II. Epidemiology
III. Types: Spinal Infection
- Spinal Epidural Abscess (SEA) - typically the primary infection site
- Infection in the space between the Dura Mater and the adjacent Vertebral Column
- Disc space infection (Discitis)
-
Vertebral infection
- Spondylitis
- Osteomyelitis
IV. Pathophysiology: Sources of Spinal Infection
- Hematogenous spread (50%)
- Contiguous spread (33%)
- Retropharyngeal Abscess
- Psoas Abscess
- Direct introduction of infection
- Spinal injection
- Spinal surgery
V. Pathophysiology: Sites of Spinal Infection
- Most cases involve thoracolumbar spine
- Anterior Epidural Abscess (20%)
- Associated infections
- Disk space infection (Discitis)
- Vertebral Osteomyelitis
- Blunt Trauma and associated hematoma infection
- Direct extension from adjacent infection
- Retropharyngeal Abscess
- Retroperitoneal abscess
- Associated infections
- Posterior Epidural Abscess (80%)
- Distant source (Cellulitis, dental, Pharyngitis)
VI. Etiology
- Acute Infection (within 5-10 days)
- Staphylococcus aureus (most common)
- Actinomycosis (rare)
- Chronic Infection (within 3-6 months)
- Other indolent infections
- Fungus
- Tuberculosis (Pott's Disease)
- Vertebral collapse
- Sharply angulated spinal deformity
VII. Risk Factors
- Idiopathic without risk factors in 20% of cases
-
Intravenous Drug Abuse
- Back pain in IVDA is a Spinal Infection until proven otherwise
-
Immunodeficiency
- AIDS
- Chronic Renal Failure (esp. Dialysis)
- Diabetes Mellitus
- Alcoholism
- Malignancy
- Recent spinal procedure
- Spinal surgery
- Epidural Anesthesia
- Recent back Trauma
- Concurrent infectious sources
- Genitourinary infection
- Skin Infection
- Poor Dentition (Associated with Actinomyces)
VIII. Symptoms
IX. Signs
- Focal tenderness at involved spinous process (60-70% of cases)
X. Precautions
- Keep a high index of suspicion
- Classic triad of back pain, fever and neurologic symptoms occurs in <37% of patients
- Avoid Lumbar Puncture
- Not diagnostic
- Risk of contiguous seeding of subarachnoid space (and secondary Meningitis)
- Disposition to rapid intervention at time of diagnosis
- Delays result in greater risk for neurologic injury
- Abscess results in direct mechanical compression of the spinal cord
- Local infection may result in ischemic injury to the cord via thrombosis of vessel Occlusion
XI. Labs
-
Complete Blood Count
- Leukocytosis (30% of cases)
- Acute phase reactants (increased in 95% of cases)
- Erythrocyte Sedimentation Rate (ESR) increased
- C-Reactive Protein (C-RP) increased
-
Blood Cultures
- Identify responsible organism in 60% of cases
XII. Imaging
- Gadolinium-enhanced Spine MRI (preferred)
- Test Sensitivity >90%
- CT with Myelography
XIII. Management
- Emergent Neurosurgery Consultation
- Surgical decompression (first-line, preferred management)
- Open decompression (preferred)
- May be performed with endoscopy-assisted surgery
- Percutaneous drainage
- Aspiration under CT guidance is performed in some cases
- Open decompression (preferred)
- Antibiotics
- Start early empiric therapy and modify based on culture results
- Discuss with neurosurgery (in some cases, may ask to withhold antibiotics until surgical culture obtained)
- Typical IV antibiotic duration: 6 weeks
- Primary empiric antibiotics (MRSA)
- Vancomycin 1 gram IV q12 hours (dosing must be calculated based on weight)
- Alternative empiric antibiotics (MSSA coverage may be used if low MRSA risk in community)
- Additional Gram Negative Bacteria coverage indications
- Intravenous Drug Abuse
- Immunocompromised patients
- Concurrent Urinary Tract Infection
- Additional Pseudomonas coverage indications
- Other modified antibiotic coverage
- Mycobacterium tuberculosis suspected
- Start early empiric therapy and modify based on culture results
XIV. Prognosis: Positive prognostic indicators
- Intact or only mild neurologic symptoms prior to intervention
- Most accurate prognostic indicator
- Age under 60 years
- Cord symptoms (e.g. Bladder dysfunction) <24 hours
- No comorbid conditions
- Thecal sac compression <50%
XV. Complications
-
Cauda Equina Syndrome
- Results from direct mechanical compression of cord
-
Meningitis (or overwhelming Sepsis)
- Results from spread into subarachnoid space
- Mortality
- Mortality rate: 5-23%
XVI. References
- Della-Giustina (2014) Crit Dec Emerg Med 28(3): 2-9
- Chao (2002) Am Fam Physician 65(7):1341-6 [PubMed]
- Tompkins (2010) J Emerg Med 39(3): 384-90 [PubMed]
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Related Studies
Definition (MSH) | Inflammation of an INTERVERTEBRAL DISC or disk space which may lead to disk erosion. Until recently, discitis has been defined as a nonbacterial inflammation and has been attributed to aseptic processes (e.g., chemical reaction to an injected substance). However, recent studies provide evidence that infection may be the initial cause, but perhaps not the promoter, of most cases of discitis. Discitis has been diagnosed in patients following discography, myelography, lumbar puncture, paravertebral injection, and obstetrical epidural anesthesia. Discitis following chemonucleolysis (especially with chymopapain) is attributed to chemical reaction by some and to introduction of microorganisms by others. |
Concepts | Disease or Syndrome (T047) |
MSH | D015299 |
ICD10 | M46.4 |
SnomedCT | 2304001 |
English | Discitides, Diskitides, Diskitis, Spondylodiscitides, Spondylodiscitis, Spondylodiskitides, Spondylodiskitis, Discitis, unspecified, discitis (diagnosis), discitis, Discitis [Disease/Finding], Unspecified discitis, spondylodiskitis, spondylodiscitis, diskitis, Intervertebral discitis, Discitis (disorder), discitis, diskitis, Discitis, NOS, Discitis |
Italian | Discite intervertebrale, Spondilodiscite, Discite |
Dutch | spondylodiscitis, Discitis, niet gespecificeerd, discitis van tussenwervelschijf, Discitis, Spondylodiscitis |
Japanese | 脊椎椎間板炎, セキツイツイカンバンエン, ツイカンバンエン, 円板炎, 椎間板炎, 脊椎円板炎, 椎間円板炎 |
Swedish | Diskit |
Czech | zánět meziobratlových plotének, discitida, Spondylodiscitida, Meziobratlová discitida, spondylodiscitida |
Finnish | Diskiitti |
Russian | DISTSIT, SPONDILODISTSIT, ДИСЦИТ, СПОНДИЛОДИСЦИТ |
German | Diszitis, nicht naeher bezeichnet, Diszitis, Spondylodiszitis |
Korean | 상세불명의 원반염 |
Croatian | DISK, UPALA |
Polish | Zapalenie krążka międzykręgowego |
Hungarian | spondylodiscitis, intervertebralis discitis |
Norwegian | Diskitt, Spondylodiskitt |
Spanish | discitis (trastorno), discitis, Discitis intervertebral, Discitis, Espondilodiscitis |
Portuguese | Discos intervertebrais, Discite, Espondilodiscite |
French | Disques intervertébraux, Discite, Spondylodiscite, Inflammation du disque intervertébral, Inflammation du disque vertébral, Spondylo-discite |
Ontology: Epidural Abscess, Spinal (C0238434)
Concepts | Disease or Syndrome (T047) |
MSH | D020802 |
SnomedCT | 230217003, 192748004, 63627007 |
English | Epidural intraspinal abscess, spinal epidural abscess, spinal epidural abscess (diagnosis), Abscess, Spinal Epidural, Spinal Epidural Abscess, Abscess, Spinal Extradural, Extradural Abscess, Spinal, Spinal Extradural Abscess, abscesses epidural spinal, epidural spinal abscess, Epidural intraspinal abscess (disorder), Spinal epidural abscess, Spinal extradural abscess, Intraspinal extradural abscess, Intraspinal epidural abscess, Extradural intraspinal abscess, Spinal epidural abscess (disorder), epidural; abscess, spinal cord, extradural; abscess, spinal cord, abscess; epidural, spinal cord, abscess; extradural, spinal cord, Epidural Abscess, Spinal, Abscess of spinal cord, epidural, Abscess of spinal cord, extradural |
French | Abcès épidural rachidien, Abcès extra-dural rachidien, Abcès extra-duraux rachidiens, Abcès extradural rachidien, Abcès extraduraux rachidiens, Abcès épiduraux rachidiens, Abcès péridural rachidien, Abcès épidural du rachis, Abcès épiduraux du rachis |
Italian | Ascesso extradurale spinale, Ascesso epidurale spinale |
Czech | spinální epidurální absces |
Norwegian | Spinal epidural abscess, Spinal ekstradural abscess |
Dutch | abces; epiduraal, ruggenmerg, abces; extraduraal, ruggenmerg, epiduraal; abces, ruggenmerg, extraduraal; abces, ruggenmerg |
Spanish | absceso espinal epidural (trastorno), absceso espinal epidural, absceso espinal extradural, absceso raquídeo epidural |
Ontology: Epidural Abscess (C0270629)
Definition (MSH) | Circumscribed collections of suppurative material occurring in the spinal or intracranial EPIDURAL SPACE. The majority of epidural abscesses occur in the spinal canal and are associated with OSTEOMYELITIS of a vertebral body; ANALGESIA, EPIDURAL; and other conditions. Clinical manifestations include local and radicular pain, weakness, sensory loss, URINARY INCONTINENCE, and FECAL INCONTINENCE. Cranial epidural abscesses are usually associated with OSTEOMYELITIS of a cranial bone, SINUSITIS, or OTITIS MEDIA. (From Adams et al., Principles of Neurology, 6th ed, p710 and pp1240-1; J Neurol Neurosurg Psychiatry 1998 Aug;65(2):209-12) |
Concepts | Disease or Syndrome (T047) |
MSH | D020802 |
SnomedCT | 310671007, 192752004, 61974008 |
English | Epidural Abscess, Extradural abscess NOS, Abscess, Epidural, Abscess, Extradural, Extradural Abscess, Epidural Abscess [Disease/Finding], abscesses epidural, epidural abscess, Epidural abscess, Extradural abscess, Epidural abscess (disorder), epidural; abscess, extradural; abscess, abscess; epidural, abscess; extradural |
Dutch | epiduraal abces, extraduraal abces NAO, abces; epiduraal, abces; extraduraal, epiduraal; abces, extraduraal; abces, extraduraal abces, Abces, epiduraal, Abces, extraduraal, Epiduraal abces |
French | Abcès extradural SAI, Abcès péridural, Abcès extradural, Abcès extra-dural, Abcès extra-duraux, Abcès extraduraux, Abcès périduraux, Abcès épidural, Abcès épiduraux |
German | extraduraler Abszess NNB, epiduraler Abszess, extraduraler Abszess, Abszeß, epidural, Abszeß, extradural, Epiduralabszeß, Epiduraler Abszeß |
Italian | Ascesso extradurale NAS, Ascesso extradurale, Ascesso epidurale |
Portuguese | Abcesso extradural NE, Abcesso epidural, Abcesso extradural, Abscesso Epidural, Abscesso Extradural |
Spanish | Absceso epidural, Absceso extradural NEOM, absceso epidural (trastorno), absceso epidural, absceso extradural, Absceso extradural, Absceso Epidural, Absceso Extradural |
Japanese | 硬膜外膿瘍NOS, コウマクガイノウヨウNOS, コウマクガイノウヨウ, 硬膜外膿瘍, 膿瘍-硬膜外 |
Swedish | Epiduralabscess |
Czech | epidurální absces, Extradurální absces NOS, Extradurální absces, Epidurální absces, extradurální absces |
Finnish | Epiduraalipaise |
Russian | EPIDURAL'NYI ABSTSESS, ABSTSESS EPIDURAL'NYI, EKSTRADURAL'NYI ABSTSESS, АБСЦЕСС ЭПИДУРАЛЬНЫЙ, ЭКСТРАДУРАЛЬНЫЙ АБСЦЕСС, ЭПИДУРАЛЬНЫЙ АБСЦЕСС |
Polish | Ropień nadoponowy |
Hungarian | Epiduralis abscessus, extraduralis abscessus k.m.n., extraduralis tályog |
Norwegian | Epidural abscess, Epiduralabscess |
Ontology: Osteomyelitis of vertebra (C0452221)
Concepts | Disease or Syndrome (T047) |
ICD10 | M46.2 , M46.20, M46.29 |
SnomedCT | 203241002 |
Dutch | spinale osteomyelitis, osteomyelitis; wervel, wervel; osteomyelitis, Osteomyelitis van wervel |
French | Ostéomyélite spinale |
German | spinale Osteomyelitis, Wirbelosteomyelitis |
English | VERTEBRAL OSTEOMYELITIS, vertebral osteomyelitis (diagnosis), vertebral osteomyelitis, Osteomyelitis of vertebra, site unspecified, Spinal osteomyelitis, Osteomyelitis of vertebra, Osteomyelitis of vertebra (disorder), osteomyelitis; vertebra, vertebra; osteomyelitis |
Italian | Osteomielite spinale |
Portuguese | Osteomielite espinhal |
Spanish | Osteomielitis espinal, osteomielitis vertebral (trastorno), osteomielitis vertebral |
Japanese | 脊椎骨髄炎, セキツイコツズイエン |
Czech | Osteomyelitida páteře |
Korean | 척추의 골수염 |
Hungarian | Gerinc osteomyelitis |
Ontology: Spinal cord infection (C0877275)
Concepts | Disease or Syndrome (T047) |
Italian | Infezione del midollo spinale |
Japanese | 脊髄感染, セキズイカンセン |
Czech | Infekce míchy |
English | infection spinal cord, cord infections spinal, spinal cord infection, cord infection spinal, Spinal cord infection, infection; spinal cord, spinal cord; infection |
Hungarian | gerincvelő fertőzés |
French | Infection de la moelle épinière |
Dutch | infectie; ruggenmerg, ruggenmerg; infectie, ruggenmerginfectie |
Portuguese | Infecções da medula espinhal |
Spanish | Infección de la médula espinal |
German | Rueckenmarksinfektion |