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#Dysfunction of the [[spinal cord]], presenting by motor and sensory deficits and [[sphincter]] incompetence
#Dysfunction of the [[spinal cord]], presenting by motor and sensory deficits and [[sphincter]] incompetence
#[[Paralysis]], which may quickly become irreversible
#[[Paralysis]], which may quickly become irreversible
According to a meta-analysis published in 2000, "the mortality rates of [[spinal cord|spinal]] [[epidural abscess]] have not changed significantly over the last 25 years". <ref name="pmid24340840">{{cite journal| author=Strauss I, Carmi-Oren N, Hassner A, Shapiro M, Giladi M, Lidar Z| title=Spinal epidural abscess: in search of reasons for an increased incidence. | journal=Isr Med Assoc J | year= 2013 | volume= 15 | issue= 9 | pages= 493-6 | pmid=24340840 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24340840  }} </ref><ref name="pmid11153548">{{cite journal| author=Reihsaus E, Waldbaur H, Seeling W| title=Spinal epidural abscess: a meta-analysis of 915 patients. | journal=Neurosurg Rev | year= 2000 | volume= 23 | issue= 4 | pages= 175-204; discussion 205 | pmid=11153548 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11153548  }} </ref>


==Complications==
==Complications==
Complications from epidural abscess include:
Complications from epidural abscess include:
*Neurological deficits
*Neurological deficits
*[[Meningitis]]
*[[Sepsis]]
*Irreversible [[paralysis]]
*Irreversible [[paralysis]]
*[[Sepsis]]
*[[Sepsis]]
Line 39: Line 38:


==Prognosis==
==Prognosis==
The most important factor to predict the final outcome is the ''patient's neurological status'' before the [[neurosurgery|surgery]]: <ref name="Darouiche2006">{{cite journal|last1=Darouiche|first1=Rabih O.|title=Spinal Epidural Abscess|journal=New England Journal of Medicine|volume=355|issue=19|year=2006|pages=2012–2020|issn=0028-4793|doi=10.1056/NEJMra055111}}</ref>
The prognosis of epidural abscess is good. Full recovery has been common among survivors and the [[mortality rate]] has been low (<5%). In the event of death, it is usually due to [[sepsis]], secondary to prolonged [[immobility]], or evolution of [[meningitis]].<ref name=McGraw>{{Cite book  | last1 = Longo | first1 = Dan L. (Dan Louis) | title = Harrison's principles of internal medici | date = 2012 | publisher = McGraw-Hill | location = New York | isbn = 978-0-07-174889-6 | pages =  }}</ref> Poor outcomes are generally associated with three factors:<ref name="pmid8905751">{{cite journal| author=Khanna RK, Malik GM, Rock JP, Rosenblum ML| title=Spinal epidural abscess: evaluation of factors influencing outcome. | journal=Neurosurgery | year= 1996 | volume= 39 | issue= 5 | pages= 958-64 | pmid=8905751 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8905751  }} </ref>
*Age
*Degree of [[thecal sac]] compression
*Duration of [[symptoms]]
*Presence of [[purulent]] material, instead of [[granulation tissue]], indicating a more acute scenario
 
 
*absence of [[paralysis]] or its presence with less than 36 hours, is associated with better chances of returning to normal function and better chances of surviving;
 
The most important factor to predict the final outcome is the patient's neurological status prior to [[neurosurgery]]:<ref name="Darouiche2006">{{cite journal|last1=Darouiche|first1=Rabih O.|title=Spinal Epidural Abscess|journal=New England Journal of Medicine|volume=355|issue=19|year=2006|pages=2012–2020|issn=0028-4793|doi=10.1056/NEJMra055111}}</ref>
 
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
|+
! style="background: #4479BA; width: 120px;" | {{fontcolor|#FFF|Staging prior to [[neurosurgery]]}}
! style="background: #4479BA; width: 550px;" | {{fontcolor|#FFF|Findings}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Hematoma]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with a collection of [[blood]], [[bruise]] (if it occurs near the [[skin]]). If it occurs near the [[brain]], it may act as a [[mass effect]], and the patient may present with [[increased intracranial pressure]], midline shift, and [[brain herniation]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''[[Epidural hematoma]]'''
| style="padding: 5px 5px; background: #F5F5F5;" |Presents with a collection of [[blood]] in the [[epidural space]], [[headache]], [[back pain]], [[confusion]], [[weakness]],  and [[focal neurologic signs]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Subdural empyema]]'''
| style="padding: 5px 5px; background: #F5F5F5;" |Presents with a collection of [[purulent]] material accumulating in the [[subdural space]], [[mass effect]], [[fever]], [[headache]], [[altered mental status]], and [[seizures]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Brain abscess]] '''
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with a collection of [[purulent]] material within the [[brain]] tissue, [[confusion]], decreased movement, decreased sensation, decreasing responsiveness, drowsiness, [[fever]], [[headache]], [[loss of coordination]], [[nausea]], [[seizure]], and [[vomiting]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Meningitis|Chronic meningitis]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with [[inflammation]] of the [[meninges]], [[headache]], [[nuchal rigidity]], [[fever]], and [[altered mental status]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Tuberculous meningitis]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with [[inflammation]] of the [[meninges]], [[fever]], [[headache]], [[confusion]], and [[focal neurologic signs]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Tumor]], including primary parenchymal, [[metastatic]], and [[meningioma]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with an [[intracranial tumor]], [[focal neurologic signs]], [[increased intracranial pressure]], and [[seizures]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Temporal arteritis]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with [[inflammation]] of the [[blood vessels]] of the [[head]], commonly the large and medium [[arteries]], [[fever]], [[headache]], and [[focal neurologic signs]].
|-
|}
 
*Patients undergoing [[neurosurgery|surgery]] during '''stages 1 or 2''' are expected to become neurologically intact with possible decrease in risk of remaining [[radicular pain]].
*Patients undergoing [[neurosurgery|surgery]] during '''stages 1 or 2''' are expected to become neurologically intact with possible decrease in risk of remaining [[radicular pain]].
*Patients undergoing [[neurosurgery|surgery]] in '''stage 3''', may experience some improvement of the [[weakness]] felt before the [[neurosurgery|surgery]].
*Patients undergoing [[neurosurgery|surgery]] in '''stage 3''', may experience some improvement of the [[weakness]] felt before the [[neurosurgery|surgery]].
*Patients undergoing [[neurosurgery|surgery]] in '''stage 4''' may experience some neurological function improvement.
*Patients undergoing [[neurosurgery|surgery]] in '''stage 4''' may experience some neurological function improvement.


In recent studies full recovery has been common among survivors and the [[mortality rate]] has been low (<5%). In the event of death, it is usually due to [[sepsis]], secondary to prolonged [[immobility]] or evolution of [[meningitis]].<ref name=McGraw>{{Cite book  | last1 = Longo | first1 = Dan L. (Dan Louis) | title = Harrison's principles of internal medici | date = 2012 | publisher = McGraw-Hill | location = New York | isbn = 978-0-07-174889-6 | pages =  }}</ref> Studies from Khanna and colleagues<ref name="pmid8905751">{{cite journal| author=Khanna RK, Malik GM, Rock JP, Rosenblum ML| title=Spinal epidural abscess: evaluation of factors influencing outcome. | journal=Neurosurgery | year= 1996 | volume= 39 | issue= 5 | pages= 958-64 | pmid=8905751 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8905751  }} </ref> revealed three factors associated with poor outcomes:
*''age''
*''degree of thecal sac compression''
*''duration of [[symptoms]]''
Other important factors include:
*absence of [[paralysis]] or its presence with less than 36 hours, is associated with better chances of returning to normal function and better chances of surviving;
*presence of [[purulent]] material, instead of [[granulation tissue]], indicating a more acute scenario.


Considering that following treatment,  neurological function improvements are noticed during one year, with the help of rehabilitation, the final neurological outcome and functional capacity of these patients should only be fully assessed after a one year period. <ref name="Darouiche2006">{{cite journal|last1=Darouiche|first1=Rabih O.|title=Spinal Epidural Abscess|journal=New England Journal of Medicine|volume=355|issue=19|year=2006|pages=2012–2020|issn=0028-4793|doi=10.1056/NEJMra055111}}</ref>
Considering that following treatment,  neurological function improvements are noticed during one year, with the help of rehabilitation, the final neurological outcome and functional capacity of these patients should only be fully assessed after a one year period. <ref name="Darouiche2006">{{cite journal|last1=Darouiche|first1=Rabih O.|title=Spinal Epidural Abscess|journal=New England Journal of Medicine|volume=355|issue=19|year=2006|pages=2012–2020|issn=0028-4793|doi=10.1056/NEJMra055111}}</ref>

Revision as of 18:32, 13 November 2015

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]; Anthony Gallo, B.S. [3]

Overview

An epidural abscess is a rare suppurative infection of the central nervous system, a collection of pus localised in the epidural space, lying outside the dura mater, which accounts for less than 2% of focal CNS infections. [1] It may occur in two different places: intracranially or in the spinal canal. Due to the fact that the initial symptoms and clinical characteristics are not always identical and are similar in other diseases, along with the fact that they are both rare conditions, the final diagnosis might be delayed in time. This late diagnosis comes at great cost to the patient, since it is usually accompanied by a bad prognosis and severe complications with a potential fatal outcome. According to the location of the collection, the two types of abscesses may have different origins, different organisms involved, symptoms, evolutions, complications and therapeutical techniques. [2] In either type of abscess, the treatment fundamentals are somehow similar, they both involve broad-spectrum antibiotics, until a specific organism is identified, at which time, antibiotics should be re-rirected to that agent, along with surgical drainage.

Natural History

Intracranial Epidural Abscess

If left untreated, intracranial epidural abscess may cause headache, fever, and seizures. If left untreated the condition will aggravate and severe complications will arise, possibly leading to a fatal outcome. Proper diagnosis and treatment are therefore mandatory. Treatment usually involves aggressive antibiotic therapy and surgical drainage.

Spinal Epidural Abscess

If left untreated, spinal epidural abscess may cause the following, which are classified into 4 stages:[3][4][5][6]

  1. Back and focal vertebral pain, with tenderness; fever; back pain; neurologic deficits
  2. Nerve root pain, described as being "electric-shock" like, radiating from affected areas, sometimes accompanied by paresthesia
  3. Dysfunction of the spinal cord, presenting by motor and sensory deficits and sphincter incompetence
  4. Paralysis, which may quickly become irreversible

Complications

Complications from epidural abscess include:

The rate of complications rises with the increase of time to reach the proper diagnosis and begin therapy.

Prognosis

The prognosis of epidural abscess is good. Full recovery has been common among survivors and the mortality rate has been low (<5%). In the event of death, it is usually due to sepsis, secondary to prolonged immobility, or evolution of meningitis.[1] Poor outcomes are generally associated with three factors:[7]


  • absence of paralysis or its presence with less than 36 hours, is associated with better chances of returning to normal function and better chances of surviving;

The most important factor to predict the final outcome is the patient's neurological status prior to neurosurgery:[4]

Staging prior to neurosurgery Findings
Hematoma Presents with a collection of blood, bruise (if it occurs near the skin). If it occurs near the brain, it may act as a mass effect, and the patient may present with increased intracranial pressure, midline shift, and brain herniation.
Epidural hematoma Presents with a collection of blood in the epidural space, headache, back pain, confusion, weakness, and focal neurologic signs.
Subdural empyema Presents with a collection of purulent material accumulating in the subdural space, mass effect, fever, headache, altered mental status, and seizures.
Brain abscess Presents with a collection of purulent material within the brain tissue, confusion, decreased movement, decreased sensation, decreasing responsiveness, drowsiness, fever, headache, loss of coordination, nausea, seizure, and vomiting.
Chronic meningitis Presents with inflammation of the meninges, headache, nuchal rigidity, fever, and altered mental status.
Tuberculous meningitis Presents with inflammation of the meninges, fever, headache, confusion, and focal neurologic signs.
Tumor, including primary parenchymal, metastatic, and meningioma Presents with an intracranial tumor, focal neurologic signs, increased intracranial pressure, and seizures.
Temporal arteritis Presents with inflammation of the blood vessels of the head, commonly the large and medium arteries, fever, headache, and focal neurologic signs.
  • Patients undergoing surgery during stages 1 or 2 are expected to become neurologically intact with possible decrease in risk of remaining radicular pain.
  • Patients undergoing surgery in stage 3, may experience some improvement of the weakness felt before the surgery.
  • Patients undergoing surgery in stage 4 may experience some neurological function improvement.


Considering that following treatment, neurological function improvements are noticed during one year, with the help of rehabilitation, the final neurological outcome and functional capacity of these patients should only be fully assessed after a one year period. [4]

References

  1. ↑ 1.0 1.1 Longo, Dan L. (Dan Louis) (2012). Harrison's principles of internal medici. New York: McGraw-Hill. ISBN 978-0-07-174889-6.
  2. ↑ Danner, R. L.; Hartman, B. J. (1987). "Update of Spinal Epidural Abscess: 35 Cases and Review of the Literature". Clinical Infectious Diseases. 9 (2): 265–274. doi:10.1093/clinids/9.2.265. ISSN 1058-4838.
  3. ↑ Mandell, Gerald L.; Bennett, John E. (John Eugene); Dolin, Raphael. (2010). Mandell, Douglas, and Bennett's principles and practice of infectious disease. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0-443-06839-9.
  4. ↑ 4.0 4.1 4.2 Darouiche, Rabih O. (2006). "Spinal Epidural Abscess". New England Journal of Medicine. 355 (19): 2012–2020. doi:10.1056/NEJMra055111. ISSN 0028-4793.
  5. ↑ Mooney RP, Hockberger RS (1987). "Spinal epidural abscess: a rapidly progressive disease". Ann Emerg Med. 16 (10): 1168–70. PMID 3662166.
  6. ↑ Liem LK, Rigamonti D, Wolf AL, Robinson WL, Edwards CC, DiPatri A (1994). "Thoracic epidural abscess". J Spinal Disord. 7 (5): 449–54. PMID 7819646.
  7. ↑ Khanna RK, Malik GM, Rock JP, Rosenblum ML (1996). "Spinal epidural abscess: evaluation of factors influencing outcome". Neurosurgery. 39 (5): 958–64. PMID 8905751.
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