Epidural abscess natural history, complications and prognosis: Difference between revisions
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==Overview== | ==Overview== | ||
If left untreated, intracranial epidural abscess may cause [[headache]], [[fever]], and [[seizures]]. If left untreated, spinal epidural abscess may cause [[back pain]], [[nerve root]] pain, and [[paralysis]]. Complications of epidural abscess include neurological deficits, [[meningitis]], and [[sepsis]]. If treated timely, the prognosis for epidural abscess is generally good. | |||
==Natural History== | ==Natural History== | ||
===Intracranial Epidural Abscess=== | ===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 | 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 necessary. Treatment usually involves aggressive [[antibiotic]] therapy and [[neurosurgery|surgical drainage]]. | ||
===Spinal Epidural Abscess=== | ===Spinal Epidural Abscess=== | ||
If left untreated, spinal epidural abscess may cause the following, which | If left untreated, spinal epidural abscess may cause the following sequelae, which is classified into 4 stages:<ref name=Mandell>{{Cite book | last1 = Mandell | first1 = Gerald L. | last2 = Bennett | first2 = John E. (John Eugene) | last3 = Dolin | first3 = Raphael. | title = Mandell, Douglas, and Bennett's principles and practice of infectious disease | date = 2010 | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | isbn = 0-443-06839-9 | pages = }}</ref><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><ref name="pmid3662166">{{cite journal| author=Mooney RP, Hockberger RS| title=Spinal epidural abscess: a rapidly progressive disease. | journal=Ann Emerg Med | year= 1987 | volume= 16 | issue= 10 | pages= 1168-70 | pmid=3662166 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3662166 }} </ref><ref name="pmid7819646">{{cite journal| author=Liem LK, Rigamonti D, Wolf AL, Robinson WL, Edwards CC, DiPatri A| title=Thoracic epidural abscess. | journal=J Spinal Disord | year= 1994 | volume= 7 | issue= 5 | pages= 449-54 | pmid=7819646 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7819646 }} </ref> | ||
#[[Back pain|Back]] and focal [[vertebral]] pain, with [[tenderness]]; [[fever | #[[Back pain|Back]] and focal [[vertebral]] pain, with [[tenderness]]; [[fever]]; neurologic deficits | ||
#[[Nerve root]] [[pain]], described as being "electric-shock" like, radiating from affected areas, sometimes accompanied by [[paresthesia]] | #[[Nerve root]] [[pain]], described as being "electric-shock" like, radiating from affected areas, sometimes accompanied by [[paresthesia]] | ||
#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 | ||
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*[[Thrombophlebitis]] of adjacent [[veins]] | *[[Thrombophlebitis]] of adjacent [[veins]] | ||
*[[Ischemia]] | *[[Ischemia]] | ||
*Bacterial | *Bacterial [[toxin]]s | ||
*[[Inflammatory]] response and its mediators | *[[Inflammatory]] response and its mediators | ||
| Line 38: | Line 38: | ||
==Prognosis== | ==Prognosis== | ||
If treated timely, the prognosis of epidural abscess is generally good. Full recovery is common among survivors and the [[mortality rate]] is low (<5%). Mortality is usually due to [[sepsis]], prolonged [[immobility]], or the development 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> Positive outcomes are generally associated with: | |||
*Presence of [[purulent]] material, instead of [[granulation tissue]], indicating a more acute case | *Presence of [[purulent]] material, instead of [[granulation tissue]], indicating a more acute case | ||
*Absence of [[paralysis]] or its presence | *Absence of [[paralysis]] or its presence for < 36 hours, indicating increased chances of returning to normal function | ||
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> | The most important factor to predict the final outcome is the patient's neurological status prior to [[neurosurgery]]. The stages are:<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="border: 0px; font-size: 90%; margin: 3px;" align=center | ||
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|- | |- | ||
| style="padding: 5px 5px; background: #DCDCDC;" | '''Stages 1 and 2''' | | style="padding: 5px 5px; background: #DCDCDC;" | '''Stages 1 and 2''' | ||
| style="padding: 5px 5px; background: #F5F5F5;" | May become fully neurologically intact with possible decrease | | style="padding: 5px 5px; background: #F5F5F5;" | May become fully neurologically intact with possible decrease of remaining [[radicular pain]] | ||
|- | |- | ||
| style="padding: 5px 5px; background: #DCDCDC;" |'''Stage 3''' | | style="padding: 5px 5px; background: #DCDCDC;" |'''Stage 3''' | ||
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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> | 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 | *[[Age]] | ||
*Degree of thecal sac compression | *Degree of thecal sac compression | ||
*Duration of [[symptoms]] | *Duration of [[symptoms]] | ||
| Line 68: | Line 68: | ||
{{Reflist|2}} | {{Reflist|2}} | ||
[[Category:Disease]] | [[Category:Disease]] | ||
[[Category:Neurology]] | [[Category:Neurology]] | ||
Latest revision as of 21:36, 29 July 2020
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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
If left untreated, intracranial epidural abscess may cause headache, fever, and seizures. If left untreated, spinal epidural abscess may cause back pain, nerve root pain, and paralysis. Complications of epidural abscess include neurological deficits, meningitis, and sepsis. If treated timely, the prognosis for epidural abscess is generally good.
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 necessary. Treatment usually involves aggressive antibiotic therapy and surgical drainage.
Spinal Epidural Abscess
If left untreated, spinal epidural abscess may cause the following sequelae, which is classified into 4 stages:[1][2][3][4]
- Back and focal vertebral pain, with tenderness; fever; neurologic deficits
- Nerve root pain, described as being "electric-shock" like, radiating from affected areas, sometimes accompanied by paresthesia
- Dysfunction of the spinal cord, presenting by motor and sensory deficits and sphincter incompetence
- Paralysis, which may quickly become irreversible
Complications
Complications from epidural abscess include:
- Neurological deficits
- Meningitis
- Sepsis
- Irreversible paralysis
- Sepsis
- Spinal cord injury
- Pressure sores
- Urinary tract infection
- Thrombophlebitis
- Pneumonia
- Thrombosis
- Thrombophlebitis of adjacent veins
- Ischemia
- Bacterial toxins
- Inflammatory response and its mediators
The rate of complications rises with the increase of time to reach the proper diagnosis and begin therapy.
Prognosis
If treated timely, the prognosis of epidural abscess is generally good. Full recovery is common among survivors and the mortality rate is low (<5%). Mortality is usually due to sepsis, prolonged immobility, or the development of meningitis.[5] Positive outcomes are generally associated with:
- Presence of purulent material, instead of granulation tissue, indicating a more acute case
- Absence of paralysis or its presence for < 36 hours, indicating increased chances of returning to normal function
The most important factor to predict the final outcome is the patient's neurological status prior to neurosurgery. The stages are:[2]
| Staging prior to neurosurgery | Patient expectation |
|---|---|
| Stages 1 and 2 | May become fully neurologically intact with possible decrease of remaining radicular pain |
| Stage 3 | May observe some neurological function improvement and improvement of the weakness felt prior to surgery |
| Stage 4 | May experience some neurological function improvement |
Poor outcomes are generally associated with three factors:[6]
References
- ↑ 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.
- ↑ 2.0 2.1 Darouiche, Rabih O. (2006). "Spinal Epidural Abscess". New England Journal of Medicine. 355 (19): 2012–2020. doi:10.1056/NEJMra055111. ISSN 0028-4793.
- ↑ Mooney RP, Hockberger RS (1987). "Spinal epidural abscess: a rapidly progressive disease". Ann Emerg Med. 16 (10): 1168–70. PMID 3662166.
- ↑ 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.
- ↑ Longo, Dan L. (Dan Louis) (2012). Harrison's principles of internal medici. New York: McGraw-Hill. ISBN 978-0-07-174889-6.
- ↑ Khanna RK, Malik GM, Rock JP, Rosenblum ML (1996). "Spinal epidural abscess: evaluation of factors influencing outcome". Neurosurgery. 39 (5): 958–64. PMID 8905751.