eMedicine Specialties > Neurology > Neurological Infections

Spinal Epidural Abscess: Differential Diagnoses & Workup

Author: J Stephen Huff, MD, Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
Contributor Information and Disclosures

Updated: Aug 13, 2009

Differential Diagnoses

Cervical Spondylosis: Diagnosis and Management
Spinal Cord Hemorrhage
Epidural Hematoma
Spinal Cord Infarction
HIV-1 Associated Vacuolar Myelopathy
Tropical Myeloneuropathies
Leptomeningeal Carcinomatosis
Vitamin B-12 Associated Neurological Diseases
Metastatic Disease to the Spine and Related Structures
Multiple Sclerosis

Other Problems to Be Considered

Cervical disk syndromes
Lumbosacral disk syndromes
Lumbosacral spondylosis
Diabetes mellitus
Intravenous drug use
Psoas abscess
Retropharyngeal abscess
Transverse myelitis
Urinary tract infection
Vertebral osteomyelitis
Back pain
Cat scratch disease8

Workup

Laboratory Studies

  • CBC count, blood cultures, and preoperative lab studies. Leukocytosis is present in about two thirds of patients.1
  • Elevated erythrocyte sedimentation rate (ESR): In one report, the mean ESR was 51 mm/h.9 ESR is often highly elevated.
  • Leukocytosis and ESR elevation are nonspecific laboratory findings and are not invariably present. Neither the presence of these findings nor the degree of laboratory abnormality is specific for spinal epidural abscess.1

Imaging Studies

  • Immediate imaging of the spinal canal and cord is imperative when the diagnosis is clinically suspected.
  • If available, spinal MRI is the procedure of choice. Recall that symptoms are often defined by spinal cord level, while MRI is ordered by regional or vertebral levels. Because abscesses frequently extend for several levels, be certain to order the anatomically correct region.
  • If MRI is unavailable, CT myelography or conventional myelography can reveal an intraspinal extramedullary mass—a "surgical" lesion.

Other Tests

Lumbar puncture (LP) is relatively contraindicated if spinal epidural abscess is suspected. However, LP may be essential to exclude meningitis from the differential diagnosis. Lumbar puncture runs the risk of introducing purulent material into the subarachnoid space. Some advocate slowly advancing the needle with gentle syringe aspiration if spinal epidural abscess is suspected; if purulent material is encountered, it should be aspirated gently to obtain laboratory specimens, and the needle should not be advanced further.

  • Cerebrospinal fluid (CSF) may show inflammatory cells, often a mixture of polymorphonuclear and mononuclear cells. Cell counts usually are increased, ranging from 10-1000 leukocytes/µL.
  • CSF protein usually is elevated above 100 mg/dL but may be higher, particularly if spinal block is present.
  • CSF glucose is usually normal; depression may indicate coexisting meningitis.

More on Spinal Epidural Abscess

Overview: Spinal Epidural Abscess
Differential Diagnoses & Workup: Spinal Epidural Abscess
Treatment & Medication: Spinal Epidural Abscess
Follow-up: Spinal Epidural Abscess
Multimedia: Spinal Epidural Abscess
References
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References

  1. Darouiche RO. Spinal epidural abscess. N Engl J Med. Nov 9 2006;355(19):2012-20. [Medline].

  2. Bremer AA, Darouiche RO. Spinal epidural abscess presenting as intra-abdominal pathology: a case report and literature review. J Emerg Med. Jan 2004;26(1):51-6. [Medline].

  3. Rigamonti D, Liem L, Sampath P, et al. Spinal epidural abscess: contemporary trends in etiology, evaluation, and management. Surg Neurol. Aug 1999;52(2):189-96; discussion 197. [Medline].

  4. Joshi SM, Hatfield RH, Martin J, Taylor W. Spinal epidural abscess: a diagnostic challenge. Br J Neurosurg. Apr 2003;17(2):160-3. [Medline].

  5. Prendergast H, Jerrard D, O'Connell J. Atypical presentations of epidural abscess in intravenous drug abusers. Am J Emerg Med. Mar 1997;15(2):158-60. [Medline].

  6. 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. Apr 2004;26(3):285-91. [Medline].

  7. Trombly R, Guest JD. Acute central cord syndrome arising from a cervical epidural abscess: case report. Neurosurgery. Aug 2007;61(2):E424-5; discussion E425. [Medline].

  8. Tasher D, Armarnik E, Mizrahi A, Liat BS, Constantini S, Grisaru-Soen G. Cat Scratch Disease With Cervical Vertebral Osteomyelitis and Spinal Epidural Abscess. Pediatr Infect Dis J. Jul 31 2009;[Medline].

  9. Mehta SH, Shih R. Cervical epidural abscess associated with massively elevated erythrocyte sedimentation rate. J Emerg Med. Jan 2004;26(1):107-9. [Medline].

  10. Siddiq F, Chowfin A, Tight R, et al. Medical vs surgical management of spinal epidural abscess. Arch Intern Med. Dec 13-27 2004;164(22):2409-12. [Medline].

  11. Pereira CE, Lynch JC. Spinal epidural abscess: an analysis of 24 cases. Surg Neurol. 2005;63 Suppl 1:S26-9. [Medline].

  12. Bluman EM, Palumbo MA, Lucas PR. Spinal epidural abscess in adults. J Am Acad Orthop Surg. May-Jun 2004;12(3):155-63. [Medline].

  13. Butler KH. Spinal epidural abscess: Current diagnostic and management protocols. Emerg Med Rep. 21:95-104.

  14. Gerberding JL, Romero JM, Ferraro MJ. Case records of the Massachusetts General Hospital. Case 34-2008. A 58-year-old woman with neck pain and fever. N Engl J Med. Oct 30 2008;359(18):1942-9. [Medline].

  15. Grewal S, Hocking G, Wildsmith JA. Epidural abscesses. Br J Anaesth. Mar 2006;96(3):292-302. [Medline].

  16. Hooten WM, Kinney MO, Huntoon MA. Epidural abscess and meningitis after epidural corticosteroid injection. Mayo Clin Proc. May 2004;79(5):682-6. [Medline].

  17. Tessman PA, Preston DC, Shapiro BE. Spinal epidural abscess in an afebrile patient. Arch Neurol. Apr 2004;61(4):590-1. [Medline].

  18. Uchida K, Nakajima H, Yayama T, Sato R, Kobayashi S, Chen KB, 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. Jun 30 2009;[Medline].

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Further Reading

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Keywords

spinal cord compression, vertebral osteomyelitis, epidural space infection, Staphylococcus aureus, Staphylococcus species, Pseudomonas species, Escherichia coli, Mycobacterium tuberculosis, brucellosis, spinal cord dysfunction, localized spinal pain, radicular pain and paresthesias, muscular weakness, sensory loss, sphincter dysfunction, paralysis

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Contributor Information and Disclosures

Author

J Stephen Huff, MD, Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Edward L Hogan, MD, Professor, Department of Neurology, Medical College of Georgia; Emeritus Professor and Chair, Department of Neurology, Medical University of South Carolina
Edward L Hogan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Neurological Association, American Society for Biochemistry and Molecular Biology, Phi Beta Kappa, Sigma Xi, Society for Neuroscience, and Southern Clinical Neurological Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Florian P Thomas, MD, MA, PhD, Drmed, Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University
Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Paraplegia Society, and National Multiple Sclerosis Society
Disclosure: Nothing to disclose.

CME Editor

Matthew J Baker, MD, Consulting Staff, Collier Neurologic Specialists, Naples Community Hospital
Matthew J Baker, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Chief Editor

Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Y Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

 
 
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