Wednesday, November 11, 2009
Epidural abscess
Today we discussed spinal epidural abscess. This is a very serious and comonly missed diagnosis, requiring a high index of suspicion.
Some points:
Predisposing conditions
1) Immunocompromise - DM2, EtOH, HIV
2) Spinal abnormality/intervention - degenerative disk disease, trauma, surgery, catheters
3) Local or systemic source of infection - skin, osteomyelitis, UTI, sepsis, catheter
Pathophysiology
Contiguous spread in a third, bacteremia in half, rest not identified.
Microbiology
1) St. aureus (MSSA or MRSA) in over half of cases
2) St. epidermidis (with devices/hardware)
3) GNs (e.coli, pseudomonas)
Rare: anaerobes, TB, fungal, parasitic
Complications:
1) cord compression
2) cord ischemia
3) osteomyelitis
4) endocarditis
5) psoas abscess
Staging of symptoms
1) back pain
2) nerve root pain
3) motor weakness, sensory deficit, bowel/bladder
4) paralysis
Tempo of progression is variable; may be hours to days.
Location: more common in posterior, thoracic, lumbar areas (more fat). Occasionally, pan-spinal.
Diagnosis:
MRI with gad and myelography then CT are methods of choice (MRI best). Bacteremia in 60%.
Treatment:
Surgical if neurological impairment and less than 24-36h of symptoms, and not panspinal infection (tx is laminectomy, drainage)
Abx: Empric coverage of staph (usu vanco), gram negatives, (ceftriaxone or pseudomonas coverage if high risk) Best to have microbiologic diagnosis prior to abx; aspirate may be needed if BC are negative.
Link:
Click here for a good NEJM review on paraspinal abscess
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