The indications and timing for operative management of spinal epidural abscess: literature review and treatment algorithm

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Delayed or inappropriate treatment of spinal epidural abscess (SEA) can lead to serious morbidity or death. It is a rare event with significant variation in its causes, anatomical locations, and rate of progression. Traditionally the treatment of choice has involved emergency surgical evacuation and a prolonged course of antibiotics tailored to the offending pathogen. Recent publications have advocated antibiotic treatment without surgical decompression in select patient populations. Clearly defining those patients who can be safely treated in this manner remains in evolution. The authors review the current literature concerning the treatment and outcome of SEA to make recommendations concerning what population can be safely triaged to nonoperative management and the optimal timing of surgery.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>A PubMed database search was performed using a combination of search terms and Medical Subject Headings, to identify clinical studies reporting on the treatment and outcome of SEA.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>The literature review revealed 28 original case series containing at least 30 patients and reporting on treatment and outcome. All cohorts were deemed Class III evidence, and in all but two the data were obtained retrospectively. Based on the conclusions of these studies along with selected smaller studies and review articles, the authors present an evidence-based algorithm for selecting patients who may be safe candidates for nonoperative management.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Patients who are unable to undergo an operation, have a complete spinal cord injury more than 48 hours with low clinical or radiographic concern for an ascending lesion, or who are neurologically stable and lack risk factors for failure of medical management may be initially treated with antibiotics alone and close clinical monitoring. If initial medical management is to be undertaken the patient should be made aware that delayed neurological deterioration may not fully resolve even after prompt surgical treatment. Patients deemed good surgical candidates should receive their operation as soon as possible because the rate of clinical deterioration with SEA is notoriously unpredictable. Although patients tend to recover from neurological deficits after treatment of SEA, the time point when a neurological injury becomes irreversible is unknown, supporting emergency surgery in those patients with acute findings.</jats:p></jats:sec>

Is There an Association Between Magnetic Resonance Imaging and Neurological Signs in Patients With Vertebral Osteomyelitis?

“…Several studies have pointed out that epidural abscesses can disappear spontaneously with a medical treatment and were not systematically associated with neurological signs. 29,30 …”

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

“…The M A N U S C R I P T A C C E P T E D ACCEPTED MANUSCRIPT moderate mortality of this condition is variable and related to both comorbid disease and extent of neurological impairment. 7,13,14 While early diagnosis and management are important to optimize the neurological trajectory 8,15 , the choice approach to managing this condition remains undefined and likely dependent on patient demographic and pretreatment neurological status as well as radiological appearance. 10,11,16,17 This systematic review evaluated the evidence supporting non-operative and operative management of patients with spinal epidural abscesses, attempting to answer the question of whether surgery provides for outcome advantage and whether it should be performed expeditiously when indicated.…”

Spinal Epidural Abscess: A Review with Special Emphasis on Earlier Diagnosis

“…This hypothesis may explain the difficulty in predicting the tempo of neurological complications following symptom onset in SEA, a view that is not universally endorsed, however [3, 22, 34]. …”