Close
New

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

 

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.

Next

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.

Previous
Next

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]

Previous
Next

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
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.