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Spinal Epidural Abscess: Zebra in horse’s clothing

Spinal epidural abscess (SEA) is a challenging diagnosis to make in the Emergency Department (ED), with a diagnostic delay occurring in about 75% of patients. To ultimately make a diagnosis of SEA, patients typically require an MRI, and so physicians may often have diagnostic hesitancy, as MRI’s are such a challenging test to obtain in the ED. Here, we will take a deeper look at the evidence surrounding spinal epidural abscess, to develop a more consistent approach to this patient population...

It is estimated that the vast majority of patients (90-98%) have at least one risk factor for SEA, making these features an critical part of the consideration in patients with back pain.

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 Diagnosing Spinal Epidural Abscesses

SEA is as deadly as it is elusive. Here’s a case-based guide to diagnosis and management of this needle in a haystack.

 High risk back pain: Spinal Epidural Abscess

SEA typically occurs from hematogenous spread, extension of nearby infection, or from iatrogenic inoculation. Staphylococcus aureus is responsible for the majority of infections. 20% of SEAs occur anterior to the spinal cord. These lesions, which are typically associated with vertebral osteomyelitis, are thought to cause more systemic features which can make the diagnosis more obvious. Unfortunately most (80% of cases) occur in the posterior region, and these patients are less likely to experience systemic symptoms such as a fever. Lesions occur most commonly in the lumbar region, however cervical and thoracic lesions often present atypically, are commonly missed, and account for a disproportionate number of cases that result in a lawsuit.

 I Ain't Missing You – Spinal Epidural Abscess

SEA is the condition with proportionately the highest misdiagnosis rate in ED... and long-term sequelae for patients with associated medico-legal costs are high. However, there is a need for clinicians to not let SEA become the next pulmonary embolism with high rates of over investigation.

 ID Rounds: Think Spinal Epidural Abscess in Nontraumatic Back Pain

Risk factors for developing an SEA include being male, over age 30 (though it can occur at any age), IV drug use, alcoholism, spinal intervention, COPD, chronic renal failure, HIV, diabetes, hypertension, morbid obesity, spinal trauma, having an indwelling catheter, skin abscess, and transient bacteremia (any cause).

 Not Another Missed Spinal Epidural Abscess

We present the following case, not as a miraculous catch, or a “zebra-hunting guide” but rather as a rare glimpse into the evolution of a disease process.

Articles of Interest

A rare case of multiple spinal epidural abscesses and cauda equina syndrome presenting to the emergency department following acupuncture

Emergency physicians should be aware that spinal abscesses may occur after acupuncture, with a broad spectrum of clinical presentations. If a history of recent acupuncture over the symptomatic area is elicited, a high index of suspicion should be maintained and appropriate imaging performed to establish the diagnosis.

An Algorithm for Diagnosing Spinal Epidural Abscess

If my patient has a neuro deficit, I do not reflexively order MRI! I risk-stratify the patient for spinal infection first. Because most spinal infection patients don’t have a fever (75%, Davis, JEM 2004), most patients with spinal infection who have a neuro deficit do not have a fever either. Therefore, spinal infection patients with neuro deficits are frequently not suspected of having an infection, and a noncontrast MRI is often ordered initially. An alternate algorithm is if the patient presents with a neuro deficit and has no risk factors for spinal infection, I order an MRI, as in your algorithm. However, if he has spinal infection risk factors, I order the MRI with contrast.

Back Pain and Spinal Epidural Abscess

We delve into core content on red flags in back pain and spinal epidural abscess using Rosen’s Emergency Medicine and Tintinalli’s Emergency Medicine Chapter 279 as a guide.

Core EM: Spinal Epidural Abscess

Spinal Epidural Abscess may present insidiously and patients often lack the classic triad of fever, back pain and neurologic symptoms.

Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome

Neck and back pain are common chief complaints and together these conditions account for more health care spending in the United States than any other condition.1 While most cases of neck and back pain are due to benign musculoskeletal causes, some are related to potentially debilitating and life-threatening etiologies such as SEA.

EM ID: Diagnosing Spinal Epidural Abscess (SEA) with Lauren Westafer

The main challenge with SEA and VO is diagnosis. Not everyone with back pain needs MRI and especially in the emergency settings. However, here are the main patients to consider for emergent MRI...

Evidence Based Diagnosis of Spinal Epidural Abscess

Spinal epidural abscesses are pyogenic bacterial infections that can have an insidious onset before rapidly progressing to complete, irreversible paralysis. The consensus among our EM group is that misdiagnosis of spinal epidural abscesses at the first emergency department evaluation is the norm rather than the exception.

Pediatric Spinal Epidural Abscess: Recognition and Management in the Emergency Department

Fever, back pain, and neurologic symptoms are the classic triad of a spinal epidural abscess (SEA), but this presentation is seen in <10% of cases. Young children may present with variable symptoms such as abdominal pain or failure to bear weight.

REBEL Core Cast 37.0 – Spinal Epidural Abscess

Spinal Epidural Abscess may present insidiously and patients often lack the classic triad of fever, back pain and neurologic symptoms. Empiric Antibiotics should cover Staphylococcus (including MRSA) and Gram negative Bacilli. All patients with clinical suspicion require rapid evaluation with MRI as the diagnostic study of choice.

Recognizing and Managing Epidural Abscess

It is estimated that up to 77% of back pain presentations in the pediatric population are due to benign causes. These benign causes include muscle strains, back contusions, and sports-related injuries. However, there are more serious, but less common, causes to be considered in adolescents with back pain, especially when patients present with fever and labs point to a possible infection. Epidural abscess is a rare but serious condition that should be considered in patients with fever and localized back pain. Failure to appropriately diagnose and treat epidural abscess in a timely manner can cause significant irreversible neurological deficits.

Spinal Epidural Abscess

Despite advances in medical knowledge, imaging techniques, and surgical interventions, spinal epidural abscess remains a challenging problem that often eludes diagnosis and receives suboptimal treatment.

Spinal Epidural Abscess (SEA)

The presence of certain comorbidities places patients at increased risk for developing disease. However, 20% of patients with SEA will have no predisposing factors.

Spinal Epidural Abscess: An Infectious Emergency Case Report and Review

Spinal epidural abscess is an unusual disease in the pediatric age group, requires early diagnosis and prompt surgical drainage to insure a good clinical outcome. Back pain and fever are usually the only presenting symptoms occurring before precipitous neurologic deterioration.

Spinal Epidural Abscess: Challenges to Diagnosis and How to Improve

Diagnosing patients with SEA can be challenging due to nonspecific symptoms and presentation that overlaps with a myriad of pathological processes. Given its potential for causing rapid clinical deterioration, time from symptom onset to diagnosis is critical in managing this disease process. Areas that could benefit from continued research include reducing this diagnostic time interval and implementation of whole spine imaging when indicated to detect the presence of noncontiguous lesions.

Spinal Epidural Abscess—Avoiding Neurologic Catastrophe in the ED

Although injection drug use is the most common hematogenous source of SEA, accounting for 52% of cases in some populations, diabetes mellitus is the most common risk factor overall, followed by trauma, intravenous drug use, and alcoholism. Back pain is the most common symptom. The “classic” triad of SEA (fever, back pain, and neurologic deficits) is uncommon and present in fewer than 20% of patients.

Toward Moving the Needle in the Haystack

The dogma that many emergency physicians learn about paralysis related to spinal epidural abscesses (SEA) goes something like “what the patient goes into the OR with is what they come out with.” Thus, over and over in M&M conference, we are taught time is of the essence.

Resources

Life in the Fastlane

Spinal epidural abscess is considered a neurosurgical emergency, morbidity and mortality is worse with delayed diagnosis, and the worse the neurological deficit at the time of surgery the worse the outcome, surgery within 24 hours of symptom onset is associated with the best prognosis.

Radiopaedia

Spinal epidural abscess is an uncommon condition with an estimated incidence of 2-3 per 10,000 hospital admissions. It has a peak incidence in the 5th-7th decades of life with a male predominance, which might be due to predisposing conditions and risk factors that are more prevalent in older people.

Taming the SRU

Abscesses arise in the spinal epidural space through a hematogenous route (accounting for approximately 50% of cases) or through direct extension from local infections (i.e. local diskitis or osteomyelitis).