Spinal Epidural Abscess

Author: Michelle Lin, MD
Updated: 8/5/2011

Spinal Epidural Abscess (SEA)

Classic triad (back pain + fever + neuro deficits) found in only 2-13% of SEA pts. 1,3

ESR test

  • If ESR >20, sensitivity=90% 1.
  • If ESR >30, sensitivity=81% [2].

Diagnostic Guideline

Spinal epidural abscess guideline flowchart Image adapted from (Davis et al., 2011)

Study design

  • Prospective cohort analysis of clinical decision guidelines to diagnose SEA
  • n = 86 patients (55 in 9-year control group, 31 in 5-year study group)

Outcome measures

  1. Diagnostic delays (multiple ED visits or admission to nonsurgical service without diagnosis of SEA
  2. Presence of motor deficits at time of diagnosis

Risk factors for SEA used in this study

  • Diabetes
  • IVDU history
  • Chronic liver or kidney disease
  • Recent spine procedure
  • Indwelling spinal hardware
  • Recent spine fracture
  • Indwelling vascular catheter
  • Immunocompromised
  • Other site of infection


1/3 of physicians did NOT follow guidelines with ≥1 risk factor esp in setting of trauma and non-midline spine pain


  • Diagnostic delays: 84% without guidelines, 10% with guidelines (OR = 48)
  • Motor deficits at diagnosis: 82% without guidelines, 19% with guidelines (OR = 19)
  • ESR: Sensitivity = 100% and specificity = 67% if ≥1 SEA risk factor
  • ROC curve better with ESR (0.96) than CRP (0.81)


  • Sidman RD, Delorie RC, Spitalnic SJ, Sucov A: Screening tests for spinal epidural abscess lack the sensitivity required to rule it out, Acad Emerg Med (abstract), 9(5):413-4, 2002.
  • Davis DP, Salazar A, Chan TC, Vilke GM. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain J Neurosurg Spine. 2011 Jun;14(6):765-70. doi: 10.3171/2011.1.SPINE1091. Epub 2011 Mar 18. [PubMed]
  • Davis DP, Wold RM, Patel RJ, Tran AJ, Tokhi RN, Chan TC, Vilke GM. The clinical presentation and impact of diagnostic delays on emergency department patients with spinal epidural abscess. J Emerg Med. 2004 Apr;26(3):285-91. [PubMed]