Readmission after spinal epidural abscess management in urban populations: a bi-institutional study

Presented at the 2019 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves

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OBJECTIVE

The incidence of spinal epidural abscess (SEA) is rising, yet there are few reports discussing readmission rates or predisposing factors for readmission after treatment. The aims of the present study were to determine the rate of 90-day readmission following medical or surgical treatment of SEA in an urban population, identify patients at increased risk for readmission, and delineate the principal causes of readmission.

METHODS

Neurosurgery records from two large urban institutions were reviewed to identify patients who were treated for SEA. Patients who died during admission or were discharged to hospice were excluded. Univariate analysis was performed using chi-square and Student t-tests to identify potential predictors of readmission. A multivariate logistic regression model, controlled for age, body mass index, sex, and institution, was used to determine significant predictors of readmission.

RESULTS

Of 103 patients with identified SEA, 97 met the inclusion criteria. Their mean age was 57.1 years, and 56 patients (57.7%) were male. The all-cause 90-day readmission rate was 37.1%. Infection (sepsis, osteomyelitis, persistent abscess, bacteremia) was the most common cause of readmission, accounting for 36.1% of all readmissions. Neither pretreatment neurological deficit (p = 0.16) nor use of surgical versus medical management (p = 0.33) was significantly associated with readmission. Multivariate analysis identified immunocompromised status (p = 0.036; OR 3.5, 95% CI 1.1–11.5) and hepatic disease (chronic hepatitis or alcohol abuse) (p = 0.033; OR 2.9, 95% CI 1.1–7.7) as positive predictors of 90-day readmission.

CONCLUSIONS

The most common indication for readmission was persistent infection. Readmission was unrelated to baseline neurological status or management strategy. However, both hepatic disease and baseline immunosuppression significantly increased the odds of 90-day readmission after SEA treatment. Patients with these conditions may require closer follow-up upon discharge to reduce overall morbidity and hospital costs associated with SEA.

ABBREVIATIONS BUN = blood urea nitrogen; CHF = congestive heart failure; CRP = C-reactive protein; ESR = erythrocyte sedimentation rate; IVDU = intravenous drug use; MRSA = methicillin-resistant Staphylococcus aureus; MSSA = methicillin-sensitive S. aureus; SEA = spinal epidural abscess; VIF = variance inflation factor; WBC = white blood cell.
Article Information

Contributor Notes

Correspondence Reza Yassari: Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY. ryassari@montefiore.org.INCLUDE WHEN CITING Published online November 22, 2019; DOI: 10.3171/2019.8.SPINE19790.

M.L. and Z.P. contributed equally to this work.

Disclosures Dr. Sciubba reports a consultant relationship with Baxter, DePuy-Synthes, Globus, K2M, Medtronic, NuVasive, and Stryker. Dr. Yassari reports a consultant relationship with Stryker.
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References
  • 1

    Adogwa OKarikari IOCarr KRKrucoff MAjay DFatemi P: Spontaneous spinal epidural abscess in patients 50 years of age and older: a 15-year institutional perspective and review of the literature: clinical article. J Neurosurg Spine 20:3443492014

    • Search Google Scholar
    • Export Citation
  • 2

    Al-Hourani KAl-Aref RMesfin A: Upper cervical epidural abscess in clinical practice: diagnosis and management. Global Spine J 6:3833932016

    • Search Google Scholar
    • Export Citation
  • 3

    Arko L IVQuach ENguyen VChang DSukul VKim BS: Medical and surgical management of spinal epidural abscess: a systematic review. Neurosurg Focus 37(2):E42014

    • Search Google Scholar
    • Export Citation
  • 4

    Avanali RRanjan MRamachandran SDevi BINarayanan V: Primary pyogenic spinal epidural abscess: How late is too late and how bad is too bad? A study on surgical outcome after delayed presentation. Br J Neurosurg 30:91962016

    • Search Google Scholar
    • Export Citation
  • 5

    Bond AManian FA: Spinal epidural abscess: a review with special emphasis on earlier diagnosis. BioMed Res Int 2016:16143282016

  • 6

    Chaker ANBhimani ADEsfahani DRRosinski CLGeever BWPatel AS: Epidural abscess: a propensity analysis of surgical treatment strategies. Spine (Phila Pa 1976) 43:E1479E14852018

    • Search Google Scholar
    • Export Citation
  • 7

    Epstein NE: Timing and prognosis of surgery for spinal epidural abscess: a review. Surg Neurol Int 6 (Suppl 19):S475S4862015

  • 8

    Farber SHMurphy KRSuryadevara CMBabu RYang SFeng L: Comparing outcomes of early, late, and non-surgical management of intraspinal abscess. J Clin Neurosci 36:64712017

    • Search Google Scholar
    • Export Citation
  • 9

    Frankel HLHancock DOHyslop GMelzak JMichaelis LSUngar GH: The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. I. Paraplegia 7:1791921969

    • Search Google Scholar
    • Export Citation
  • 10

    Ghobrial GMBeygi SViereck MJMaulucci CMSharan AHeller J: Timing in the surgical evacuation of spinal epidural abscesses. Neurosurg Focus 37(2):E12014

    • Search Google Scholar
    • Export Citation
  • 11

    Grewal SHocking GWildsmith JAW: Epidural abscesses. Br J Anaesth 96:2923022006

  • 12

    Hawkins MBolton M: Pediatric spinal epidural abscess: a 9-year institutional review and review of the literature. Pediatrics 132:e1680e16852013

    • Search Google Scholar
    • Export Citation
  • 13

    Hosmer DWLemeshow S: Applied Logistic Regression. New York: Wiley2000 Vol 2

    • Export Citation
  • 14

    Huang PYChen SFChang WNLu CHChuang YCTsai NW: Spinal epidural abscess in adults caused by Staphylococcus aureus: clinical characteristics and prognostic factors. Clin Neurol Neurosurg 114:5725762012

    • Search Google Scholar
    • Export Citation
  • 15

    Ju KLKim SDMelikian RBono CMHarris MB: Predicting patients with concurrent noncontiguous spinal epidural abscess lesions. Spine J 15:951012015

    • Search Google Scholar
    • Export Citation
  • 16

    Kangovi SGrande D: Hospital readmissions—not just a measure of quality. JAMA 306:179617972011

  • 17

    Karikari IPowers CReynolds RMehta AIsaacs R: 14. Surgical vs. medical management of spinal epidural abscess: a single center 10 year experience. Spine J 9 (Suppl):7S2009 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 18

    Kim SDMelikian RJu KLZurakowski DWood KBBono CM: Independent predictors of failure of nonoperative management of spinal epidural abscesses. Spine J 14:167316792014

    • Search Google Scholar
    • Export Citation
  • 19

    Lau DChan AKTheologis AAChou DMummaneni PVBurch S: Costs and readmission rates for the resection of primary and metastatic spinal tumors: a comparative analysis of 181 patients. J Neurosurg Spine 25:3663782016

    • Search Google Scholar
    • Export Citation
  • 20

    Lissauer MEDiaz JJNarayan MShah PKHanna NN: Surgical intensive care unit admission variables predict subsequent readmission. Am Surg 79:5835882013

    • Search Google Scholar
    • Export Citation
  • 21

    Menke ACasagrande SGeiss LCowie CC: Prevalence of and trends in diabetes among adults in the United States, 1988-2012. JAMA 314:102110292015

    • Search Google Scholar
    • Export Citation
  • 22

    Nagar VRSpringer JESalles S: Increased incidence of spinal abscess and substance abuse after implementation of state mandated prescription drug legislation. Pain Med 16:203120352015

    • Search Google Scholar
    • Export Citation
  • 23

    Nichols GASchroeder EBKarter AJGregg EWDesai JLawrence JM: Trends in diabetes incidence among 7 million insured adults, 2006-2011: the SUPREME-DM project. Am J Epidemiol 181:32392015

    • Search Google Scholar
    • Export Citation
  • 24

    O’Daly BJMorris SFO’Rourke SK: Long-term functional outcome in pyogenic spinal infection. Spine (Phila Pa 1976) 33:E246E2532008

    • Search Google Scholar
    • Export Citation
  • 25

    Ortega-Prieto AMDorner M: Immune evasion strategies during chronic hepatitis B and C virus infection. Vaccines (Basel) 5:E252017

  • 26

    Patel ARAlton TBBransford RJLee MJBellabarba CBChapman JR: Spinal epidural abscesses: risk factors, medical versus surgical management, a retrospective review of 128 cases. Spine J 14:3263302014

    • Search Google Scholar
    • Export Citation
  • 27

    Schoenfeld AJWahlquist TC: Mortality, complication risk, and total charges after the treatment of epidural abscess. Spine J 15:2492552015

    • Search Google Scholar
    • Export Citation
  • 28

    Sendi PBregenzer TZimmerli W: Spinal epidural abscess in clinical practice. QJM 101:1122008

  • 29

    Shah AAOgink PTHarris MBSchwab JH: Development of predictive algorithms for pre-treatment motor deficit and 90-day mortality in spinal epidural abscess. J Bone Joint Surg Am 100:103010382018

    • Search Google Scholar
    • Export Citation
  • 30

    Shah NHRoos KL: Spinal epidural abscess and paralytic mechanisms. Curr Opin Neurol 26:3143172013

  • 31

    Shorr AFZilberberg MDReichley RKan JHoban AHoffman J: Readmission following hospitalization for pneumonia: the impact of pneumonia type and its implication for hospitals. Clin Infect Dis 57:3623672013

    • Search Google Scholar
    • Export Citation
  • 32

    Strauss ICarmi-Oren NHassner AShapiro MGiladi MLidar Z: Spinal epidural abscess: in search of reasons for an increased incidence. Isr Med Assoc J 15:4934962013

    • Search Google Scholar
    • Export Citation
  • 33

    Szabo G: Consequences of alcohol consumption on host defence. Alcohol Alcohol 34:8308411999

  • 34

    Tang HJLin HJLiu YCLi CM: Spinal epidural abscess—experience with 46 patients and evaluation of prognostic factors. J Infect 45:76812002

    • Search Google Scholar
    • Export Citation
  • 35

    Tompkins MPanuncialman ILucas PPalumbo M: Spinal epidural abscess. J Emerg Med 39:3843902010

  • 36

    Vakili MCrum-Cianflone NF: Spinal epidural abscess: a series of 101 cases. Am J Med 130:145814632017

  • 37

    Vest JRGamm LDOxford BAGonzalez MISlawson KM: Determinants of preventable readmissions in the United States: a systematic review. Implement Sci 5:882010

    • Search Google Scholar
    • Export Citation
  • 38

    Vittinghoff EMcCulloch CE: Relaxing the rule of ten events per variable in logistic and Cox regression. Am J Epidemiol 165:7107182007

    • Search Google Scholar
    • Export Citation
  • 39

    Wu MYFu TSChang CHHsu HHChang MYTian YC: Aggressive surgical intervention in end-stage renal disease patients with spinal epidural abscess. Ren Fail 33:5825862011

    • Search Google Scholar
    • Export Citation
  • 40

    Yoo WMayberry RBae SSingh KPeter He QLillard JW Jr: A study of effects of multicollinearity in the multivariable analysis. Int J Appl Sci Technol 4:9192014

    • Search Google Scholar
    • Export Citation
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