Epidural Abscess Workup

  • Author: Mark R Wallace, MD, FACP, FIDSA; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Sep 13, 2011
 

Laboratory Studies

  • Routine tests[1, 2, 7]
    • The CBC count may reveal leukocytosis, left shift, thrombocytopenia, and anemia. Only about two thirds of patients who present with spinal epidural abscess have leukocytosis at the time of initial evaluation.
    • The erythrocyte sedimentation rate (ESR) is almost invariably elevated; this is a nonspecific finding.
    • Always obtain blood cultures, as they are positive in 60% of cases.
  • Abscess fluid/operative material
    • Perform Gram staining and routine aerobic and anaerobic cultures on aspirated or surgically obtained abscess fluid.
    • Special stains and cultures for mycobacteria and fungi are indicated.
    • Consider Brucella cultures and serologies when this is a possibility; alert laboratory personnel that Brucella may be involved so they can take precautions.
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Imaging Studies

  • MRI is the cornerstone of diagnosis in both intracranial epidural abscess and spinal epidural abscess. MRI has the greatest diagnostic accuracy and is the method of first choice in the diagnostic process.[13, 14, 1]
    • The sensitivity of MRI is 90%-95%, and its specificity also exceeds 90%. In some cases, MRI findings are indeterminate, necessitating a repeat of the study.
    • Gadolinium enhancement increases sensitivity for detecting spinal epidural abscess, even in the absence of contiguous bony infection, and enables better differentiation between abscess and surrounding neurological structures.
  • CT scanning with intravenous contrast may demonstrate fluid collections in the epidural space. CT scanning is the procedure of choice when MRI cannot be performed.
  • When combined with myelography, CT scanning is a fairly sensitive tool to diagnose spinal epidural abscess, but it carries considerable risk, including introduction of infection, bleeding, nerve injury, and spinal shock. Myelography may underestimate the length of a spinal epidural abscess and carries a risk of paralysis.
  • Plain radiographs may demonstrate osteomyelitis or vertebral collapse. While these should be performed in all cases, they are never enough to establish the diagnosis.
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Procedures

  • Make every effort to establish a microbiological diagnosis. Blood cultures are positive in 60% of patients with spinal epidural abscess and are essential.[2]
  • CT-guided needle aspiration may be used to obtain material for analysis.
  • Surgical specimens must be stained and cultured appropriately (see Causes).
  • Lumbar puncture is generally not indicated in spinal epidural abscess and carries the risk of spreading the bacteria into the subarachnoid space, with consequent meningitis. It is contraindicated in intracranial epidural abscess because of the high risk of cerebellar tonsillar herniation due to increased intracranial pressure. When obtained in spinal epidural abscess, lumbar puncture usually reveals a nonspecific parameningeal infection picture, with elevated protein levels, normal or slightly depressed glucose levels, and modest pleocytosis. Results may also be normal or indicative of frank bacterial meningitis. Culture results may be positive in up to 25% of cases, but almost all of these patients have positive blood cultures.[2]
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Staging

A staging system for the progression of spinal epidural abscess exists and may be of some diagnostic value, but it must be stressed that not all patients move sequentially through the stages, and that deterioration may be rapid.[1]

  1. Back pain, tenderness, and fever
  2. Radicular pain, reflex abnormalities
  3. Sensory abnormalities, motor weakness, bowel and bladder problems
  4. Paralysis, which rapidly becomes permanent without surgical intervention
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Contributor Information and Disclosures
Author

Mark R Wallace, MD, FACP, FIDSA  Clinical Professor of Medicine, Florida State University College of Medicine; Head of Infectious Disease Fellowship Program, Orlando Regional Medical Center

Mark R Wallace, MD, FACP, FIDSA 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, Assistant Professor of Medicine, Warren Alpert Medical School of Brown University

Disclosure: Nothing to disclose.

Gopala K Yadavalli, MD  Staff Physician and Chief, Infectious Diseases Clinic, Louis Stokes Cleveland Veterans Affairs Medical Center; Associate Program Director, Internal Medicine, University Hospitals Case Medical Center; Assistant Professor of Medicine, Division of Infectious Diseases, Case Western Reserve University School of Medicine

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.

Specialty Editor Board

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.

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

Disclosure: Medscape Salary Employment

Ronald A Greenfield, MD  Professor, Department of Internal Medicine, 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; Abbott Honoraria Speaking and teaching; Astellas Honoraria Speaking and teaching; Cubist Honoraria Speaking and teaching; Forest Pharmaceuticals Speaking and teaching

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.

References

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  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].

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

  6. Hooten WM, Kinney MO, Huntoon MA. Epidural abscess and meningitis after epidural corticosteroid injection. Mayo Clin Proc. May 2004;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. Aug 2002;45(2):76-81. [Medline].

  8. 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].

  9. Tunkell, AR. Subdural empyema, epidural abscess, and suppurative intracranial thrombophlebitis. In: 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. Jun 1994;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. Oct 30 2008;359(18):1942-9. [Medline].

  12. 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].

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

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

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

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

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

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

  19. 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].

  20. Karikari IO, Powers CJ, Reynolds RM, Mehta AI, Isaacs RE. Management of a spontaneous spinal epidural abscess: a single-center 10-year experience. Neurosurgery. Nov 2009;65(5):919-23; discussion 923-4. [Medline].

  21. 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). Feb 2005;147(2):159-66; discussion 166. [Medline].

  22. 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. Apr 2007;28(4):693-9. [Medline].

  23. 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].

 
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