Approach Considerations

The diagnosis of spinal epidural abscesses is difficult due to numerous issues, and a thorough history, physical examination, and lab work should be obtained in a timely fashion. According to one study of retrospective chart reviews of 250 randomly selected patients, 119 had a new diagnosis of spinal epidural abscess, 66 (55.5%) of which experienced diagnostic error. Red flags that were frequently not evaluated in error cases included unexplained fever, focal neurological deficits with progressive or disabling symptoms, and active infection.^[12]

Laboratory Studies

The following laboratory tests may be helpful in patients suspected of having an spinal epidural abscess:

CBC count, blood cultures, urinalysis/urine culture, and pre-operative lab studies. Fever may be absent in patients; however, leukocytosis is present in about two thirds of patients. ^[1]
Elevated erythrocyte sedimentation rate (ESR) and/or C-reactive protein are often elevated in patients presenting with spinal epidural abscess. ^[13]
Leukocytosis and ESR elevation are nonspecific laboratory findings and are not always present. Neither the presence of these findings nor the degree of laboratory abnormality is specific for spinal epidural abscess. A treatment guideline incorporating ESR, C-reactive protein, and other risk factors has been proposed based on a small patient series. ^[14]

Imaging Studies

While suspicion for spinal epidural abscess is influenced by patient history, clinical exam and labs, a definitive diagnosis requires obtaining contrast-enhanced MRI, or a CT myleogram in patients who are unable to obtain an MRI. Patients who present with spinal epidural abscess often have non-contiguous lesions, which may not be symptomatic;^[15]thus, consideration should be given to obtaining imaging of the spinal neuroaxis in patients with suspected or confirmed abscess.

Treatment & Management

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Media Gallery

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.

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Author

Omaditya (Goldey) Khanna, MD Resident Physician, Department of Neurological Surgery, Thomas Jefferson University Hospital

Disclosure: Nothing to disclose.

Coauthor(s)

James S Harrop, MD Associate Professor, Departments of Neurological and Orthopedic Surgery, Jefferson Medical College of Thomas Jefferson University

James S Harrop, MD is a member of the following medical societies: American Association of Neurological Surgeons, American College of Surgeons, American Spinal Injury Association, Cervical Spine Research Society, Congress of Neurological Surgeons, North American Spine Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Depuy spine consulant, Asterias, Bioventus, Tejin serve on advisory boards<br/>Received research grant from: DOD, PICORI<br/>Received income in an amount equal to or greater than $250 from: Stryker honorarium.

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.

Florian P Thomas, MD, PhD, MA, MS Chair, Neuroscience Institute and Department of Neurology, Director, Hereditary Neuropathy Center, Co-Director, Center for Memory Loss and Brain Health, Co-Director, ALS Center, Hackensack University Medical Center; Associate Dean of Faculty, Founding Chair and Professor, Department of Neurology, Hackensack Meridian School of Medicine

Florian P Thomas, MD, PhD, MA, MS is a member of the following medical societies: Academy of Spinal Cord Injury Professionals, American Academy of Neurology, American Neurological Association, Consortium of Multiple Sclerosis Centers, National Multiple Sclerosis Society, Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Chief Editor

Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM Adjunct Associate Professor of Neurology, University of Missouri-Columbia School of Medicine; Medical Director of St Mary's Stroke Program, SSM Neurosciences Institute, SSM Health

Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Headache Society

Disclosure: Nothing to disclose.

Additional Contributors

Edward L Hogan, MD Professor, Department of Neurology, Medical College of Georgia; Emeritus Professor and Chair, Department of Neurology, Medical University of South Carolina

Edward L Hogan, MD is a member of the following medical societies: Alpha Omega Alpha, Society for Neuroscience, American Society for Biochemistry and Molecular Biology, American Academy of Neurology, American Neurological Association, Phi Beta Kappa, Sigma Xi, The Scientific Research Honor Society, Southern Clinical Neurological Society

Disclosure: Nothing to disclose.

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.

Spinal Epidural Abscess Workup

Approach Considerations

Laboratory Studies

Imaging Studies

References

Tables

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