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Epidural and Subdural Infections Clinical Presentation

  • Author: J Stephen Huff, MD, FACEP; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
 
Updated: Aug 12, 2015
 

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.

If 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, indwelling catheters, 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 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, HIV infection, or chronic liver or kidney disease, 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.

Unusual indolent courses may follow neurosurgical procedures.

A history of recent sinusitis or otitis media may be present.

Antibiotic therapy may lessen systemic symptoms.

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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 or may not be present.

Signs of spinal cord dysfunction, such as loss of sphincter tone, sensory loss, or localized motor weakness are late findings.

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

An abnormal postvoiding residual volume may be a sign of spinal cord disfunction.

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.

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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 or discitis. 

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.

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Contributor Information and Disclosures
Author

J Stephen Huff, MD, FACEP Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

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

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.

Barry J Sheridan, DO Chief Warrior in Transition 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.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, South Carolina Medical Association, Columbia Medical Society, South Carolina College of Emergency Physicians, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Chief Editor for Medscape.

Additional Contributors

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, Ohio State Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the medical review of this article by Joseph U Becker, MD.

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Spinal epidural abscess with cord edema and compression. Abscess extends into paravertebral tissues.
 
 
 
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