Spinal Epidural Abscess: Diagnosis, Management, and Outcomes

Joseph H. Schwab, MD, MS; Akash A. Shah, MD


J Am Acad Orthop Surg. 2020;28(21):e929-e938. 

In This Article

Abstract and Introduction


An infection of the spinal epidural space, spinal epidural abscess (SEA) is a potentially devastating entity that is rising in incidence. Its insidious presentation, variable progression, and potential for precipitous neurologic decline make diagnosis and management of SEA challenging. Prompt diagnosis is key because treatment delay can lead to paralysis or death. Owing to the nonspecific symptoms and signs of SEA, misdiagnosis is alarmingly common. Risk factor assessment to determine the need for definitive MRI reduces diagnostic delays compared with relying on clinical or laboratory findings alone. Although decompression has long been considered the benchmark for SEA, considerable risk associated with spinal surgery is noted in an older cohort with multiple comorbidities. Nonoperative management may represent an alternative in select cases. Failure of nonoperative management is a feared outcome associated with motor deterioration and poor clinical outcomes. Recent studies have identified independent predictors of failure and residual neurologic dysfunction, recurrence, and mortality. Importantly, these studies provide tools that generate probabilities of these outcomes. Future directions of investigation should include external validation of existing algorithms through multi-institutional collaboration, prospective trials, and incorporation of powerful predictive statistics such as machine learning methods.


Spinal epidural abscess (SEA) is a rare and challenging entity that represents a suppurative process in the spinal epidural space. Its low incidence, insidious presentation, and precipitous neurologic decline make diagnosis and management of SEA challenging. Although the incidence of SEA has remained stably low for much of the 20th century—most studies conducted between 1930 and 1975 reported an incidence of 0.2 to 1.2 cases per 10,000 admissions—it is increasing in recent decades.[1–5] The increasing incidence may be due to higher rates of risk factors for SEA in the modern cohort: increased age, immunosuppressive comorbidities (eg, diabetes mellitus, end-stage renal disease, and malignancy), intravenous drug use, and spinal procedures.[2,3] Heightened awareness of SEA and increased use of MRI and CT may contribute to higher rates of diagnosis. Furthermore, SEA is a costly diagnosis for the healthcare system with median charges ranging from nearly $50,000 to $71,000 per admission.[6] Given its increasing incidence, significant morbidity, and high cost, SEA is an important entity that has been the subject of many recent studies.