Spinal Epidural Abscess Treatment & Management

Updated: Aug 22, 2017
  • Author: J Stephen Huff, MD, FACEP; Chief Editor: Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM  more...
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Treatment

Medical Care

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  • Treatment most often consists of both medical [14] and surgical therapy.
  • Empiric antibiotic coverage should include antistaphylococcal antibiotics. With the increasing incidence of methicillin-resistant staphylococcal infections, coverage that includes antibiotics effective against MRSA is recommended. If the infection follows a neurosurgical procedure, an antistaphylococcal penicillin, a third-generation cephalosporin, and an aminoglycoside are prescribed in combination. Culture results guide definitive therapy.
  • If the patient remains neurologically stable and has a mechanically stable spine, some recommend that antibiotic treatment be delayed until material is obtained for a culture. [15]
  • Antibiotic treatment with CT-guided aspiration of the epidural space is increasingly used in patients without neurologic deficits.
  • Resolution of the abscess with antibiotics alone has been reported in patients who are not candidates for surgery because of spine instability or coexisting medical problems.
  • Deterioration of clinical and functional status while undergoing antibiotic therapy alone has been observed and may dictate emergency surgical decompression.
  • Because of the rarity of the disorder, no randomized trial results are available to guide the clinician.
  • For the rare case associated with the recent outbreak of fungal-contaminated methylprednisolone injections, the recommended drug is voriconazole at a dose of 6 mg/kg of body weight twice daily. [5]
  • No specific guidelines exist for children, but a recent case series showed benefit with medical therapy of most patients in that case series. [16]
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Surgical Care

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  • Emergency surgical decompression of the spinal cord with drainage of the abscess is the usual surgical treatment. [17, 18]
  • Successful treatment with a combination of abscess aspiration and antibiotic treatment has been reported and seems to be used increasingly.
  • Increasing neurologic deficit, persistent severe pain, or persistent fever and leukocytosis are all indications for decompressive surgery.
  • Patients with spinal epidural abscess may be clinically unstable because of concomitant systemic infection, shock, complications of diabetes mellitus, or other complications. As a result, an increased surgical risk often must be weighed in the decision process.
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Consultations

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  • Consultation with a spine surgeon should be requested when spinal epidural abscess is detected or strongly suspected.
  • Consultation with an infectious disease specialist may be helpful in the selection of antibiotics and combinations.
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