Illness script
Spinal epidural abscess
Fever, back pain, and neurologic deficits from a pus collection compressing the spinal cord.
This illness script for Spinal epidural abscess covers the classic presentation, who it affects, how you work it up, the mechanism, and first-line treatment—written for USMLE Step 1 and clerkship clinical reasoning.
Updated Jul 18, 2026All scripts
01
Who it affects
- Middle-aged and older adults, slight male predominance
- IV drug use, diabetes, immunosuppression
- Recent spinal procedure, epidural catheter, or bacteremia
- Indwelling vascular catheters, hemodialysis
- Concurrent skin/soft tissue infection or endocarditis
02
Diagnostics & workup
- Classic triad: fever, back pain, neuro deficit (often incomplete)
- Focal spinal tenderness, progressive weakness/sensory loss, bowel/bladder dysfunction
- Elevated ESR/CRP and WBC; blood cultures often positive
- Gadolinium-enhanced MRI of spine is gold standard
- CT-guided or surgical aspiration for organism identification
- Avoid lumbar puncture through infected area (seeding risk)
03
Pathophysiology
- Infection in epidural space, usually posterior thoracic/lumbar spine
- Hematogenous spread most common; also contiguous or direct inoculation
- Staphylococcus aureus (incl. MRSA) is leading pathogen
- Mass effect plus septic thrombophlebitis causes cord ischemia
- Untreated leads to irreversible paralysis
04
Treatment
- Emergent neurosurgical consult for decompression/drainage
- Empiric IV vancomycin plus antipseudomonal/gram-negative coverage (e.g., cefepime)
- Narrow antibiotics per culture; typically 4-6+ weeks IV
- Surgical laminectomy if neuro deficits or cord compression
- Nonoperative antibiotics only if no deficits and stable, with close monitoring
- Serial neuro exams; disposition to inpatient/ICU
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Educational use only. This illness script is a study framework, not medical advice. Confirm decisions with current guidelines and your clinical supervisors.