View source for Epidural abscess (spinal)

==Background==
*Abscess confined to epidural adipose tissue in spine<ref>Darouiche RO et al. Bacterial spinal epidural abscess. Review of 43 cases and literature survey. Medicine (Baltimore) 1992; 71:369-85</ref>
*Thoracic and lumbar spine most common; C-spine least common
*Usually spans up to 3-5 vertebral spaces
*Typically hematogenous spread from other source of infection

===Organisms<ref>Darouiche RO. Spinal epidural abscess. N Engl J Med. 2006;355(19):2012–2020. doi:10.1056/NEJMra055111.</ref>===
*''[[S. aureus]]'' (most common, 2/3 of cases)
*''[[S. epidermidis]]'' (associated with device, instrumentation)
*''[[E. coli]]'' (urine spread)
*''[[P. aeruginosa]]'' ([[IVDA]])
*Rare: [[anaerobes]], [[mycobacterium|mycobacteria]], [[fungi]]

===Risk Factors===
*98% of patients have at least one of the following risk-factors:<ref>Sampath P, Rigamonti D. Spinal epidural abscess: a review of epidemiology, diagnosis, and treatment. J Spinal Disord 1999; 12:89-93</ref>
**Injection [[substance abuse|drug use]]
**Immunocompromised
**[[Alcohol use disorder]]
**Cancer
**Recent spine procedure
**Recent spine fracture
**Distant site of infection
**Indwelling catheter
**Chronic [[renal failure]]
**[[Diabetes]]

{{Epidural compression syndromes types}}

==Clinical Features==
*[[Fever]] + localized [[back pain]] is epidural abscess until proven otherwise
**Classic triad of fever, back pain, and [[focal neuro|neuro deficits]] is rare (13%)<ref>Reihsaus E. et al. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev 2000; 23:175-204</ref>
**Fever is only present in ~50% of cases

===Prevalence of Clinical Findings <ref>Davis DP, Wold RM, Patel RJ, et al. The clinical presentation and impact of diagnostic delays on emergency department patients with spinal epidural abscess. J Emerg Med. 2004;26(3):285–291. doi:10.1016/j.jemermed.2003.11.013.</ref>===	
{| class="wikitable"
|-
! Finding !! Prevalence
|-
| Fever (T>38°C) || 19-32%
|-
| Focal spinal TTP || 52-62%
|-
| Diffuse spinal TTP || 63-65%
|-
| Positive SLR || 11-13%
|-
| Abnormal sensation || 17-27%
|-
| Weakness || 29-40%
|-
| Abnormal reflexes || 8-17%
|-
| Abnormal rectal tone || 5-10%
|-
| Saddle anesthesia || 2%
|}

===Staging===
Progression through stages is highly variable and may evolve rapidly.
#Back pain at affected site
#Nerve root pain from affected level
#[[Weakness]], [[numbness|sensory deficit]], [[urinary retention|bladder]]/bowel dysfunction
#Paralysis

==Differential Diagnosis==
{{Spinal infection types}}

{{Lower back pain DDX}}

==Evaluation==
[[File:Sea.png|thumb|A clinical decision algorithm for evaluation of SEA which may decrease diagnostic delay. <ref>Davis DP, Salazar A, Chan TC, Vilke GM. 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.</ref>]]
[[File:MRI of the lumbar spine with abscess in the posterior epidural space, causing cauda equina syndrome.jpg|thumb|MRI of an abscess causing cauda equina syndrome.]]
===Work-up===
'''Labs<ref>Cornett CA, Vincent SA, Crow J, et al. Bacterial spine infections in adults: evaluation and management. Journal of the American Academy of Orthopaedic Surgeons. 2016; 24(1):11-8.</ref>'''
*[[leukocytosis|WBC elevated]] in <45% of patients
*ESR and CRP are almost consistently elevated
**Sensitivity of ESR in pt with SEA risk factors ~100%<ref>Davis DP, Salazar A, Chan TC, Vilke GM. 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. doi: 10.3171/2011.1.SPINE1091. Epub 2011 Mar 18. PubMed PMID:
21417700.
</ref>
*Blood cultures are indicated to identify the source organism (Staph in 2/3 of cases)
'''CSF<ref>Darouiche RO. Spinal epidural abscess. N Engl J Med. 2006; 355(19):2012-2020.</ref>'''
*Gram stain typically negative
*Cultures are positive in <25% of patients
'''Imaging'''
*Strongly consider imaging the entire spine to assess for non-contiguous epidural abscess<ref>Ju, K.L., et al. Predicting Patients with concurrent noncontinguous spinal epidural abscess lesions. Spine J. 2005 15(1):95</ref>
*[[mri|MRI]] with gadolinium is the diagnostic test of choice<ref>Angtuaco E. et al. MR imaging of spinal epidural sepsis. Am J Roentgenoli 1987; 149:1249-53</ref>
*CT with IV contrast may provide usual information regarding bony integrity and fluid collections while awaiting MRI

==Management==
*Early surgical decompression and drainage<ref>Bluman E. et al. Spinal epidural abscess in adults. J Am Acad Orthop Surg 2004; 12:155-163</ref>
*Aspiration (for diagnosis) and [[antibiotics]] may be sufficient for patients without neuro deficits 
===[[Antibiotics]]===
{{Epidural Abscess Treatment}}

==Disposition==
*Admit

==See Also==
*[[Epidural abscess (intracranial)]]
*[[Epidural compression syndromes]]

==External Links==
*[http://ddxof.com/spinal-epidural-abscess/ DDxOf: Differential Diagnosis of Spinal Epidural Abscess]

==References==
<references/>

[[Category:ID]]
[[Category:Neurology]]