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Update on spinal epidural abscess

Babic, Majaa; Simpfendorfer, Claus S.b; Berbari, Elie F.c

Current Opinion in Infectious Diseases: June 2019 - Volume 32 - Issue 3 - p 265–271
doi: 10.1097/QCO.0000000000000544
CNS INFECTIONS: Edited by Adarsh Bhimraj

Purpose of review Spinal epidural abscess (SEA) is still a rare but potentially very morbid infection of the spine. In recent years, the incidence has risen sharply but the condition remains a medical conundrum wrought with unacceptably long diagnostic delays. The outcome depends on timely diagnosis and missed opportunities can be associated with catastrophic consequences. Management and outcomes have improved over the past decade. This review focuses on risk factors and markers that can aid in establishing the diagnosis, the radiological characteristics of SEA on MRI and their clinical implications, as well as the importance of establishing clear indications for surgical decompression.

Recent findings This once exclusively surgically managed entity is increasingly treated conservatively with antimicrobial therapy. Patients diagnosed in a timely fashion, prior to cord involvement and the onset of neurologic deficits can safely be managed without decompressive surgery with targeted antimicrobial therapy. Patients with acute cord compression and gross neurologic deficits promptly undergo decompression. The greatest therapeutic dilemma remains the group with mild neurological deficits. As failure rates of delayed surgery approach 40%, recent research is focused on predictive models for failure of conservative SEA management. In addition, protocols are being implemented with some success, to shorten the diagnostic delay of SEA on initial presentation.

Summary SEA is a potentially devastating condition that is frequently missed. Protocols are put in place to facilitate early evaluation of back pain in patients with red flags with appropriate cross-sectional imaging, namely contrast-enhanced MRI. Efforts for establishing clear-cut indications for surgical decompression of SEA are underway.

aSection of Bone and Joint Infections, Department of Infectious Diseases

bSection of Musculoskeletal Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio

cDivision of Infectious Diseases, Mayo Clinic School of Medicine, Rochester, Minnesota, USA

Correspondence to Maja Babic, MD, Section of Bone and Joint Infections, Department of Infectious Diseases, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 441295, USA. Tel: +1 216 390 1023; fax: +1 216 445 9446; e-mail:

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