Spinal Epidural Abscess: Diagnosis and Treatment

Spinal epidural abscess (SEA) is an uncommon entity, with an incidence of 0.2 to 2 per 10,000 hospital admissions. It is associated with potentially devastating neurological consequences. The incidence is increasing with the increase in intravenous drug use and increasing spinal procedures. SEA is classically described as presenting with fever, focal back pain, and progressive neurological symptoms. However, patients rarely fulfill all the characteristics of this pathognomonic triad. The key in diagnosis is a high level of suspicion when patients present with back pain. MRI is highly accurate in the evaluation. Empiric antibiotics for SEA must include coverage for staphylococci (vancomycin pending organism identification and susceptibility testing) and gram-negative bacilli (e.g., ceftazidime, cefepime, or meropenem), and antibiotics should continue for at least 8 weeks. Surgical evacuation remains the standard treatment in patients who present with neurologic signs on physical examination or who have failed medical management. The prognosis depends on the presenting neurologic status. Despite recent efforts, SEA is associated with a high mortality rate, most likely a result of delayed diagnosis and poor neurologic status at presentation. Therefore, high suspicion and early diagnosis remain the most important factors in the management of SEA.