Comparison of operative and nonoperative management of spinal epidural abscess: a retrospective review of clinical and laboratory predictors of neurological outcome

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Spinal epidural abscess (SEA), once considered a rare occurrence, has showed a rapid increase in incidence over the past 20–30 years. Recent reports have advocated for conservative, nonoperative management of this devastating disorder with appropriate risk stratification. Crucial to a successful management strategy are decisive diagnosis, prompt intervention, and consistent follow-up care. The authors present a review of their institutional experience with operative and nonoperative management of SEA to assess morbidity and mortality and the accuracy of microbiological diagnosis.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>A retrospective analysis of patient charts, microbiology reports, operative records, and radiology reports was performed on all cases involving patients admitted with the diagnosis of SEA between July 1998 and May 2009.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>Seventy-seven cases were reviewed (median patient age 51.4 years, range 17–78 years). Axial pain was the most common presenting symptom (67.5% of cases). Presenting signs included focal weakness (55.8%), radiculopathy (28.6%), and myelopathy (5.2%). Abscesses were localized to the lumbar, thoracic, and cervical spine, respectively, in 39 (50.6%), 20 (26.0%), and 18 (23.4%) of the patients. Peripheral blood cultures were negative in 32 (45.1%) of 71 patients. Surgical site or interventional biopsy cultures were diagnostic in 52 cases (78.8%), with concordant blood culture results in 36 (60.0%). Methicillin-resistant <jats:italic>Staphylococcus aureus</jats:italic> (MRSA) was the most frequent isolate in 24 cases (31.2%). The mean time from admission to surgery was 5.5 days (range 0–42 days; within 72 hours in 66.7% of cases). Outcome data were available in 72 cases. At discharge, patient condition had improved or resolved in 57 cases (79.2%), improved minimally in 6 (8.3%), and showed no improvement or worsening in 9 (12.5%). Patient age and premorbid weakness were the only factors found to be significantly associated with outcome (p = 0.04 and 0.012, respectively).</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>These results strongly support immediate surgical decompression combined with appropriately tailored antibiotic therapy for the treatment of symptomatic SEA presenting with focal neurological deficit. The nonsuperiority discovered in other patient subsets may be due to allocation biases between surgically treated and nonsurgically treated cohorts. The present data demonstrate the accuracy of peripheral blood culture for the prediction of causative organisms and confirm patient age as a predictor of outcomes.</jats:p></jats:sec>

Medical management of spinal epidural empyema in five dogs

“…In human patients, positive results for bacterial culture of blood samples in conjunction with consistent clinical signs and MRI findings are considered diagnostic for spinal epidural empyema, 19 and organisms isolated from blood samples closely match those recovered from empyema fluid. 3,5,10,12 Even without surgical debridement of the affected area, bacterial organisms were identified in 3 of the 5 dogs described in the present report. Although a causative agent was not identified in the other 2 dogs, the clinical signs and MRI findings provided sufficient evidence for a presumptive diagnosis of spinal epidural empyema.…”

“…Medical management of the spinal epidural empyema was chosen on the basis of 1 or more of the following criteria used for human patients [2][3][4][5][6][7][8][9][10][11][12] : minimal to no spinal cord compression (dogs 2 and 4), mild neurologic deficits (dog 3), and severe lesion extension (dogs 1 and 4). In dog 5, medical management was chosen because financial limitations of the owner precluded surgical intervention.…”

How Best to Manage the Spinal Epidural Abscess? A Current Systematic Review

“…,14,17, 21, 25, 35 Younger age correlated with better neurological outcomes1,11,14, 21 , with patients over 70 years of age having especially poor neurological recovery. Diabetes mellitus was also a strong predictor of poor neurological outcome, seen in four12,14, 21, 37 of the six studies describing this factor.…”

Extensive spinal epidural abscess complicated with hydrocephalus

“…[1,2,3,4,5,6] The gold standard treatment, well supported by multiple published reports, consists of prompt surgical surgical debridement and drainage in combination with systemic antibiotic therapy [7,8,9]. Final outcomes have been strongly and significantly correlated to both duration of the deficit and severity immediately prior to decompression, with morbidity of 33-46% and up to 22% definitive paralysis, even in 2013 papers [11].…”

“…Regarding the case presented, it has the particularities of the inoculation of the germ via infiltration with corticoids, seldom described in literature; even rare are the abscesses extended on such length (2 of 65 cases in the series presented by Velissaris in 2009 [12] and none in 77 cases reviewed by Connor in 2013 [11]). The onset of hydrocephalus as complication determined by such spinal epidural abscess was not found on Pubmed.…”