Spinal epidural abscess
- Daniel J Sexton, MD
Daniel J Sexton, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — Bacterial Infections
- Professor of Medicine
- Duke University Medical Center
- John H Sampson, MD, PhD, MBA
John H Sampson, MD, PhD, MBA
- Robert H. and Gloria Wilkins Distinguished Professor of Neurosurgery
- Professor of Biomedical Engineering, Immunology, and Pathology
- Chair, Department of Neurosurgery
- Duke University Medical Center
Epidural abscess is a rare but important suppurative infection of the central nervous system (CNS). Abscesses that are enclosed within the bony confines of the skull or spinal column can expand to compress the brain or spinal cord and cause severe symptoms, permanent complications, or even death. Prompt diagnosis and proper treatment can avert complications and achieve cure in many cases. Both the diagnosis and management of epidural abscess, which often includes a surgical procedure for aspiration or drainage of the abscess, have been greatly aided by the advent of modern imaging techniques, such as computed tomography (CT) and especially magnetic resonance imaging (MRI) [1-4].
Two distinct varieties of epidural abscess occur: spinal epidural abscess (SEA) and intracranial epidural abscess (IEA). SEA is more common by a factor of nine to one. The distinction between these two entities is based upon the different anatomy of the two locations within the CNS and some differences in symptoms and natural history. SEA and IEA require prompt recognition and proper management to avoid potentially disastrous complications. However, clinical recognition of these entities is often challenging, and treatment discussions can be complex.
The epidemiology, microbiology, clinical manifestations, diagnosis, and treatment of SEA will be reviewed here. Intracranial epidural abscess, brain abscess, and bacterial meningitis are discussed separately. (See "Intracranial epidural abscess" and "Pathogenesis, clinical manifestations, and diagnosis of brain abscess" and "Treatment and prognosis of bacterial brain abscess" and "Epidemiology of bacterial meningitis in adults" and "Pathogenesis and pathophysiology of bacterial meningitis" and "Clinical features and diagnosis of acute bacterial meningitis in adults" and "Initial therapy and prognosis of bacterial meningitis in adults" and "Treatment of bacterial meningitis caused by specific pathogens in adults" and "Neurologic complications of bacterial meningitis in adults".)
The epidural space is the area between the dura mater and the vertebral wall. The anatomy of the spinal canal and dura mater determines many features of epidural abscesses . For example, the dura is adherent to the bone above the foramen magnum. In contrast, an actual or true epidural space exists below the foramen magnum posterior and lateral to the spinal cord that extends down the length of the spinal canal (figure 1). This space is small in the cervical region and larger in the sacral region. The epidural space contains fat as well as arteries and a venous plexus. Spinal epidural abscesses (SEAs) are most common in the thoracolumbar areas, where the epidural space is larger and contains more infection-prone fat tissue [1,5,6].
The majority of SEAs are located posteriorly; when anterior SEAs occur, they are usually below L1. Because the epidural space is a vertical sheath, abscesses that begin at one level commonly extend to multiple levels.
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- PORTALS OF ENTRY
- CLINICAL MANIFESTATIONS
- LABORATORY FINDINGS
- Approach to diagnosis
- Challenges in diagnosis
- DIFFERENTIAL DIAGNOSIS
- Approach to therapy
- Medical plus surgical therapy versus medical therapy alone
- Antimicrobial therapy
- - Empiric therapy
- - Subsequent treatment
- Staphylococcus aureus
- - Duration
- SUMMARY AND RECOMMENDATIONS