February 7, 2011 by dailybolusoflr
Spinal epidural abscess is a collection of pus between the dura and the bones of the spine. It is most commonly posterior but can be anterior as well ( anterior locations are usually related to spread from vertebral osteomyelitis).
It is most appropriately treated with urgent decompressive laminectomy and intravenous antibiotics.
Patients may have rapid progression of impairment of neurologic function and a baseline neurologic exam is essential as well as highly predictive of ultimate outcome for the patient.
Bugs and Drugs:
· The most common organisms are staphylococci, including MRSA, as well as gram negative bacilli (often from urinary sources).
· The most appropriate antibiotic choice would be vancomycin and an extended spectrum cephalosporin such as cefipime or ceftazadime.
· underlying immunocompromised disease states (diabetes, alcoholism, HIV)
· spinal abnormalities or procedures
· local infections or sepsis states
· indwelling catheters
· intravenous drug abuse
· Urgent decompressive laminectomy
· Conservative therapy (ie. non-operative) may be considered for patients who refuse surgery or are poor operative candidates. Additional situations which have been suggested as acceptable for delayed or lack of surgical intervention include patients who have exhibited signs of paralysis for over 24 hours or those with infections which extend through most of the spinal canal. The literature is controversial on this topic.
· For patients in whom surgery is not planned, antibiotics should be guided based on positive blood cultures or on organisms cultured by radiologic-guided aspiration of the abscess fluid.
Rabih O. Darouiche, M.D. N Engl J Med 2006; 355:2012-2020
Linda Regan, MD FACEP
Associate Director, Emergency Medicine Residency
Johns Hopkins Medical Institutions