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Update on Spinal Epidural Abscess

Early diagnosis and treatment are vital.

Rabih O. Darouiche reviews the pathogenesis of bacterial spinal epidural abscess, its clinical features, diagnosis, treatment, common diagnostic and therapeutic hazards, and outcomes.

Spinal epidural abscess generally presents as a hematogenous spread of bacterial infection (most commonly, Staphylococcus aureus). Clinical signs and symptoms are caused either directly by compression or indirectly by ischemia due to thrombophlebitis. Symptoms progress from back pain to nerve root pain to neurologic compromise to paralysis. The most vital diagnostic modality is MRI with intravenous gadolinium. White blood cell counts, tests for inflammatory markers, blood cultures, plain radiographs, and CT scans provide diagnostic confirmation. Management generally consists of surgical decompression and antibiotics. Conservative treatment (antibiotics) usually is reserved for patients with high operative risk, paralysis lasting up to 24 to 36 hours, panspinal infection, or lack of consent to surgery.

Comment: This interesting, concise review of the literature highlights the paucity of analytical studies on the management of spinal epidural abscess. The conclusions therefore are generally based on retrospective observational case series. The article nevertheless is important in emphasizing some important management issues. Darouiche supports early intervention because of the unpredictable and variable rate of progression of neurologic decline and because of the importance of disease stage at intervention in treatment outcome. The author also suggests a role for surgical intervention, even in patients with complete paralysis, to manage the source of sepsis. The article illustrates the need for further evaluation of nonsurgical therapy, as selection bias mars the current literature on this subject. Darouiche concludes by accentuating the need for close monitoring during treatment, as recurrence after initial recovery is not unusual.

— Sagun Tuli, MD, MSc, FRCSc

Dr. Tuli is Spine Neurosurgeon, Brigham and Women’s Hospital, and Assistant Professor, Harvard Medical School, Boston.

Published in Journal Watch Neurology January 2, 2007

Citation(s):

Darouiche RO. Spinal epidural abscess. N Engl J Med 2006 Nov 9; 355:2012-20.

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