment of SEA for optimal recovery.[ncbi.nlm.nih.gov]

References

Article

  1. Reihsaus E, Waldbaur H, Seeling W. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev. 2000;23(4):175-204
  2. Krishnamohan P, Berger JR. Spinal epidural abscess. Curr Infect Dis Rep. 2014;16(11):436.
  3. Chao D, Nanda A. Spinal epidural abscess: a diagnostic challenge. Am Fam Physician. 2002;65(7):1341-1346.
  4. Oktenoglu T, Sasani M, Cetin B, et al. Spontaneous pyogenic spinal epidural abscess. Turk Neurosurg. 2011;21(1):74-82.

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