Medical Care
Treatment most often consists of both medical [16] and surgical therapy.
-
If the patient remains neurologically stable and has a mechanically stable spine, antibiotic treatment may be held until a biopsy sample is obtained via imminent surgical intervention. [17]
-
Empiric antibiotic coverage should include anti-staphylococcal antibiotics. With the increasing incidence of methicillin-resistant staphylococcal infections, initial coverage that includes antibiotics effective against MRSA is recommended, which can be narrowed once a definitive organism is identified. If the infection follows a neurosurgical procedure, an anti-staphylococcal penicillin, a third-generation cephalosporin, and an aminoglycoside are prescribed in combination. Culture results guide definitive therapy.
-
Antibiotic treatment with CT-guided aspiration of the epidural space is increasingly used in patients without neurologic deficits.
-
For the rare case caused by a fungal organism, the recommended drug is voriconazole at a dose of 6 mg/kg of body weight twice daily. [18]
-
No specific guidelines exist for children, but a case series showed benefit with medical therapy of most patients. [19]
Surgical Care
Surgical intervention to evacuate the spinal epidural abscess is beneficial to achieve favorable outcomes. A surgical procedure serves to obtain tissue for biopsy and culture, and evacuates the loculated collection(s) such that antibiotic treatment is more efficacious.
In patients with cervical and/or thoracic spinal epidural abscess, there is an increased risk of neurological decline from thrombophlebitis causing spinal cord edema and infarction. Surgical risk benefits should be weighed against potential adverse effects. Patients with lumbar epidural abscesses in whom there is an alternative lesion that may be biopsied (adjacent osteomyelitis, discitis, or psoas abscess), or a systemic source of infection, may be initially treated with antibiotic therapy. [20, 21]
In patients undergoing medical management of spinal epidural abscess, increasing neurologic deficit, persistent severe pain, progressive kyphosis and/or spinal instability, and failure of antibiotic treatment are all potential indications for surgical intervention.
Consultations
Prompt consultation with a spine surgeon should be considered when spinal epidural abscess is identified.
Consultation with an infectious disease specialist may be helpful in the selection of an antibiotic treatment regimen and length of therapy.
Complications
Surgical intervention that provides decompression of the neural elements, as well as providing diagnosis, is the definitive treatment for patients presenting with spinal epidural abscesses, and is associated with a low rate (0-2.5%) of necessitating repeat surgical intervention for treatment failure. [22] In one series, 13% of patients undergoing laminectomy alone, without instrumented fusion, developed a progressive kyphotic deformity that warranted repeat surgery. [23] Despite the presence of infection, the rate of pseudoarthrosis in patients who undergo spinal fusion for treatment of epidural abscess is low (2.5-7%). [7, 22]
Surgical treatment inherently confers risk of bleeding, infection, or development of neurological deficits such as weakness, numbness, paresthesia, and loss of bowel/bladder/sexual function. and, in patients with significant medical co-morbidities, may result in severe morbidity and/or mortality.
Activity
Patients who undergo surgical treatment for evacuation of spinal epidural abscess should be mobilized early with physical and occupational therapy to reduce their risk of venous thromboembolism.
Long-Term Monitoring
Patients with persistent symptoms should undergo repeat imaging to identify adequate treatment of the spinal epidural abscess, and to evaluate for the formation of any new lesion(s). Routine follow-up with standing x-rays of the spine should be obtained in order to assess for any progressive kyphosis or other spinal instability that warrants further surgical treatment.
Patients should have long-term follow-up with an infectious disease physician to ensure compliance of treatment and to evaluate overall length of antibiotic therapy. Follow-up with infectious disease also serves to detect any metabolic abnormalities (eg, renal failure) that may occur as a result of prolonged antibiotic treatment.
-
Cervical epidural abscess with spinal cord compression and spinal cord edema.
-
Spinal epidural abscess lumbar area.
-
An MRI of the lumbar spine (T1-weighted, post-contrast) shows a spinal epidural abscess at the level of L3-L4, with an associated left paraspinal muscle abscess.
