Spinal Epidural Abscess

1. Spinal Epidural Abscess
Ade Wijaya MD – March 2018

2. Outline:
 Introduction
 Anatomy
 Epidemiology
 Etiology
 Risk factors
 Pathophysiology
 Clinical presentation
 Imaging
 Laboratory
 Differential diagnosis
 Management (medical & surgical)
 Summary

3. Introduction
 Rare spinal infection
 Potentially catastrophic condition
 Posterior
 Thorakal and lumbar spine

4. Anatomy

5. Epidemiology
 12,5 per 10.000
 10 % of all primary spine infection
 Male > female
 Adult, usually > 60 y.o

6. Etiology
 Staphylococcis
 Streptococcus
 Gram negatives
 Micobacterium tuberculosis
 Rare: fungal, parasites, & anaerobs

7. Risk Factors
 Intravenous drug use,
 HIV infection,
 Diabetes mellitus,
 Chronic renal failure (on dialysis),
 Hepatic cirrhosis,
 Alcoholism,
 Underlying malignancy,
 Morbid obesity,
 Spinal procedures,
 Trauma
 Immunosuppressive therapy.

8. Pathophysiology
Hematogen Contiguous
Direct inoculation Cryptogenic
Trauma

9. Clinical Presentation
Pain
Fever
Neurologic
deficits

10. Clinical Presentation
 (1) spinal pain,
 (2) radicular pain,
 (3) muscular weakness, and
 (4) complete paralysis
 Systemic signs of infection (fever, malaise, irritability, night sweats, and headache)

11. Imaging
 MRI
- Hypo / iso intense in T1, hyperintese in T2
- Enhance peripherally
- Granulation tissue (hypo/iso intense in T2)
- Combination with spondylodiscitis

13. Laboratory
 WBC, CRP, ESR
 Imaging-guided needle biopsy
 Urine, sputum, and blood cultures to screen for other potential sources of infection
are important
 NO LP  risk for bacterial meningitis!

14. Differential Diagnosis
 Hematoma,
 Herniated disc,
 Myelitis,
 Spinal subdural abscess,
 Spinal epidural tumors, especially lymphoma and metastatic neoplasms.

15. Algorhytm

16. Medical Treatment
 Empirical antibiotics (3rd generation cephalosporin + vancomycin)
 Duration:
- 6 weeks in immunocompetent with little/no spondylodiscitis
- 8 weeks or longer in immunocompromised patients with spondylodiscitis /
osteomyelitis
 Corticosteroids for few days
 Definitive treatment after culture results

17. Surgical Treatment
 Decompressive laminectomy at the appropriate levels,
 Surgical drainage of the abscess cavity,
 Debridement of granulation tissue.
 Occasionally, less invasive methods are used, like hemilaminectomy, interlaminar
fenestration, or CT-guided needle aspiration
 In patients with concomitant spondylodiscitis and significant vertebral body destruction,
wide laminectomy should be used, taking care not to destabilize thespine.
 If potential spinal instability requires reconstruction of the spine with spinal implants,
the procedure does not have contraindications regarding infection

18. Summary
 Rare and devastating
 Difficult to diagnose but need to be treated early
 MRI for diagnosis
 Most cases need surgical procedures

19. References:
 Arko IV, L., Quach, E., Nguyen, V., Chang, D., Sukul, V., & Kim, B. S. (2014). Medical
and surgical management of spinal epidural abscess: a systematic
review. Neurosurgical focus,37(2), E4.
 DeFroda, S. F., DePasse, J. M., Eltorai, A. E., Daniels, A. H., & Palumbo, M. A. (2016).
Evaluation and management of spinal epidural abscess. Journal of hospital
medicine, 11(2), 130-135.
 Akhaddar, A. (2017). Spinal Epidural Abscesses. In Atlas of Infections in
Neurosurgery and Spinal Surgery (pp. 171-176). Springer, Cham.
 Krishnamohan, P., & Berger, J. R. (2014). Spinal epidural abscess. Current infectious
disease reports, 16(11), 436.