Dr. Greenlee of the University of Utah School of Medicine received an honorarium from Merck for authorship and compensation as an expert witness from Wheeler Trigg O'Donnell LLP.)
This article includes discussion spinal epidural abscess, spinal pachymeningitis externa, spinal peripachymeningitis, acute spinal epidural abscess, chronic spinal epidural abscess, and tuberculous epidural abscess. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.
Spinal epidural abscess is the result of loculated infection within the fat-filled space that separates the spinal dura and arachnoid. The condition is a neurologic and neurosurgical emergency that, if unrecognized, may cause devastating neurologic injury. Because of its infrequent occurrence, however, the possibility of epidural abscess tends to be ignored in patients presenting with fever and back or neck pain. Failure to recognize this condition makes epidural abscess a significant cause of litigation for malpractice. In this article, the author reviews the pathogenesis, clinical features, diagnosis, and treatment of this disorder.
• Acute spinal epidural abscess characteristically presents with a consistent sequence of clinical symptoms and signs: severe focal pain, often unrelieved by narcotics, followed by radicular pain, followed by signs of spinal cord compression.
• Chronic epidural abscesses may exhibit a similar sequence of symptoms and signs, but these may develop slowly over time. The most common presentation of chronic epidural abscess is that of a compressive lesion, sometimes with minimal, if any, pain.
• Treatment of spinal epidural abscess, in most cases, involves both antibiotic treatment and surgical drainage. Delay in diagnosis and treatment may result in death or profound, irreversible neurologic impairment.
Historical note and terminology
The first report of spinal epidural abscess is credited to Albers (Dandy 1926). Ducheck termed the condition "peripachymeningitis" in 1853, a name changed by later reports to "pachymeningitis externa." In 1926, Dandy provided the first thorough review of the condition and its pathogenesis, including the observation that usually invasive organisms, such as Staphylococcus aureus, could produce extremely protracted infections within the spinal epidural space (Dandy 1926). In 1948, Heusner delineated the clinical features of spinal epidural abscess in a classical and still valid report (Heusner 1948).
Initially, diagnosis of spinal epidural abscess was based on neurologic localization alone, and treatment was purely surgical. Myelography provided the initial means of localizing spinal epidural abscesses with some precision, with CT offering an additional diagnostic tool. MRI, with its ability to visualize the cord over its entire length, has replaced both myelography and CT as the diagnostic method of choice. For the most part, spinal epidural abscess remains a surgical condition. In some patients, however, CT-guided needle aspiration has been used in place of surgery, and the ability to monitor an abscess with serial MRI examinations has made it possible to treat selected patients with small epidural abscesses using antibiotics alone (Leys et al 1985; Hanigan et al 1990; Parkinson and Sekhorn 2004; Gonzalez-Lopez et al 2009; Pourtaheri et al 2016; Suppiah et al 2016; Vakili and Crum-Cianflone 2017). Guidelines for the use of CT-guided aspiration and nonsurgical therapy, however, are still being developed (Wheeler et al 1992; Lyu et al 2002; Sendi et al 2008; Pourtaheri et al 2016).
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