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]
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 has greatly improved.
Pathophysiology
According to the location of the epidural abscess, its pathophysiology will differ, particularly in the origin of the infection but also in the symptoms, commonly responsible organism, progression of the condition and therefore the required treatment. In the case of intracranial epidural abscess, it occurs most frequently as a complication of surgical procedures or sinusitis, particularly paranasal sinusitis, as the infection progresses intracranially. [3] On the other hand, spinal epidural abscess happens most frequently due to spinal instrumentation, vascular access and IV drug use. [4]
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.
Causes
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. According to the region of infection, some infectious organisms will be shared by both types of abscess however, others will be different, mainly because of the risk factors involved in that particular area and the mechanisms of infection. In the case of intracranial epidural abscess, the most common risk factors are sinusitis and neurosurgical procedures, while in the case of spinal epidural abscess, the most common risk factors are infections of the surrounding tissues and spinal procedures.
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. [7] 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][8]
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" [9]
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 [10]
- Thrombocytosis, particullarly in children [10]
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. [11] 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 therapeutical approaches, including: aspiration, drainage and antibiotic therapy. An early surgical decompression and drainage, followed by 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 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.
- ↑ 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.
- ↑ 10.0 10.1 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.