SPINAL EPIDURAL ABSCESS

Clinical Vignette

A 52-year-old diabetic man experienced a nonspecific upper respiratory tract syndrome typically thought of as influenza. Within Just a few days, he developed increasingly severe midthoracic spine pain. He soon developed rigors, chills, and vomiting. His symptoms rapidly worsened over the subsequent 12-24 hours. He then suddenly noted numbness in both legs spreading up to his midback. He soon had trouble climbing stairs and after lying down to regain his strength was unable to arise from bed even with his wife’s attempted help. He could not urinate. His family called the local emergency ambulance and had him taken to the hospital.

Neurologic examination demonstrated that he was paraplegic and had a T6 sensory level with marked loss of sensation below his nipple line. The patient required urinary catheterization. Spinal MRI demonstrated an epidural abscess extending between T4 and T10. Although an immediate neurosurgical decompression was carried out, unfortunately this patient had only partial resolution of his neurologic deficit.

Epidural spinal abscess patients typically present with fever and relatively severe back pain, sometimes with varying degrees of leg weakness. There are four clinical stages: (1) focal vertebral pain, (2) radicular pain corresponding to the dermatomal course of the specific involved nerve roots, (3) early signs of spinal cord compression such as paresthesias, weakness, or delayed ability to urinate, and (4) paralysis below the lesion level.

A purulent or granulomatous collection within the spinal epidural space may overlie or encircle the spinal cord, nerve roots, and nerves (Fig. 48-5). Although the infection is usually localized within three to four vertebral segments, it rarely extends the length of the spinal canal.

S. aureus is the most common organism leading to a spinal epidural abscess, but aerobic or anaerobic streptococci and gram-negative organisms are occasionally isolated. Mixed anaerobic and aerobic organisms are sometimes responsible. When no organism is isolated or if granulomas are identified,

M. tuberculosis infection of the spine, for example, Pott disease, also requires consideration. A skin infection, especially a furuncle, is the most common focus for a hematogenous spread to the epidural space. An antecedent vertebral osteomyelitis with a prior hematogenous source is responsible for approximately 40% of spinal epidural abscess. Dental and upper respiratory tract infections are other common predisposing lesions.

Any patient presenting with back pain, fever, and localized tenderness or signs of cord compression requires immediate and complete spinal MRI. Surgical or CT-guided needle aspiration is necessary to define an accurate diagnosis and possible decompression. Blood cultures are recommended. Lumbar puncture

Anterior sp

Artery.

Epidural abscess. Sagittal T1-weighted images without (A.) and with (B) gadolinium enhancement demonstrate an extensive posterior epidural process from T6 to T11. Enhancement of the granulation tissue allows appreciation of nonenhancing focal pus collections.

Figure 48-5 Spinal Epidural Abscess.

Should not be performed. Appropriate parenteral antibiotics are necessary for 3 to 4 weeks in uncomplicated cases and for up to 8 weeks or more if osteomyelitis is present.

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