Spinal Epidural Abscess: A Series of 101 Cases

  • Martin Vakili
    Requests for reprints should be addressed to Martin Vakili, MD, MSc, Scripps Mercy Hospital, Internal Medicine Department, 4077 Fifth Ave, San Diego, CA 92103.
    Internal Medicine Department, Scripps Mercy Hospital, San Diego, Calif

    Department of Hospital Medicine, Summit Medical Center, Berkeley, Calif
    Search for articles by this author
  • Nancy F. Crum-Cianflone
    Internal Medicine Department, Scripps Mercy Hospital, San Diego, Calif

    Infectious Disease Division, Scripps Mercy Hospital, San Diego, Calif

    Infectious Disease Division, Naval Medical Center San Diego, San Diego, Calif
    Search for articles by this author



      Spinal epidural abscesses are uncommon but potentially devastating infections that often elude early diagnosis. An increasing incidence has been suggested; however, few contemporary data are available regarding risk factors and epidemiologic trends over time.


      A retrospective study of spinal epidural abscesses from 2004 to 2014 at a large academic hospital was conducted. Cases were identified using International Classification of Diseases, Ninth Revision (ICD-9) code 324.1, and a review of medical and radiographic records was performed to confirm each case. Data collected included sociodemographics, medical history, suspected route of infection, treatments, and outcome.


      The incidence was 5.1 cases for each 10,000 admissions, with no significant changes during the study period. The route of infection was identified in 52% of cases, with bacteremia as the most common (26%), followed by recent surgery/procedure (21%) and spinal injection (6%). An identifiable underlying risk factor was present in 84% of cases, most commonly diabetes and intravenous drug use. A causative organism was identified in 84% of cases, most commonly Staphylococcus aureus; methicillin-resistant isolates accounted for 25% of S. aureus cases. All cases received intravenous antibiotic therapy, and 73% underwent a drainage procedure. Fifteen percent had an adverse outcome (8% paralysis and 7% death).


      The incidence of spinal epidural abscesses may be increasing, with the present study demonstrating a ≥5-fold higher rate compared with historical data. Although the outcome in most cases was favorable, spinal epidural abscesses continue to cause substantial morbidity and mortality and should remain a “not to be missed diagnosis.”


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Davis D.P.
        • Wold R.M.
        • Patel R.J.
        • et al.
        The clinical presentation and impact of diagnostic delays on emergency department patients with spinal epidural abscess.
        J Emerg Med. 2004; 26: 285-291
        • Reihsaus E.
        • Waldbaur H.
        • Seeling W.
        Spinal epidural abscess: a meta-analysis of 915 patients.
        Neurosurg Rev. 2000; 23: 175-204
        • Baker A.S.
        • Ojemann R.G.
        • Swartz M.N.
        • et al.
        Spinal epidural abscess.
        N Engl J Med. 1975; 293: 463-468
        • Darouiche R.O.
        Spinal epidural abscess.
        N Engl J Med. 2006; 355: 2012-2020
        • Darouiche R.O.
        Bacterial spinal epidural abscess.
        Medicine (Baltimore). 1992; 71: 369-385
        • Sendi P.
        • Bregenzer T.
        • Zimmerli W.
        Spinal epidural abscess in clinical practice.
        QJM. 2008; 101: 1-12
        • Mackenzie A.R.
        • Laing R.B.S.
        • Karr G.F.
        • et al.
        Spinal epidural abscess: the importance of early diagnosis and treatment.
        J Neurol Neurosurg Psychiatry. 1998; 65: 209-212
        • Pereira C.E.
        • Lynch J.C.
        Spinal epidural abscess: an analysis of 24 cases.
        Surg Neurol. 2004; 63: 26-29
        • Patel A.R.
        • Alton T.B.
        • Bransford R.J.
        • et al.
        Spinal epidural abscess: risk factors, medical versus surgical management, a retrospective review of 128 cases.
        Spine J. 2014; 13: 326-330
        • Rigamonti D.
        • Liem L.
        • Sampath P.
        • et al.
        Spinal epidural abscess: contemporary trends in etiology, evaluation, and management.
        Surg Neurol. 1999; 52: 189-197
        • Nussbaum E.S.
        • Rigamonti D.
        • Standiford H.
        • et al.
        Spinal epidural abscess: a report of 40 cases and review.
        Surg Neurol. 1992; 38: 225-231
        • Khanna R.K.
        • Malik G.M.
        • Rock J.P.
        • Rosenblum M.L.
        Spinal epidural abscess: evaluation of factors influencing outcome.
        Neurosurgery. 1996; 39: 958-964
        • Heusner A.P.
        Nontuberculous spinal epidural infections.
        N Engl J Med. 1948; 239: 845-854
        • Pourtaheri S.
        • Issa K.
        • Stewart T.
        • et al.
        When do you drain epidural abscesses of the spine?.
        Surg Technol Int. 2016; XXIX: 374-378
        • Ju K.L.
        • Kim S.D.
        • Melikian R.
        • et al.
        Predicting patients with concurrent noncontiguous spinal epidural abscess lesions.
        Spine J. 2015; 15: 95-101
        • Kim S.D.
        • Melikian R.
        • Ju K.L.
        • et al.
        Independent predictors of failure of nonoperative management of spinal epidural abscesses.
        Spine J. 2014; 14: 1673-1679
        • Shweikeh F.
        • Saeed K.
        • Bukavina L.
        • et al.
        An institutional series and contemporary review of bacterial spinal epidural abscess: current status and future directions.
        Neurosurg Focus. 2014; 37: E9
        • Karikari I.O.
        • Powers C.J.
        • Reynolds R.M.
        • et al.
        Management of a spontaneous spinal epidural abscess: a single-center 10-year experience.
        Neurosurgery. 2009; 5: 919-923
        • Berbari E.F.
        • Kanj S.S.
        • Kowalski T.J.
        • et al.
        2015 Infectious Diseases Society of America (IDSA) clinical practice guidelines for the diagnosis and treatment of native vertebral osteomyelitis in adults.
        Clin Infect Dis. 2015; 61: e26-e46
        • Wheeler D.
        • Keiser P.
        • Rigamonti D.
        • et al.
        Medical management of spinal epidural abscesses: case report and review.
        Clin Infect Dis. 1992; 15: 22-27
        • Stratton A.
        • Gustafson K.
        • Thomas K.
        • et al.
        Incidence and risk factors for failed medical management of spinal epidural abscess: a systematic review and meta-analysis.
        J Neurosurg Spine. 2016; 16: 1-9
        • Kowalski T.J.
        • Layton K.F.
        • Berbari E.F.
        • et al.
        Follow-up MR imaging in patients with pyogenic spine infections: lack of correlation with clinical features.
        AJNR Am J Neuroradiol. 2007; 28: 693-699
        • Park K.H.
        • Cho O.H.
        • Lee J.H.
        • et al.
        Optimal duration of antibiotic therapy in patients with hematogenous vertebral osteomyelitis at low risk and high risk of recurrence.
        Clin Infect Dis. 2016; 62: 1262-1269
        • Bernard L.
        • Dinh A.
        • Ghout I.
        • et al.
        Antibiotic treatment for 6 weeks versus 12 weeks in patients with pyogenic vertebral osteomyelitis: an open-label, non-inferiority, randomised, controlled trial.
        Lancet. 2015; 385: 875-882
        • Dandy W.E.
        Abscesses and inflammatory tumors in the spinal epidural space (so-called pachymeningitis externa).
        Arch Surg. 1926; 13: 477-494
        • Akalan N.
        • Ozgen T.
        Infection as a cause of spinal cord compression: a review of 36 spinal epidural abscess cases.
        Acta Neurochir (Wien). 2000; 142: 17-23