Epidural and Subdural Infections Clinical Presentation

  • Author: J Stephen Huff, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: May 2, 2011
 

History

Spinal epidural abscess

  • Early presentations may be subtle, and diagnosis may be difficult, if not impossible, at early stages.
  • History of fever is often but not invariably present.
  • Localized back pain may be present.
  • Neurologic deficit is consistent with a spinal cord syndrome.
  • History may suggest a source or cause of infection (eg, soft tissue infection, intravenous drug abuse, recent epidural injections, neurosurgical procedures or other instrumentation).
  • Duration of symptoms is typically a few days but may extend over weeks. Symptom onset may also be abrupt.
  • Radicular pain consistent with nerve root irritation may be present and confound evaluation, particularly if the pain occurs in the abdomen or the chest.
  • Progressive sensory disturbances in the extremities, weakness, and incontinence suggest progression to spinal cord involvement.
  • An immunosuppressive condition, such as diabetes, alcoholism, or HIV infection, is often present.

Subdural empyema

  • Headaches may be initially unilateral but then become generalized.
  • Fever and vomiting may be present.
  • Focal or generalized seizures may be present.
  • Tempo of clinical course usually is fulminant with rapid deterioration.
  • Uncommon indolent courses may follow neurosurgical procedures.
  • A history of recent sinusitis or otitis media may be present.
  • Antibiotic therapy may lessen systemic symptoms.
Next

Physical

Both spinal epidural abscess and subdural empyema may manifest generalized signs and symptoms of infection such as fever, sepsis, or septic shock.

Spinal epidural abscess

Localized tenderness to percussion or palpation over the involved region may be present.

Signs of spinal cord dysfunction, such as loss of sphincter tone, sensory loss, or localized motor weakness, may be present.

Reflexes may vary from hypoactive or absent to brisk and spastic.

Subdural empyema

Focal neurologic deficit or focal seizures may be present in a patient with signs of meningeal irritation.

Altered mental status is present in most patients.

Focal neurologic signs, such as hemiparesis or aphasia, may precede further alteration in consciousness.

Papilledema is absent in most patients, reflecting a short duration of increased intracranial pressure.

Previous
Next

Causes

Spinal epidural abscess

  • Most cases arise from hematogenous seeding of the epidural space from a distant source of infection.
  • Another etiology is extension of infection from adjacent vertebral osteomyelitis.
  • Penetrating trauma, recent neurosurgical procedures, or recent epidural injections or catheter placements are other causes.
  • Staphylococcus aureus is the most frequent bacteriologic cause, with methicillin-resistant S aureus (MRSA) being increasingly reported.

Subdural empyema

  • Most cases are extensions of infections from the paranasal sinuses.
  • Otitis media or mastoiditis also may extend into the subdural space.
  • Recent neurosurgical procedures and penetrating trauma cause other cases.
  • Hematogenous spread of infection from a pulmonary source also has been reported.
Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

J Stephen Huff, MD  Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center

J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mark S Slabinski, MD, FACEP, FAAEM  Vice President, EMP Medical Group

Mark S Slabinski, MD, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Ohio State Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Barry J Sheridan, DO  Chief, Department of Emergency Medical Services, Brooke Army Medical Center

Barry J Sheridan, DO is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD 

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

References

  1. Tunkel AR. Subdural empyema, epidural abscess, and suppurative intracranial thrombophlebitis. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Disease. Vol 1. Elsevier Churchill Livingstone Inc; 2005:1164-1171.

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

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

  4. Bluman EM, Palumbo MA, Lucas PR. Spinal epidural abscess in adults. J Am Acad Orthop Surg. May-Jun 2004;12(3):155-63. [Medline].

  5. Ptaszynski AE, Hooten WM, Huntoon MA. The incidence of spontaneous epidural abscess in Olmsted County from 1990 through 2000: a rare cause of spinal pain. Pain Med. May-Jun 2007;8(4):338-43. [Medline].

  6. Osman Farah J, Kandasamy J, May P, Buxton N, Mallucci C. Subdural empyema secondary to sinus infection in children. Childs Nerv Syst. Feb 2009;25(2):199-205. [Medline].

  7. Mehta SH, Shih R. Cervical epidural abscess associated with massively elevated erythrocyte sedimentation rate. J Emerg Med. Jan 2004;26(1):107-9. [Medline].

  8. Lefebvre L, Metellus P, Dufour H, Bruder N. Linezolid for treatment of subdural empyema due to Streptococcus: case reports. Surg Neurol. Jan 2009;71(1):89-91; discussion 91. [Medline].

  9. 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].

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

  11. Joshi SM, Hatfield RH, Martin J, Taylor W. Spinal epidural abscess: a diagnostic challenge. Br J Neurosurg. Apr 2003;17(2):160-3. [Medline].

  12. Marsh EB, Chow GV, Gong GX, Rastegar DA, Antonarakis ES. A cut above. Am J Med. Dec 2007;120(12):1031-3. [Medline].

  13. 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].

  14. Rigamonti D, Liem L, Sampath P, et al. Spinal epidural abscess: contemporary trends in etiology, evaluation, and management. Surg Neurol. Aug 1999;52(2):189-96; discussion 197. [Medline].

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

  16. 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].

  17. Soehle M, Wallenfang T. Spinal epidural abscesses: clinical manifestations, prognostic factors, and outcomes. Neurosurgery. Jul 2002;51(1):79-85; discussion 86-7. [Medline].

  18. Trombly R, Guest JD. Acute central cord syndrome arising from a cervical epidural abscess: case report. Neurosurgery. Aug 2007;61(2):E424-5; discussion E425. [Medline].

 
Previous
Next
 
Spinal epidural abscess with cord edema and compression. Abscess extends into paravertebral tissues.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.