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.
- Danner RL, Hartman BJ. Update on spinal epidural abscess: 35 cases and review of the literature. Rev Infect Dis 1987; 9:265.
- Nussbaum ES, Rigamonti D, Standiford H, et al. Spinal epidural abscess: a report of 40 cases and review. Surg Neurol 1992; 38:225.
- Pradilla G, Ardila GP, Hsu W, Rigamonti D. Epidural abscesses of the CNS. Lancet Neurol 2009; 8:292.
- Pfister H-W, Klein M, Tunkel AR, Scheld WM. Epidural abscess. In: Infections of the Central Nervous System, Fourth Edition, Scheld WM, Whitley RJ, Marra CM (Eds), Wolters Kluwer Health, Philadelphia 2014. p.550.
- Darouiche RO, Hamill RJ, Greenberg SB, et al. Bacterial spinal epidural abscess. Review of 43 cases and literature survey. Medicine (Baltimore) 1992; 71:369.
- Akalan N, Ozgen T. Infection as a cause of spinal cord compression: a review of 36 spinal epidural abscess cases. Acta Neurochir (Wien) 2000; 142:17.
- Kapeller P, Fazekas F, Krametter D, et al. Pyogenic infectious spondylitis: clinical, laboratory and MRI features. Eur Neurol 1997; 38:94.
- Torda AJ, Gottlieb T, Bradbury R. Pyogenic vertebral osteomyelitis: analysis of 20 cases and review. Clin Infect Dis 1995; 20:320.
- Gellin BG, Weingarten K, Gamache FW Jr, et al. Epidural Abscess. In: Infections of the Central Nervous System, 2nd Ed, Scheld WM, Whitley RJ, Durack DT (Eds), Lippincott-Raven Publishers, Philadelphia 1997. p.507.
- Ju KL, Kim SD, Melikian R, et al. Predicting patients with concurrent noncontiguous spinal epidural abscess lesions. Spine J 2015; 15:95.
- Sørensen P. Spinal epidural abscesses: conservative treatment for selected subgroups of patients. Br J Neurosurg 2003; 17:513.
- Ptaszynski AE, Hooten WM, Huntoon MA. The incidence of spontaneous epidural abscess in Olmsted County from 1990 through 2000: a rare cause of spinal pain. Pain Med 2007; 8:338.
- Park KH, Cho OH, Jung M, et al. Clinical characteristics and outcomes of hematogenous vertebral osteomyelitis caused by gram-negative bacteria. J Infect 2014; 69:42.
- Cook TM, Counsell D, Wildsmith JA, Royal College of Anaesthetists Third National Audit Project. Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists. Br J Anaesth 2009; 102:179.
- Sethna NF, Clendenin D, Athiraman U, et al. Incidence of epidural catheter-associated infections after continuous epidural analgesia in children. Anesthesiology 2010; 113:224.
- Pöpping DM, Zahn PK, Van Aken HK, et al. Effectiveness and safety of postoperative pain management: a survey of 18 925 consecutive patients between 1998 and 2006 (2nd revision): a database analysis of prospectively raised data. Br J Anaesth 2008; 101:832.
- Reynolds F. Neurological infections after neuraxial anesthesia. Anesthesiol Clin 2008; 26:23.
- Gosavi C, Bland D, Poddar R, Horst C. Epidural abscess complicating insertion of epidural catheters. Br J Anaesth 2004; 92:294; author reply 294.
- Scott DB, Hibbard BM. Serious non-fatal complications associated with extradural block in obstetric practice. Br J Anaesth 1990; 64:537.
- Gaul C, Neundörfer B, Winterholler M. Iatrogenic (para-) spinal abscesses and meningitis following injection therapy for low back pain. Pain 2005; 116:407.
- Darouiche RO. Spinal epidural abscess. N Engl J Med 2006; 355:2012.
- Krishnamohan P, Berger JR. Spinal epidural abscess. Curr Infect Dis Rep 2014; 16:436.
- Sendi P, Bregenzer T, Zimmerli W. Spinal epidural abscess in clinical practice. QJM 2008; 101:1.
- Rigamonti D, Liem L, Wolf AL, et al. Epidural abscess in the cervical spine. Mt Sinai J Med 1994; 61:357.
- Griffiths DL. Tuberculosis of the spine: a review. Adv Tuberc Res 1980; 20:92.
- Chen WC, Wang JL, Wang JT, et al. Spinal epidural abscess due to Staphylococcus aureus: clinical manifestations and outcomes. J Microbiol Immunol Infect 2008; 41:215.
- Holt HM, Andersen SS, Andersen O, et al. Infections following epidural catheterization. J Hosp Infect 1995; 30:253.
- Phillips JM, Stedeford JC, Hartsilver E, Roberts C. Epidural abscess complicating insertion of epidural catheters. Br J Anaesth 2002; 89:778.
- Centers for Disease Control and Prevention. Injection Safety. http://www.cdc.gov/injectionsafety/ (Accessed on June 24, 2014).
- 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; 26:285.
- Curry WT Jr, Hoh BL, Amin-Hanjani S, Eskandar EN. Spinal epidural abscess: clinical presentation, management, and outcome. Surg Neurol 2005; 63:364.
- 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; 14:765.
- Reihsaus E, Waldbaur H, Seeling W. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev 2000; 23:175.
- Wong D, Raymond NJ. Spinal epidural abscess. N Z Med J 1998; 111:345.
- Shifrin A, Lu Q, Lev MH, et al. Paraspinal Edema Is the Most Sensitive Feature of Lumbar Spinal Epidural Abscess on Unenhanced MRI. AJR Am J Roentgenol 2017; 209:176.
- Euba G, Narváez JA, Nolla JM, et al. Long-term clinical and radiological magnetic resonance imaging outcome of abscess-associated spontaneous pyogenic vertebral osteomyelitis under conservative management. Semin Arthritis Rheum 2008; 38:28.
- Uchida K, Nakajima H, Yayama T, et al. Epidural abscess associated with pyogenic spondylodiscitis of the lumbar spine; evaluation of a new MRI staging classification and imaging findings as indicators of surgical management: a retrospective study of 37 patients. Arch Orthop Trauma Surg 2010; 130:111.
- Tuchman A, Pham M, Hsieh PC. The indications and timing for operative management of spinal epidural abscess: literature review and treatment algorithm. Neurosurg Focus 2014; 37:E8.
- Moseley IF, Kendall BE. Radiology of intracranial empyemas, with special reference to computed tomography. Neuroradiology 1984; 26:333.
- Liem LK, Rigamonti D, Wolf AL, et al. Thoracic epidural abscess. J Spinal Disord 1994; 7:449.
- Mooney RP, Hockberger RS. Spinal epidural abscess: a rapidly progressive disease. Ann Emerg Med 1987; 16:1168.
- Patel AR, Alton TB, Bransford RJ, et al. Spinal epidural abscesses: risk factors, medical versus surgical management, a retrospective review of 128 cases. Spine J 2014; 14:326.
- Kim SD, Melikian R, Ju KL, et al. Independent predictors of failure of nonoperative management of spinal epidural abscesses. Spine J 2014; 14:1673.
- Alton TB, Patel AR, Bransford RJ, et al. Is there a difference in neurologic outcome in medical versus early operative management of cervical epidural abscesses? Spine J 2015; 15:10.
- Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004; 39:1267.
- Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011; 52:e18.
- Pfausler B, Spiss H, Beer R, et al. Treatment of staphylococcal ventriculitis associated with external cerebrospinal fluid drains: a prospective randomized trial of intravenous compared with intraventricular vancomycin therapy. J Neurosurg 2003; 98:1040.
- Jorgenson L, Reiter PD, Freeman JE, et al. Vancomycin disposition and penetration into ventricular fluid of the central nervous system following intravenous therapy in patients with cerebrospinal devices. Pediatr Neurosurg 2007; 43:449.
- Wang Q, Shi Z, Wang J, et al. Postoperatively administered vancomycin reaches therapeutic concentration in the cerebral spinal fluid of neurosurgical patients. Surg Neurol 2008; 69:126.
- Nau R, Prange HW, Menck S, et al. Penetration of rifampicin into the cerebrospinal fluid of adults with uninflamed meninges. J Antimicrob Chemother 1992; 29:719.
- Perlroth J, Kuo M, Tan J, et al. Adjunctive use of rifampin for the treatment of Staphylococcus aureus infections: a systematic review of the literature. Arch Intern Med 2008; 168:805.
- von Specht M, Gardella N, Tagliaferri P, et al. Methicillin-resistant Staphylococcus aureus in community-acquired meningitis. Eur J Clin Microbiol Infect Dis 2006; 25:267.
- Pintado V, Meseguer MA, Fortún J, et al. Clinical study of 44 cases of Staphylococcus aureus meningitis. Eur J Clin Microbiol Infect Dis 2002; 21:864.
- Gallagher RM, Pizer B, Ellison JA, Riordan FA. Glycopeptide insensitive Staphylococcus aureus subdural empyema treated with linezolid and rifampicin. J Infect 2008; 57:410.
- Kessler AT, Kourtis AP. Treatment of meningitis caused by methicillin-resistant Staphylococcus aureus with linezolid. Infection 2007; 35:271.
- Naesens R, Ronsyn M, Druwé P, et al. Central nervous system invasion by community-acquired meticillin-resistant Staphylococcus aureus. J Med Microbiol 2009; 58:1247.
- Ntziora F, Falagas ME. Linezolid for the treatment of patients with central nervous system infection. Ann Pharmacother 2007; 41:296.
- Levitz RE, Quintiliani R. Trimethoprim-sulfamethoxazole for bacterial meningitis. Ann Intern Med 1984; 100:881.
- Vartzelis G, Theodoridou M, Daikos GL, et al. Brain abscesses complicating Staphylococcus aureus sepsis in a premature infant. Infection 2005; 33:36.
- Lee DH, Palermo B, Chowdhury M. Successful treatment of methicillin-resistant staphylococcus aureus meningitis with daptomycin. Clin Infect Dis 2008; 47:588.
- Wallace WR, Sander AW, Licitra C, et al. Methicillin-resistant Staphylococcus aureus meningitis successfully treated with daptomycin. Infect Dis Clin North Am 2009; 17:69.
- Khanna RK, Malik GM, Rock JP, Rosenblum ML. Spinal epidural abscess: evaluation of factors influencing outcome. Neurosurgery 1996; 39:958.
- Baker AS, Ojemann RG, Swartz MN, Richardson EP Jr. Spinal epidural abscess. N Engl J Med 1975; 293:463.
- Koo DW, Townson AF, Dvorak MF, Fisher CG. Spinal epidural abscess: a 5-year case-controlled review of neurologic outcomes after rehabilitation. Arch Phys Med Rehabil 2009; 90:512.
- 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