Background

A spinal epidural abscess is a suppurative CNS infection. Although individuals with this condition typically exhibit neurologic abnormalities, fever, and back pain, the manifestations of this condition might vary. If it’s not suspected clinically, diagnosing this illness is challenging.

If it’s not suspected clinically, diagnosing this illness is challenging.  substantial mortality and morbidity if left untreated. Consequently, any clinical concerns associated with this diagnosis require early investigation and treatment.

The emergence of current radiographic techniques, such as MRIs and computerized tomography, has substantially facilitated the identification and treatment of this condition.

Epidemiology

It’s unusual to be diagnosed with this condition. Only 1.2 out of 10,000 individuals are affected. Although spinal epidural abscesses are uncommon, their prevalence has increased over the past decade. This increase in diagnosis is attributed to the increased use of invasive spinal surgeries, the increased use of intravenous drugs, and the ageing of the population.

In 1/3rd of cases, there isn’t any source of infection, but the main risk factor is diabetes mellitus. 33% of the patients diagnosed with this condition have diabetes. Other significant risk factors which contribute to the development of this condition include the use of intravenous drugs, and the use of any instrumentation in the epidural space.

Instrumentation of the epidural space during a epidural catheter installation or lumbar puncture can inoculate bacteria straight into the epidural space, resulting in infection. Notably, the incidence of this condition after implementing an epidural catheter is between 0.5% and 3%.

Here is the breakdown for the agents which cause this illness:

• Streptococcal infections- 9%
• Gram-negative Bacilli- 16%
• Staphylococcus aureus- 63%
• Other fungi/mycobacteria/bacteria- 10%

Anatomy

Pathophysiology

Bacteria infiltrate the epidural space and colonize the spinal canal region between the vertebral wall and dura matter. The introduction of these germs into this typically sterile area causes a suppurative infection in this restricted area. This typically arises through hematogenous seeding of the epidural space.

Respiratory tract infections, UTIs, infected catheters, and endocarditis can cause hematogenous dissemination. Additionally, bacteria can infiltrate the epidural space via direct extension of contaminated tissue. This occurs when vertebral osteomyelitis, discitis, or a psoas abscess results in an epidural spinal abscess.

Moreover, such an abscess may occur from the direct infection of this tissue. Lumbar punctures, epidural injections, epidural catheter placements and any other procedures involving the central nervous system (CNS) may all result in epidural abscess via direct inoculation. Upon gaining access to the epidural space, bacteria cause a pyogenic infection that leads to an abscess.

Several processes can cause injure the spinal cord, including

• Direct compression from an enlarging abscess,
• Thrombophlebitis or thrombosis of surrounding veins
• Blockage of arterial blood supply
• Bacterial toxins

Typically, 3-5 spinal cord segments are affected by a spinal epidural abscess. Due to the fact that spinal epidural abscesses are typically produced by hematogenous dissemination, 9% of patients will have two or more noncontiguous pyogenic collections.

Etiology

In individuals affected with this condition, germs invade the epidural space and cause a suppurative infection. Typically, germs enter the epidural area by hematogenous dissemination.

Risk factors for this condition include:

• Direct instrumentation (epidural or paraspinal injections, CNS surgery)
• The use of intravenous drugs
• Immunosuppressive conditions like AIDS, renal disease, cirrhosis, alcoholism, diabetes

Diabetes mellitus is the most significant risk factor for this condition. However, epidural catheter implantation and intravenous drug use are becoming increasing more prevalent risk factors for the onset of this condition.

Genetics

Prognostic Factors

A delayed diagnosis may result in an increase in residual weakness or a permanent neurologic disability. Approximately 5% of people die from sepsis or other associated conditions.

In addition, 4% to 22% of patients suffer from permanent paraplegia. If surgery is postponed 24-48 hours after the onset of neurologic deficit, neurologic recovery is typically favorable.

There is little data in the literature regarding neurological recovery after surgery. However, recovery is unpredictable and often influenced by numerous factors, such as time, health, time after diagnosis, and age. Treatment must be initiated as soon as possible.

Clinical History

Physical Examination

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Medication

Future Trends

Media Gallary

References

https://www.ncbi.nlm.nih.gov/books/NBK441890/