II. Epidemiology

  1. Incidence: 0.2 to 2.8 cases per 10,000 per year
  2. Most common in ages 31 to 70 years old (peak Incidence ages 60-70 years old)
    1. Also occurs in children <5 years old
  3. Gender predominance: Males by a ratio >2:1

III. Precautions

  1. Spinal Epidural Abscess is frequently misdiagnosed on initial presentation
    1. Triad of back pain, fever and neurologic deficit is present in <15% of cases
    2. Fever is present in <50% of cases
  2. Be alert for red flag presentations (esp. with back pain)
    1. Unexplained fever (present in 86% of cases)
    2. Focal neurologic deficits with progressive or disabling symptoms (present in 82% of cases)
  3. References
    1. Bhise (2017) Am J Med 130(8): 975-81 +PMID: 28366427

IV. Types: Spinal Infection

  1. Spinal Epidural Abscess (SEA) - typically the primary infection site
    1. Infection in the space between the Dura Mater and the adjacent Vertebral Column
    2. Of the Spinal Infections, SEA is the most acute of presentations with fever, neurologic deficits and spinal pain
  2. Disc space infection (Discitis)
  3. Vertebral infection
    1. Spondylitis
    2. Osteomyelitis

V. Pathophysiology: Spinal Cord Injury Mechanisms

  1. Direct compression from Epidural Abscess
  2. Venous thrombosis or Thrombophlebitis of nearby veins
  3. Arterial perfusion disrupted
  4. Bacterial toxin induced injury
  5. Inflammatory mediator related injury

VI. Pathophysiology: Sources of Spinal Infection

  1. Hematogenous spread (50%)
  2. Contiguous spread (33%)
    1. Retropharyngeal Abscess
    2. Psoas Abscess
  3. Direct introduction of infection
    1. Spinal injection
    2. Spinal surgery

VII. Pathophysiology: Sites of Spinal Infection

  1. Most cases involve thoracolumbar spine
  2. Anterior Epidural Abscess (20%)
    1. Associated infections
      1. Disk space infection (Discitis)
      2. Vertebral Osteomyelitis
    2. Blunt Trauma and associated Hematoma infection
    3. Direct extension from adjacent infection
      1. Retropharyngeal Abscess
      2. Retroperitoneal abscess
  3. Posterior Epidural Abscess (80%)
    1. Distant source (Cellulitis, dental, Pharyngitis)

VIII. Causes

  1. Acute Infection (within 5-10 days)
    1. Staphylococcus aureus (most common)
    2. Actinomycosis (rare)
  2. Chronic Infection (within 3-6 months)
    1. Other indolent infections
    2. Fungus
    3. Tuberculosis (Pott's Disease)
      1. Vertebral collapse
      2. Sharply angulated spinal deformity

IX. Risk Factors

  1. Idiopathic without risk factors in 20% of cases
  2. Intravenous Drug Abuse
    1. Back pain in IVDA is a Spinal Infection until proven otherwise
  3. Immunodeficiency
    1. HIV Infection or AIDS
    2. Chronic Renal Failure (esp. Dialysis)
    3. Advanced Liver Disease
    4. Diabetes Mellitus
    5. Alcoholism
    6. Malignancy
    7. Immunosuppressants (e.g. Chemotherapy, Corticosteroids)
    8. Advanced Age
  4. Recent spinal procedure
    1. Spinal surgery
    2. Epidural Anesthesia
  5. Recent back Trauma
  6. Concurrent infectious sources
    1. Genitourinary infection
    2. Skin Infection
    3. Poor Dentition (Associated with Actinomyces)

X. Symptoms

  1. Back pain (70-90% of cases)
    1. Associated with secondary Muscle spasm
    2. Severe localized back pain not relieved with rest
    3. Pain provoked by standing and bearing weight
      1. Children may limp or refuse to crawl or walk
  2. Systemic symptoms
    1. Fever (30-60% of cases)
    2. Rigors
    3. Malaise
  3. Neurologic compromise (33% to 70% of cases, indicates spinal compression)
    1. Findings are often subtle, especially early in course
    2. Bowel or Bladder dysfunction
    3. Extremity weakness

XI. Signs

  1. Focal tenderness at involved spinous process (60-70% of cases)

XII. Precautions

  1. Keep a high index of suspicion
    1. Classic triad of back pain, fever and neurologic symptoms occurs in <37% of patients
  2. Avoid Lumbar Puncture
    1. Not diagnostic
    2. Risk of contiguous seeding of subarachnoid space (and secondary Meningitis)
  3. Disposition to rapid intervention at time of diagnosis
    1. Delays result in greater risk for neurologic injury
    2. Abscess results in direct mechanical compression of the spinal cord
    3. Local infection may result in ischemic injury to the cord via thrombosis of vessel Occlusion

XIII. Labs

  1. Complete Blood Count
    1. Leukocytosis (30 to 66% of cases)
  2. Acute phase reactants (increased in 95% of cases)
    1. Erythrocyte Sedimentation Rate (ESR) increased
    2. C-Reactive Protein (C-RP) increased
  3. Blood Cultures
    1. Identify responsible organism in 60% of cases

XIV. Imaging

  1. Gadolinium-enhanced Spine MRI (preferred)
    1. Test Sensitivity >90%
    2. Enhancing Lesion seen in T2-Weighted Images
    3. Differentiates Diskitis from Vertebral Osteomyelitis
    4. Skip lesions are present in 15% of cases and have several associated risk factors
      1. Older age
      2. Very high Erythrocyte Sedimentation Rate (ESR)
      3. Concurrent area of infection outside the spine
      4. Longer symptom duration
  2. CT with Myelography
    1. Indicated when MRI is contraindicated or unavailable
    2. Underestimates Spinal Epidural Abscess size

XV. Evaluation

  1. Have a high index of suspicion (see precautions above)
  2. Low risk patients (significant risk factors, reassuring history and exam)
    1. No imaging needed
  3. Moderate risk patients (risk factors present, but no motor deficits)
    1. Obtain CRP and ESR and if elevated obtain MRI
  4. High risk patients (motor deficits identified)
    1. Obtain MRI

XVI. Management

  1. Emergent Neurosurgery or Spine SurgeryConsultation
  2. Surgical decompression (first-line, preferred management)
    1. Indications
      1. Developing or worsening neurologic deficits
        1. However, pre-surgical paralysis may not benefit from surgery
      2. Cervical or Thoracic Spine involvement
        1. Higher risk for neurologic complications than Lumbar Spine (except Cauda Equina Syndrome)
      3. Phlegmon
    2. Open decompression (preferred)
      1. May be performed with endoscopy-assisted surgery
    3. Percutaneous drainage (aspiration under CT guidance)
      1. Consider in posterior Spinal Epidural Abscess AND
      2. Lack of neurologic deficit OR high surgical risk patient
    4. References
      1. Epstein (2015) Surg Neurol Int 6(suppl 19): S476-86 [PubMed]
  3. Empiric Antibiotics
    1. Start early empiric therapy and modify based on culture results
      1. Discuss with neurosurgery (may ask to withhold antibiotics until surgical culture obtained)
      2. Typical IV antibiotic duration: 6 weeks
    2. Drug 1: MRSA Coverage (Staphylococcus aureus is most common cause, used with drug 2 below)
      1. Vancomycin 15-20 mg/kg IV every 8-12 hours (dosing must be calculated based on weight, levels)
      2. Alternatives: Linezolid, Daptomycin
    3. Drug 2: Gram Negative, esp. IVDA, Immunosuppression, UTI (used in combination with MRSA Drug 1 coverage)
      1. Gram Negative Coverage without Pseudomonas coverage
        1. Ceftriaxone 2 g IV every 24 hours
        2. Cefepime 2 g IV every 8 hours
        3. Levofloxacin 750 mg IV every 24 hours
      2. Gram Negative With Pseudomonas coverage as indicated (e.g. IV Drug Abuse, recent hospitalization)
        1. Ceftazidime 1-2 g IV every 8-12 hours
        2. Ciprofloxacin 400 mg IV every 12 hours
        3. Piperacillin-Tazobactam 4.5 g IV every 6 to 8 hours
        4. Meropenem 1 g IV every 8 hours
    4. Drug 3: Anaerobe Coverage
      1. Metronidazole 500 mg IV every 6 hours
    5. Candida Coverage Indications
      1. Immunocompromised State
      2. Recent Spine Surgery
    6. Other modified antibiotic coverage
      1. Mycobacterium tuberculosis suspected

XVII. Prognosis: Positive prognostic indicators

  1. Intact or only mild neurologic symptoms prior to intervention
    1. Most accurate prognostic indicator
    2. Neurologic symptoms progress with delayed diagnosis
    3. Residual deficits persist after surgery in 50% of cases (paralysis is often irreversible)
  2. Age under 60 years
  3. Cord symptoms (e.g. Bladder dysfunction) <24 hours
  4. No comorbid conditions
  5. Thecal sac compression <50%

XVIII. Complications

  1. Cauda Equina Syndrome
    1. Results from direct mechanical compression of cord
  2. Meningitis (or overwhelming Sepsis)
    1. Results from spread into subarachnoid space
  3. Mortality
    1. Mortality rate: 5%

XIX. References

  1. Dasburg (2020) Crit Dec Emerg Med 34(6): 28-9
  2. Della-Giustina (2014) Crit Dec Emerg Med 28(3): 2-9
  3. Long and Carlson in Swadron (2022) EM:Rap 22(7): 7-9
  4. Bond (2016) Biomed Res Int 2016:1614328 +PMID: 28044125 [PubMed]
  5. Chao (2002) Am Fam Physician 65(7):1341-6 [PubMed]
  6. Tompkins (2010) J Emerg Med 39(3): 384-90 [PubMed]

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Related Studies

Ontology: Discitis (C0012624)

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: 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