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

  The classical triad of symptoms includes back pain, fever and neurological deterioration. [ncbi.nlm.nih.gov]

  SEA most frequently develops in the thoracic and lumbar spine, and the two principal complaints are nonspecific back pain and fever. [symptoma.com]

• 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]

  Clinical Presentation  (1) spinal pain,  (2) radicular pain,  (3) muscular weakness, and  (4) complete paralysis  Systemic signs of infection (fever, malaise, irritability, night sweats, and headache) 11. [fr.slideshare.net]

  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]

  Other bacteria that have been implicated includePseudomonas, Pneumococcus, Escherichia coli, Fusobacterium, andSalmonella.1 Common early presentations of this disease include fever, malaise, and spinal tenderness. [pediatrics.aappublications.org]

• 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]

• Fecal Incontinence

  The summary was then compared with those of previously published data.The average age, duration of symptoms before admission, hypoesthesia rate, and urinary/fecal incontinence rate of our patients were 69.5 years old, 21.2 days, 76.9%, and 53.9%, respectively [insights.ovid.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]

  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]

  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]

• Right Upper Quadrant Tenderness

  On admission her Glasgow Coma Scale was 14/15; she was septic and examination revealed right upper quadrant tenderness. She deteriorated quickly, becoming acidotic and hypoxic, and was sedated, intubated and transferred to the intensive care unit. [ncbi.nlm.nih.gov]

• Intestinal Perforation

  While it usually afflicts older, immunocompromised patients, this condition has been reported as a result of intestinal perforation in the setting of inflammatory bowel disease. [ncbi.nlm.nih.gov]

• 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]

  Examination of the heart revealed a regular rhythm with borderline tachycardia, but without murmurs, rubs, or gallops. The patient had 2+ pulses in all four extremities, and capillary refill was less than 2 seconds. [mdedge.com]

• Back Pain

  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]

  An 8-year-old previously healthy boy presents with back pain and fever for 4 days. He complains of pain in the low back, which is increased with bending or twisting. The pain radiates down into his left leg. He denies trauma. [foamcast.org]

  When discharging these patients as MSK back pain, give them verbal and written advice explaining the red flags and when to return back. Department of Emergency Medicine [emdidactic.blogspot.com]

• 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]

  Thoracic spinal epidural abscess is a rare but serious condition that may only present with low back pain. [psnet.ahrq.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]

  Back pain at affected site Nerve root pain from affected level Weakness, sensory deficit, bladder/bowel dysfunction Paralysis Differential Diagnosis Spinal infection Epidural Abscess (Spinal) Discitis Vertebral osteomyelitis Lower Back Pain Spine related [wikem.org]

  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 (6): 765-70. [aliem.com]

  The classic triad of spine pain, fever, and neurologic abnormality has a sensitivity of 2.0-7.9% for spinal epidural abscess in ED patients. [emergencymedicine.wustl.edu]

• Mid Back Pain

  Her mid lumbar back pain worsened this morning when she was walking in her kitchen. She noted a snap and had sudden lumbar back pain that radiated to her legs bilaterally with associated numbness. [blog.thesullivangroup.com]

  Failed to diagnose and treat appropriately P (125,000) F/49 Low back pain ER L No 60 d No Pain manag Chronic low back pain Failed to diagnose and treat appropriately D [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]

  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]

  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]

  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]

• 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]

• 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]

  Patellar clonus was present, with hypoesthesia below D 9 level. The chest x-ray was within normal limits. [atmph.org]

  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]

• 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

  Although the epidural abscess was initially treated with antibiotic (cefozopran) for 5 days, he subsequently developed motor weakness, paresthesia and urinary retention. MRI demonstrated spinal cord compression at the C1-C4 level. [ncbi.nlm.nih.gov]

  Any complaint or finding regarding new onset of sphincter dysfunction (urinary retention or incontinence) should be considered a gigantic red flag for compression of the spinal cord or cauda equina. There may be NO identifiable risk factors! [blog.thesullivangroup.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]

• Urinary Incontinence

  RESULTS: 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]

  This is the Epic smartphrase I use: Patient currently denies any recent history of fever, neurologic symptoms, urinary incontinence or retention. Patient denies any history of cancer, IVDU, AAA, AVM, spinal surgery or recent trauma, steroid use. [forums.studentdoctor.net]

  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]

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].

• Neutrophilia

  […] 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 [lifeinthefastlane.com]

  The most relevant laboratory test results included: WBC, 18,600 (3500–12,000g/L) with neutrophilia (86% neutrophils); hemoglobin, 7.79g/dL (12–16g/dL); hematocrit, 24% (33–53%); platelet count and coagulation within the normal range; urea, 74mg/dL (18 [elsevier.es]

• Salmonella Typhi

  Histological examination of the bone found osteomyelitis, and culture of the soft tissue showed Salmonella typhi sensitive to ceftriaxone and ciprofloxacin. [ncbi.nlm.nih.gov]

• Scedosporium

  To describe a rare case of chronic spinal epidural abscess caused by Scedosporium prolificans in an immunocompetent patient. [ncbi.nlm.nih.gov]

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]

The therapeutic results showed that 28 patients had a good prognosis and 17 had a poor prognosis. [ncbi.nlm.nih.gov]

Etiology  Staphylococcis  Streptococcus  Gram negatives  Micobacterium tuberculosis  Rare: fungal, parasites, & anaerobs 7. [fr.slideshare.net]

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]

I have low suspicion for cauda equina, renal etiology, AVM or aortic aneurysm/dissection, fracture, tumor, or infection. [forums.studentdoctor.net]

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]

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]

The epidemiological data in southern Taiwan is still lacking. [ncbi.nlm.nih.gov]

Outline:  Introduction  Anatomy  Epidemiology  Etiology  Risk factors  Pathophysiology  Clinical presentation  Imaging  Laboratory  Differential diagnosis  Management (medical & surgical)  Summary 3. [fr.slideshare.net]

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]

PURPOSE OF REVIEW: 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]

Pathophysiology Hematogen Contiguous Direct inoculation Cryptogenic Trauma 9. Clinical Presentation Pain Fever Neurologic deficits 10. [fr.slideshare.net]

[…] 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]

The characteristics of spinal epidural abscess that develop after acupuncture and how to prevent such complications are also discussed. [ncbi.nlm.nih.gov]

Because rapid treatment is necessary to prevent or minimize neurologic deficits, clinicians should consider spinal epidural abscess if patients have significant atraumatic back pain, particularly when there is focal percussion tenderness over the spine [msdmanuals.com]

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.