Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Epidural Abscess Treatment & Management

  • Author: Mark R Wallace, MD, FACP, FIDSA; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
 
Updated: Feb 17, 2016
 

Medical Care

Spinal epidural abscess

A combined medical-surgical approach, with emergent surgical decompression and drainage of purulent material, has been the standard approach to spinal epidural abscess. Antibiotic-based therapy, sometimes combined with CT-directed needle aspiration, has traditionally been used only in patients who are determined to be at prohibitively high risk of surgery or who have a fixed paralysis that lasts more than 48-72 hours and that is presumed to be irreversible.

In recent years, wider use of antibiotic-based, nonsurgical therapy for spinal epidural abscess has been advocated,[16, 17, 18] condemned,[19, 20] and cautiously discussed.[13, 21, 22, 23, 24] The current literature on the subject consists largely of small case series and remains inadequate to resolve the controversy.[1, 2]

If medical therapy is to be used as initial therapy for spinal epidural abscess and surgery held in reserve, a number of caveats apply, as follows:

  • The patient should have no neurological deficits.
  • A culture-proven microbiological diagnosis should be available (from blood culture or aspiration).
  • Stringent follow-up by both the primary team and neurosurgeons must be available and emergent surgery available, if needed.
  • The physicians caring for the patient must be aware that rapid deterioration may occur at any time (the first 72 hours being most risky) and that even prompt rescue surgery may leave the patient with a neurological deficit that might have been avoided with surgery at first diagnosis. Failure rates with medical management in one recent study were 41%, with some these failures termed "catastrophic". [24]
  • Risk factors for failure of medical therapy include neurological deficit, diabetes, bacteremia, age older than 65 years, and MRSA as the causative organism. [23, 24] Patients with multiple risk factors for failure of medical therapy should have the traditional combined medical/surgical approach, with the surgery performed soon after diagnosis.
  • A follow-up MRI is necessary within 2-4 weeks to evaluate for improvement with medical therapy.

Empirical antibiotic therapy should include coverage of gram-positive cocci, particularly staphylococci (including MRSA), and gram-negative bacilli. Vancomycin has been the standard agent for gram-positive infections, although linezolid, daptomycin, ceftaroline, or tigecycline could be considered. The third- and fourth-generation cephalosporins and meropenem offer excellent gram-positive (except MRSA) and gram-negative coverage in addition to CNS penetration.

Pending cultures, a combination of agents (vancomycin plus cefepime or similar) is needed. Additional coverage may be needed if some of the less-common etiologic agents (see Causes) are suspected. Always tailor coverage once culture data are available; for example, nafcillin is a much better drug for MSSA infections than vancomycin. Note that failures due to the development of resistance have occurred when daptomycin alone was used for MRSA spinal epidural abscess.[25] Experience with ceftaroline for these infections is extremely limited, but this maybe a useful second-line MRSA agent.[26]

Intracranial epidural abscess

A combined medical-surgical approach is used for intracranial epidural abscess. A craniotomy is usually performed. Empiric antibiotic therapy is similar to that described for spinal epidural abscess; since many of these infections result from prior interventions, the possibility of more-resistant nosocomial organisms must be considered. Vancomycin plus cefepime or meropenem would be good starting choices, with metronidazole added to the cefepime if anaerobes are a major concern.

Next

Surgical Care

Prompt decompression is used to manage intracranial epidural abscess, as it is uniformly considered a neurosurgical emergency.

As discussed in detail above, most patients with spinal epidural abscess require urgent decompressive laminectomy; other surgical techniques may be preferred in certain situations.[27] In some patients without neurologic deficits, medical therapy might be cautiously attempted, recognizing that disastrous outcomes may ensue from this conservative approach (see Medical Therapy). CT-guided drainage might be helpful in some cases of posterior spinal epidural abscess, but the literature on this is scant.

Previous
Next

Consultations

Emergent consultation with a neurosurgeon is mandatory for surgical decompression and drainage of purulent material in patients with intracranial epidural abscess. Emergent surgical intervention is needed in most patients with spinal epidural abscess, and prompt consultation and tight follow-up are mandatory in those in whom surgery is deferred (see Treatment). Consultation with an infectious disease specialist is strongly recommended for both diagnostic and therapeutic assistance.

Previous
 
 
Contributor Information and Disclosures
Author

Mark R Wallace, MD, FACP, FIDSA Clinical Professor of Medicine, Florida State University College of Medicine; Clinical Professor of Medicine, University of Central Florida College of Medicine

Mark R Wallace, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, International AIDS Society, Florida Infectious Diseases Society

Disclosure: Nothing to disclose.

Coauthor(s)

Gopala K Yadavalli, MD Residency Educator, Department of Internal Medicine, Boston Medical Center

Gopala K Yadavalli, MD is a member of the following medical societies: American Association for the Advancement of Science, American Society for Microbiology, Association of Program Directors in Internal Medicine, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Aadia Rana, MD Assistant Professor of Medicine, Warren Alpert Medical School of Brown University

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Pranatharthi Haran Chandrasekar, MBBS, MD Professor, Chief of Infectious Disease, Program Director of Infectious Disease Fellowship, Department of Internal Medicine, Wayne State University School of Medicine

Pranatharthi Haran Chandrasekar, MBBS, MD is a member of the following medical societies: American College of Physicians, American Society for Microbiology, International Immunocompromised Host Society, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

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, Louisiana State Medical Society

Disclosure: Nothing to disclose.

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

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

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

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

  5. Kabbara A, Rosenberg SK, Untal C. Methicillin-resistant Staphylococcus aureus epidural abscess after transforaminal epidural steroid injection. Pain Physician. 2004 Apr. 7(2):269-72. [Medline].

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

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

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

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

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

  11. 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].

  12. Chiller TM, Roy M, Nguyen D, Guh A, Malani AN, Latham R. Clinical findings for fungal infections caused by methylprednisolone injections. N Engl J Med. 2013 Oct 24. 369(17):1610-9. [Medline].

  13. 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. 2008 Jun. 41(3):215-21. [Medline].

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

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

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

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

  18. Avilucea FR, Patel AA. Epidural infection: Is it really an abscess?. Surg Neurol Int. 2012. 3(Suppl 5):S370-6. [Medline].

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

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

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

  22. 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].

  23. Kim SD, Melikian R, Ju KL, Zurakowski D, Wood KB, Bono CM. Independent predictors of failure of nonoperative management of spinal epidural abscesses. Spine J. 2013 Oct 30. [Medline].

  24. 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].

  25. Velazquez A, DeRyke CA, Goering R, Hoover V, Wallace MR. Daptomycin non-susceptible Staphylococcus aureus at a US medical centre. Clin Microbiol Infect. 2013 Dec. 19(12):1169-72. [Medline].

  26. Bucheit J, Collins R, Joshi P. Methicillin-resistant Staphylococcus aureus epidural abscess treated with ceftaroline fosamil salvage therapy. Am J Health Syst Pharm. 2014 Jan 15. 71(2):110-3. [Medline].

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

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

  29. 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].

 
Previous
Next
 
CT scan showing a lenticular-shaped intracranial epidural abscess.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.