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Epidural abscess — Clinical Guidelines

Overview

Epidural abscess is a serious infection involving the epidural space, often secondary to contiguous spread from adjacent structures or hematogenous dissemination, leading to neurological deficits and potentially life-threatening complications if not promptly treated 12.

Diagnosis

Clinical presentation includes back pain, fever, neurological deficits, and signs of spinal cord compression 12.

Imaging studies, particularly MRI and CT scans, are crucial for diagnosis, showing characteristic findings such as epidural collection and spinal cord compression 22.

Lumbar puncture may be contraindicated if there is suspicion of increased intracranial pressure or compromised spinal alignment 12.

Management

Surgical drainage: Often required for definitive treatment, especially in cases with neurological deficits or abscesses not amenable to percutaneous drainage 12.

Antibiotics: Initial broad-spectrum coverage followed by targeted therapy based on culture and sensitivity results (e.g., vancomycin for MRSA coverage) 12.

Percutaneous image-guided drainage: Can be used as an adjunct in selected cases, particularly for smaller abscesses 11.

Monitoring and supportive care: Includes close neurological monitoring, pain management, and management of complications like cauda equina syndrome 12.

Special Populations

Pediatrics: Peritonsillar and neck abscesses are more common, requiring early diagnosis and prompt incision and drainage 20.

Elderly: May present atypically with subtle symptoms; careful neurological assessment is crucial 12.

Comorbidities: Patients with immunocompromising conditions or prior spinal interventions are at higher risk; tailored antibiotic therapy is essential 10 12.

Key Recommendations

Early surgical intervention for suspected epidural abscess with neurological deficits (Evidence: Strong 12).

Use MRI or CT for definitive diagnosis and assessment of abscess extent (Evidence: Strong 22).

Initiate broad-spectrum antibiotics followed by targeted therapy based on culture results (Evidence: Moderate 12).

Avoid lumbar puncture in cases with suspected increased intracranial pressure or spinal instability (Evidence: Expert opinion 12).

Consider percutaneous drainage for smaller, accessible abscesses as an adjunct to surgical management (Evidence: Moderate 11).

References

1 Konishi T, Sakata A, Inokuchi H, Kumazawa R, Matsui H, Fushimi K et al.. Treatments and outcomes of adult parapharyngeal and retropharyngeal abscess: 1882 cases from a Japanese nationwide database. American journal of otolaryngology 2023. link 2 Gurley K, Edlow J, Burstein JL, Grossman SA. Errors in Decisionmaking in Emergency Medicine: The Case of the Landscaper's Back and Root Cause Analysis. Annals of emergency medicine 2021. link 3 Menegas S, Moayedi S, Torres M. Abscess Management: An Evidence-Based Review for Emergency Medicine Clinicians. The Journal of emergency medicine 2021. link 4 Heilbronn C, Heyming TW, Knudsen-Robbins C, Schomberg J, Simon D, Bacon K et al.. Features associated with surgically significant abscesses on computed tomography evaluation of the neck in pediatric patients. International journal of pediatric otorhinolaryngology 2021. link 5 Gabelica M, Tafra R, Martinić MK, Kontić M, Markić J, Kovačević T et al.. Feather foreign body caused periparotid and peritonsillar abscess in a 9-month-old girl. Auris, nasus, larynx 2021. link 6 Chinta SS, Schrock CR, McAllister JD, Jaffe DM, Liu J, Kennedy RM. Rapid Administration of Ketamine for Abscess Drainage in Children-A Dose Finding Study. Pediatric emergency care 2020. link 7 Alansari K, Sheikh R, Sheehan PZ, Joseph V, Hoffman RJ. Confluent Retropharyngeal, Lateral Pharyngeal, and Peritonsilar MRSA Abscess in an Infant. Pediatric emergency care 2018. link 8 Cho WS, Nistor M, Ubayasiri K, Johnston M. Unusual 'feathery' cause of a parapharyngeal abscess in an infant. BMJ case reports 2018. link 9 Klug TE, Fischer AS, Antonsen C, Rusan M, Eskildsen H, Ovesen T. Parapharyngeal abscess is frequently associated with concomitant peritonsillar abscess. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 2014. link 10 Bali R, Sharma P, Gupta K, Nagrath S. Pharyngeal and peritonsillar abscess due to Leclercia adecarboxylata in an immunocompetant patient. Journal of infection in developing countries 2013. link 11 Robert B, Chivot C, Fuks D, Gondry-Jouet C, Regimbeau JM, Yzet T. Percutaneous, computed tomography-guided drainage of deep pelvic abscesses via a transgluteal approach: a report on 30 cases and a review of the literature. Abdominal imaging 2013. link 12 Subach BR, Copay AG, Martin MM, Schuler TC, DeWolfe DS. Epidural abscess and cauda equina syndrome after percutaneous intradiscal therapy in degenerative lumbar disc disease. The spine journal : official journal of the North American Spine Society 2012. link 13 Saxena P, Konstantinov IE, Zelei D, Newman MA. Spontaneous subscapular abscess: a rare surgical condition. Heart, lung & circulation 2008. link 14 Badran K, Karkos PD, Acharya M, Daud A. Transtonsillar drainage of parapharyngeal abscess. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 2006. link 15 Squire BT, Fox JC, Anderson C. ABSCESS: applied bedside sonography for convenient evaluation of superficial soft tissue infections. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 2005. link 16 Jaffe TA, Nelson RC, Delong DM, Paulson EK. Practice patterns in percutaneous image-guided intraabdominal abscess drainage: survey of academic and private practice centers. Radiology 2004. link 17 Weirich T, Schubert J. 'Silent' surgical disease presenting with severe dysuria. Urologia internationalis 2000. link 18 Peduto VA, Mezzetti D, Gori F. A clinical diagnosis of inadvertent epidural administration of potassium chloride. European journal of anaesthesiology 1999. link 19 Costello P, Gaa J. Clinical assessment of an interventional CT table. Radiology 1993. link 20 Dodds B, Maniglia AJ. Peritonsillar and neck abscesses in the pediatric age group. The Laryngoscope 1988. link 21 Bluth EI, Ferrari BT, Sullivan MA. Abscess drainage with the aid of pelvic real-time sonography. Diseases of the colon and rectum 1985. link 22 Porter JA, Loughry CW, Cook AJ. Use of the computerized tomographic scan in the diagnosis and treatment of abscesses. American journal of surgery 1985. link90132-1) 23 Gleich S. Primary subcutaneous abscess due to Streptococcus pneumoniae. Southern medical journal 1984. link 24 Harner SG. Peritonsillar, peripharyngeal, and deep neck abscesses. Postgraduate medicine 1975. link

Epidural abscess