Epidural abscess natural history, complications and prognosis: Difference between revisions
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*Stage 3 - dysfunction of the [[spinal cord]], presenting by motor and sensory deficits and [[sphincter]] incompetence. | *Stage 3 - dysfunction of the [[spinal cord]], presenting by motor and sensory deficits and [[sphincter]] incompetence. | ||
*Stage 4 - [[Paralysis]]. | *Stage 4 - [[Paralysis]]. | ||
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. <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> | |||
==Complications== | ==Complications== | ||
Revision as of 01:30, 25 March 2014
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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]
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. [1] It may occur in two different places: 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. [2]
|==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
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 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 neurosurgical procedure, the responsible organisms are usually staphylococci or 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 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. [3][4] 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 surgical drainage.
Spinal Epidural Abscess
This type of abscess usually develops following hematogenous dissemination of an infection, located elsewhere in the body or following neurosurgical procedure or trauma, particularly in patients with predisposing conditions, such as spinal deformities or bacteremia.[5] 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: [6][7]
- Stage 1 - back and focal vertebral pain, with tenderness on physical exam.
- Stage 2 - nerve root pain, radiating from affected areas, sometimes accompanied by paresthesia.
- Stage 3 - dysfunction of the spinal cord, presenting by motor and sensory deficits and sphincter incompetence.
- Stage 4 - Paralysis.
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. [7][8]
Complications
Prognosis
References
- ↑ Longo, Dan L. (Dan Louis) (2012). Harrison's principles of internal medici. New York: McGraw-Hill. ISBN 978-0-07-174889-6.
- ↑ Danner, R. L.; Hartman, B. J. (1987). "Update of Spinal Epidural Abscess: 35 Cases and Review of the Literature". Clinical Infectious Diseases. 9 (2): 265–274. doi:10.1093/clinids/9.2.265. ISSN 1058-4838.
- ↑ 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.
- ↑ Longo, Dan L. (Dan Louis) (2012). Harrison's principles of internal medici. New York: McGraw-Hill. ISBN 978-0-07-174889-6.
- ↑ 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.
- ↑ 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.
- ↑ 7.0 7.1 Darouiche, Rabih O. (2006). "Spinal Epidural Abscess". New England Journal of Medicine. 355 (19): 2012–2020. doi:10.1056/NEJMra055111. ISSN 0028-4793.
- ↑ 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.