Epidural Abscess of spine

FACTS

  • Classically: Triad = back pain + fever + neurologic deficits (but occurs in <15%).
  • Most commonly hematogenous seeding → posterior thoracic or lumbar epidural space.
  • Staph aureus (esp. MRSA) is most common organism.
  • Rapid progression: hours to days from pain → radiculopathy → weakness → paralysis.
  • Risk factors: IVDU, diabetes, immunosuppression, recent spinal procedure/injection, bacteremia.
  • Early MRI is critical—delays in diagnosis worsen neurologic outcomes.

HPI

universal ROS
  • timeline of neurologic deficit
  • any spine history ever
  • any history of infected hardware in joints
 
Labs / Vitals
  • fevers
  • obtain ESR/CRP

Risk factors
  • Distant infectious focus (history of other hardware being infected)
  • Any recent dental procedures
  • Social: IVDU, Alcoholism, STI history, advanced age
  • PMHx: Diabetes, cirrhosis, oncological history / rheumatological disease (immunosuppressed)
  • Drugs: steroid use / chemo use / immunotherapy use

PHYSICAL EXAM

universal neuro exam
  • check for meningismus
  • check for TTP in entire spine
  • evaluate dentition
  • evaluate feet (any diabetic/vascular wounds)
  • is patient toxic appearing
  • rectal exam
  • bladder scan —> if voided, PVR

IMAGING

MRI pan-spine (see below)
  • when describing the abscess during staff, state whether it is ventral vs. dorsal, compressive or not, rim-enhancing or not
CT pan-spine to evaluate for disc osteo

A/P

  • Echo to r/o vegetations (started with transtracheal, ideally transesophageal)
  • MRI pan-spine w/wo - ideally must image the entire spine before you operate
  • consider MRI Brain w/wo while already scanning patient if any cranial nerve deficits or headaches/meningismus
  • Blood cultures
  • Surg ID consult
  • UDS / UA
  • CXR
  • If indicated
    • panorex X-rays of teeth and dental consult
    • HIV / Hep C
    • Addiciton med consult
  • Cervical/Thoracic EDA are operative emergencies:
    • thrombophlebitis and cord ischemia can cause sudden irreversible paralysis
    • cervicothoracic compression is very unforgiving, especially in the very narrow thoracic spine, it does not take much to impair perfusion
  • Lumbar EDA:
    • still emergent but relatively less so because lumbar spinal canal is larger, nerve roots are more resilient to compression than cord (cauda equina is still an operative emergency).

Cases

Young adult with an IVDU history

peripheral rim-enhancing ventral epidural abscess in a previously healthy young adult found to have MSSA bacteremia.
peripheral rim-enhancing ventral epidural abscess in a previously healthy young adult found to have MSSA bacteremia.

Middle aged adult with IVDU

Sagittal T2 (upper left), axial T1 with contrast (upper right), sagittal T1 (lower left), sagittal T1+c (right lower) demonstrating a compressive lumbar epidural abscess at L5-S1.
Sagittal T2 (upper left), axial T1 with contrast (upper right), sagittal T1 (lower left), sagittal T1+c (right lower) demonstrating a compressive lumbar epidural abscess at L5-S1.