High risk and low prevalence diseases: Spinal epidural abscess

Introduction: Spinal epidural abscess (SEA) is a rare but serious condition that carries with it a high rate of morbidity and mortality. Objective: This review highlights the pearls and pitfalls of SEA, including presentation, initial evaluation, and management in the emergency department (ED) based on current evidence. Discussion: SEA is a suppurative infection and infectious disease emergency that may result in significant morbidity and even mortality. It is a challenging diagnosis due to its range of risk factors and variety of presentations with up to 90% of patients misdiagnosed on their first ED visit. Factors associated with increased risk of SEA include immunocompromise, bacteremia, contiguous infection (e.g., psoas muscle abscess, osteomyelitis, skin infection), and spinal instrumentation. However, the absence of risk factors cannot be used to exclude SEA. The classic triad of back pain, fever, and neurologic deficit occurs in less than 8% of cases, though back pain is a common presenting symptom. Up to half of patients experience a neurologic abnormality, but fever is absent in 50%. Laboratory assessment may assist with inflammatory markers elevated in the majority of cases. Diagnosis includes magnetic resonance imaging with and without contrast and blood cultures, and management includes spinal specialist consultation and antibiotic therapy. Conclusions: An understanding of SEA can assist emergency clinicians in diagnosing and managing this potentially deadly disease.