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Spinal Epidural Abscess in an Obese Woman With Back Pain: Page 3 of 3

Spinal Epidural Abscess in an Obese Woman With Back Pain: Page 3 of 3

Treatment of patients with SEA involves emergency surgery as well as the use of antibiotics. Surgery should prevent progression of neurological damage; in the long run, however, the patient often is left with the same degree of neurological deficit present at the time of surgery. Therefore, early diagnosis and rapid surgical decompression are essential for reaching the best possible outcome (see Table).

The patient is this case did well and had a good recovery, although she was left with some mild weakness in her legs. Key aspects of her ED care were early recognition that her current symptoms were significantly different from her typical back pain episodes; appropriate concern about the presence of bilateral leg symptoms; the presence of DM as an important risk factor for SEA; and early recognition of a low-grade fever, meningismus, and mild leg weakness on physical examination.

The radiology department’s refusal to expedite the MRI scan was less than ideal. However, the CT results were available promptly so that minimal time was lost.

Spinal Epidural Abscess (from Quick Essentials Emergency Medicine pocketbook)
General

Delayed diagnosis in 50% of patients because initially insidious; progression later becomes rapid

Stages

1. Back pain that may start as mild and often is thoracic, fever
2. Nerve root pain (sciatica or cervical)
3. Motor and sensory findings
4. Paralysis from cord compression

Examination

Early: Spinal tenderness, positive straight-leg raise test result, meningismus, fever in 50% of patients
Late: Sensory level (a vertebral level below which sensation is absent), weakness, urinary retention, decreased rectal tone

Bugs

Staphylococcus, Escherichia coli, Pseudomonas; concomitant discitis, osteomyelitis, or endocarditis common

Risk factors

Central line (central venous catheter), injection drug abuse, recent procedure, acupuncture
Depressed immunity: diabetes mellitus, cancer, corticosteroid, alcohol, kidney or liver failure, pregnancy
Distant infection (UTI, pneumonia, neck furuncle), spinal fracture

Tests

Best: MRI with contrast or CT myelography
Alternatives: CT with contrast (50% sensitive), ESR > 20 mm/h (reportedly 98% sensitive) 

Differential diagnosis

Psoas or deep neck abscess, meningitis, herniated disc, UTI, discitis, osteomyelitis

Treatment

Surgery stat with spine surgeon (spine orthopedist or neurosurgeon)
Antibiotics: ceftriaxone 1 g IV + clindamycin 300 mg IV + vancomycin 1 g IV or alternative

UTI, urinary tract infection; ESR, erythrocyte sedimentation rate. Copyright Emresource.org.

 

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