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{{Epidural abscess}}
{{Epidural abscess}}
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==Overview==
==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. <ref>{{Cite book  | last1 = Longo | first1 = Dan L. (Dan Louis) | title = Harrison's principles of internal medici | date = 2012 | publisher = McGraw-Hill | location = New York | isbn = 978-0-07-174889-6 | pages =  }}</ref> It may occur in two different places: [[intracranial space|intracranially]] or in the [[spinal canal]]. Due to the fact that the initial symptoms and clinical characteristics are not always identical and are similar to 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 [[abscess]] may have different origins, different organisms involved, symptoms, evolutions, complications and therapeutical techniques. <ref name="DannerHartman1987">{{cite journal|last1=Danner|first1=R. L.|last2=Hartman|first2=B. J.|title=Update of Spinal Epidural Abscess: 35 Cases and Review of the Literature|journal=Clinical Infectious Diseases|volume=9|issue=2|year=1987|pages=265–274|issn=1058-4838|doi=10.1093/clinids/9.2.265}}</ref>
If left untreated, intracranial epidural abscess may cause [[headache]], [[fever]], and [[seizures]]. If left untreated, spinal epidural abscess may cause [[back pain]], [[nerve root]] pain, and [[paralysis]]. Complications of epidural abscess include neurological deficits, [[meningitis]], and [[sepsis]]. If treated timely, the prognosis for epidural abscess is generally good.  


|==Natural History==
==Natural History==
Depending on the location of the epidural abscess, its natural history and related symptoms will invariably change. Therefore, it is important to distinguish the two:
===Intracranial Epidural Abscess===
===Intracranial Epidural Abscess===
The less common of the three main focal [[suppurative]] [[central nervous system]] [[infections]] ''([[brain abscess]] and [[subdural empyema]])''. It may have several origins, however the more common are: complication of [[sinusitis]] or following [[neurosurgery|neurosurgical procedures]] or [[head trauma]]. Since the [[dura mater]] is tightly adherent to the [[bone]] surface of the [[skull]], making the [[epidural space]] a ''virtual space'', the [[abscess]] tends to have an indolent evolution, usually creating small, round collections of [[purulent]] material. Since this [[infected]] material is able to cross the [[dura mater]], along the [[emissary veins]], the epidural abscess is usually accompanied by a [[subdural empyema]]. This explains the fact that these two entities share common [[etiologies]]. In the case of the [[abscess]] originating from [[sinusitis]], the responsible organisms are usually similar to the ones causing [[subdural empyema]], such as [[streptococci]] and [[anaerobes]], while if the [[abscess]] originates on a [[trauma]] or a [[neurosurgery|neurosurgical procedure]], the responsible organisms are usually [[staphylococci]] or [[Gram-negative bacteria|gram-negatives]]. At the time of presentation, patients usually complain of [[headache]], [[fever]] and [[seizures]] and present with [[nuchal rigidity]] and focal neurologic deficits. Since the [[abscess]] develops slowly, the [[signs]] and [[symptoms]] may develop insidiously. A particular situation may arise, when the [[abscess]] is located near the [[Petrous portion of the temporal bone|petrous bone]], compressing the nearby structures, being responsible for the so called ''Gradenigo’s syndrome'', in which compression of the [[cranial nerves]] V and VI, results in unilateral [[facial pain]] and [[lateral rectus muscle]] [[weakness]]. <ref>{{Cite book  | last1 = Mandell | first1 = Gerald L. | last2 = Bennett | first2 = John E. (John Eugene) | last3 = Dolin | first3 = Raphael. | title = Mandell, Douglas, and Bennett's principles and practice of infectious disease | date = 2010 | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | isbn = 0-443-06839-9 | pages =  }}</ref><ref>{{Cite book  | last1 = Longo | first1 = Dan L. (Dan Louis) | title = Harrison's principles of internal medici | date = 2012 | publisher = McGraw-Hill | location = New York | isbn = 978-0-07-174889-6 | pages =  }}</ref> 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 [[neurosurgery|surgical drainage]].
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 necessary. Treatment usually involves aggressive [[antibiotic]] therapy and [[neurosurgery|surgical drainage]].


===Spinal Epidural Abscess===
===Spinal Epidural Abscess===
This type of [[abscess]] usually develops following hematogenous dissemination of an [[infection]], located elsewhere in the [[body]] or following [[neurosurgery|neurosurgical procedure]] or [[trauma]], particularly in patients with predisposing conditions, such as spinal deformities or [[bacteremia]].<ref>{{Cite book  | last1 = Mandell | first1 = Gerald L. | last2 = Bennett | first2 = John E. (John Eugene) | last3 = Dolin | first3 = Raphael. | title = Mandell, Douglas, and Bennett's principles and practice of infectious disease | date = 2010 | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | isbn = 0-443-06839-9 | pages =  }}</ref> In this particular type of epidural abscess, its progression of symptoms and clinical findings, within hours to days or months in more chronicle settings, may be described according to 4 stages: <ref>{{Cite book  | last1 = Mandell | first1 = Gerald L. | last2 = Bennett | first2 = John E. (John Eugene) | last3 = Dolin | first3 = Raphael. | title = Mandell, Douglas, and Bennett's principles and practice of infectious disease | date = 2010 | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | isbn = 0-443-06839-9 | pages =  }}</ref><ref name="Darouiche2006">{{cite journal|last1=Darouiche|first1=Rabih O.|title=Spinal Epidural Abscess|journal=New England Journal of Medicine|volume=355|issue=19|year=2006|pages=2012–2020|issn=0028-4793|doi=10.1056/NEJMra055111}}</ref>
If left untreated, spinal epidural abscess may cause the following sequelae, which is classified into 4 stages:<ref name=Mandell>{{Cite book  | last1 = Mandell | first1 = Gerald L. | last2 = Bennett | first2 = John E. (John Eugene) | last3 = Dolin | first3 = Raphael. | title = Mandell, Douglas, and Bennett's principles and practice of infectious disease | date = 2010 | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | isbn = 0-443-06839-9 | pages =  }}</ref><ref name="Darouiche2006">{{cite journal|last1=Darouiche|first1=Rabih O.|title=Spinal Epidural Abscess|journal=New England Journal of Medicine|volume=355|issue=19|year=2006|pages=2012–2020|issn=0028-4793|doi=10.1056/NEJMra055111}}</ref><ref name="pmid3662166">{{cite journal| author=Mooney RP, Hockberger RS| title=Spinal epidural abscess: a rapidly progressive disease. | journal=Ann Emerg Med | year= 1987 | volume= 16 | issue= 10 | pages= 1168-70 | pmid=3662166 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3662166 }} </ref><ref name="pmid7819646">{{cite journal| author=Liem LK, Rigamonti D, Wolf AL, Robinson WL, Edwards CC, DiPatri A| title=Thoracic epidural abscess. | journal=J Spinal Disord | year= 1994 | volume= 7 | issue= 5 | pages= 449-54 | pmid=7819646 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7819646 }} </ref>
*Stage 1 - [[back pain|back]] and focal [[vertebral]] pain, with [[tenderness]] on [[physical exam]].
#[[Back pain|Back]] and focal [[vertebral]] pain, with [[tenderness]]; [[fever]]; neurologic deficits
*Stage 2 - [[nerve root]] [[pain]], radiating from affected areas, sometimes accompanied by [[paresthesia]].
#[[Nerve root]] [[pain]], described as being "electric-shock" like, radiating from affected areas, sometimes accompanied by [[paresthesia]]
*Stage 3 - dysfunction of the [[spinal cord]], presenting by motor and sensory deficits and [[sphincter]] incompetence.
#Dysfunction of the [[spinal cord]], presenting by motor and sensory deficits and [[sphincter]] incompetence
*Stage 4 - [[Paralysis]].
#[[Paralysis]], which may quickly become irreversible
The typical triad of symptoms is: [[fever]], [[back pain]] and neurologic deficits. However, these may not be present at all times on admission which, along with the vast differential diagnosis, may delay the final diagnosis. The progression of the disease from stage to stage and the duration of [[symptoms]] before admission (between 1 day to 2 months) are also highly variable. Along with these [[symptoms]], others may be present, such as: [[weakness]], [[urinary retention]], and [[tenderness]]. Attending to the fact that the abscesses tend to form in larger [[epidural space]]s, they will be more frequent in posterior and thoracolumbar areas, where is located [[fat]], susceptible in being [[infected]]. <ref name="Darouiche2006">{{cite journal|last1=Darouiche|first1=Rabih O.|title=Spinal Epidural Abscess|journal=New England Journal of Medicine|volume=355|issue=19|year=2006|pages=2012–2020|issn=0028-4793|doi=10.1056/NEJMra055111}}</ref><ref>{{Cite book  | last1 = Mandell | first1 = Gerald L. | last2 = Bennett | first2 = John E. (John Eugene) | last3 = Dolin | first3 = Raphael. | title = Mandell, Douglas, and Bennett's principles and practice of infectious disease | date = 2010 | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | isbn = 0-443-06839-9 | pages =  }}</ref><ref name="pmid1359381">{{cite journal| author=Darouiche RO, Hamill RJ, Greenberg SB, Weathers SW, Musher DM| title=Bacterial spinal epidural abscess. Review of 43 cases and literature survey. | journal=Medicine (Baltimore) | year= 1992 | volume= 71 | issue= 6 | pages= 369-85 | pmid=1359381 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1359381 }} </ref>


==Complications==
==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 [[toxin]]s
*[[Inflammatory]] response and its mediators
The rate of [[complications]] rises with the increase of time to reach the proper [[diagnosis]] and begin therapy.


==Prognosis==
==Prognosis==
If treated timely, the prognosis of epidural abscess is generally good. Full recovery is common among survivors and the [[mortality rate]] is low (<5%). Mortality is usually due to [[sepsis]], prolonged [[immobility]], or the development of [[meningitis]].<ref name=McGraw>{{Cite book  | last1 = Longo | first1 = Dan L. (Dan Louis) | title = Harrison's principles of internal medici | date = 2012 | publisher = McGraw-Hill | location = New York | isbn = 978-0-07-174889-6 | pages =  }}</ref> Positive outcomes are generally associated with:
*Presence of [[purulent]] material, instead of [[granulation tissue]], indicating a more acute case
*Absence of [[paralysis]] or its presence for < 36 hours, indicating increased chances of returning to normal function
The most important factor to predict the final outcome is the patient's neurological status prior to [[neurosurgery]]. The stages are:<ref name="Darouiche2006">{{cite journal|last1=Darouiche|first1=Rabih O.|title=Spinal Epidural Abscess|journal=New England Journal of Medicine|volume=355|issue=19|year=2006|pages=2012–2020|issn=0028-4793|doi=10.1056/NEJMra055111}}</ref>
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
|+
! style="background: #4479BA; width: 120px;" | {{fontcolor|#FFF|Staging prior to neurosurgery}}
! style="background: #4479BA; width: 550px;" | {{fontcolor|#FFF|Patient expectation}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Stages 1 and 2'''
| style="padding: 5px 5px; background: #F5F5F5;" | May become fully neurologically intact with possible decrease of remaining [[radicular pain]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Stage 3'''
| style="padding: 5px 5px; background: #F5F5F5;" | May observe some neurological function improvement and improvement of the [[weakness]] felt prior to [[neurosurgery|surgery]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Stage 4'''
| style="padding: 5px 5px; background: #F5F5F5;" | May experience some neurological function improvement
|-
|}


Poor outcomes are generally associated with three factors:<ref name="pmid8905751">{{cite journal| author=Khanna RK, Malik GM, Rock JP, Rosenblum ML| title=Spinal epidural abscess: evaluation of factors influencing outcome. | journal=Neurosurgery | year= 1996 | volume= 39 | issue= 5 | pages= 958-64 | pmid=8905751 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8905751  }} </ref>
*[[Age]]
*Degree of thecal sac compression
*Duration of [[symptoms]]


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


[[Category:Wikinfect]]
[[Category:Infectious disease]]
[[Category:Disease]]
[[Category:Disease]]
[[Category:Neurology]]
[[Category:Neurology]]
[[Category:Primary care]]

Latest revision as of 21:36, 29 July 2020

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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

If left untreated, intracranial epidural abscess may cause headache, fever, and seizures. If left untreated, spinal epidural abscess may cause back pain, nerve root pain, and paralysis. Complications of epidural abscess include neurological deficits, meningitis, and sepsis. If treated timely, the prognosis for epidural abscess is generally good.

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 necessary. Treatment usually involves aggressive antibiotic therapy and surgical drainage.

Spinal Epidural Abscess

If left untreated, spinal epidural abscess may cause the following sequelae, which is classified into 4 stages:[1][2][3][4]

  1. Back and focal vertebral pain, with tenderness; fever; neurologic deficits
  2. Nerve root pain, described as being "electric-shock" like, radiating from affected areas, sometimes accompanied by paresthesia
  3. Dysfunction of the spinal cord, presenting by motor and sensory deficits and sphincter incompetence
  4. Paralysis, which may quickly become irreversible

Complications

Complications from epidural abscess include:

The rate of complications rises with the increase of time to reach the proper diagnosis and begin therapy.

Prognosis

If treated timely, the prognosis of epidural abscess is generally good. Full recovery is common among survivors and the mortality rate is low (<5%). Mortality is usually due to sepsis, prolonged immobility, or the development of meningitis.[5] Positive outcomes are generally associated with:

  • Presence of purulent material, instead of granulation tissue, indicating a more acute case
  • Absence of paralysis or its presence for < 36 hours, indicating increased chances of returning to normal function

The most important factor to predict the final outcome is the patient's neurological status prior to neurosurgery. The stages are:[2]

Staging prior to neurosurgery Patient expectation
Stages 1 and 2 May become fully neurologically intact with possible decrease of remaining radicular pain
Stage 3 May observe some neurological function improvement and improvement of the weakness felt prior to surgery
Stage 4 May experience some neurological function improvement

Poor outcomes are generally associated with three factors:[6]

  • Age
  • Degree of thecal sac compression
  • Duration of symptoms

References

  1. ↑ 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.
  2. ↑ 2.0 2.1 Darouiche, Rabih O. (2006). "Spinal Epidural Abscess". New England Journal of Medicine. 355 (19): 2012–2020. doi:10.1056/NEJMra055111. ISSN 0028-4793.
  3. ↑ Mooney RP, Hockberger RS (1987). "Spinal epidural abscess: a rapidly progressive disease". Ann Emerg Med. 16 (10): 1168–70. PMID 3662166.
  4. ↑ 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.
  5. ↑ Longo, Dan L. (Dan Louis) (2012). Harrison's principles of internal medici. New York: McGraw-Hill. ISBN 978-0-07-174889-6.
  6. ↑ Khanna RK, Malik GM, Rock JP, Rosenblum ML (1996). "Spinal epidural abscess: evaluation of factors influencing outcome". Neurosurgery. 39 (5): 958–64. PMID 8905751.
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