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

Clinical article

Restricted access

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.

Headings

Figures

  • View in gallery

    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.

  • View in gallery

    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.

  • View in gallery

    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).

References

1

Ahl THedström Mvon Heijne AHammers Stiernstedt S: Acute spinal epidural abscess without concurrent spondylodiscitis. Successful closed treatment in 10 cases. Acta Orthop Scand 70:1992021999

2

Bouchez BArnott GDelfosse JM: Acute spinal epidural abscess. J Neurol 231:3433441985

3

Curry WT JrHoh BLAmin-Hanjani SEskandar EN: Spinal epidural abscess: clinical presentation, management, and outcome. Surg Neurol 63:3643712005

4

Danner RLHartman BJ: Update on spinal epidural abscess: 35 cases and review of the literature. Rev Infect Dis 9:2652741987

5

Darouiche RO: Spinal epidural abscess. N Engl J Med 355:201220202006

6

Darouiche ROHamill RJGreenberg SBWeathers SWMusher DM: Bacterial spinal epidural abscess. Review of 43 cases and literature survey. Medicine (Baltimore) 71:3693851992

7

Davis DPWold RMPatel RJTran AJTokhi RNChan TC: The clinical presentation and impact of diagnostic delays on emergency department patients with spinal epidural abscess. J Emerg Med 26:2852912004

8

Del Curling O JrGower DJMcWhorter JM: Changing concepts in spinal epidural abscess: a report of 29 cases. Neurosurgery 27:1851921990

9

Grant FC: Epidural spinal abscess. J Am Med Assoc 128:5095121945

10

Guerado ECerván AM: Surgical treatment of spondylodiscitis. An update. Int Orthop 36:4134202012

11

Hadjipavlou AGMader JTNecessary JTMuffoletto AJ: Hematogenous pyogenic spinal infections and their surgical management. Spine (Phila Pa 1976) 25:166816792000

12

Hlavin MLKaminski HJRoss JSGanz E: Spinal epidural abscess: a ten-year perspective. Neurosurgery 27:1771841990

13

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

14

Karikari IOPowers CJReynolds RMMehta AIIsaacs RE: Management of a spontaneous spinal epidural abscess: a single-center 10-year experience. Neurosurgery 65:9199242009

15

Mixter WJSmithwick RH: Acute intraspinal epidural abscess. N Engl J Med 207:1261311932

16

Morgagni G: De sedibus et causis morborum per anatomen indagatis: dissectiones et animadversiones nunc primum ed. complectuntur propemodum innumeras medicis chirurgis anatomicis profuturas Padua, ItalySumptibus Remondinianis1765

17

Nussbaum ESRigamonti DStandiford HNumaguchi YWolf ALRobinson WL: Spinal epidural abscess: a report of 40 cases and review. Surg Neurol 38:2252311992

18

Parkinson JFSekhon LHS: Spinal epidural abscess: appearance on magnetic resonance imaging as a guide to surgical management. Report of five cases. Neurosurg Focus 17:6E122004

19

Pereira CELynch JC: Spinal epidural abscess: an analysis of 24 cases. Surg Neurol 63:Suppl 1S26S292005

20

Reihsaus EWaldbaur HSeeling W: Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev 23:1752052000

21

Rigamonti DLiem LSampath PKnoller NNamaguchi YSchreibman DL: Spinal epidural abscess: contemporary trends in etiology, evaluation, and management. Surg Neurol 52:1891971999

22

Savage KHoltom PDZalavras CG: Spinal epidural abscess: early clinical outcome in patients treated medically. Clin Orthop Relat Res 439:56602005

23

Siddiq FChowfin ATight RSahmoun AESmego RA Jr: Medical vs surgical management of spinal epidural abscess. Arch Intern Med 164:240924122004

24

Sørensen P: Spinal epidural abscesses: conservative treatment for selected subgroups of patients. Br J Neurosurg 17:5135182003

25

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

26

Wheeler DKeiser PRigamonti DKeay S: Medical management of spinal epidural abscesses: case report and review. Clin Infect Dis 15:22271992

27

Yang SY: Spinal epidural abscess. N Z Med J 95:3023041982

28

Zimmerer SMEConen AMüller AASailer MTaub EFlückiger U: Spinal epidural abscess: aetiology, predisponent factors and clinical outcomes in a 4-year prospective study. Eur Spine J 20:222822342011

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 57 57 22
Full Text Views 73 73 17
PDF Downloads 107 107 15
EPUB Downloads 0 0 0

PubMed

Google Scholar