Spinal epidural abscesses: risk factors, medical versus surgical management, a retrospective review of 128 cases

• Published in: The spine journal 2014-02, Vol.14 (2), p.326-330
• Main Authors: Patel, Amit R., MD, Alton, Timothy B., MD, Bransford, Richard J., MD, Lee, Michael J., MD, Bellabarba, Carlo B., MD, Chapman, Jens R., MD
• Format: Article
• Language: English
• Subjects: Adult; Aged; Aged, 80 and over; Anti-Bacterial Agents - therapeutic use; Combined Modality Therapy; Disease Management; Electronic Health Records; Epidural abscess; Epidural Abscess - drug therapy; Epidural Abscess - microbiology; Epidural Abscess - surgery; Female; Humans; Male; Management; Medical; Middle Aged; Motor score; Orthopedic Procedures - methods; Orthopedic Procedures - trends; Orthopedics; Outcomes; Predictive Value of Tests; Retrospective Studies; Risk Factors; Surgical; Young Adult
• ISSN: 1529-9430; 1878-1632
• DOI: 10.1016/j.spinee.2013.10.046

Abstract Background context Spinal epidural abscess (SEA) is a rare, serious and increasingly frequent diagnosis. Ideal management (medical vs. surgical) remains controversial. Purpose The purpose of this study is to assess the impact of risk factors, organisms, location and extent of SEA on neurologic outcome after medical management or surgery in combination with medical management. Study design Retrospective electronic medical record (EMR) review. Patient sample We included 128 consecutive, spontaneous SEA from a single tertiary medical center, from January 2005 to September 11. There were 79 male and 49 female with a mean age of 52.9 years (range, 22–83). Outcome measures Patient demographics, presenting complaints, radiographic features, pre/post-treatment neurologic status (ASIA motor score [MS] 0–100), treatment (medical vs. surgical) and clinical follow-up were recorded. Neurologic status was determined before treatment and at last available clinical encounter. Imaging studies reviewed location/extent of pathology. Methods Inclusion criteria were a diagnosis of a bacterial SEA based on radiographs and/or intraoperative findings, age greater than 18 years, and adequate EMR. Exclusion criteria were postinterventional infections, Pott's disease, isolated discitis/osteomyelitis, treatment initiated at an outside facility, and imaging suggestive of a SEA but negative intraoperative findings/cultures. Results The mean follow-up was 241 days. The presenting chief complaint was site-specific pain (100%), subjective fevers (50%), and weakness (47%). In this cohort, 54.7% had lumbar, 39.1% thoracic, 35.9% cervical, and 23.4% sacral involvement spanning an average of 3.85 disc levels. There were 36% ventral, 41% dorsal, and 23% circumferential infections. Risk factors included a history of IV drug abuse (39.1%), diabetes mellitus (21.9%), and no risk factors (22.7%). Pathogens were methicillin-sensitive Staphylococcus aureus (40%) and methicillin-resistance S aureus (30%). Location, SEA extent, and pathogen did not impact MS recovery. Fifty-one patients were treated with antibiotics alone (group 1), 77 with surgery and antibiotics (group 2). Within group 1, 21 patients (41%) failed medical management (progressive MS loss or worsening pain) requiring delayed surgery (group 3). Irrespective of treatment, MS improved by 3.37 points. Thirty patients had successful medical management (MS: pretreatment, 96.5; post-treatment, 96.8). Twenty-one patients failed medica