Spinal epidural abscess drainage is an emergency operation to decompress the spinal cord or nerve roots from a collection of pus in the epidural space. Without urgent treatment, the abscess causes irreversible spinal cord damage and paralysis.
A midline incision is made over the affected spinal level(s). Laminectomy is performed to access the epidural space. The abscess is identified, drained, and thoroughly irrigated. Infected tissue and granulation tissue are debrided. Multiple tissue and fluid samples are taken for microbiology. If the spine is unstable (from vertebral osteomyelitis or discitis), stabilisation with screws and rods may be added. The operation takes one and a half to three hours.
Emergency surgery is indicated for epidural abscess with neurological deficit (weakness, bladder dysfunction), progressive neurological deterioration, failure of antibiotic treatment alone, or abscess confirmed on MRI with clinical signs of spinal cord compression. Time to surgery directly affects neurological outcome — patients treated within 24–36 hours of neurological onset have the best chance of recovery.
Antibiotics alone may be appropriate for small abscesses without neurological deficit, identified early on MRI, with a known organism sensitive to antibiotics, and with the ability for close neurological monitoring. However, any neurological deterioration mandates immediate surgery.
Emergency MRI of the entire spine (abscesses may be multi-level). Blood cultures. Assessment of neurological function. Source identification (urinary, skin, dental, IV drug use). This is a surgical emergency.
Decompression of the spinal cord/nerves, drainage of the infection, and microbiological diagnosis guiding antibiotic therapy. Neurological recovery depends on the duration and severity of deficit before surgery — earlier intervention gives better outcomes.
Intravenous antibiotics for at least six weeks, often longer.
If the spinal cord was compressed for more than 24–36 hours, recovery may be partial or absent.
The abscess may recur, requiring repeat surgery.
Paralysis, bladder/bowel dysfunction if the cord was damaged before or during surgery.
Extensive laminectomy may cause instability requiring later fusion.
High risk in the context of systemic infection.
Dural tear during decompression.
Systemic spread of infection.
In severely unwell patients with sepsis and multiple comorbidities.
General anaesthesia. The patient may be septic and haemodynamically unstable. Positioned prone.
Intensive care or high-dependency unit initially if septic. IV antibiotics for at least six weeks via PICC line. Regular blood tests (CRP, ESR, white cell count). Repeat MRI to monitor resolution. Physiotherapy for mobility and neurological rehabilitation. Recovery depends on the extent of neurological damage — may require prolonged inpatient rehabilitation.
Daily neurological assessment initially. Regular blood tests. Repeat MRI at six weeks and three months. Infectious diseases team involvement. PICC line management. Follow-up for months to ensure infection clearance.
Spinal epidural abscesses most commonly arise from haematogenous spread (bacteria travelling through the bloodstream from another infection site — skin, urinary, dental, endocarditis) or direct spread from vertebral osteomyelitis/discitis. Risk factors include diabetes, immunosuppression, IV drug use, and recent spinal procedures.
Recovery depends on the duration and severity of neurological deficit before surgery. Patients treated within 24–36 hours of onset generally have the best chance. Complete paralysis lasting more than 48–72 hours has a much poorer prognosis for recovery.