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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
  • 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]
  • SEA most frequently develops in the thoracic and lumbar spine, and the two principal complaints are nonspecific back pain and fever.[symptoma.com]
  • Most common signs and symptoms of SEA reported are initially backache (71%) and fever (66%) as initial symptoms [4] followed by neurological deficits including muscle weakness. [4] In our case, the patient presented with fever, backache, and muscle weakness[atmph.org]
  • Infection should be suspected in patients presenting with axial pain, fever, or elevated inflammatory markers.[journalofhospitalmedicine.com]
  • Pain , [[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[mdnxs.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]
  • 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]
  • Back pain is a common presentation to the ED, accounting for approximately 3% of all visits. It is usually classified as acute nonspecific back pain, essentially a wastebasket term for back strain/sprain, mechanical back pain, and lumbago [1-3].[epmonthly.com]
  • Maintain a high index of suspicion for patients with repeat ED visits for back pain.[ahcmedia.com]
  • 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]
Low Back Pain
  • 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]
  • 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]
  • Case presentation We present the case of a 41-year-old male Caucasian farmer complaining of acute, progressively worsening low back pain of five days duration.[casesjournal.biomedcentral.com]
  • Emlyn’s team which breaks down a recently published article in Annals of Emergency Medicine comparing diazepam with placebo in patients with acute low back pain. We recommend you read the full text of the article by Friedman et al .[foamcast.org]
  • Case presentation: Here we report a case of SEA in a 63-year-old man with type II diabetes who presented with severe low back pain. He was found to have SEA likely secondary to a hip joint injection.[nature.com]
Spine Pain
  • 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]
  • 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):765–770. doi:10.3171/2011.1.SPINE1091.[ddxof.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]
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]
Urinary Retention
  • 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]
  • These narcotics can cause constipation, and can also cause urinary retention, although this is less common.[cmglaw.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]
  • On postoperative day 15, urinary retention was noted along with a persisting fever. Leukocyte scanning showed accumulation in the lumbar spine.[anesthesiology.pubs.asahq.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]
  • 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]
  • incontinence, and difficulty ambulating after a fall three weeks earlier.[aafp.org]

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

  • Abstract 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.[pediatrics.aappublications.org]
  • Antimicrobial therapy Empirical antimicrobial treatment of spinal epidural abcess should be bactericidal, start early, be delivered intravenously in high doses, and be continued well into the postoperative period. 7 Initial treatment should be broad spectrum[jnnp.bmj.com]
  • CASE REPORT A 3-year-old girl was sent from an outside hospital for the evaluation and treatment of an epidural abscess.[pediatrics.aappublications.org]
  • This condition requires a high index of suspicion for early diagnosis and treatment.[omicsonline.org]
  • The most common presentation of chronic epidural abscess is that of a compressive lesion. • Treatment of spinal epidural abscess, in most cases, involves both antibiotic treatment and surgical drainage.[medlink.com]

Prognosis

  • […] 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 medical literature regarding spinal epidural abscess has two common threads: reports of poor prognosis and appeals for rapid treatment.[jamanetwork.com]
  • Prognosis The prognosis is dependent on the clinical and neurological condition of the patient at presentation and any delay in the diagnosis 4 29 or instigation of appropriate antimicrobial treatment.[jnnp.bmj.com]
  • The prognosis of patients who develop SEA following epidural anesthesia or analgesia is not better than that of patients with noniatrogenic SEA, and the mortality rate is also comparable.[link.springer.com]
  • Each hour is critical to a patient’s hypothetical, cause-in-fact prognosis.[cmglaw.com]

Etiology

  • 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]
  • We conclude that M. tuberculosis should be included in the differential etiology of SEA.[atmph.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]
  • 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]
  • Spinal epidural abscess: contemporary trends in etiology, evaluation, and management . Surg Neurol 1999; 52 : 189–196, discussion 197. 13. Pilkington SA , Jackson SA , Gillett GR . Spinal epidural empyema . Br J Neurosurg 2003; 17 : 196–200. 14.[nature.com]

Epidemiology

  • Some literature supports a changing epidemiology and risk profile of this infection in the current era compared with reports from before the year 2000 [ 4 ].[academic.oup.com]
  • 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]
  • Keywords Epidural abscess Meta-analysis Epidemiology Outcome This is a preview of subscription content, log in to check access. Preview Unable to display preview. Download preview PDF.[link.springer.com]
  • […] intervention: degenerative joint disease; trauma; surgery or procedure potential local or systemic source of infection: IVDU Many clinical features are non-specific, even in an acute case of a spinal epidural abscess, mainly if there are no demographic or epidemiological[radiopaedia.org]
  • Epidemiology Frequency United States The frequency in large tertiary care centers is estimated to be about 2.8 cases per 10,000 admissions.[emedicine.medscape.com]
Sex distribution
Age distribution

Pathophysiology

  • […] 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]
  • The precise pathophysiologic cause of the neurologic impairment is not known.[ahcmedia.com]
  • The pathophysiologic al background of the clinically significant effects of the epidural abscess seems to be mostly from involvement of the vascular supply to the spinal cord and subsequent infarction rather than direct compression [ 1 , 2 , 6 , 8 ].[medical-case-reports.imedpub.com]
  • 61.5 (range 48–75) The disease is rare in children, with fewer than 90 cases reported. 5 Conditions commonly associated with spinal epidural abcess include diabetes mellitus, intravenous drug misuse, chronic renal failure, alcoholism, and cancer. 2-4 Pathophysiology[jnnp.bmj.com]

Prevention

  • It is generally believed that a sterile environment prevents direct contamination, but no systematic investigation was conducted.[academic.oup.com]
  • And fortunately, until nearly all of the above symptoms, physical findings and lab results are present, intervention can prevent complete paralysis.[pilchermd.com]
  • We highlight the importance of meticulous post-ESI followup in early detection of such complications, so that swift surgical intervention can be undertaken to prevent permanent neurological damage.[omicsonline.org]
  • A minimal surgical technique can be adequate for pus drainage as well as for preventing spinal instability in the setting of an extended spinal epidural abscess.[medical-case-reports.imedpub.com]
  • In addition, individual metamers are separated, preventing free communication between the anterior and posterior epidural space.[ahcmedia.com]

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.

Symptoms

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