BACKGROUND CONTEXT Spinal epidural abscesses (SEA's) are a rare but potentially devastating infection that can lead to neurologic deficit, sepsis, or even death. Over the past few decades, the incidence has almost doubled to 10 per every 10,000 admissions. There remains limited data to predict which patients can be treated successfully with antibiotics alone and which require surgery. PURPOSE To assess which patient demographics, comorbidities, clinical presentations, and laboratory results are associated with successful medical management, failed medical management, and surgical management. STUDY DESIGN/SETTING Retrospective electronic medical record (EMR) review. PATIENT SAMPLE All patients diagnosed with SEA (ICD9 324.1, ICD10 G06.1) between April 2011-May 2019 at a single tertiary medical center were included. Postoperative infection, intracranial abscesses, and isolated osteomyelitis/discitis were excluded. OUTCOME MEASURES Ultimate treatment methods (medical, failed medical, surgical). Failure of medical management was defined by neurologic or clinical deterioration after starting antibiotic therapy that then required surgical management. Successful medical management was defined by completion of initial 6-week antibiotic regimen without surgical intervention. METHODS A retrospective EMR review was completed to collect demographics, presenting signs, duration of symptoms, initial laboratory values, medical comorbidities, neurologic status, organism(s), and ultimate treatment. Patients were classified as having had surgical treatment, successful medical treatment, or failed medical treatment. Patient and disease characteristics were compared among the groups using appropriate statistical tests. RESULTS A total of 213 patients were included in the study. Of those, 108 patients underwent initial surgical treatment versus 105 that were treated medically initially. Twenty-two (21%) of those patients failed medical management. The mean age was 57.5 years, the mean symptom duration was 16 days, and 24.4% had a history of intravenous drug use. The most common organism cultured was methicillin-sensitive Staphylococcus aureus (47.9%), and methicillin-resistant S. aureus (18.8%). Of total patients, 32.9% initially presented with a neurologic deficit. Demographic characteristics (age, gender, BMI), and proportion with IVDU, smoking, malignancy, and immunosuppression were similar among the three treatment groups. Patients who failed medical management had a mean presenting CRP of 152, versus 124 in those treated successfully with medical management (p=0.038). Patients who failed medical management had significantly longer symptom duration prior to diagnosis compared to those with successful medical management (26.1 versus 18.1 days, p=0.038); 36.4% of patients failing medical management had a neurologic deficit, versus 18.1% of medical management patients treated successfully (p=0.001). A significantly higher proportion of patients that failed medical management had a concurrent non-spinal infection compared to those treated successfully with medical management (50% versus 25.3%, p=0.005). CONCLUSIONS Twenty-one percent of SEA patients failed medical management. Patients who failed medical management had significantly greater initial CRP, longer symptom duration, and more commonly had neurologic deficits and non-spinal infections compared to those with successful medical management. These variables may be used to identify which patients are at risk for failure of medical management, and therefore require closer, more involved clinical evaluation, and consideration for surgical intervention. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.