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Epidural Abscess Workup

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

Laboratory Studies

Routine tests

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.[1, 2, 7]

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.


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.[1, 14, 15] 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 (see image below). CT scanning is the procedure of choice when MRI cannot be performed.

CT scan showing a lenticular-shaped intracranial eCT scan showing a lenticular-shaped intracranial epidural abscess.

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.



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]



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
Contributor Information and Disclosures

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.


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.

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CT scan showing a lenticular-shaped intracranial epidural abscess.
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