The classic triad of a spinal epidural abscess is back pain (75%), fever (48%), and neurologic deficits (33%) due to the direct compressive effects of the abscess. The classic triad presents in as few as 8% of patients, thus if clinical concern exists for this disease prompt diagnostic evaluation must be undertaken.

Pain may be elicited through palpation or percussion of spinous processes overlaying spinal epidural abscess. Pain also may be elicited through straight leg raise from compression of spinal nerve roots. As this disease process progresses patients will develop neurologic deficits consistent with spinal cord or cauda equina compression: urinary retention, bowel incontinence, anesthesia (perianal and saddle anesthesia), motor weakness, or paralysis.

Lab evaluation should include blood cultures, complete blood count, inflammatory markers, and coagulation studies. These studies often will reveal an elevated white blood cell count and elevated inflammatory markers. Although the erythrocyte sedimentation rate is often elevated in these patients, it does not rule out the diagnosis of spinal epidural abscess (85% to 94% sensitivity).[10]

Positive cultures by frequency in specimen type is (1) abscess aspirate: 90%, (2) blood: 62%, and (3) CSF: 19%.

If there is a concern for spinal epidural abscess, patients should undergo immediate MRI of the entire spine. If MRI is unavailable, CT with IV contrast is an alternative although less sensitive.

Lumbar puncture is unnecessary as it lends little diagnostic utility and has potential morbidity in the setting of spinal epidural abscess.

Emergent surgical spine consultation is the standard of care for all patients with radiographic findings epidural abscess and abnormal neurological examinations due to mass effect from an epidural abscess. These patients usually require an emergent surgical evaluation to decompress the spinal cord and nerve roots.[11][12][13]

Overall, the treatment of spinal epidural abscess focuses on the elimination of the suppurative mass and eradication of the causative organism. This is accomplished through aspiration, surgical drainage, and antibiotic therapy. The assistance of interventional radiology or spine surgery (orthopedics or neurosurgery) will be required in the management of many if not all of these patients.

Empiric antibiotic regimens should include vancomycin (30-60 mg/kg) plus a third or fourth-generation cephalosporin (2g cefotaxime Q6H, 2g ceftriaxone Q12H, 2g ceftazidime Q8H, or 2g cefepime Q8H) until speciation and sensitivities of the infecting organism result for more targeted antibiotic therapy. Typically, patients will require a prolonged course of antibiotics (4 to 6 weeks) to treat this infection.

Repeat MRI should be obtained if the patient has worsening symptoms, deteriorating clinical exam, or at 4 to 6 weeks of therapy.

• Cervical/lumbar disc stenosis
• Meningitis 
• Vertebral discitis and osteomyelitis
• Psoas abscess
• Transverse myelitis
• Low back pain
• Pyelonephritis
• Spinal cord hematoma

A delay in the diagnosis of spinal epidural abscess (defined as multiple visits before the definite diagnosis and treatment) can result in increased residual weakness or permanent neurologic deficit. Around 5 percent of the patients die with sepsis or other related causes.[14] Moreover, 4-22 percent of the patients experience irreversible paraplegia. Neurological recovery is usually appreciable if the surgery is delayed 24-48 hours after the neurologic deficit onset.

There is limited data available in the literature about neurological recovery after the surgery. However, the recovery is variable and generally depends on multiple factors including age, health status, comorbidities, and time to diagnosis, and to the treatment initiation is crucial.[15]

• Pressure ulcers
• Meningitis 
• Urine retention
• Supine hypertension
• Sepsis
• Deep vein thrombosis
• Paralysis 

• Patients should tightly follow up with the surgeon in case of secondary complications of the surgery or in case of new neurologic deficit or fever. 
• Rehabilitation by physical/occupational therapists is necessary for patients with motor weakness or neurological deficits.
• Patient should be compliant in taking medications which can be arranged by home health care. 
• Patients should involve their doctor for lack of motivation, depression, and suicidal ideation for screening and further referral.

The management of spinal abscess is an interprofessional and includes a neurosurgeon, neurologist, intensivist, an infectious disease expert, physical therapy and nurse. These patients develop a multitude of complications like urinary retention, DVT, sepsis, pressure ulcers, and supine hypertension. After discharge, most patients require home healthcare and ongoing physical therapy. A home care nurse is often required to monitor these patients for recovery and potential problems. Many of these patients need a long-term indwelling catheter, which also increases the risk of an infection. Gastric aperistalsis is common, and constipation is a recurrent problem. As the infection improves, many patients may benefit from rehabilitation to regain their muscle mass and exercise endurance.  [16][17](Level V)

Outcomes

A spinal abscess is rare in the US, but when it occurs, it does have a significant morbidity. The prognosis depends on the extent of the abscess, neurological deficits present at the time of presentation and response to treatment. Even after treatment, most patients are left with some type of neurological deficit. Many patients require long-term rehabilitation to regain function. During the recovery, pressure ulcers and deep vein thrombosis are also a common occurrence. [4][18][19](Level V)