From the Guidelines
Epidural abscess is a medical emergency that requires immediate attention, and treatment typically involves prompt surgical drainage combined with intravenous antibiotics, with MRI with contrast being the preferred diagnostic imaging modality 1.
Key Considerations
- Epidural abscess is a serious infection that occurs in the space between the skull or vertebral bones and the dura mater, the protective membrane covering the brain and spinal cord.
- Risk factors include diabetes, intravenous drug use, spinal procedures, and immunosuppression.
- Symptoms may include fever, severe back or neck pain, and neurological deficits like weakness or numbness.
- MRI with contrast has a sensitivity of 96% and a specificity of 94% for the evaluation of patients with suspected spine infection, including epidural abscess 1.
Diagnostic Approach
- The use of MRI without and with IV contrast on an emergent or urgent basis, in patients with preexisting risk factors for possible spine infection and with an elevated ESR, may facilitate a more prompt diagnosis of spinal canal compromise by epidural abscess or other infected displaced structures 1.
- MRI performed with IV contrast only is not considered to be useful because the precontrast MRI study is required for comparison in order to confirm areas of suspected abnormality within the spine segment(s) of interest 1.
Treatment
- Empiric antibiotic therapy, such as vancomycin 15-20 mg/kg IV every 8-12 hours plus ceftriaxone 2g IV every 12 hours, is commonly used until culture results are available 1.
- Antibiotic therapy usually continues for 4-6 weeks.
- Surgical intervention is crucial to decompress neural structures and obtain samples for culture.
- Patients require close neurological monitoring as deterioration can occur rapidly.
Prognosis
- Delay in treatment can lead to permanent neurological damage, including paralysis or death.
- Early diagnosis and aggressive treatment are essential for preventing long-term complications and improving outcomes.
- The incidence of epidural abscess is 2.5 to 3 per 10,000 hospital admissions, and it is often associated with diagnostic delay that can potentially lead to significant neurologic morbidity and mortality 1.
From the Research
Definition and Overview
- Spinal epidural abscess is an uncommon disease with a relatively high rate of associated morbidity and mortality 2.
- It is an infection leading to an epidural collection of purulent material, estimated to occur less than 12 times per 100,000 hospital admissions 3.
Clinical Manifestations
- Presenting symptoms include back pain, fever, and neurological changes such as motor weakness, sensory changes, and bladder or bowel dysfunction 4, 3.
- Back pain is the most frequent presenting symptom, occurring in about 70%-90% of cases, while fever is the least frequent presenting symptom 3.
- Neurological symptoms occur in about one-third of cases and may include motor weakness, sensory changes, urinary retention, and bowel dysfunction 3.
Diagnostic Evaluation
- Gadolinium-enhanced magnetic resonance imaging (MRI) is the diagnostic modality of choice to confirm the presence and determine the location of the abscess 2, 3.
- Computed tomography (CT) with myelography can be considered if MRI is contraindicated 3.
- Laboratory findings may include systemic leukocytosis and elevated inflammatory markers, such as an elevated erythrocyte sedimentation rate (ESR) 4, 3.
Treatment Principles
- Emergent surgical decompression and debridement, followed by long-term antimicrobial therapy, remains the treatment of choice 2.
- In select cases, non-operative management can be cautiously considered when the risk of neurologic complications is determined to be low 2, 5.
- Empiric antibiotic treatments generally include vancomycin and a third- or fourth-generation cephalosporin 3.
- Staphylococcus aureus is the most common microbial cause, contributing to about two-thirds of cases 3, 5.