Nontubercular Primary Spinal Epidural Abscess – A Retrospective Study of 11 Culture-Positive Cases

Abstract

Abstract Background: An epidural abscess that occurs in the absence of contiguous spread from vertebral osteomyelitis or following spinal surgery, spinal anesthesia, or open spinal injuries is considered to be a primary spinal epidural abscess (SEA). The triad of back pain, fever, and progressive neurological dysfunction has long been considered to be the hallmark of primary SEA. Objective: The vast majority of epidural abscesses in our country are either tubercular or associated with pyogenic spondylitis. Primary non tubercular spinal epidural abscesses are rare and also need a different paradigm of management in terms of need for stabilization and duration of antibiotic treatment that we wish to highlight. Material and Methods: Eleven consecutive cases of nontubercular primary SEA were operated by the corresponding author between 2010 and 2019. Their clinical presentation, magnetic resonance imaging (MRI) findings, blood investigations, bacteriological profile, and outcomes were extracted from the patient files and follow-up visits to the outpatient clinic and analyzed 5 years after the last case. Results: All patients had spinal pain at presentation. Seven patients had fever and ten had neurological deficits at presentation. Diabetes and renal failure were the most common comorbidities. All patients had elevated erythrocyte sedimentation rate and C-reactive protein at presentation. The total leukocyte count was not uniformly elevated. One patient who was human immunodeficiency virus positive with a low cell count could not be operated. Diagnosis in his case was established by computed tomography-guided aspirate of the pus. Of the remainder, one patient had no recovery following surgery and two patients had residual deficits. Gram-positive coverage was started empirically in all patients who were operated and based on cultures changed and later extended orally for 4 weeks after discharge till repeat MRI and blood cultures were satisfactory. Conclusions: SEA is a surgical emergency. The majority of cases are caused by Gram-positive bacteria, and many of the patients have comorbidities that need to be addressed. Patients with better preoperative neurological status and those with lumbar location of abscess tend to have a better recovery. Antibiotic treatment must be continued till postoperative radiological and hematological parameters are satisfactory.