Infectious Disease Compendium

Epidural Abscess

Diagnosis

Back pain and progressive neurological deterioration, depending on the level of the pain/discitis. Symptoms can be remarkably slow in progression.

Paralysis can occur by mass effect, or, in the case of S. aureus, from vertebral artery thrombosis. Why do you think it's other name is coagulase POSITIVE staph?

Epidemiologic Risks

Post spine surgery and hematogenous. Usually needle users are the biggest risks: IDDM, hemodialysis and IVDA.

Bladder infections spread by way of Batson's (Shazam!) plexus to the LS spine, or so they say. I have seen multiple times.

And evidently the diagnosis is missed more than half the time at presentation (PubMed). I guess there is a reason it the most common infection to lead to a lawsuit, or so I have been told.

Microbiology

S. aureus >> streptococci (esp milleri group). Occasionally anaerobic streptococci and aerobic gram negative rods, predominantly Escherichia coli and Pseudomonas aerugenosa; Tb.

As in all body spaces, any bug can rear its ugly head and cause disease where you do not expect it. That is why you get cultures before antibiotics. If possible. Progressive paralysis takes precedence over purity.

Empiric Therapy

Given all the MRSA in my neck of the woods (i.e. planet earth), I go for the belt and suspenders approach: nafcillin AND vancomycin +/- ceftazadime; surgery emergently if neurological symptoms.

And I kind of wonder about giving something to mess with the coagulase: clindamycin or rifampin. No data. But I wonder

Specific Therapy

4 to 6 weeks IV as there is almost always concomitant discitis and osteomyelitis.

Pearls

It usually starts as a discitis (but not always) and spreads to the adjacent vertebral bodies and thence into the epidural space.

Occasionally it will present as severe abdominal pain.

Rants

They can progress slowly or rapidly, MRI is best diagnostic test. Call a neurosurgeon. Stat. Patient can go to complete paralysis in a surprisingly short period of time.

And do not get one in jail. They might ignore your pain and progressive weakness until you have a complete paralysis, thinking you are malingering. Just saying.