Management Of Spinal Epidural Abscess Research Articles

Long-Term Survivability of Surgical and Non-Surgical Management of Spinal Epidural Abscess

Spinal epidural abscess (SEA) is a rare and life-threatening infection within the epidural space with significant functional impairment and morbidity. Active debate remains over whether to operate for SEAs, with limited existing data comparing the long-term survivability after surgical versus nonsurgical management. This study aims to determine the long-term survival of patients who underwent surgical and nonsurgical management for SEA. Retrospective cohort study. A total of 250 consecutive SEA patients. Survival and mortality rates, complications. All patients treated at a tertiary medical center for a primary SEA from January 2000 to June 2020 are identified. Data collection is by retrospective chart review. Cox proportional hazards regression models are used for all survival analyses while controlling for potential confounding variables and with multiple testing corrections. A total of 35 out of 250 patients died with an overall all-cause mortality of 14%. More than half of all deaths occurred within 90 days after treatment. The 90-day, 3-year, and 5-year survival rates are 92.8%, 89.2%, and 86.4%, respectively. Among surgery patients, the all-cause mortality was 13.07%, compared to 16.22% for medically-managed patients. Surgical treatment (decompression, fusion, debridement) significantly reduced the risk of death by 62.4% compared to medical therapy (p=.03), but surgery patients experienced a significantly longer mean length of stay (p=.01). Risk factors of short-term mortality included hypoalbuminemia (<3.5 g/dL), American Society of Anesthesiologists (ASA) 4+, and cardiac arrest. Risk factors of long-term mortality were immunocompromised state, elevated WBC count >12,000, sepsis, septic shock, ASA 4+, and cardiac arrest (p<.05). In terms of complications, surgically-managed patients experienced a higher proportion of deep vein thrombosis (p<.05). The overall long-term survivability of SEA treatment is relatively high at (86% at 5-year) in this study. The following SEA mortality risk factors were identified: hypoalbuminemia (short-term), immunocompromised state (long-term), leukocytosis (long-term), sepsis and septic shock (long-term), ASA 4+ and cardiac arrest (overall). For primary SEA patients, surgical management may reduce mortality risk compared to nonsurgical management.

External Validation of Predictive Models for Failed Medical Management of Spinal Epidural Abscess

ObjectiveThere is limited consensus regarding management of spinal epidural abscesses (SEA), particularly in patients without neurologic deficits. Several models have been created to predict failure of medical management in patients with SEA. We evaluate the external validity of five predictive models in an independent cohort of patients with SEA. Methods176 patients with SEA between 2010 and 2019 at our institution were identified, and variables relevant to each predictive model were collected. Published prediction models were used to assign probability of medical management failure to each patient. Predicted probabilities of medical failure and actual patient outcomes were used to create Receiver Operating Characteristic (ROC) curves, with the area under the ROC curve (AUROC) used to quantify a model’s discriminative ability. Calibration curves were plotted using predicted probabilities and actual outcomes. The Spiegelhalter Z-test was used to determine adequate model calibration. ResultsOne model (Kim et al.) demonstrated good discriminative ability and adequate model calibration in our cohort (ROC = 0.831, p-value = 0.83). Parameters included in the model were age >65, diabetes, MRSA infection, and neurologic impairment. Four additional models did not perform well for discrimination or calibration metrics (Patel et al., ROC=0.580, p=<0.0001; Shah et al., ROC=0.653, p=<0.0001; Baum et al., ROC=0.498, p=<0.0001; Page et al., ROC=0.534, p=<0.0001). ConclusionOnly one published predictive model demonstrated acceptable discrimination and calibration in our cohort, suggesting limited generalizability of the evaluated models. Multi-institutional data may facilitate the development of widely applicable models to predict medical management failure in patients with SEA.

Long-term quality of life and functional outcomes after management of spinal epidural abscess

BACKGROUND/CONTEXTIn recent years, the incidence of spinal epidural abscesses (SEA) has tripled in number and nonoperative management has risen in popularity. While there has been a shift towards reserving surgical intervention for patients with focal neurologic deficits, a third of patients will still fail medical management and require surgical intervention. Failure to understand long-term quality of life and functional outcomes hinders effective decision making and prognostication. PURPOSETo describe patterns and associated factors impacting long-term quality of life following treatment of spinal epidural abscess. STUDY DESIGN/SETTINGMulticenter cohort study at two urban academic tertiary referral centers and two community centers. PATIENT SAMPLEAdult patients treated for a spinal epidural abscess. OUTCOME MEASURESEuroQoL 5-Dimension 5L (EQ5D), Neuro-Quality of Life Lower Extremity – Mobility (Short Form; NeuroQoL-LE), Patient-Reported Outcomes Measurement Information System Physical Function (short form 4a; PROMIS PF), and PROMIS Global Mental Health score (PROMIS Mental). METHODSEligible patients were enrolled and administered questionnaires. Multivariable analysis assessed the influence of ambulatory status on HRQL, adjusting for covariates including age, biologic sex, Charlson comorbidity index, intravenous drug use, management approach, and ASIA grade on presentation. RESULTSSixty-one patients were enrolled (mean age 60.5 years, 46% male). Thirty-four patients (58%) underwent operative management. Mean standard deviation (SD) results for HRQL measures were: EQ5D 0.51 (0.37), EQ5D visual analogue scale 60.34 (25.11), NeuroQoL Lower extremity 41.47 (10.64), PROMIS physical function 39.49 (10.07), and PROMIS Global Mental Health 44.23 (10.36). Adjusted analysis demonstrated ambulatory status at presentation, and at 1 year, to be important drivers of HRQL, irrespective of other factors including IVDU and ASIA grade. Patients with independent ambulatory function at 1 year had mean EQ5D utility of 0.65 (95% CI 0.55, 0.75), whereas those requiring assistive devices saw a 49% decrease with mean EQ5D utility of 0.32 (0.14, 0.51). Ambulatory status was associated with global and physical function but did not impact overall health self-assessment or mental health scores. CONCLUSIONSWe found that ambulatory status was the most important factor associated with long-term HRQL regardless of other factors such as ASIA grade or IVDU. Given prior literature demonstrating the protective effect of operative intervention on ambulatory function, this highlights ambulatory dysfunction as a potential indication for surgery and a marker of poor long-term prognosis, even in the absence of focal neurologic deficits. Our work also highlights the importance of optimized long-term rehabilitation strategies aimed to preserve ambulatory function in this high-risk population. Level of EvidenceLevel III, cohort study

P51. Surgical versus non-surgical management of spinal epidural abscess: long-term outcomes of 250 patients

P51. Surgical versus non-surgical management of spinal epidural abscess: long-term outcomes of 250 patients

Surgical Management of Spinal Epidural Abscess in Elderly Patients: A Comparative Analysis Between Patients 65–79 Years and ≥80 Years with 3-Year Follow-Up

Recently, the incidence of pyogenic vertebral osteomyelitis with spinal epidural abscess (SEA) has increased. However, the most appropriate surgical management remains debatable, especially for older patients. This study aimed to compare the clinical course in older patients aged between 65 and 79 years and those 80 years or older undergoing surgery for SEA. Data on patient demographics, surgical characteristics, complications, hospital clinical course, and 90-day mortality of patients diagnosed with pyogenic vertebral osteomyelitis and SEA between September 2005 and December 2021 were collected. Comorbidities were assessed using the age-adjusted Charlson comorbidity index. We enrolled 45 patients aged 65-79 years and 32 patients ≥80 years. Patients ≥80 years had significantly higher rates of Charlson comorbidity index (9.2 ± 2.4) than younger patients (6.5 ± 2.5; P < 0.001). Arterial hypertension, renal failure, and dementia were significantly more prevalent in octogenarians (P < 0.05). Patients aged ≥80 years had a significantly longer length of hospitalization, while the intensive care unit stay was similar between groups. In-hospital mortality was significantly greater in those ≥80 years (n= 3, 9.4% vs. n= 0, 0.0%; P= 0.029), whereas no differences in 90-day mortality or 30-day readmission were observed. In the second-stage analysis, significant improvements in blood infection parameters and neurologic status were detected in both groups. Of adverse events, pneumonia occurred significantly more frequently in patients aged ≥80 years. Surgical management leads to significant improvements in both laboratory and clinical parameters in older patients. Nevertheless, a personalized medical approach is mandatory in frail patients, especially octogenarians. A clear discussion regarding the potential risk is unambiguously recommended.

P44. Surgical management of spinal epidural abscess: risk factors and outcomes

<h3>BACKGROUND CONTEXT</h3> A spinal epidural abscess (SEA), a pyogenic infection, can often lead to permanent neurological deficits and mortality. Over the past three decades, the incidence of SEAs, while uncommon, has risen from 0.2-1.0 cases per 10,000 hospital admissions to 2.5-5.1 per 10,000 admissions. Given this rising incidence and potential of SEAs to become a surgical emergency, it is imperative that we develop new methods of prospectively identifying at-risk patients. <h3>PURPOSE</h3> To analyze patient demographics and clinical outcomes of patients undergoing operative management for SEAs in order to decrease diagnostic delay and elucidate factors associated with a better or worse prognosis. <h3>STUDY DESIGN/SETTING</h3> Retrospective study at an academic medical center. <h3>PATIENT SAMPLE</h3> Adult patients (18 and above) treated surgically for SEA. <h3>OUTCOME MEASURES</h3> Patient demographics, LOS, procedures performed, pre-and postoperative American Spinal Injury Association (ASIA) score, comorbidities, lab values. <h3>METHODS</h3> Electronic medical records of patients diagnosed with spinal epidural abscesses and surgically managed from September 2003-December 2021, were reviewed. <h3>RESULTS</h3> A total of 76 patients met our inclusion criteria. A majority were men (46; 60.5%) and Caucasian (62; 81.6%). The mean age on admission was 58.5 years (range: 29-84) and the average LOS was 22 days (SD 20.3 days). The most common location of SEA was in the thoracic spine (26, 34.2%) followed by lumbar (22, 28.9%), cervical (19, 25 %), and multilevel (9, 11.8%) regions. Patient comorbidities included DM (23, 30.3%), IVDU (13, 17.1%) and coexisting infections (53, 69.7%), which included vertebral osteomyelitis (24, 31.6%), bacteremia (25, 32.9%), other abscesses (6, 7.9%) and meningitis (2, 2.6%). Surgical intervention consisted of: transpedicular decompression (n=9 patients, average 1.0 levels), corpectomies (n=17 patients, average 1.2 levels), laminectomies (n =56 patients, average 3.7 levels), discectomies (n=16 patients, average 1.4 levels) and fusions (n=26 patients, average 4.7 levels). Intraoperative complications occurred in 1 (1.3%) patient and involved a dural tear, which was successfully repaired. Average lab values at presentation were WBC (13.8), ESR (80.6) and CRP (171.4). On admission, 13 (17.1%) patients were febrile and 40 (52.6%) had a positive blood culture. The most cultured organisms were MSSA (31; 46.3%) and MRSA (11; 16.4%). Preoperative ASIA scores were ASIA A (4.4%), ASIA B (0.0%), ASIA C (4.4%), ASIA D (26.7%), and ASIA E (64.4%). Postoperative ASIA scores were ASIA A (4.4%), ASIA B (2.2%), ASIA C (2.2%), ASIA D (11.1%) and ASIA E (80.0%). <h3>CONCLUSIONS</h3> Most SEAs occurred in the thoracic and lumbar regions of the spine. Patients typically have a history DM and IVDU and more likely present with coexisting infection, such as bacteremia, vertebral osteomyelitis and other abscesses. S. aureus is the most cultured organism. Most patients present with ASIA D and E scores and are subsequently treated predominantly with laminectomies and fusions. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Development and Validation of a Predictive Model for Failure of Medical Management in Spinal Epidural Abscesses.

The optimal management of spinal epidural abscesses (SEA) secondary to primary spinal infections has demonstrated large variability in the literature. Although some literature suggests a high rate of neurological deterioration, others suggest failure of medical management is uncommon. To develop a predictive model to evaluate the likelihood of failure of medical therapy in the setting of SEA. A retrospective review was conducted of all patients presenting with SEA from primary spinal infections. Patients presenting with MRI evidence of SEA without neurological deficits were included. Failure of medical management was defined as requiring surgical intervention over 72 hours after the initiation of antibiotics. A machine learning method (Risk-Calibrated Supersparse Linear Integer Model) was used to create a risk stratification score to identify patients at high risk for requiring surgical intervention. In total, 159 patients were identified as presenting with MRI findings of SEA without evidence of neurological deficit. Of these patients, 50 required delayed surgery compared with 109 whose infection were successfully treated with surgical intervention. The Spinal Epidural Abscess Predictive Score was created using a machine learning model with an area under the curve of 0.8043 with calibration error of 14.7%. Factors included active malignancy, spondylodiscitis, organism identification, blood cultures, and sex. The probability of failure of medical management ranged from <5% for a score of 2 or less and >95% for a score of 7 or more. The Spinal Epidural Abscess Predictive Score model is a quick and accurate tool to assist in clinical decision-making in SEA.

Readmission and Associated Factors in Surgical Versus Non-Surgical Management of Spinal Epidural Abscess: A Nationwide Readmissions Database Analysis.

Retrospective cohort study. Spinal epidural abscess (SEA) is a rare but potentially life-threatening infection treated with antimicrobials and, in most cases, immediate surgical decompression. Previous studies comparing medical and surgical management of SEA are low powered and limited to a single institution. As such, the present study compares readmission in surgical and non-surgical management using a large national dataset. We identified all hospital admissions for SEA using the Nationwide Readmissions Database (NRD), which is the largest collection of hospital admissions data. Patients were grouped into surgically and non-surgically managed cohorts using ICD-10 coding and compared using information retrieved from the NRD such as demographics, comorbidities, length of stay and cost of admission. We identified 350 surgically managed and 350 non-surgically managed patients. The 90-day readmission rates for surgical and non-surgical management were 26.0% and 35.1%, respectively (P < .05). Expectedly, surgical management was associated with a significantly higher charge and length of stay at index hospital admission. Surgically managed patients had a significantly lower risk of readmission for osteomyelitis (P < .05). Finally, in patients with a low comorbidity burden, we observed a significantly lower 90-day readmission rate for surgically managed patients (surgical: 23.0%, non-surgical: 33.8%, P < .05). In patients with a low comorbidity burden, we observed a significantly lower readmission rate for surgically managed patients than non-surgically managed patients. The results of this study suggest a lower readmission rate as an advantage to surgical management of SEA and emphasize the importance of SEA as a not-to-miss diagnosis.

8. Factors contributing to cost in management of spinal epidural abscesses

<h3>BACKGROUND CONTEXT</h3> Spinal epidural abscesses (SEA) are increasing in incidence and may be associated with high rates of morbidity and mortality. While management classically consisted of urgent surgical decompression, advances in diagnostic imaging and antibiotic therapies have made possible earlier diagnosis and nonoperative management. Previous work examining the cost of surgically managed SEA demonstrates that this clinical entity is both expensive and associated with high mortality rates. <h3>PURPOSE</h3> To compare costs between operatively and nonoperatively managed spinal epidural abscesses. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort study at 2 tertiary academic centers. <h3>PATIENT SAMPLE</h3> Adult patients receiving treatment for spinal epidural abscesses (2016-2017). <h3>OUTCOME MEASURES</h3> Cumulative charges at index hospital discharge, and at 90-days and one-year following discharge. <h3>METHODS</h3> Medical records, laboratory results and hospital billing data were reviewed for data abstraction. Demographic factors including age, sex, region of abscess, intravenous drug use, and comorbidities were abstracted, along with clinical factors such as symptoms and ambulatory function at presentation, spinal instability, ICU admission and complications. The primary outcome was total charges of initial admission, with charges for admission and care delivered in the first 90 days, and total 1-year charges (with only related charges recorded between 90-days and 1-year) considered secondarily. All covariates abstracted were included in this exploratory analysis using negative binomial regression that accounted for confounders and the nonparametric nature of cost data. Results are presented as an incidence rate ratio (IRR) with 95% confidence intervals (CI). <h3>RESULTS</h3> Sixty-six patients were included with mean age 56.6 (SD 16.2). The majority of patients (57.2%) were male and White (77.8%). Thirty-three (52.4%) patients had axial pain on presentation without other symptoms, 10 (15.8%) radicular pain, and 20 (31.7%) paresis or paralysis. Mean charges for initial admission were $202,404 (range: 16,237-927,379); total 90-day charges $250,622 (range 29,698-948,020); and 1-year charges $286,731 (range 32,384-1,232,551). Significant predictors of initial admission charges included surgical management (IRR 1.54, 95% CI 1.23-1.90, p<0.001), ambulatory status on admission (nonambulatory vs independent, IRR 1.62, 95% 1.12-2.33, p = 0.009), radicular vs axial symptoms (IRR 1.60, 95% CI 1.21-2.12, p = 0.001), thoracic vs cervical abscess (IRR 1.51, 95% CI 1.11-2.04, p=0.008) and length of stay (IRR 1.04, 95% CI 1.04-1.06, p<0.001). Factors associated with 1-year total charges included nonambulatory status at initial presentation (IRR 2.05, 95% CI 1.28-3.29, p=0.003), paresis/paralysis on presentation (IRR 1.37, 95% CI 1.02-1.83, p=0.034), spinal mechanical instability (IRR 1.89, 95% 1.23-2.93, p=0.004) and length of stay (IRR 1.05, 95% CI 1.03-1.07, p<0.001). Surgical management was not a significant predictor of charges beyond the initial admission. <h3>CONCLUSIONS</h3> Surgical management of spinal epidural abscess patients is associated with increased health care expenditures during the index hospital admission, but not with total costs 1 year after the initial episode. Length of stay, paresis or paralysis on initial presentation and spinal mechanical instability contributed more to increased charges over the first year following management. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

The NIMS framework: an approach to the evaluation and management of epidural abscesses

Among the different types of spinal infections, spinal epidural abscesses (SEAs) pose a particular diagnostic and management challenge due to their close proximity to the thecal sac, potential for neurologic compromise, and close association with other spinal infections such as adjacent osteomyelitis, diskitis, or septic facet arthritis [ [1] Hadjipavlou AG Mader JT Necessary JT Muffoletto AJ. Hematogenous pyogenic spinal infections and their surgical management. Spine (Phila Pa 1976). 2000; 25: 1668-1679 Crossref PubMed Scopus (495) Google Scholar ]. While early reports on SEA stressed the importance of urgent surgical decompression, the popularity of nonoperative treatment for epidural abscesses has risen, with multiple studies having endeavored to predict failure of nonoperative management of epidural abscesses [ 2 Shah AA Ogink PT Nelson SB Harris MB Schwab JH. Nonoperative Management of Spinal Epidural Abscess: Development of a Predictive Algorithm for Failure. J Bone Joint Surg Am. 2018; 100: 546-555 Crossref PubMed Scopus (19) Google Scholar , 3 Shah AA Ogink PT Harris MB Schwab JH. Development of Predictive Algorithms for Pre-Treatment Motor Deficit and 90-Day Mortality in Spinal Epidural Abscess. J Bone Joint Surg Am. 2018; 100: 1030-1038 Crossref PubMed Scopus (14) Google Scholar , 4 Karhade AV Shah AA Bono CM Ferrone ML Nelson SB Schoenfeld AJ et al. Development of machine learning algorithms for prediction of mortality in spinal epidural abscess. Spine J. 2019; 19: 1950-1959 Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar , 5 Du JY Schell AJ Kim CY Trivedi NN Ahn UM Ahn NU. 30-day Mortality Following Surgery for Spinal Epidural Abscess: Incidence, Risk Factors, Predictive Algorithm, and Associated Complications. Spine (Phila Pa 1976). 2019; 44: E500-E5E9 Crossref PubMed Scopus (13) Google Scholar , 6 Kim SD Melikian R Ju KL Zurakowski D Wood KB Bono CM et al. Independent predictors of failure of nonoperative management of spinal epidural abscesses. Spine J. 2014; 14: 1673-1679 Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar ].

Keys to diagnosis and management of spinal epidural abscesses: 9 years of institutional experience

Objective: Spinal epidural abscesses (SEA's) are a challenge to diagnose, particularly if there are non-contiguous (skip) lesions. There is also limited data to predict which patients can be treated with antibiotics alone and which require surgery. We sought to assess which demographics, clinical and laboratory findings can guide both diagnosis and management of SEA's. MethodsAll patients with SEA (ICD9 324.1, ICD10 G06.1) between April 2011-May 2019 at a single tertiary center were included. A retrospective EMR review was completed. Patient and disease characteristics were compared using appropriate statistical tests. Results108 patients underwent initial surgical treatment versus 105 that were treated medically initially; 22 (21 %) of those failed medical management.Patients who failed medical management had significantly higher CRP, longer symptom duration, and had higher rates of concurrent non-spinal infections. 9% of patients had skip lesions. Patients with skip lesions had significantly higher WBC, ESR, as well as higher rates of bacteremia and concurrent non-spinal infections. Demographic characteristics and proportion with IVDU, smoking, malignancy, and immunosuppression were similar among the three treatment groups. Conclusions21 % of SEA patients failed initial medical management; they had significantly greater CRP, longer symptom duration, more commonly had neurologic deficits, and concurrent non-spinal infections. 9% of patients had skip lesions; they had significantly higher WBC, ESR, rates of bacteremia and infections outside the spine. These variables may guide diagnostic imaging, and identify those at risk of failing of medical management, and therefore require more involved clinical evaluation, and consideration for surgical intervention.

Spinal Epidural Abscess.

Spinal Epidural Abscess.

Predictors of Failure for Nonoperative Management of Spinal Epidural Abscess.

Study Design:Retrospective cohort study.Objectives:The aim of this study is to identify predictive factors associated with failure of nonoperative management of spinal epidural abscess (SEA).Methods:Between January 2007 and January 2017, there were 97 patients 18 years or older treated for SEA at a tertiary referral center. Of these, 58 were initially managed nonoperatively. Details on presenting complaint, laboratory parameters, radiographic evaluation, demographics, comorbidities, and neurologic status (Frankel grades A-E) were collected. Success of treatment was defined as eradication of infection with no requirement for further antimicrobial therapy. Diagnosis of SEA was made via evaluation of imaging and intraoperative findings. Patients with repeat presentation of SEA, children, and those who were transferred for immediate surgical decompression were excluded.Results:Fifty-eight patients initially treated nonoperatively were included. Of these, 21 failed nonoperative management and required surgical intervention. The mean age was 60 years, 66% male, and 19% of Maori ethnicity. Abscess location was predominantly dorsal, and in the lumbar region (53%). Multivariate analysis identified Maori ethnicity, multifocal sepsis, and elevated white cell count as predictors of failure of nonoperative management. With 1 predictor the risk of failure was 44%. In the presence of 2 predictive variables, failure rate increased to 60%, and if all 3 variables were present, patients had a 75% risk of failure.Conclusion:Thirty-six percent of patients treated nonoperatively failed nonoperative management—the failure rate was significantly increased in patients with multifocal sepsis, in patients with elevated white cell count, and in patients of Maori ethnicity.

First case of cervical epidural abscess caused by brucellosis in Saudi Arabia: A case report and literature review.

Spinal epidural abscess (SEA) is an extremely rare and disastrous musculoskeletal complication of spondylodiscitis and sacroilitis secondary to brucellosis infection. Few case reports and retrospective studies have been published reporting patients with epidural abscesses mainly lumbar, and thoracic while cervical abscess are rare. Management of spinal epidural abscess due to Brucella species is not standard and remains controversial. To the best of our knowledge this is the first case of brucellar cervical epidural abscess reported in Saudi Arabia. In this paper, we review the literature and report a case of a 67-year-old Saudi gentleman, who presented with fever and back pain. Further evaluation revealed cervical epidural abscess and a positive serology for brucellosis. Following 6 months of antibiotic therapy alone against brucellosis, he showed significant clinical and radiological improvement. Spinal epidural abscess caused by brucellosis is a rare condition, difficult to diagnose, and can be complicated by disastrous neurological or vascular complication if left untreated. Brucellosis must be considered as a possible cause of spinal epidural abscess in patients from endemic area. Hence, early detection and initiation of appropriate medical treatment alone is crucial in preventing permanent neurological complication, and possibly avoid surgical intervention.

The time-sensitive challenge of diagnosing spinal epidural abscess in the emergency department.

Spinal epidural abscess (SEA) is a rare but devastating condition. Entry of infectious contents into the epidural space occurs via contiguous infected tissue, hematogenous spread, or iatrogenic inoculation. Traditionally, emergency providers are taught to assess for the "classic triad" of spinal pain, fever, and neurological deficits, but this constellation of findings is seen in only 10-15% of cases. Delays in diagnosis and treatment of this condition directly correspond to worse, and often debilitating, outcomes for these patients. This review will demonstrate the challenges of diagnosing SEA, describe key diagnostic pitfalls, and present a model and framework for its evaluation. The authors conducted a systematic review in PubMed and Google Scholar for articles describing the emergency medicine evaluation and management of spinal epidural abscess dating from 1996 to 2016. Of the initial 219 articles found, 18 articles were selected based on their relevancy to emergency medicine. Lower back pain is a common chief complaint, whereas SEA is a rare condition and may not be anticipated. The "classic triad" of SEA symptoms presents infrequently. Moreover, the early symptoms of back pain and fever are non-specific, and patients seek medical attention at varying stages of disease progression. Once the more conspicuous and wide-ranging neurological symptoms develop, they are often irreversible. In fact, final outcomes correlate with the severity and duration of symptoms before surgery. Furthermore, discovering these late neurological symptoms can be particularly difficult in bed-bound and chronically ill patients. MRI is the best diagnostic imaging tool for SEA. Early diagnosis is the major prognostic factor for favorable outcome of SEA, and yet, making this diagnosis in the emergency department (ED) has proved challenging. Shifting from a "classic triad" screening to a risk factor-based model of evaluation represents the current optimal strategy for diagnosing SEA. An algorithm incorporating the most recent data is provided.

Characteristics and predictors of outcome of spontaneous spinal epidural abscesses treated conservatively: A retrospective cohort study in a referral center

ObjectiveRecent studies have shown that in carefully selected patients, conservative treatment alone can be an option in the management of spinal epidural abscess (SEA). The aim of this study was to identify prognostic factors of outcome in patients with spontaneous SEA treated conservatively. Patients and methodsA retrospective cohort study of all patients with spontaneous SEA treated with antibiotics alone from January 2012 to December 2015 was conducted in a 1200-bed tertiary referral center. Demographic, clinical, microbiological, and radiological characteristics were analyzed. Failure of medical treatment was defined as the need for delayed surgical intervention, no neurological improvement or deterioration, death due to the infection, or relapse after hospital discharge. ResultsWe identified 21 patients diagnosed with spontaneous SEA treated conservatively. Median age was 72 years and 10 patients were male. Eleven patients presented with radicular weakness and/or radicular sensory deficit, or incomplete cord injury. Inflammatory markers were markedly elevated in all patients. Thirteen patients were successfully treated with conservative treatment, while among 8 patients with treatment failure, 1 died due to the infection. Presence of serious neurological deficits and infection due to methicillin-resistant S. aureus (MRSA) were associated with failure of conservative treatment. Notably, neither the extension nor the location of the abscess on magnetic resonance imaging (MRI) was associated with failed medical management. ConclusionsA significant proportion of patients with spontaneous SEA can respond to antibiotic treatment alone. However, in patients with infection due to MRSA or with severe neurological impairment, conservative management has an increased risk of failure.

Incidence and risk factors for failed medical management of spinal epidural abscess: a systematic review and meta-analysis.

OBJECTIVE Spinal epidural abscess (SEA) is a life-threatening infection. It is uncertain whether medical versus surgical treatment is the ideal initial approach for neurologically intact patients with SEA. Recent evidence demonstrates that initial medical management is increasingly common; however, patients who ultimately require surgery after failed medical management may have a worse prognosis than those whose treatment was initially surgical. The primary objective of this study was to establish the current incidence of failed medical management for SEA. The secondary aim was to identify risk factors associated with the failure of medical management. METHODS The authors conducted a systematic review and meta-analysis by searching electronic databases (MEDLINE, Embase, CINAHL, and PubMed), recent conference proceedings, and reference lists of relevant articles. Studies that reported original data on consecutive adult patients with SEA treated medically were eligible for inclusion. RESULTS Twelve studies met the inclusion criteria, which included a total of 489 medically treated patients with SEA. Agreement on articles for study inclusion was very high between the reviewers (kappa 0.86). In a meta-analysis, the overall pooled risk of failed medical management was 29.3% (95% CI 21.4%-37.2%) and when medical to surgical crossover was used to define failure the rate was 26.3% (95% CI 13.0%-39.7%). Only 6 studies provided data for analysis by intended treatment, with a pooled estimate of 35.1% (95% CI 15.7%-54.4%) of failed medical management. Two studies reported predictors of the failure of medical management. CONCLUSIONS Although the incidence of failed medical management of SEA was relatively common in published reports, estimates were highly heterogeneous between studies, thus introducing uncertainty about the frequency of this risk. A consensus definition of failure is required to facilitate comparison of failure rates across studies.

Evaluation and management of spinal epidural abscess.

Spinal epidural abscess (SEA) is an uncommon and potentially catastrophic condition. SEA often presents a diagnostic challenge, as the "classic triad" of fever, spinal pain, and neurological deficit is evident in only a minority of patients. When diagnosis is delayed, irreversible neurological damage may ensue. To minimize morbidity, an appropriate level of suspicion and an understanding of the diagnostic evaluation are essential. Infection should be suspected in patients presenting with axial pain, fever, or elevated inflammatory markers. Although patients with no known risk factors can develop SEA, clinical concern should be heightened in the presence of diabetes, intravenous drug use, chronic renal failure, immunosuppressant therapy, or a recent invasive spine procedure. When the clinical profile is consistent with the diagnosis of SEA, gadolinium-enhanced magnetic resonance imaging of the spinal column should be obtained on an emergent basis to delineate the location and neural compressive effect of the abscess. Rapid diagnosis allows for efficient treatment, which optimizes the potential for a positive outcome.

Timing and prognosis of surgery for spinal epidural abscess: A review

Background:The nonsurgical versus surgical management of spinal epidural abscesses (SEAs) remains controversial. Even with the best preoperative screening for multiple risk factors, high nonoperative failure rates are attended by considerable morbidity (e.g., irreversible paralysis) and mortality. Therefore, the focus remains on early surgery.Methods:Most papers promote early recognition of the clinical triad (e.g., fever [50%], spinal pain [92–100%], and neurological deficits [47%]) for SEA. They also identify SEA-related risk factors for choosing nonsurgical versus surgical approaches; advanced age (>65 or 80), diabetes (15–30%), cancer, intravenous drug abuse (25%), smoking (23%), elevated white blood cell count (>12.5), high C-reactive protein >115, positive blood cultures, magnetic resonance imaging/computed tomographic documented cord compression, and significant neurological deficits (e.g., 19–45%).Results:Surgical options include: decompressions, open versus minimally invasive biopsy/culture/irrigation, or fusions. Up to 75% of SEA involve the thoracolumbar spine, and 50% are located ventrally. Wound cultures are positive in up to 78.8% of cases and are often (60%) correlated with positive blood cultures. The most typical offending organism is methicillin resistant Staphylococcus aureus, followed by methicillin sensitive S. aureus. Unfortunately, the failure rates for nonoperative treatment of SEA remain high (e.g., 41–42.5%), contributing to significant morbidity (22% risk of permanent paralysis), and mortality (3–25%).Conclusion:The vast majority of studies advocated early surgery to achieve better outcomes for treating SEA; this avoids high failure rates (41–42.5%) for nonoperative therapy, and limits morbidity/mortality rates.

The indications and timing for operative management of spinal epidural abscess: literature review and treatment algorithm.

Delayed or inappropriate treatment of spinal epidural abscess (SEA) can lead to serious morbidity or death. It is a rare event with significant variation in its causes, anatomical locations, and rate of progression. Traditionally the treatment of choice has involved emergency surgical evacuation and a prolonged course of antibiotics tailored to the offending pathogen. Recent publications have advocated antibiotic treatment without surgical decompression in select patient populations. Clearly defining those patients who can be safely treated in this manner remains in evolution. The authors review the current literature concerning the treatment and outcome of SEA to make recommendations concerning what population can be safely triaged to nonoperative management and the optimal timing of surgery. A PubMed database search was performed using a combination of search terms and Medical Subject Headings, to identify clinical studies reporting on the treatment and outcome of SEA. The literature review revealed 28 original case series containing at least 30 patients and reporting on treatment and outcome. All cohorts were deemed Class III evidence, and in all but two the data were obtained retrospectively. Based on the conclusions of these studies along with selected smaller studies and review articles, the authors present an evidence-based algorithm for selecting patients who may be safe candidates for nonoperative management. Patients who are unable to undergo an operation, have a complete spinal cord injury more than 48 hours with low clinical or radiographic concern for an ascending lesion, or who are neurologically stable and lack risk factors for failure of medical management may be initially treated with antibiotics alone and close clinical monitoring. If initial medical management is to be undertaken the patient should be made aware that delayed neurological deterioration may not fully resolve even after prompt surgical treatment. Patients deemed good surgical candidates should receive their operation as soon as possible because the rate of clinical deterioration with SEA is notoriously unpredictable. Although patients tend to recover from neurological deficits after treatment of SEA, the time point when a neurological injury becomes irreversible is unknown, supporting emergency surgery in those patients with acute findings.