eMedicine Specialties > Infectious Diseases > Skin and Soft-Tissue Infections

Epidural Abscess: Follow-up

Author: Mark Raymond Wallace, MD, Infectious Disease Fellowship Director, Orlando Regional Healthcare; Clinical Professor of Medicine, Florida State University
Coauthor(s): Aadia Rana, MD, Research Fellow, Department of Medicine, Division of Infectious Diseases, The Miriam Hospital, Brown University School of Medicine; Gopala K Yadavalli, MD, Associate Program Director of Internal Medicine, Assistant Professor of Medicine, Division of Infectious Diseases, Case Western Reserve University School of Medicine and Louis Stokes Cleveland Veterans Affairs Medical Center
Contributor Information and Disclosures

Updated: Apr 20, 2009

Follow-up

Further Inpatient Care

  • Frequent neurological examination is warranted during the postsurgical recovery period and is especially critical in patients undergoing medical treatment for spinal epidural abscess.
  • Fever, leukocytosis, or new neurological deficit necessitates repeated imaging, and further (or initial) surgical exploration may be required.16
  • Follow-up MRIs to evaluate spinal epidural abscess in patients who are doing well may not be helpful, as the findings may not correlate well with clinical course.17
  • Physical therapy may be necessary for individuals with a residual neurological deficit.

Further Outpatient Care

  • Follow-up MRI should be obtained if any clinical deterioration is noted in patients with an intracranial epidural abscess or spinal epidural abscess. Follow-up MRI at 2-4 weeks should be performed in patients with spinal epidural abscess undergoing medical treatment to ensure the abscess has improved. It is unclear whether surgically treated patients with spinal epidural abscess who are doing well require follow-up MRI, as the MRI findings do seem not to correlate with the clinical course.17
  • Follow-up with the neurosurgeon is needed.
  • Follow-up with an infectious diseases specialist is advised to monitor intravenous antibiotics.

Inpatient & Outpatient Medications

See Treatment and Medication.

Transfer

  • In the United States, by law, any unstable patient must be stabilized to the extent possible, including consultation and surgery, if indicated, before transfer.

Complications

Death or permanent neurologic sequelae occur in a substantial proportion of patients with epidural abscess, especially those who present with major neurological deficits or sepsis.

Prognosis

  • The degree of neurologic recovery after surgery correlates with the duration and initial severity of the neurologic defect.
  • Spinal epidural abscess carries a mortality rate of 2%-20%; intracranial epidural abscess, about 10% (see Mortality).
  • A worse outcome has been observed in patients with the following:1
    • Multiple medical problems
    • Prior spinal surgery
    • Prior cervical or thoracic abscess location
    • Thrombocytopenia
    • Leukocytosis (>14,000 WBCs/µL)
    • Persistently elevated inflammatory markers
    • Infection with methicillin-resistant staphylococci
    • Significant degree of thecal sac compression
    • Sepsis

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Diagnostic delays are common in both spinal epidural abscess and intracranial epidural abscess and can lead to poor outcomes and legal action.18 Although these are rare infections, all clinicians who might encounter these patients must be aware of their presentation and be ready to obtain an MRI. Waiting for the classic triad of spinal epidural abscess (see History) or for a possible intracranial epidural abscess to progress is fraught with hazard.
  • Delay in surgical drainage and decompression has repeatedly been associated with high morbidity and mortality rates.
 


More on Epidural Abscess

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

  1. Sendi P, Bregenzer T, Zimmerli W. Spinal epidural abscess in clinical practice. QJM. Jan 2008;101(1):1-12. [Medline].

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

  3. Tsiodras S, Falagas ME. Clinical assessment and medical treatment of spine infections. Clin Orthop Relat Res. Mar 2006;444:38-50. [Medline].

  4. Tang HJ, Lin HJ, Liu YC, Li CM. Spinal epidural abscess--experience with 46 patients and evaluation of prognostic factors. J Infect. Aug 2002;45(2):76-81. [Medline].

  5. Reihsaus E, Waldbaur H, Seeling W. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev. Dec 2000;23(4):175-204; discussion 205. [Medline].

  6. Tunkell, AR. Subdural empyema, epidural abscess, and suppurative intracranial thrombophlebitis. In: Mandell GL, Bennet JE, Dolin R, eds. Mandell, Douglas, and Bennett's Principles and Practices of Infectious Diseases. 2005:1165-8.

  7. Hlavin ML, Kaminski HJ, Fenstermaker RA. Intracranial suppuration: a modern decade of postoperative subdural empyema and epidural abscess. Neurosurgery. Jun 1994;34(6):974-80; discussion 980-1. [Medline].

  8. Chen WC, Wang JL, Wang JT, Chen YC, Chang SC. Spinal epidural abscess due to Staphylococcus aureus: clinical manifestations and outcomes. J Microbiol Immunol Infect. Jun 2008;41(3):215-21. [Medline].

  9. Lury K, Smith JK, Castillo M. Imaging of spinal infections. Semin Roentgenol. Oct 2006;41(4):363-79. [Medline].

  10. An HS, Seldomridge JA. Spinal infections: diagnostic tests and imaging studies. Clin Orthop Relat Res. Mar 2006;444:27-33. [Medline].

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

  12. Sørensen P. Spinal epidural abscesses: conservative treatment for selected subgroups of patients. Br J Neurosurg. Dec 2003;17(6):513-8. [Medline].

  13. Curry WT, Hoh BL, Amin-Hanjani S. Spinal epidural abscess: clinical presentation, management, and outcome. Surg Neurol. Apr 2005;63(4):364-71; discussion 371. [Medline].

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

  15. Savage K, Holtom PD, Zalavras CG. Spinal epidural abscess: early clinical outcome in patients treated medically. Clin Orthop Relat Res. Oct 2005;439:56-60. [Medline].

  16. Löhr M, Reithmeier T, Ernestus RI, Ebel H, Klug N. Spinal epidural abscess: prognostic factors and comparison of different surgical treatment strategies. Acta Neurochir (Wien). Feb 2005;147(2):159-66; discussion 166. [Medline].

  17. Kowalski TJ, Layton KF, Berbari EF, Steckelberg JM, Huddleston PM, Wald JT. Follow-up MR imaging in patients with pyogenic spine infections: lack of correlation with clinical features. AJNR Am J Neuroradiol. Apr 2007;28(4):693-9. [Medline].

  18. Davis DP, Wold RM, Patel RJ. 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].

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Further Reading

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Keywords

epidural abscess, spinal epidural abscess, SEA, intracranial epidural abscess, IEA, increased intracranial pressure, ICP, diabetes mellitus, subdural empyema

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Contributor Information and Disclosures

Author

Mark Raymond Wallace, MD, Infectious Disease Fellowship Director, Orlando Regional Healthcare; Clinical Professor of Medicine, Florida State University
Mark Raymond Wallace, MD is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Tropical Medicine and Hygiene, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Coauthor(s)

Aadia Rana, MD, Research Fellow, Department of Medicine, Division of Infectious Diseases, The Miriam Hospital, Brown University School of Medicine
Disclosure: Nothing to disclose.

Gopala K Yadavalli, MD, Associate Program Director of Internal Medicine, Assistant Professor of Medicine, Division of Infectious Diseases, Case Western Reserve University School of Medicine and Louis Stokes Cleveland Veterans Affairs Medical Center
Gopala K Yadavalli, MD is a member of the following medical societies: American Society for Microbiology, American Society of Transplantation, Association of Program Directors in Internal Medicine, Infectious Diseases Society of America, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Medical Editor

Fred A Lopez, MD, Associate Professor and Vice Chair, Department of Medicine, Assistant Dean for Student Affairs, Louisiana State University School of Medicine
Fred A Lopez, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, Infectious Diseases Society of America, and Louisiana State Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Ronald A Greenfield, MD, Professor, Department of Internal Medicine, Section of Infectious Diseases, University of Oklahoma College of Medicine
Ronald A Greenfield, MD is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Central Society for Clinical Research, Infectious Diseases Society of America, Medical Mycology Society of the Americas, Phi Beta Kappa, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology
Disclosure: Pfizer Honoraria Speaking and teaching; Gilead Honoraria Speaking and teaching; Ortho McNeil Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; Abbott Honoraria Speaking and teaching; Astellas Honoraria Speaking and teaching; Cubist  Speaking and teaching

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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