Spinal Epidural Abscess Treatment & Management
- Author: J Stephen Huff, MD, FACEP; Chief Editor: Niranjan N Singh, MD, DM more...
See the list below:
- Treatment most often consists of both medical and surgical therapy.
- Empiric antibiotic coverage should include antistaphylococcal antibiotics. With the increasing incidence of methicillin-resistant staphylococcal infections, coverage that includes antibiotics effective against MRSA is recommended. If the infection follows a neurosurgical procedure, an antistaphylococcal penicillin, a third-generation cephalosporin, and an aminoglycoside are prescribed in combination. Culture results guide definitive therapy.
- If the patient remains neurologically stable and has a mechanically stable spine, some recommend that antibiotic treatment be delayed until material is obtained for a culture.
- Antibiotic treatment with CT-guided aspiration of the epidural space is increasingly used in patients without neurologic deficits.
- Resolution of the abscess with antibiotics alone has been reported in patients who are not candidates for surgery because of spine instability or coexisting medical problems.
- Deterioration of clinical and functional status while undergoing antibiotic therapy alone has been observed and may dictate emergency surgical decompression.
- Because of the rarity of the disorder, no randomized trial results are available to guide the clinician.
- For the rare case associated with the recent outbreak of fungal-contaminated methylprednisolone injections, the recommended drug is voriconazole at a dose of 6 mg/kg of body weight twice daily.
- No specific guidelines exist for children, but a recent case series showed benefit with medical therapy of most patients in that case series.
See the list below:
- Emergency surgical decompression of the spinal cord with drainage of the abscess is the usual surgical treatment.[17, 18]
- Successful treatment with a combination of abscess aspiration and antibiotic treatment has been reported and seems to be used increasingly.
- Increasing neurologic deficit, persistent severe pain, or persistent fever and leukocytosis are all indications for decompressive surgery.
- Patients with spinal epidural abscess may be clinically unstable because of concomitant systemic infection, shock, complications of diabetes mellitus, or other complications. As a result, an increased surgical risk often must be weighed in the decision process.
See the list below:
- Consultation with a spine surgeon should be requested when spinal epidural abscess is detected or strongly suspected.
- Consultation with an infectious disease specialist may be helpful in the selection of antibiotics and combinations.
Darouiche RO. Spinal epidural abscess. N Engl J Med. 2006 Nov 9. 355(19):2012-20. [Medline].
Bremer AA, Darouiche RO. Spinal epidural abscess presenting as intra-abdominal pathology: a case report and literature review. J Emerg Med. 2004 Jan. 26(1):51-6. [Medline].
Rigamonti D, Liem L, Sampath P, et al. Spinal epidural abscess: contemporary trends in etiology, evaluation, and management. Surg Neurol. 1999 Aug. 52(2):189-96; discussion 197. [Medline].
Karikari IO, Powers CJ, Reynolds RM, Mehta AI, Isaacs RE. Management of a spontaneous spinal epidural abscess: a single-center 10-year experience. Neurosurgery. 2009 Nov. 65(5):919-23; discussion 923-4. [Medline].
Kauffman CA, Pappas PG, Patterson TF. Fungal infections associated with contaminated methylprednisolone injections. N Engl J Med. 2013 Jun 27. 368(26):2495-500. [Medline].
Joshi SM, Hatfield RH, Martin J, Taylor W. Spinal epidural abscess: a diagnostic challenge. Br J Neurosurg. 2003 Apr. 17(2):160-3. [Medline].
Prendergast H, Jerrard D, O'Connell J. Atypical presentations of epidural abscess in intravenous drug abusers. Am J Emerg Med. 1997 Mar. 15(2):158-60. [Medline].
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 Apr. 26(3):285-91. [Medline].
Trombly R, Guest JD. Acute central cord syndrome arising from a cervical epidural abscess: case report. Neurosurgery. 2007 Aug. 61(2):E424-5; discussion E425. [Medline].
Dugas AF, Lucas JM, Edlow JA. Diagnosis of spinal cord compression in nontrauma patients in the emergency department. Acad Emerg Med. 2011 Jul. 18(7):719-25. [Medline].
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. 2009 Jul 31. [Medline].
Mehta SH, Shih R. Cervical epidural abscess associated with massively elevated erythrocyte sedimentation rate. J Emerg Med. 2004 Jan. 26(1):107-9. [Medline].
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. [Medline].
Siddiq F, Chowfin A, Tight R, et al. Medical vs surgical management of spinal epidural abscess. Arch Intern Med. 2004 Dec 13-27. 164(22):2409-12. [Medline].
Pradilla G, Ardila GP, Hsu W, Rigamonti D. Epidural abscesses of the CNS. Lancet Neurol. 2009 Mar. 8(3):292-300. [Medline].
Hawkins M, Bolton M. Pediatric spinal epidural abscess: a 9-year institutional review and review of the literature. Pediatrics. 2013 Dec. 132(6):e1680-5. [Medline].
Pereira CE, Lynch JC. Spinal epidural abscess: an analysis of 24 cases. Surg Neurol. 2005. 63 Suppl 1:S26-9. [Medline].
Patel AR, Alton TB, Bransford RJ, Lee MJ, Bellabarba CB, Chapman JR. Spinal epidural abscesses: risk factors, medical versus surgical management, a retrospective review of 128 cases. Spine J. 2014 Feb 1. 14(2):326-30. [Medline].
Bluman EM, Palumbo MA, Lucas PR. Spinal epidural abscess in adults. J Am Acad Orthop Surg. 2004 May-Jun. 12(3):155-63. [Medline].
Butler KH. Spinal epidural abscess: Current diagnostic and management protocols. Emerg Med Rep. 21:95-104.
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. 2008 Oct 30. 359(18):1942-9. [Medline].
Grewal S, Hocking G, Wildsmith JA. Epidural abscesses. Br J Anaesth. 2006 Mar. 96(3):292-302. [Medline].
Hooten WM, Kinney MO, Huntoon MA. Epidural abscess and meningitis after epidural corticosteroid injection. Mayo Clin Proc. 2004 May. 79(5):682-6. [Medline].
Tessman PA, Preston DC, Shapiro BE. Spinal epidural abscess in an afebrile patient. Arch Neurol. 2004 Apr. 61(4):590-1. [Medline].
Tompkins M, Panuncialman I, Lucas P, Palumbo M. Spinal epidural abscess. J Emerg Med. 2010 Sep. 39(3):384-90. [Medline].
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. 2009 Jun 30. [Medline].