Epidural abscess overview
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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 to 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 abscess may have different origins, different organisms involved, symptoms, evolutions, complications and therapeutical techniques. [2] With the advent of antibiotics, along with accurate imaging studies and surgical techniques, prognosis and outcome of epidural abscess have greatly improved.
Historical Perspective
In general, abscesses were first described by Hippocrates between 400-370 B.C. Despite scientific advances, both epidural abscesses remain a serious health condition, with significant risks for patients. However, diagnosis, management and outcome have been considerably improved due to more accurate imaging studies, better antibiotics, and improved surgical techniques.[2]
Classification
Epidural abscess may be classified according to the location of the infection into 2 groups: intracranial and spinal.[2] Additionally, spinal epidural abscess can be further classified based on the duration of symptoms into either acute or chronic.
Pathophysiology
Epidural abscess pathophysiology differs based on the location of the infection and responsible organism. Intracranial epidural abscess occurs most frequently as a complication of cranial surgical procedures and sinusitis.[3] Spinal epidural abscess occurs most frequently as a result of spinal instrumentation, vascular access, and IV drug use.[4]
Causes
Common causes of intracranial epidural abscess include paranasal sinusitis, osteomyelitis of the skull, and extension of infection from otitis, mastoiditis or orbit. Common causes of spinal epidural abscess include spinal instrumentation, vascular access, and IV drug use. Irrespective of cause, epidural abscess is a life-threatening, but treatable, condition.
Differentiating Epidural Abscess from Other Diseases
Intracranial epidural abscess must be differentiated from epidural hematoma, subdural empyema, brain abscess, tuberculous meningitis, and other intracranial mass lesions. Spinal epidural abscess must be differentiated from other conditions that cause back pain, motor weakness, and/or spinal tenderness, such as arthritis, osteoarthritis, intervertebral disc disease, vertebral osteomyelitis, primary or metastatic tumors, and musculoskeletal pain.
Epidemiology and Demographics
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. [5]. It may occur in two different places: intracranially or in the spinal canal. According to the location of the infection, the epidemiology of each of the two types of abscess will differ. This is due to the nature of the location of the disease, but also due to other factors. In either case, to prevent severe morbidity and fatal outcomes, accurate diagnosis and prompt therapy should be applied as early as possible.
Diagnosis
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. [6] 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 to the ones 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. The diagnosis of epidural abscess should be first suspected from the clinical findings and posteriorly supported by laboratory tests and imaging studies, however it can only be confirmed after surgical drainage and proper study of the collected material. According to the location of the collection, the abscess may have different origins, different organisms involved, symptoms, evolutions, complications and therapeutical techniques. [2][7]
Symptoms
Symptoms will depend on the location of the abscess, therefore:
- Intracranial epidural abscess:
- Spinal epidural abscess:
- Fever
- Neurologic deficits, such as weakness and paresthesia
- Spinal pain
- Malaise
- Meningism
- Pain on palpation during physical examination of the spine
- Neonates and infants are often unspecifically described as being "unwell" [8]
Laboratory Findings
Patients with either type of epidural abscess, usually have:
- Elevated Erythrocyte Sedimentation Rate
- Elevated C-reactive protein
- Leukocytosis (about 2/3 of patients)
- Bacteremia, detected in about 60% of patients, may be the cause or be originated in the abscess, commonly Staphylococcus aureus
- Possible thrombocytopenia, particularly in adults [9]
- Thrombocytosis, particullarly in children [9]
Treatment
Medical Therapy
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. [10] 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 to 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 abscess may have different origins, different organisms involved, symptoms, evolutions, complications and therapeutical techniques. [2] The treatment of epidural abscess focuses in two main aspects: reduction of the inflammatory mass and eradication of the responsible organism. These goals can be reached through a combination of medical and surgical approaches. An early surgical decompression and drainage, along with an aggressive antibiotic treatment is the ideal procedure to increase the chances of a better outcome.
References
- ↑ Longo, Dan L. (Dan Louis) (2012). Harrison's principles of internal medici. New York: McGraw-Hill. ISBN 978-0-07-174889-6.
- ↑ 2.0 2.1 2.2 2.3 2.4 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.
- ↑ Fountas KN, Duwayri Y, Kapsalaki E, Dimopoulos VG, Johnston KW, Peppard SB; et al. (2004). "Epidural intracranial abscess as a complication of frontal sinusitis: case report and review of the literature". South Med J. 97 (3): 279–82, quiz 283. PMID 15043336.
- ↑ Strauss I, Carmi-Oren N, Hassner A, Shapiro M, Giladi M, Lidar Z (2013). "Spinal epidural abscess: in search of reasons for an increased incidence". Isr Med Assoc J. 15 (9): 493–6. PMID 24340840.
- ↑ Longo, Dan L. (Dan Louis) (2012). Harrison's principles of internal medici. New York: McGraw-Hill. ISBN 978-0-07-174889-6.
- ↑ Longo, Dan L. (Dan Louis) (2012). Harrison's principles of internal medici. New York: McGraw-Hill. ISBN 978-0-07-174889-6.
- ↑ Darouiche, Rabih O. (2006). "Spinal Epidural Abscess". New England Journal of Medicine. 355 (19): 2012–2020. doi:10.1056/NEJMra055111. ISSN 0028-4793.
- ↑ Fischer EG, Greene CS, Winston KR (1981). "Spinal epidural abscess in children". Neurosurgery. 9 (3): 257–60. PMID 7301067.
- ↑ 9.0 9.1 Grewal, S. (2006). "Epidural abscesses". British Journal of Anaesthesia. 96 (3): 292–302. doi:10.1093/bja/ael006. ISSN 0007-0912.
- ↑ Longo, Dan L. (Dan Louis) (2012). Harrison's principles of internal medici. New York: McGraw-Hill. ISBN 978-0-07-174889-6.