Epidural abscess natural history, complications and prognosis
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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]
- Back and focal vertebral pain, with tenderness; fever; back pain; 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
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]
- 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:[4]
- 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
- ↑ 1.0 1.1 Longo, Dan L. (Dan Louis) (2012). Harrison's principles of internal medici. New York: McGraw-Hill. ISBN 978-0-07-174889-6.
- ↑ 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.
- ↑ 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.
- ↑ 4.0 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.
- ↑ 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.
- ↑ Khanna RK, Malik GM, Rock JP, Rosenblum ML (1996). "Spinal epidural abscess: evaluation of factors influencing outcome". Neurosurgery. 39 (5): 958–64. PMID 8905751.