59. Long-term survival and clinical outcomes in patients managed with emergent surgery for a spinal epidural abscess with associated sepsis and neurologic decline

Abstract

<h3>BACKGROUND CONTEXT</h3> Patients with a spinal epidural abscess (SEA) and associated sepsis and neurologic deterioration require immediate evaluation and prompt surgical intervention. The goals of surgery are life preservation, eradication of the infectious nidus, and restoration of neurologic function. The focus of treatment in these critically ill patients is to achieve these immediate goals. There has been limited attention given to the long-term status of patients who have survived this life threatening condition. <h3>PURPOSE</h3> To identify the survivability and long-term outcome of patients who underwent emergent surgical management for a SEA with associated sepsis and neurologic decline. <h3>STUDY DESIGN/SETTING</h3> A retrospective review of all consecutive patients with a SEA, sepsis and neurologic decline treated at a single, tertiary referral medical center from 2000-2010. <h3>PATIENT SAMPLE</h3> Fifty-four patients. <h3>OUTCOME MEASURES</h3> Survival/mortality, neurologic improvement (ASIA Grade), need for further spine surgery. <h3>METHODS</h3> All patients were clinically septic and had documented neurologic deterioration directly related to a spinal epidural abscess. Surgery was performed emergently from the time of notification of the spine service. Surgical approach was determined by the location of the abscess in relation to the thecal sac; 8 occurred in the cervical spine (all anterior), 20 in the thoracic spine (7 anterior, 13 posterior) and 26 in the lumbar spine (9 anterior, 17 posterior). All cervical SEA underwent an anterior decompression and fusion with structural grafting and plating, while anterior SEA within the thoracic or lumbar spines underwent anterior decompression and fusion with structural grafting followed by a staged, posterior instrumented fusion. Posterior SEA in the thoracic or lumbar spine underwent decompression and abscess evacuation only. Preoperative neurologic status was ASIA B in 20 patients, C in 20, and D in 10. The mean time of neurologic deterioration documented in the medical record was 24 hours (range: 6 hours-5 days). Stepwise multiple regression analysis was performed to identify risk factors for survival and neurologic improvement. Long-term survival was assessed using the institution's electronic medical record and subsequently confirmed by direct patient contact. <h3>RESULTS</h3> All patients survived the surgery, although 6 (11%) died within one month. Significant risk factors for early mortality included age >70 (p=.01), hospitalization >5 days prior to surgery (p=.02), ASIA D (p=.02), diabetes (p=.02), end stage renal disease (p=.02), and MRSA sepsis (p=.02). Of the surviving patients, the mean neurologic improvement was 2.4 ASIA grades. Of surviving patients, 92% (44/48) regained the ability to ambulate. Significant factors for neurologic improvement included age <70 (p=.01), documented neurologic decline <24 hours (p=.01), non-diabetic (p=.02), a cervical abscess (p=.01), a thoracic or lumbar abscess not requiring fusion (p=.02), and preoperative ASIA D (p=.01). At the 10-year follow-up, 88% (42/48) of the patients who survived their perioperative course were still alive. The six non-surviving patients had died of causes unrelated to their spine infections. At the 10-year follow-up, all 42 patients were noted to have maintained their level of neurologic recovery, with none having evidence of recurrent neurologic deficits or loss of ambulatory ability. Ten percent (4/42) of the long-term surviving patients had undergone additional spine surgery, 2 for removal of painful segmental instrumentation and 2 for extension of fusions for symptomatic adjacent level disease. None of the long-term survivors required additional surgery for a recurrent spine infection. Advanced imaging (MRI or CT scan) was available for 30 of the surviving patients. Aside from the 2 patients requiring surgery for adjacent level stenosis, there were no instances of residual infectious spinal column involvement, segmental instability or sagittal plane deformity in any patient. <h3>CONCLUSIONS</h3> Spinal epidural abscesses in patients with sepsis and neurologic deterioration can be effectively managed when diagnosed promptly and treated with emergent surgery. In this series, the majority of patients survived, had neurologic recovery and regained independent ambulation. However, there was a notable early mortality rate (11%), with older, diabetic patients with prolonged neurologic deficits most susceptible. Long-term survival occurred in 88% of patients, with evidence of sustained neurologic improvement, permanent eradication of the spine infection, and relatively uncommon need for additional surgery. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.