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epidural abscess



  • Spontaneous epidural abscess is rare, accounting for 0.2–1.2 cases per 10 000 hospital admissions per year
  • some patients have a pre-existing haematoma from an injury in the preceding weeks which then becomes infected.
  • usually are haematogenous spread and seeding in patients with either:
  • may spread from bacterial vertebral osteomyelitis / discitis
    • most are from haematogenous seeding as for epidural abscesses (see above), but in this case they may be from UTIs or respiratory infections
    • discitis occurs in 1-2% of post-op spinal surgery patients in which case they are generally skin flora
    • some cases are due to tuberculosis (TB)
  • rarely, they may result from direct inoculation of bacterial such as with:
    • complication of dry needling or acupuncture of the spine
      • epidural haematomas are uncommon complications of dry needling of the spine 1)2), and when these occur, they may develop into abscesses
    • complication of central nerve blocks such as epidural blocks or epidural steroid injections 3) 4) 5)
      • incidence 1:1000 to 1:100 000
      • most patients have risk factors such as compromised immunity, spinal column disruption, source of infection
      • risk increases with duration of epidural > 2 days
      • even with aseptic technique and 10% povidone iodine skin prep, 18% of the used epidural or spinal needles end up contaminated with bacteria suggesting that there is a risk of inoculation of skin or nasal flora into the epidural space.


Clinical presentation

  • usually present with progressive midline spine pain
  • usually have fever and this is usually the first clinical feature, but fever may also be a late feature
  • some may have clinical evidence of acute spinal cord compression, although only around 13% have the classic triad of fever, back pain and new neurology
  • some may develop meningism, especially if cervical


Initial Ix of suspected spinal infection

  • clinical history and examination, particularly looking for risk factors and for evidence of focal spinal tenderness and neurology
  • FBE, U&E, CRP, ESR, 2 sets of blood cultures
  • if sepsis is possible based upon clinical features or WCC or raised CRP, then consider emergent MRI scan that day and referral to neurosurgery
  • consider empirical broad spectrum antibiotics with staph coverage after discussion with neurosurgery
  • definitive management will probably require laminectomy and drainage at a neurosurgical center
    • some patients may be medically managed
      • if organism not detected on cultures, consider CT guided needle aspirate to determine organism and sensitivities
    • all patients usually required many weeks of iv antibiotics
  • use of corticosteroids is inconclusive


  • irreversible neurology
  • seeding or spread of infection to other sites:
    • vertebral osteomyelitis
    • endocarditis
    • psoas muscle abscess
    • meningitis
  • severe sepsis


  • many factors determine prognostic outcome:
    • age - probability of a worse outcome doubles with each decade of age
    • degree of thecal sac compression
    • duration of symptoms
    • severity of sepsis
    • presence of neurology (especially if persistent for > 36hrs)
    • location - in general, thoracic ones cause more neurology than lumbar ones
epidural_abscess.txt · Last modified: 2020/03/04 04:43 by

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