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

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Object

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.

Methods

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.

Results

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 Staphylococcus aureus (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).

Conclusions

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.

Abbreviations used in this paper:MRSA = methicillin-resistant Staphylococcus aureus; MSSA = methicillin-sensitive S. aureus; SEA = spinal epidural abscess.

Article Information

Current affiliation for Dr. Chittiboina: National Institute of Neurological Diseases and Stroke, National Institutes of Health, Bethesda, Maryland.

Address correspondence to: Anil Nanda, M.D., M.P.H., LSU Health Sciences Center–Shreveport, Department of Neurosurgery, 1501 Kings Highway, P.O. Box 33932, Shreveport, Louisiana 71130-3932. email: ananda@lsuhsc.edu.

Please include this information when citing this paper: published online May 10, 2013; DOI: 10.3171/2013.3.SPINE12762.

© AANS, except where prohibited by US copyright law.

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    Age distribution among patients in operative cohort with and without neurological improvement at discharge. Box plots representing median age bounded by the first and third quartiles in operative cases, comparing the age of patients who demonstrated neurological improvement at discharge with those showing no improvement.

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    Anatomical distribution of SEA at the lumbar, thoracic, and cervical levels. Bar graph representing the distribution of cases by abscess location among operative and nonoperative cases. No significant difference could be identified between operative and nonoperative cases.

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    Culture results among operative and nonoperative cases. Bar graph representing comparison of definitive culture results between operative and nonoperative cases. Results are displayed in terms of percentage of total culture results. MRSA (36.8%) or MSSA (35.1%) was isolated significantly more frequently in operative cases (p = 0.01).

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