Spinal Epidural Abscess

A collection of pus within the spinal epidural space, most commonly from hematogenous spread (Staphylococcus aureus is the leading cause), direct extension from vertebral osteomyelitis or discitis, or direct inoculation (epidural anesthesia, spinal surgery, IV drug use).

A spinal surgical emergency given the risk of irreversible cord compression.

The classic triad, back pain, fever, and neurological deficit, is present together in only a minority; back pain is usually the earliest and most consistent feature, often severe and localized, evolving over days to a radicular pattern, then progressive weakness, sensory loss, and bladder/bowel dysfunction as cord compression develops.

Progression from pain to paralysis can occur within hours once neurological signs begin.

Urgent surgical decompression and drainage is indicated for any significant or progressive neurological deficit, and should not be delayed for prolonged antibiotic trials in this situation
Empirical IV vancomycin plus a third-generation cephalosporin (ceftriaxone 2 g od) or, where gram negative/Pseudomonas risk is higher, cefepime, started immediately after cultures, rationalized once organism identified
Total antibiotic duration typically 6 to 8 weeks, guided by clinical and inflammatory marker response
Conservative management (antibiotics alone with close monitoring) may be considered only in the absence of neurological deficit, with a very low threshold for surgery if any deterioration occurs

Referral: spinal surgery emergency for any neurological deficit; infectious disease for antibiotic duration guidance.

Depressed Skull Fracture

A depressed skull fracture occurs when a fragment of cranial vault is displaced inward relative to the surrounding skull.

It can be:

Closed

Skin and scalp remain intact.

Open or compound

The fracture communicates with an overlying wound.

Open depressed fractures can additionally involve:

Dural laceration
Brain laceration
Contamination
CSF leakage
Intracranial foreign material

Common locations include:

Frontal bone
Parietal bone
Temporal bone

Open frontal sinus involvement requires separate attention because violation of the posterior table can communicate the sinonasal tract with the intracranial compartment.

Operative indications

An open depressed fracture depressed by more than the thickness of the adjacent skull should generally undergo operative elevation and debridement.

Operate particularly when there is:

Depression greater than approximately 1 cm
Dural penetration
Gross contamination
Intracranial haematoma requiring evacuation
CSF leak
Frontal sinus posterior table injury
Gross cosmetic deformity
Wound infection
Significant pneumocephalus
Neurological compression.

A closed uncomplicated depressed fracture can often be observed when there is no neurological compression or unacceptable deformity.

Operation

Perform early surgery for an open compound injury.

Steps include:

Debride contaminated scalp and devitalised tissue
Remove obvious foreign material
Elevate depressed bone fragments
Control intracranial bleeding
Repair dura watertight where possible
Irrigate thoroughly
Replace viable bone fragments when contamination and infection risk permit

Primary replacement of bone is acceptable in a clean adequately debrided injury without established infection.

Avoid uncontrolled elevation of fragments embedded in a major venous sinus without a vascular control strategy.

Antibiotics

Open depressed skull fracture requires antimicrobial prophylaxis.

A practical regimen for uncomplicated open cranial fracture is:

Cefazolin 2 g IV every 8 hours

with broader therapy when there is:

Gross contamination
Sinus violation
Penetrating intracranial debris

For significant sinus or soil contamination, a practical broader regimen is:

Ceftriaxone 2 g IV every 12 hours plus metronidazole 500 mg IV every 8 hours

with duration individualised according to wound contamination and operative findings.

Seizure prophylaxis

Use a 7 day early seizure prophylaxis course when significant cortical injury, open depression or intracranial haematoma is present.

Spinal Epidural Abscess

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management