Multilevel Epidural Abscess After Epidural Injection
John Teijido, 1Pinky Jha, MD MPH FACP
1Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI
Objectives
Hospital Course
Learning Objective 1:
Consider the risk of developing spinal epidural abscess after benign procedures such as
spinal corticosteroid injections
Infectious Disease was consulted.
oAntibiotic treatment with ampicillin was initiated; however, her acute on
chronic back pain and hip pain persisted.
Point tenderness on the lower lumbar spine raised concerns for vertebral
osteomyelitis; however, lumbar spine MRI results showed multilevel multiloculated
epidural abscesses extending from T12 through L3 and the left iliopsoas muscle had a
probable intramuscular abscess as well.
Learning Objective 2:
Recognize and prepare for the challenges of diagnosing and managing spinal epidural
abscesses
Discussion
Presentation:
Presenting symptoms are commonly nonspecific (i.e. fever and back pain.)
Physical exam shows local tenderness with or without neurologic deficit
Leukocytosis may be present unless chronically infected
ESR is generally above 25mm/hr
Blood cultures are positive 60-70% of time with Staphylococcus aureus
MRI is highly accurate in evaluation of SEA
Patient Presentation
Subjective:
82 yo female presenting with subjective fevers for a few days, bilateral hip pain, and
worsening low back pain
PMH of rheumatoid arthritis and chronic back pain
RA managed with daily prednisone
Chronic low back pain managed with epidural steroid injections
Hip pain was constant and sharp in both hips
Back pain was worse than her baseline and sharp with radiation to her bilateral
buttocks and posterior thighs
On ROS, she endorsed dysuria as well as cramping lower abdominal pain.
Objective:
T: 102.7 °F
P: 121 bmp
BP: 146/75
R:16
Oxygen Saturation: 100%
Abdomen - soft and non-tender.
MSK - left hip area was tender to palpitation without restricted range of motion.
•Back - point tenderness in the central lumbar region over the spinous processes.
•Neuro - no focal neurologic deficits; equal strength in upper and lower extremities
WBC initially normal at 6.3x103/μL
ESR elevated at 50mm/hr
Blood cultures and urine cultures grew Enterococcus faecalis susceptible to ampicillin
and vancomycin.
Hip MRI showed no evidence of fracture, effusion, or osteomyelitis; although, there
were some indurations and edema of the subcutaneous fat overlying the greater
trochanter.
TEE was negative
Neurosurgery was reluctant to do any surgical intervention with the lack of neurologic
compromise on exam.
Infectious Disease recommended 8 weeks of IV vancomycin.
After being afebrile and clinically stable for five days, the patient was discharged to a
long term assisted facility on IV antibiotics for 8 weeks with close follow up.
Treatment:
Traditionally surgical evacuation combined with long-term administration of
antibiotics
Medical management with antibiotics alone may be considered in patients without
signs of spinal cord or cauda equine involvement; although, this requires vigilant
monitoring and follow up
The development of neurological deficits prompts emergency surgical
decompression to avoid permanent consequences
References
Discussion
Etiology:
Spinal epidural abscess (SEA) is the accumulation of purulent material in the space
between the dura matter and the osseo-ligamentous structure making up the vertebral
canal.
SEA forms via inoculation through hematogenous spread, direct extension from an
infected contiguous structure, or iatrogenic inoculation.
Risk factors of SEA include spinal surgery, immune suppression, and IV abuse.
However, benign spinal procedures such as epidural corticosteroid injections are often
overlooked as a risk factor for such a concerning diagnosis.
oAs this case alludes to, such an assumption may lead to devastating
consequences.
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