From the Guidelines
Spinal epidural abscess is a medical emergency that requires immediate attention, and treatment typically involves surgical drainage combined with intravenous antibiotics, with vancomycin and either ceftriaxone or cefepime being the recommended initial empiric antibiotic regimen, as suggested by 1. The total duration of antibiotic therapy is typically 4-6 weeks, and surgical intervention is indicated for patients with neurological deficits, spinal instability, or failure to respond to antibiotics alone. MRI with contrast is the diagnostic imaging of choice, and risk factors include diabetes, intravenous drug use, immunosuppression, recent spinal procedures, and bloodstream infections. Patients typically present with back pain, fever, and neurological symptoms like weakness or numbness, and early diagnosis and aggressive treatment are crucial to prevent permanent spinal cord damage, as the infection can cause compression of the spinal cord and its blood supply, as noted in 1. The goals of surgical debridement are to debulk infected tissue, to secure an adequate blood supply for tissue healing, and to maintain or restore spinal stability, as stated in 1. Some key points to consider in the management of spinal epidural abscess include:
- Neurosurgical evaluation for incision and drainage is recommended, as stated in 1
- IV vancomycin for 4–6 weeks is recommended, with some experts suggesting the addition of rifampin, as noted in 1
- Alternatives to vancomycin include linezolid and TMP-SMX, as suggested in 1
- Surgical intervention is indicated for patients with neurological deficits, spinal instability, or failure to respond to antibiotics alone, as stated in 1
- MRI with contrast is the diagnostic imaging of choice, as noted in 1
From the Research
Overview of Spinal Epidural Abscess
- Spinal epidural abscess is an uncommon disease with a relatively high rate of associated morbidity and mortality 2.
- The most important determinant of outcome is early diagnosis and initiation of appropriate treatment 2.
Clinical Manifestations
- Presenting symptoms include back pain, fever, and neurological deficits, although the "classic triad" of these symptoms is seen in only 10-15% of cases 3.
- Back pain is the most frequent presenting symptom, occurring in about 70%-90% of cases 4.
- Neurological symptoms include motor weakness, sensory changes, urinary retention, and bowel dysfunction 4.
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, 4.
- MRI with gadolinium contrast is the preferred imaging modality for diagnosing spinal epidural abscesses 4.
- Computed tomography (CT) with myelography can be considered if MRI is contraindicated 4.
Treatment Principles
- Emergent surgical decompression and debridement (with or without spinal stabilization) 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.
- Early surgery improves neurologic outcomes compared with surgical treatment delayed by a trial of medical management 5.
Risk Factors
- Risk factors include a history of IV drug abuse, diabetes mellitus, and other immunocompromising conditions 4, 5.
- Diabetes mellitus, C-reactive protein greater than 115, white blood count greater than 12.5, and positive blood cultures predict medical failure 5.