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

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

  METHODS: A 54-year-old man presented with neck pain and fever. Magnetic resonance imaging of the cervical spine revealed an epidural abscess at C4 to T2. [ncbi.nlm.nih.gov]

  Abdominal Pain]]): may occur in thoracic spine epidural abscess Fever (see Fever, [[Fever]]) Back (75% of cases) (see Back Pain, [[Back Pain]]) Common in lumbar epidural abscess Usually focal and severe, occurs early Diagnostic Guidelines for Evaluation [mdnxs.com]

  He again presented to us with relapse of the infection on 28th post-operative day with similar fever and back pain. He was reinvestigated with MRI and blood investigations which revealed relapse of the infection. [nepjol.info]

• 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]

  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]

  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]

  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]

• 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 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]

  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]

• Back Pain

  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]

  Back pain is the leading complaint during the development of a spinal epidural abscess, and is reported in up to 90% of cases.3 However, the incidence of back pain is high after delivery, regardless of the use of epidural analgesia.6 Therefore, back pain [academic.oup.com]

  Abstract Because spinal epidural abscess is usually ignored in the preliminary differential diagnosis of low back pain, appropriate treatment may be delayed. [ncbi.nlm.nih.gov]

  Symptoms and Signs Symptoms of spinal epidural abscess begin with local or radicular back pain and percussion tenderness, which become severe; pain may be worsened by recumbency. Fever is common. [msdmanuals.com]

• Low Back Pain

  Abstract Because spinal epidural abscess is usually ignored in the preliminary differential diagnosis of low back pain, appropriate treatment may be delayed. [ncbi.nlm.nih.gov]

  Chung SY, Chen CH, Yu WL (2005) Spinal epidural abscess caused by group B Streptococcus in a diabetic woman presenting with febrile low back pain. Jpn J Infect Dis 58:177-179. [medical-case-reports.imedpub.com]

• 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]

  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 (6): 765-70. Pubmed Image (modified) [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]

• 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

  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]

  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]

  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 Lower Extremity [mdnxs.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]

• Streptococcus Pneumoniae

  Streptococcus pneumoniae was isolated from the evacuated pus. Definitive treatment of SEA is a combination of surgical decompression and iv antibiotics. Timely management limits the extent of neurological deficit. [ncbi.nlm.nih.gov]

  (see Streptococcus, [[Streptococcus]]): 9% of cases Streptococcus Pneumoniae (see Streptococcus Pneumoniae, [[Streptococcus Pneumoniae]]) Staphylococcus Epidermidis (see Staphylococcus Epidermidis, [[Staphylococcus Epidermidis]]): 3% of cases Risk is [mdnxs.com]

  Spinal epidural abscess due to Streptococcus pneumoniae in an HIV-infected adult. Infection. 2001;29(4):234–6. PubMed CrossRef Google Scholar 15. Darouiche RO et al. Bacterial spinal epidural abscess. Review of 43 cases and literature survey. [link.springer.com]

  pneumoniae (18%), Escherichia coli, Pseudomonas, Fusobacterium, and Salmonella found less commonly (13%). 3,7,10,12,13,15,16 The most common (and conservative) approach to management is administration of IV antibiotics for 4 to 6 weeks (and possibly [healio.com]

  Other gram-positive cocci such as Staphylococcus epidermidis, Streptococcus pneumoniae, and Streptococcus viridans account for an additional 10% of cases. [reliasmedia.com]

No complications of treatment were noted. [ncbi.nlm.nih.gov]

Most of these infections are secondary to pyogenic infection.6–8 Treatment options depend on many factors, such as the site and severity of compression, as well as clinical presentation. Medical treatment can be offered in certain cases. [spinalnewsinternational.com]

[…] groups: medical treatment alone, failed medical management leading to subsequent surgery, and early surgery. [surgicalneurologyint.com]

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

[…] 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 [lifeinthefastlane.com]

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]

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

Record: found Abstract: found Article: not found Spinal epidural abscess: contemporary trends in etiology, evaluation, and management. [scienceopen.com]

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]

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]

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]

Epidemiology Precautions Types: Spinal Infection Pathophysiology: Spinal Cord Injury Mechanisms Pathophysiology: Sources of Spinal Infection Pathophysiology: Sites of Spinal Infection Causes Risk Factors Symptoms Signs Precautions Labs Imaging Evaluation [fpnotebook.com]

To prevent serious morbidity and mortality, early diagnosis is essential. [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]

MRI 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 [merckmanuals.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.