The time-sensitive challenge of diagnosing spinal epidural abscess in the emergency department

Stephen Alerhand, Sumintra Wood, Brit Long, Alex Koyfman

Research output: Contribution to journalArticle

9 Citations (Scopus)

Abstract

Spinal epidural abscess (SEA) is a rare but devastating condition. Entry of infectious contents into the epidural space occurs via contiguous infected tissue, hematogenous spread, or iatrogenic inoculation. Traditionally, emergency providers are taught to assess for the “classic triad” of spinal pain, fever, and neurological deficits, but this constellation of findings is seen in only 10–15% of cases. Delays in diagnosis and treatment of this condition directly correspond to worse, and often debilitating, outcomes for these patients. This review will demonstrate the challenges of diagnosing SEA, describe key diagnostic pitfalls, and present a model and framework for its evaluation. The authors conducted a systematic review in PubMed and Google Scholar for articles describing the emergency medicine evaluation and management of spinal epidural abscess dating from 1996 to 2016. Of the initial 219 articles found, 18 articles were selected based on their relevancy to emergency medicine. Lower back pain is a common chief complaint, whereas SEA is a rare condition and may not be anticipated. The “classic triad” of SEA symptoms presents infrequently. Moreover, the early symptoms of back pain and fever are non-specific, and patients seek medical attention at varying stages of disease progression. Once the more conspicuous and wide-ranging neurological symptoms develop, they are often irreversible. In fact, final outcomes correlate with the severity and duration of symptoms before surgery. Furthermore, discovering these late neurological symptoms can be particularly difficult in bed-bound and chronically ill patients. MRI is the best diagnostic imaging tool for SEA. Early diagnosis is the major prognostic factor for favorable outcome of SEA, and yet, making this diagnosis in the emergency department (ED) has proved challenging. Shifting from a “classic triad” screening to a risk factor-based model of evaluation represents the current optimal strategy for diagnosing SEA. An algorithm incorporating the most recent data is provided.

Original languageEnglish (US)
Pages (from-to)1-5
Number of pages5
JournalInternal and Emergency Medicine
DOIs
StateAccepted/In press - Aug 4 2017

Fingerprint

Epidural Abscess
Hospital Emergency Service
Emergency Medicine
Fever
Epidural Space
Diagnostic Imaging
Back Pain
Low Back Pain
PubMed
Disease Progression
Early Diagnosis
Emergencies
Chronic Disease
Pain

Keywords

  • Spinal epidural abscess
  • Spinal infection

ASJC Scopus subject areas

  • Internal Medicine
  • Emergency Medicine

Cite this

The time-sensitive challenge of diagnosing spinal epidural abscess in the emergency department. / Alerhand, Stephen; Wood, Sumintra; Long, Brit; Koyfman, Alex.

In: Internal and Emergency Medicine, 04.08.2017, p. 1-5.

Research output: Contribution to journalArticle

@article{6959f9af5d554074ba6446e027b8a07a,
title = "The time-sensitive challenge of diagnosing spinal epidural abscess in the emergency department",
abstract = "Spinal epidural abscess (SEA) is a rare but devastating condition. Entry of infectious contents into the epidural space occurs via contiguous infected tissue, hematogenous spread, or iatrogenic inoculation. Traditionally, emergency providers are taught to assess for the “classic triad” of spinal pain, fever, and neurological deficits, but this constellation of findings is seen in only 10–15{\%} of cases. Delays in diagnosis and treatment of this condition directly correspond to worse, and often debilitating, outcomes for these patients. This review will demonstrate the challenges of diagnosing SEA, describe key diagnostic pitfalls, and present a model and framework for its evaluation. The authors conducted a systematic review in PubMed and Google Scholar for articles describing the emergency medicine evaluation and management of spinal epidural abscess dating from 1996 to 2016. Of the initial 219 articles found, 18 articles were selected based on their relevancy to emergency medicine. Lower back pain is a common chief complaint, whereas SEA is a rare condition and may not be anticipated. The “classic triad” of SEA symptoms presents infrequently. Moreover, the early symptoms of back pain and fever are non-specific, and patients seek medical attention at varying stages of disease progression. Once the more conspicuous and wide-ranging neurological symptoms develop, they are often irreversible. In fact, final outcomes correlate with the severity and duration of symptoms before surgery. Furthermore, discovering these late neurological symptoms can be particularly difficult in bed-bound and chronically ill patients. MRI is the best diagnostic imaging tool for SEA. Early diagnosis is the major prognostic factor for favorable outcome of SEA, and yet, making this diagnosis in the emergency department (ED) has proved challenging. Shifting from a “classic triad” screening to a risk factor-based model of evaluation represents the current optimal strategy for diagnosing SEA. An algorithm incorporating the most recent data is provided.",
keywords = "Spinal epidural abscess, Spinal infection",
author = "Stephen Alerhand and Sumintra Wood and Brit Long and Alex Koyfman",
year = "2017",
month = "8",
day = "4",
doi = "10.1007/s11739-017-1718-5",
language = "English (US)",
pages = "1--5",
journal = "Internal and Emergency Medicine",
issn = "1828-0447",
publisher = "Springer-Verlag Italia",

}

TY - JOUR

T1 - The time-sensitive challenge of diagnosing spinal epidural abscess in the emergency department

AU - Alerhand, Stephen

AU - Wood, Sumintra

AU - Long, Brit

AU - Koyfman, Alex

PY - 2017/8/4

Y1 - 2017/8/4

N2 - Spinal epidural abscess (SEA) is a rare but devastating condition. Entry of infectious contents into the epidural space occurs via contiguous infected tissue, hematogenous spread, or iatrogenic inoculation. Traditionally, emergency providers are taught to assess for the “classic triad” of spinal pain, fever, and neurological deficits, but this constellation of findings is seen in only 10–15% of cases. Delays in diagnosis and treatment of this condition directly correspond to worse, and often debilitating, outcomes for these patients. This review will demonstrate the challenges of diagnosing SEA, describe key diagnostic pitfalls, and present a model and framework for its evaluation. The authors conducted a systematic review in PubMed and Google Scholar for articles describing the emergency medicine evaluation and management of spinal epidural abscess dating from 1996 to 2016. Of the initial 219 articles found, 18 articles were selected based on their relevancy to emergency medicine. Lower back pain is a common chief complaint, whereas SEA is a rare condition and may not be anticipated. The “classic triad” of SEA symptoms presents infrequently. Moreover, the early symptoms of back pain and fever are non-specific, and patients seek medical attention at varying stages of disease progression. Once the more conspicuous and wide-ranging neurological symptoms develop, they are often irreversible. In fact, final outcomes correlate with the severity and duration of symptoms before surgery. Furthermore, discovering these late neurological symptoms can be particularly difficult in bed-bound and chronically ill patients. MRI is the best diagnostic imaging tool for SEA. Early diagnosis is the major prognostic factor for favorable outcome of SEA, and yet, making this diagnosis in the emergency department (ED) has proved challenging. Shifting from a “classic triad” screening to a risk factor-based model of evaluation represents the current optimal strategy for diagnosing SEA. An algorithm incorporating the most recent data is provided.

AB - Spinal epidural abscess (SEA) is a rare but devastating condition. Entry of infectious contents into the epidural space occurs via contiguous infected tissue, hematogenous spread, or iatrogenic inoculation. Traditionally, emergency providers are taught to assess for the “classic triad” of spinal pain, fever, and neurological deficits, but this constellation of findings is seen in only 10–15% of cases. Delays in diagnosis and treatment of this condition directly correspond to worse, and often debilitating, outcomes for these patients. This review will demonstrate the challenges of diagnosing SEA, describe key diagnostic pitfalls, and present a model and framework for its evaluation. The authors conducted a systematic review in PubMed and Google Scholar for articles describing the emergency medicine evaluation and management of spinal epidural abscess dating from 1996 to 2016. Of the initial 219 articles found, 18 articles were selected based on their relevancy to emergency medicine. Lower back pain is a common chief complaint, whereas SEA is a rare condition and may not be anticipated. The “classic triad” of SEA symptoms presents infrequently. Moreover, the early symptoms of back pain and fever are non-specific, and patients seek medical attention at varying stages of disease progression. Once the more conspicuous and wide-ranging neurological symptoms develop, they are often irreversible. In fact, final outcomes correlate with the severity and duration of symptoms before surgery. Furthermore, discovering these late neurological symptoms can be particularly difficult in bed-bound and chronically ill patients. MRI is the best diagnostic imaging tool for SEA. Early diagnosis is the major prognostic factor for favorable outcome of SEA, and yet, making this diagnosis in the emergency department (ED) has proved challenging. Shifting from a “classic triad” screening to a risk factor-based model of evaluation represents the current optimal strategy for diagnosing SEA. An algorithm incorporating the most recent data is provided.

KW - Spinal epidural abscess

KW - Spinal infection

UR - http://www.scopus.com/inward/record.url?scp=85026833133&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85026833133&partnerID=8YFLogxK

U2 - 10.1007/s11739-017-1718-5

DO - 10.1007/s11739-017-1718-5

M3 - Article

C2 - 28779448

AN - SCOPUS:85026833133

SP - 1

EP - 5

JO - Internal and Emergency Medicine

JF - Internal and Emergency Medicine

SN - 1828-0447

ER -