Spinal Abscess. Why Care

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Spinal Abscess. Why Care?

• Irreversible paralysis affects up to 22 of
  patients, not because of bacterial virulence but
  due to delayed diagnosis.
• 50 of patients are initially misdiagnosed.
• Paralysis lasting greater than 24 hrs is
  irreversible.

• Khanna RK. Spinal epidural abscess evaluation of
  factors influencing outcome. Neurosurgery
  199639958-964.
• Darouiche, R. Spinal Epidural Abscess, Review
  Article. NEJM 2006 3552012-20
• Heusner AP. Nontuberculous spinal epidural
  infections. N Engl J Med 239845-854

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Epidural Abscess

• Classic description is focal vertebral pain,
  which becomes radiating pain along involved nerve
  roots.
• Most commonly involves the thoracic spine (50-80
  of cases) lumbar in 17-38 and the cervical
  spine in 10-25 of cases.
• Spinal epidural abscess most often occurs by
  systematic hematogenous spread of the infectious
  organism.
• A spinal epidural abscess can less commonly occur
  by direct infection of the epidural space as with
  a catheter or needle. (eg. Lumbar Puncture)

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Distribution of Spinal Abscess
The larger posterior epidural space contains
more infection-prone fat (than anterior).
Therefore, they are more in posterior space.
Rigamonti D, Liem L, Sampath P, et al. Spinal
epidural abscess contemporary trends in
etiology, evaluation, and management. Surg Neurol
199952189-197.
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Intramedullary (located within the spinal cord)
Leptomeningeal (subarachnoid space. Hence,
extramedullary and intradural)
Paravertebral
Epidural
Epidural
Byrne T. Spinal cord compression from epidural
metastases. N Engl J Med 1992327614
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Axial T2-weighted magnetic resonance imaging of
Staphylococcus aureus L2 epidural abscess
impinging the dorsolateral aspect of the spinal
canal. Marx Rosens Emergency Medicine
Concepts and Clinical Practice, 6th ED .
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Predisposing factors

• Trauma, prior surgery, or spinal procedures.
• Immunocompromised states
• Pregnancy
• Diabetes mellitus (Type I or II)
• Bacteremia (endocarditis, lung or abdominal
  abscess, or previous septic episodes)
• Osteomyelitis
• IV drug use
• Alcoholism
• Chronic renal failure

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Epidemiology

• 20 patients per 100,000 hospital admissions.
• Age injection drug users)
• Men Women

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Buggs
MRSA 15 in 1995, now up to 40 in 2006.
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Diagnosis

• Classic Triad

Fever
Spine pain
Neurological deficit
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Diagnosis

• Incontinence of bowel/bladder.
• Weakness / numbness below the level of the lesion.

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Diagnosis

• Nuchal rigidity suggesting the presence of
  meningeal irritation.
• Four clinical stages of spinal epidural abscess
  
• onset of focal vertebral pain.
• radiation of the pain along regionally involved
  nerve roots suggesting a radicular component.
• evidence of spinal cord compression with long
  tract signs.
• paralysis below the level of the spinal cord
  lesion.

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Differential Diagnosis

• Spinal Radiculopathy / polyradiculopathy
• Herniated Disk
• Bacterial meningitis.
• Osteomyelitis
• Spinal tumor / spinal hematoma.
• Multiple Sclerosis
• Spinal cord infraction

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Pitfalls in diagnosis

• Stage 2 nerve-root pain radiating from involved
  spinal area. (no motor weakness or sensory
  deficit at this point)
• Cervical or lumbar abscess neck pain radiating
  to the arms or low back pain radiating down to
  the legs, respectively.
• Thoracic abscess chest or abdominal pain.

Bremer AA, Darouiche RO. Spinal epidural abscess
presenting as intra-abdominal pathology a case
report and literature review. J Emerg Med
20042651-56
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Pitfalls in Diagnosis
Reihsaus E, Waldbaur H, Seeling W. Spinal
epidural abscess a meta-analysis of 915
patients. Neurosurg Rev 200023175-204.
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Treatment

• Neurosurgical consultation for possible
  decompression.
• Empiric antibiotics Nafcillin or Vancomycin
  (both for S. aureus) along with Ceftriaxone
  (Gram-negative) and Metronidazole (anaerobic
  organisms).
• 4 weeks course if osteomyelitis is not present.
• and 8 weeks for osteo is present

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Darouiche, R. Spinal Epidural Abscess, Review
Article. NEJM 2006 3552012-20
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Outcomes
Chao D, Nanda A. Spinal epidural abscess a
diagnostic challenge. Am Fam Physician
2002651341-6
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• 64yo woman is evaluated in the ED for 4 day hx
  of progressive leg weakness and numbness and a 1
  day hx of urinary incontinence. She also had
  increasingly severe midback pain for the past 2
  months. She has a history of breast cancer
  diagnosed 2 years ago, treated with surgery and
  local radiation therapy. Her only medication is
  tamoxifen.
• Physical exam shows normal mental status and
  cranial nerves. Strength in the arms is normal.
  Legs are diffusely weak, 3/5 proximally and 4/5
  distally. Sensory exam shows diminished pin
  sensation from the nipple downward vibratory
  sense is severely diminished in the feet.
  Reflexes are 2 in the biceps and triceps and 3
  in the knees and ankles. An extensor plantar
  response is present bilaterlly. Anal sphincter
  tone is deministed.
• Which of the following is the most appropriate
  diagnostic study at this time?
• CT of lumbar spine
• Electromyography and nerve conduction studies
• MRI of brain
• MRI of the entire spine
• Plain radiographs of the entire spine

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• 32yo woman is evaluated in the ED for 2 day hx
  of progressive numbness and weakness in the legs
  she has also noted urinary incontinence since
  awakening this morning. She has no significant
  medical history and has not had recent infections
  or vaccinations.
• Physical exam shows normal mental status and
  cranial nerves. Strength is normal in the arms.
  Both legs are very weak diffusely (2/5).
  Sensation to pinprick is diminished from the
  umbilicus down, and vibratory sensation is
  diminished in the toes. Reflexes are 2 in the
  biceps and triceps, 3 in the knees and ankles,
  with a bilateral extensor plantar response.
  Sagittal MRO of the spinal cord shows an
  enchancing lesion within the spinal cord, with
  edema, extending from the T8 to T10 level.
• Which of the following is the most appropriate
  initial management of this patient?
• Intramuscular interferon-beta
• Intravenous acyclovir
• Intravenous methylprednisolone
• Neurological decompenssion
• Oral prednisone

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• 82yo woman is brought to the ED after the sudden
  onset of bilateral leg weakness that occurred
  while she was gardening this morning. She has a
  hx of hypertension and peripherial vascular
  disease.
• Physical exam shows mental status and cranial
  nerves. Upper extremity strength is normal, but
  lower extremities are both severely weak (0/5).
  Sensation to pinprick is diminished from the T8
  level down vibration and proprioception are
  normal. Reflexes are 1 and symmetric in the
  upper and lower extremities an extenor plantar
  response is present bilaterally.
• Which of the following is the most likely
  diagnosis?
• Cauda equina compression
• Cerebellar hemorhage
• Pontine hemorrhage
• Spinal cord infarction

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