Clinical review
Spinal Epidural Abscess

https://doi.org/10.1016/j.jemermed.2009.11.001Get rights and content

Abstract

Background: Spinal epidural abscess is an uncommon disease with a relatively high rate of associated morbidity and mortality. The most important determinant of outcome is early diagnosis and initiation of appropriate treatment. Objectives: We aim to highlight the clinical manifestations, describe the early diagnostic evaluation, and outline the treatment principles for spinal epidural abscess in the adult. Discussion: Spinal epidural abscess should be suspected in the patient presenting with complaints of back pain or a neurologic deficit in conjunction with fever or an elevated erythrocyte sedimentation rate. Gadolinium-enhanced magnetic resonance imaging is the diagnostic modality of choice to confirm the presence and determine the location of the abscess. Emergent surgical decompression and debridement (with or without spinal stabilization) followed by long-term antimicrobial therapy remains the treatment of choice. In select cases, non-operative management can be cautiously considered when the risk of neurologic complications is determined to be low. Conclusion: Patients with a spinal epidural abscess often present first in the emergency department setting. It is imperative for the emergency physician to be familiar with the clinical features, diagnostic work-up, and basic management principles of spinal epidural abscess.

Introduction

Spinal epidural abscess (SEA) represents the accumulation of purulent material in the space between the dura matter and the osseo-ligamentous confines of the vertebral canal. Though first mentioned by Morgagni in 1761, this condition was not clearly defined as a clinical entity until 1820 by Bergamaschi (1, 2). Reports pertaining to spinal epidural abscess before the advent of antibiotic therapy and surgical treatment documented that the disease was nearly always fatal (3). Although the development of modern diagnostic and management methods over the past half century has improved the prognosis, the associated morbidity and mortality remain high.

Prompt diagnosis is the most important determinant of outcome. As the volume of purulent material increases within the epidural compartment, the space available for the neural elements diminishes. If prompt treatment is not instituted, irreversible neurologic deficit can and often does develop. Because these patients typically present first in the emergency department setting, it is imperative for the emergency physician to be familiar with the clinical features, diagnostic evaluation, and basic management principles of spinal epidural abscess.

Section snippets

Epidemiology

Spinal epidural abscess accounts for 0.2–1.2 cases per 10,000 hospital admissions (4). Though uncommon, this condition seems to have increased in incidence over the past 25 years (5). Potential reasons for the increase include: aging of the general population, growing numbers of intravenous drug abusers and patients with human immunodeficiency virus (HIV) infection, a rise in the number of invasive spinal procedures, and the improved sensitivity of neuroradiologic imaging techniques.

The disease

Conclusion

Spinal epidural abscess is an uncommon disease that can lead to irreversible neurologic dysfunction and even death. Patients often present first to an emergency physician. Prompt diagnosis and treatment are important determinants of outcome. Accordingly, all emergency clinicians should be familiar with the clinical presentation, the diagnostic evaluation, and the basic treatment principles of SEA.

A high level of suspicion for spinal epidural abscess is warranted in the patient with: a) back

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      Morbidity is significant with severe neurologic disability such as irreversible paraplegia or other deficits occurring in 4-22%, and less than half of patients return to baseline neurologic status [15-21]. Mortality rates range from 2 to 20% [3,4,15-18,22-26]. SEA occurs through entry into the epidural space from a contiguous infection (e.g., psoas muscle abscess, osteomyelitis, skin infection), hematogenous spread, or by direct inoculation (e.g., steroid injection, surgery, nerve block, acupuncture) [2-6,19,20,24-28].

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