Laboratory Studies

Sedimentation rate is often elevated and, in cases with low pretest probability for spinal epidural abscess, may be useful as a screening laboratory test.^[14]

Liberal use of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) evaluation following historical risk factor assessment for spinal epidural abscess have been incorporated into a clinical decision guideline based on experience at one institution.^[15]

CBC may reveal a high WBC count (but normal WBC counts reported as well).

Other tests may include blood cultures, electrolyte levels, and preoperative laboratory studies (as needed by neurosurgery, eg, prothrombin time [PT], activated partial thromboplastin time [aPTT], ECG, chest radiograph [CXR]).

Postsurgical tissue/fluid cultures of infected space may be indicated.

Spinal epidural abscess

Immediate imaging of the spinal cord is needed upon suspicion for spinal epidural abscess. Techniques that are immediately available vary at different institutions.

MRI with gadolinium contrast is the procedure of choice because of the noninvasive nature of the test. It also delineates the extent of the abscess, which frequently extends over several levels.

For patients with signs or symptoms suggestive of spinal cord compression, it is prudent to image the lumbar and thoracic spine because of the bony spine and spinal cord anatomy. Thoracic spine lesions may cause lower extremity neurologic symptoms, and imaging confined to the lumbar vertebrae may not demonstrate the level of spinal cord compression.

"Skip lesions," which are concurrent noncontiguous spinal epidural abscess lesions, may be present, and imaging should be considered to detect these, especially in patients with delayed presentations, concurrent infection outside the spine, or a very high sedimentation rate.^[16]

CT scan myelography or conventional myelography may be used if MRI is unavailable.

Subdural empyema

Cranial CT scan is the modality of choice.

Lumbar puncture

Lumbar puncture (LP) is relatively contraindicated in both conditions because of the risk of precipitating shifts of CNS content in the presence of a mass lesion. However, LP often is performed in the course of patient evaluation, particularly since meningitis is in the differential diagnosis. A typical cerebrospinal fluid (CSF) profile for these parameningeal infections would reveal only a few inflammatory cells with elevated protein level and decreased glucose level.

Treatment & Management

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Media Gallery

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

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Author

Hina Z Ghory, MD Assistant Medical Director, Emergency Department, East Orange General Hospital

Hina Z Ghory, MD is a member of the following medical societies: American College of Emergency Physicians, Phi Beta Kappa

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, Prisma Health Richland Hospital

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

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

Additional Contributors

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.

Mark S Slabinski, MD, FACEP, FAAEM Vice President, USACS Central

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.