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Epidural Abscess


KEY FACTS

Terminology

  • Spinal epidural abscess

  • Extradural spinal infection with abscess formation

Imaging

  • Lower thoracic and lumbar > upper thoracic and cervical

  • CT

    • Enhancing epidural mass narrowing central canal

  • MR

    • T1WI: Iso- to hypointense to cord

    • T2WI/STIR: Hyperintense

    • T1WI C+: Homogeneously or heterogeneously enhancing phlegmon

    • Peripherally enhancing necrotic abscess

  • Fat saturation: STIR, T2WI FS, T1WI C+ FS

    • Increases lesion conspicuity by suppressing signal from epidural fat and vertebral marrow

  • Signal alteration in spinal cord secondary to compression, ischemia, or direct infection

  • Persistent epidural enhancement without mass effect on follow-up MR imaging

    • Probable sterile granulation tissue or fibrosis

    • Correlate with ESR and CRP for disease activity

Top Differential Diagnoses

  • Extradural metastasis

    • Often contiguous with vertebral lesion

  • Epidural hematoma

    • ± mild peripheral enhancement

Pathology

  • Staphylococcus aureus most common cause; Mycobacterium tuberculosis next most frequent

Clinical Issues

  • Fever, acute or subacute spinal pain, and tenderness

  • Neurosurgical emergency if cord complications (bowel, bladder dysfunction)

    • Decompression + 4-6 weeks of IV antibiotics

Sagittal graphic through the lumbar spine demonstrates vertebral osteomyelitis with an intervertebral abscess
extending ventrally
and dorsally into the epidural space
, where it is narrowing the central canal.

Sagittal T1WI C+ MR in an intravenous drug abuser shows a large ventral epidural abscess collection
with peripheral enhancement causing a severe mass effect upon the cervical cord. There is relative preservation of the C5-C6 endplates
with no disc enhancement.

Sagittal T1WI C+ FS MR shows homogeneously enhancing epidural phlegmon in the ventral epidural space
adjacent to the osteomyelitis/discitis
. Dorsal epidural phlegmon
contributes to the mass effect on the cord.

Sagittal T2WI MR shows a large prevertebral abscess
as increased signal. Note the extensive ventral epidural abscess
with posterior displacement of the cord. A small amount of cord edema is present
.

TERMINOLOGY

Abbreviations

  • Spinal epidural abscess (SEA)

Synonyms

  • Spinal epidural empyema

Definitions

  • Extradural spinal infection with abscess formation

IMAGING

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