History and exam

Key diagnostic factors

common

fever

Observed in around 50% of patients; may be accompanied by sweats or rigors.[2][12][30]

spinal pain or tenderness

Back or neck pain is the most common symptom in patients with spinal epidural abscess (SEA), occurring in 70% to 100% of cases.[2][12][30]​ Back tenderness has been reported in 17% to 98% of patients with SEA.[2]

Most patients with SEA report severe localized back pain.[2][30] Cervical SEA may result in neck pain rather than back pain. Pain is increased with weight-bearing and not relieved by rest.

When SEA is suspected, severe back pain alone should prompt emergent workup with magnetic resonance imaging (MRI), as neurologic deficit may develop rapidly.

uncommon

weakness of extremities

Prompts emergent workup with magnetic resonance imaging, as neurologic deficit may progress rapidly. The average time to paralysis once weakness is present is 24 hours.

paralysis

Reported to be present in up to 34% of patients with spinal epidural abscess.[12]

Prompts emergent workup with magnetic resonance imaging, as neurologic deficit may progress rapidly.

sensory disturbance

Prompts emergent workup with magnetic resonance imaging, as neurologic deficit may progress rapidly.

abnormal reflexes

Ranges from hyperreflexia to reduced or absent responses.

Prompts emergent workup with magnetic resonance imaging, as neurologic deficit may progress rapidly.

Other diagnostic factors

uncommon

isolated sphincter dysfunction

May be present in patients with spinal epidural abscess.[30]

Prompts emergent workup with magnetic resonance imaging, as neurologic deficit may progress rapidly.

Risk factors

strong

intravenous drug use

Previous or current history has been reported to be associated with up to 53% of cases of spinal epidural abscess (SEA).[9][22] The proportion of SEAs in this group of patients has increased, in part associated with concomitant HIV infection.[20][23]

recent spinal surgery or trauma

Spinal epidural abscess may develop after spinal surgery or spinal trauma.[9]

indwelling spinal catheter

Spinal epidural abscess is associated with neuraxial blocks, especially for the placement of indwelling spinal catheters (e.g., intrathecal/epidural pumps).[9]

contiguous local infection

Up to 30% of spinal epidural abscesses result from direct extension of local infection, usually vertebral osteomyelitis, psoas abscess, or contiguous soft-tissue infection.[9][17][18][19]​​ Staphylococcus aureus is the most reported causative organism, found in 50% to 93% of reported cases.[9]

immunosuppression

May be due to, for example, HIV infection, corticosteroids, or malignancy.[2][9]

diabetes mellitus

Reported to be associated with between 21% and 42% of cases of spinal epidural abscess.[9]

chronic kidney disease

End-stage renal disease has been reported in 3% to 30% of patients with spinal epidural abscess (SEA).[9][24][25]​ Renal failure is also associated with SEA.[2]

concomitant bacteremia or endocarditis

Hematogenous spread of pathogens to the epidural space is the most frequent cause of spinal epidural abscess (SEA).[18] Simultaneous disk infection may occur, allowing for contiguous spread to the anterior epidural space.[21] Bacteremia was reported to be present in 63.6% of patients and endocarditis in 7.4% of patients with SEA.[24]

alcohol misuse

Associated with up to 22% of cases of spinal epidural abscess (SEA).[9] In one case-control study, 19.1% of patients with SEA had alcohol misuse, compared with 8.0% of control patients.[24] Strongly associated with thoracic SEAs in particular.[22]

weak

male sex

Prevalence of spinal epidural abscess is strikingly predominant in men.[12] However, this likely relates to the predominance of other risk factors, rather than any true predilection as such.

obesity

A BMI of over 30 kg/m² is associated with spinal epidural abscess.[9]

noncontiguous coinfection (excluding bacteremia)

Includes pneumonia, soft-tissue infections, and urinary tract infections.[2][24]

chronic liver disease

Predisposing conditions to spinal epidural abscess may include the presence of underlying cirrhosis or other chronic liver diseases.[9][25]

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