The increasing frequency of intravenous drug abuse–associated spinal epidural abscesses: a case series

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Few studies have been published specifically examining intravenous drug abuse (IVDA)–associated spinal epidural abscesses (SEAs), an unfortunate sequela of the opioid crisis in the United States. Here, the authors examined a series of patients with IVDA-associated SEAs in order to shed light on this challenging disease entity.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>This study is a retrospective chart review of patients presenting with IVDA-associated SEAs at the authors’ institution from 2013 to 2018, spanning the statewide implementation of opioid-prescribing restrictions.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>A total of 45 patients presented with IVDA-associated SEAs; 46.5% presented with a neurological deficit. Thirty-one patients underwent surgery for neurological deficit, failure of medical therapy, or both. Nineteen surgical patients underwent a fusion procedure along with decompression. The complication rate was 41.9%, and the mortality rate was 6.7%. The average length of stay was 27.6 days. Patients who underwent surgery within 24 hours of onset of neurological symptoms trended toward more improvement in their American Spinal Cord Association Impairment Scale grade than those who did not (0.5 vs −0.2, p = 0.068). Methicillin-resistant <jats:italic>Staphylococcus aureus</jats:italic> was isolated as the causative pathogen in 57.8% of patients. Twenty-three patients (51.5%) kept their scheduled clinic follow-up appointments. Of the fusion patients with adequate follow-up, 5 showed bony arthrodesis and 3 had pseudarthrosis. The rate of IVDA-associated SEAs increased after opioid-prescribing restrictions were put in place, from 0.54 cases per month to 1.15 cases per month (p = 0.017).</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>Patients with IVDA-associated SEAs are challenging to treat, with high complication rates and poor follow-up. This disease is increasing in frequency, and opioid-prescribing restrictions did not slow that rise. Community outreach to promote prevention, early medical attention, and medication compliance would benefit this largely publicly funded patient population.</jats:p></jats:sec>

Spinal Epidural Abscess: A Review of Presentation, Management, and Medicolegal Implications

“…These patients have more cervical involvement, less posterior involvement (29% versus 66%), more circumferential abscesses (39% versus 27%), a higher rate of paralysis on presentation, a higher incidence of skip lesions (approximately 20%), and are more likely to be on antibiotics at presentation [ 31 ]. Furthermore, they have a higher rate of early hardware failure and postoperative neurological deterioration [ 31 , 76 ]. Still, this patient population has a higher rate of motor score improvement with surgical decompression than the non-IVDU patient population (26 versus 9 points on the American Spinal Injury Association [ASIA] impairment scale and total motor score scale) [ 31 ].…”

<p>Studies on 11 Cases of Spinal Epidural Abscess and Literature Review</p>

“…7 The incidence of SEA is estimated to be 1.2-8/10,000. Due to the increase in the aging population of multiple comorbidities and the application of advanced imaging technology, 8 the diagnosis rate and incidence of SEA continue to rise. 9…”

Primary Spinal Epidural Abscesses Not Associated With Pyogenic Infectious Spondylodiscitis: A New Pathogenetic Hypothesis

“…Symptoms usually begin with spinal pain and evolve with a variable temporal lag to root pain and weakness followed by paralysis (2). Overall, the incidence of SEAs in developed countries is estimated to be between 0.2 and 2 cases for every 10,000 hospital admissions (3), and recent studies indicate that the incidence of SEAs is rising possibly due to an increase in active intravenous drug users (IVDUs) (4). While the majority of the authors agree that early surgical treatment with spinal cord decompression and drainage of SEA is indicated (5,6), the number of patients intentionally treated conservatively is increasing and it is reaching values as high 57% of all patients affected by SEA (7).…”