Continuing Education Activity
Spinal epidural abscess is an infection of the central nervous system that classically presents with midline back pain, fever, and neurologic deficits. It is difficult to diagnose and requires a high index of suspicion. When left untreated spinal epidural abscess can cause significant morbidity and mortality. Thus any clinical concern for this diagnosis requires prompt evaluation and treatment. This activity illustrates the assessment and treatment of spinal epidural abscess and describes the role of the interprofessional team in managing those with this condition.
- Describe the various potential etiologies for spinal epidural abscess.
- Review the steps in a complete evaluation and workup for patients presenting with spinal epidural abscess.
- Outline the appropriate treatment options and case management for spinal epidural abscess.
- Review the importance of coordination among interprofessional teams that monitor for complications and treat patients with epidural abscesses.
A spinal epidural abscess is a suppurative infection of the central nervous system. Although classically, patients with spinal epidural abscess present with midline back pain, fever, and neurologic deficits, presentations of this disease process can be variable. Spinal epidural abscess is difficult to diagnose if clinical suspicion is not high. When left untreated spinal epidural abscess can cause significant morbidity and mortality. Thus any clinical concern for this diagnosis requires prompt evaluation and treatment. The diagnosis and the management of spinal epidural abscess are greatly aided by the advent of modern radiological techniques, including computerized tomography and magnetic resonance imaging (MRI).
In patients presenting with spinal epidural abscess, bacteria enter the epidural space resulting in a suppurative infection. Most often, the bacteria enter the epidural space through hematogenous spread. Risk factors for spinal epidural abscess include an immunosuppressed state (i.e., diabetes mellitus, alcoholism, cirrhosis, end-stage renal disease, HIV infection), intravenous drug abuse, direct instrumentation (i.e., acupuncture, paraspinal or epidural injection, lumbar puncture, CNS surgery), and bacteremia. Diabetes mellitus is the most common risk factor associated with spinal epidural abscess. However, intravenous drug use and epidural catheter placement are becoming increasingly important, and frequent risk factors in the development of this disease process.
Spinal epidural abscess is an uncommon diagnosis. The incidence of this disease process is 1.2 per 10,000 patients. Although spinal epidural abscess is uncommon, its incidence has been increasing in recent years. This increased diagnosis is thought to be because of the expanded utilization of invasive spinal procedures, increasing age of the population, and increasing rates of intravenous drug use.
In one-third of cases of spinal epidural abscess, there is no identifiable nidus of infection. Diabetes mellitus is the greatest risk factor for a spinal epidural abscess. In total, 33% of patients presenting with spinal epidural abscess have diabetes mellitus. Other important risk factors for the development of spinal epidural abscess include intravenous drug use and instrumentation of the epidural space. In intravenous drug use, hematogenous seeding of the epidural space occurs, which leads to a spinal epidural abscess. Instrumentation of the epidural space occurring during a lumbar puncture or epidural catheter placement can directly inoculate bacteria into the epidural space causing this infectious process. Of note, the incidence of a spinal epidural abscess after epidural catheter placement is approximately 0.5% to 3%.
Staphylococcus aureus accounts for 63% of spinal epidural abscess infections, followed by gram-negative bacilli (16%), streptococcal infections (9%), and other bacteria/mycobacteria/fungi accounting for ~10% of infections.
Bacteria enter the epidural space and seed the area between the dura mater and vertebral wall within the spinal canal. This introduction of bacteria into this normally sterile space results in a suppurative infection within this confined area. Most commonly, this occurs via hematogenous seeding of the epidural space. The hematogenous spread can occur from soft tissue infections, infected catheters, endocarditis, urinary tract, or respiratory tract infections. Bacteria also can enter the epidural space through the direct extension of infected tissue. This occurs when psoas abscess, vertebral osteomyelitis, or discitis leads to a spinal epidural abscess. Additionally, a spinal epidural abscess can be the result of the direct inoculation of this tissue. Epidural injections, epidural catheter placements, lumbar punctures, and other central nervous systems (CNS) procedures all can result in epidural abscess through direct inoculation.
Infection also can be the result of the contiguous spread of a disease such as vertebral osteomyelitis, discitis, retropharyngeal abscess, retroperitoneal abscess, or through penetrating injury, epidural injection or catheter placement, lumbar puncture, or recent CNS surgery.
Once bacteria have gained entrance into the epidural space, a resulting pyogenic infection occurs, which then results in abscess formation. Damage to the spinal cord may occur through a number of mechanisms, including (1) direct compression from expanding abscess, (2) thrombosis and thrombophlebitis of adjacent veins, (3) interruption of arterial blood supply, and (4) bacterial toxins.
Typically, the spinal epidural abscess will involve 3 to 5 spinal cord segments. Given that spinal epidural abscesses most commonly are caused by hematogenous spread, 9% of patients presenting with this diagnosis will have two or more noncontiguous areas of pyogenic collections.
History and Physical
The classic triad of a spinal epidural abscess is back pain (75%), fever (48%), and neurologic deficits (33%) due to the direct compressive effects of the abscess. The classic triad presents in as few as 8% of patients, thus if clinical concern exists for this disease prompt diagnostic evaluation must be undertaken.
Pain may be elicited through palpation or percussion of spinous processes overlaying spinal epidural abscess. Pain also may be elicited through straight leg raise from compression of spinal nerve roots. As this disease process progresses patients will develop neurologic deficits consistent with spinal cord or cauda equina compression: urinary retention, bowel incontinence, anesthesia (perianal and saddle anesthesia), motor weakness, or paralysis.
Lab evaluation should include blood cultures, complete blood count, inflammatory markers, and coagulation studies. These studies often will reveal an elevated white blood cell count and elevated inflammatory markers. Although the erythrocyte sedimentation rate is often elevated in these patients, it does not rule out the diagnosis of a spinal epidural abscess (85% to 94% sensitivity).
Positive cultures by frequency in specimen type is (1) abscess aspirate: 90%, (2) blood: 62%, and (3) CSF: 19%.
If there is a concern for spinal epidural abscess, patients should undergo an immediate MRI of the entire spine. If MRI is unavailable, CT with IV contrast is a less sensitive alternative.
Lumbar puncture is unnecessary as it lends little diagnostic utility and has potential morbidity in the setting of spinal epidural abscess.
Treatment / Management
Emergent surgical spine consultation is the standard of care for all patients with radiographic findings of an epidural abscess and abnormal neurological examinations due to mass effect from an epidural abscess. These patients usually require an emergent surgical evaluation to decompress the spinal cord and nerve roots.
Overall, the treatment of spinal epidural abscess focuses on the elimination of the suppurative mass and eradication of the causative organism. This is accomplished through aspiration, surgical drainage, and antibiotic therapy. The assistance of interventional radiology or spine surgery (orthopedics or neurosurgery) will be required in the management of many if not all of these patients.
Empiric antibiotic regimens should include vancomycin (30-60 mg/kg) plus a third or fourth-generation cephalosporin (2g cefotaxime Q6H, 2g ceftriaxone Q12H, 2g ceftazidime Q8H, or 2g cefepime Q8H) until speciation and sensitivities of the infecting organism result for more targeted antibiotic therapy. Typically, patients will require a prolonged course of antibiotics (4 to 6 weeks) to treat this infection.
Repeat MRI should be obtained if the patient has worsening symptoms, deteriorating clinical exam, or at 4 to 6 weeks of therapy.
- Cervical/lumbar disc stenosis
- Vertebral discitis and osteomyelitis
- Psoas abscess
- Transverse myelitis
- Low back pain
- Spinal cord hematoma
A delay in the diagnosis of a spinal epidural abscess (defined as multiple visits before the definite diagnosis and treatment) can result in increased residual weakness or permanent neurologic deficit. Around 5 % of the patients die with sepsis or other related causes. Moreover, 4-22 percent of the patients experience irreversible paraplegia. Neurological recovery is usually appreciable if the surgery is delayed 24-48 hours after the neurologic deficit onset.
There is limited data available in the literature about neurological recovery after the surgery. However, the recovery is variable and generally depends on multiple factors including age, health status, comorbidities, and time to diagnosis. Timely treatment initiation is crucial.
- Pressure ulcers
- Urinary retention
- Supine hypertension
- Deep vein thrombosis
Deterrence and Patient Education
- Patients should closely follow up with the surgical service in case of secondary complications of the surgery or in case of new neurological deficits or fever.
- Rehabilitation by physical/occupational therapists is of vital importance for patients with motor weakness or other neurological deficits.
- Patients should be compliant in taking medications which can be arranged through home health care.
- Patients should involve their health care professionals for lack of motivation, depression, and suicidal ideation for screening and further referral.
Enhancing Healthcare Team Outcomes
The management of spinal abscess mandates a multidisciplinary and interprofessional approach and involves a neurosurgeon, neurologist, intensivist, an infectious disease expert, physical therapy, and nursing. These patients can develop a multitude of complications like urinary retention, DVT, sepsis, pressure ulcers, and supine hypertension. After discharge from the hospital, most patients require home healthcare and ongoing physical therapy. A home care nurse is often required to monitor these patients for recovery and potential problems. Many of these patients need a long-term indwelling catheter, which can also increase the risk of infection. Gastric peristalsis is common, and constipation is a recurrent problem. As the infection improves, many patients may benefit from rehabilitation to regain their muscle mass and exercise endurance. (Level V)
A spinal abscess is rare in the US, but when it occurs, it may lead to significant morbidity. The prognosis depends on the extent of the abscess, neurological deficits present at the time of presentation, and response to treatment. Even after treatment, most patients are left with some type of residual neurological deficit. Many patients require long-term rehabilitation to regain function. During the recovery, pressure ulcers and deep vein thrombosis are also a common occurrence. (Level V)