Diagnostic Delays Are Common, and Classic Presentations Are Rare in Spinal Epidural Abscess

TL;DR

Spinal epidural abscess is often diagnosed late, with few patients showing classic symptoms, making early detection difficult.

Contribution

This study provides insights into the frequency of diagnostic delays and atypical presentations in spinal epidural abscess cases.

Findings

71% of patients had related ambulatory or emergency visits before diagnosis.

Classic triad of symptoms was present in only 10% of patients.

Diabetes and recent infection were common risk factors.

Abstract

Spinal epidural abscess (SEA) is a rare surgical emergency of the spine that can result in permanent neurological injury if not diagnosed and treated in a timely manner. Because early presentation can appear similar to benign back or neck pain, delays in diagnosis may be relatively common. We sought an improved understanding of the characteristics associated with SEA and frequency of delays in SEA diagnosis.

We conducted a retrospective cohort study of adult patients with new magnetic resonance imaging-confirmed SEA from January 1, 2016–December 31, 2019 in an integrated healthcare system. We applied electronic data abstraction and focused manual chart review to describe potentially SEA-related ambulatory and emergency visits in the 30 days prior to SEA diagnosis, and patient characteristics including comorbidities, potential risk factors, and presenting signs and symptoms. We described the frequency of potential delays in diagnosis and of previously described clinical characteristics and risk factors for SEA.

Spinal epidural abscess was diagnosed in 457 patients during the study period, 178 (39%) of whom were female, with median age 63 years (interquartile range 45–81 years). More than two-thirds of patients had at least one visit prior to diagnosis (323, 71%), and SEA location was most commonly the lumbar spine (235, 51%). Although over 90% of patients presented with back or neck pain or tenderness, the classic triad of back pain, fever, and neurologic symptoms was present in only 10% of patients. Diabetes mellitus and infection in the prior 90 days were common, while injection drug use, chronic steroid use, HIV infection, and solid organ transplant were rare.

In an integrated healthcare system, 71% of patients with spinal epidural abscess had potentially related ambulatory care or emergency visits in the 30 days prior to diagnosis. Diagnosis of SEA remains challenging, with multiple visits common before the diagnosis is clear.

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