Treatment Of Spinal Epidural Abscess Research Articles

“May the odds be ever in your favor”: modulating risk and surgical selection in the treatment of spinal epidural abscess

“May the odds be ever in your favor”: modulating risk and surgical selection in the treatment of spinal epidural abscess

The utility of vertebral Hounsfield units as a prognostic indicator of adverse events following treatment of spinal epidural abscess

Spinal epidural abscesses (SEAs) are a devastating condition with high levels of associated morbidity and mortality. Hounsfield units (HUs), a marker of radiodensity on CT scans, have previously been correlated with adverse events following spinal interventions. We evaluated whether HUs might also be associated with all-cause complications and/or mortality in this high-risk population. This retrospective cohort study was carried out within an academic health system in the United States. Adults diagnosed with a SEA between 2006 and 2021 and who also had a CT scan characterizing their SEA within 6 months of diagnosis were considered. HUs were abstracted from the 4 vertebral bodies nearest to, but not including, the infected levels. Our primary outcome was the presence of composite 90-day complications and HUs represented the primary predictor. A multivariable logistic regression analysis was conducted adjusting for demographic and disease-specific confounders. In sensitivity testing, separate logistic regression analyses were conducted (1) in patients aged 65 and older and (2) with mortality as the primary outcome. Our cohort consisted of 399 patients. The overall incidence of 90-day complications was 61.2% (n=244), with a 7.8% (n=31) 90-day mortality rate. Those experiencing complications were more likely to have undergone surgery to treat their SEA (58.6% vs. 46.5%; p=.018) but otherwise the cohorts were similar. HUs were not associated with composite 90-day complications (Odds ratio [OR] 1.00 [95% CI 1.00-1.00]; p=.842). Similar findings were noted in sensitivity testing. While HUs have previously been correlated with adverse events in certain clinical contexts, we found no evidence to suggest that HUs are associated with all-cause complications or mortality in patients with SEAs. Future research hoping to leverage 3-dimensional imaging as a prognostic measure in this patient population should focus on alternative targets. Level III; Observational Cohort study.

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

Letter to Editor Regarding "Socioeconomic Disparities in Outcomes Following Conservative Treatment of Spinal Epidural Abscesses".

Letter to Editor Regarding "Socioeconomic Disparities in Outcomes Following Conservative Treatment of Spinal Epidural Abscesses".

Risk Factors for Neurologic Deficits in Patients With Spinal Epidural Abscess: An Analysis of One-Hundred-Forty Cases.

retrospective study. In addition to surgical treatment of spinal epidural abscesses (SEA), a conservative, medical treatment for patients without acute neurologic deficits has been proposed. However, the risk factors for neurologic deficits are unclear. This study aims to identify factors predisposing patients with SEA to neurological impairment. All patients treated for SEA between 2008 and 2021 were identified from a prospective vertebral-osteomyelitis registry of a tertiary referral centre. Patient demographics, comorbidities, pathogens, degree of osseous destruction, location of SEA and preoperative neurologic status were retrospectively collected. Differences between patients with (Group 1) and without (Group 2) pretreatment neurologic deficits were assessed by univariate and logistic regression analysis. A total of 140 patients with SEA were included. Forty-three patients (31%) had a neurologic deficit and 97 patients (69%) had no neurologic deficit prior to therapy. The prevalence of diabetes mellitus (35% vs 19%, P = .03), median visual analogue scale leg pain (8 vs 5, P = .01), median American Society of Anesthesiologists (ASA) Score (3 vs 2.6, P = .003) and mean Body-Mass-Index (29 vs 26, P = .02) differed between Group 1 and 2 in univariate analysis. In multivariable analysis, diabetes mellitus (odds ratio = 2.7), female sex (odds ratio = 2.5) and ASA-Score (odds ratio = 2.4) were significant contributors for neurologic deficits. In patients with a SEA without neurologic deficits, the ASA score and diabetes mellitus should be considered, especially in female patients. These patients may be at a higher risk for developing a neurologic deficit and may benefit from an early surgical treatment.

Mortality, complication risks, and clinical outcomes after surgical treatment of spinal epidural abscess: a comparative analysis of patients aged 18–64 years, 65–79 years, and ≥ 80 years, with a 3-year follow-up

Spinal epidural abscess (SEA) with pyogenic vertebral osteomyelitis (PVO) is a rare illness with a steadily increasing incidence. However, comparative analyses of young and older patients with SEA are lacking. We aimed to compare the clinical course of patients aged 18–64 years, 65–79 years, and ≥ 80 years undergoing surgery for SEA. Clinical and imaging data were retrospectively collected from the institutional database between September 2005 and December 2021. Ninety-nine patients aged 18–64 years, 45 patients aged 65–79 years, and 32 patients ≥ 80 years were enrolled. Patients ≥ 80 years presented with a poorer baseline history (9.2 ± 2.4), as indicated by the CCI, than their younger counterparts (18–74 years: 4.8 ± 1.6;6.5 ± 2.5; p < 0.001). Patients aged 65–79 years and 80 years had a significantly longer length of stay. In-hospital mortality was significantly higher in those aged ≥ 80 years compared to their younger counterparts (≥ 80 years, n = 3, 9.4% vs. 18–64 years, n = 0, 0.0%; 65–79 years, n = 0, 0.0%; p < 0.001), while no differences in 90-day mortality or 30-day readmission were observed. After surgery, a significant decrease in C-reactive protein levels and leukocytes and amelioration of motor scores were observed in all the groups. Of note, older age (> 65 years), presence of comorbidities, and poor preoperative neurological condition were significant predictors of mortality. Surgical management led to significant improvements in laboratory and clinical parameters in all age groups. However, older patients are prone to multiple risks, requiring meticulous evaluation before surgery. Nevertheless, the risk profile of younger patients should not be underestimated. The study has the limitations of a retrospective design and small sample size. Larger randomized studies are warranted to establish the guidelines for the optimal management of patients from every age group and to identify the patients who can benefit from solely conservative management.

Socioeconomic Disparities in Outcomes Following Conservative Treatment of Spinal Epidural Abscesses.

Primary spinal epidural abscess (SEA) is a rare but serious pathology that may result in severe neurologic injury. While certain literature has identified medical risk factors for failure of conservative therapy, no current evidence has been published regarding socioeconomic risk factors associated with failure of medical therapy. A retrospective review was conducted of patients presenting with SEA from primary spinal infections. Patients presenting with magnetic resonance imaging evidence of SEA treated conservatively in the absence of neurologic deficits were included. Baseline clinical and socioeconomic characteristics were collected. Failure of medical management was defined as requiring surgical intervention despite maximal medical therapy due to the development of neurologic deficits or clinically significant deformity. A total of 150 patients were identified as presenting with magnetic resonance imaging evidence of SEAs without evidence of neurologic deficit. Of these patients, 42 required surgical intervention compared with 108 whose infection was successfully treated with medical therapy alone. Estimated average annual income was $64,746 vs $62,615 in those who successfully cleared their infection with medical management without requiring surgery, which was not statistically significant (P = 0.5). Insured patients were 5 times more likely to be successfully treated with antibiotics alone compared with uninsured patients (OR = 5.83, P = 0.008). Payer type, employment status, and incarceration status were not associated with failure of conservative therapy. In the treatment of primary SEA, absence of medical insurance is associated with failure of medical management. Payer status, employment status, average salary, and incarceration are not significant risk factors for failure of conservative management.

WITHDRAWN: Spinal epidural abscess with emphasis on early diagnosis and surgical treatment: Report of twenty-five cases and review of literature

To improve the diagnostic identification and subsequent treatment of spinal epidural abscess (SEA) by analysing the clinical data of 25 cases. Method: We retrospectively analysed patient characteristics, disease characteristics, biomarkers, neurological function, visual analogue scale (VAS), and Oswestry Disability Index (ODI) scores of 25 patients with SEA who were admitted to the Department of Spinal Surgery, The Third Hospital of Hebei Medical University from January 2018 to June 2021. Results: Eleven out of 22 patients who received surgery showed improvement of the average muscle strength score at the time of discharge (2.00 ± 1.14 vs 4.00 ± 0.63). Muscle strength did not improve at the time of discharge for three patients who were treated with conservative antibiotic therapy. At the time of admission, patients exhibited increased white blood cell (WBC) count (7.972 ± 2.570×10 9 /L), increased neutrophil percentage (64.120 ± 14.984 %), increased procalcitonin (PCT) (0.083 ± 0.192ng/L), increased C-reactive protein (CRP) (42.181 ± 59.653 mg/L), and increased erythrocyte sedimentation rate (ESR) (40.720 ± 15.913 mm/h). During follow-up, VAS scores of all patients were improved (7.12±1.13 vs 1.48±0.96), and ODI were improved (71.80±11.94 vs 11.96±6.00) after treatment. Conclusion: For the patients with SEA, early diagnosis and surgical intervention should be considered, taking into account the patient's conditions. We recommend parenteral antibiotics treatment in parallel to one-stage posterior surgery to completely eliminate the source of infection, resulting in favourable conditions for the optimal recovery of neurological functions.

Spinal Epidural Abscess.

Spinal Epidural Abscess.

Применение вакуум-терапии в хирургическом лечении спинальных эпидуральных абсцессов

Применение вакуум-терапии в хирургическом лечении спинальных эпидуральных абсцессов

Epidural Abscess: A Propensity Analysis of Surgical Treatment Strategies.

Observational analysis of retrospectively collected data. A retrospective study was performed in order to compare the surgical profile of risk factors and perioperative complications for laminectomy and laminectomy with fusion procedures in the treatment of spinal epidural abscess (SEA). SEA is a highly morbid condition typically presenting with back pain, fever, and neurologic deficits. Posterior fusion has been used to supplement traditional laminectomy of SEA to improve spinal stability. At present, the ideal surgical strategy-laminectomy with or without fusion-remains elusive. Thirty-day outcomes such as reoperation and readmission following laminectomy and laminectomy with fusion in patients with SEA were investigated utilizing the American College of Surgeons National Quality Improvement Program database. Demographics and clinical risk factors were collected, and propensity matching was performed to account for differences in risk profiles between the groups. Seven hundred thirty-eight patients were studied (608 laminectomy alone, 130 fusion). The fusion population was in worse health. The fusion population experienced significantly greater rate of return to the operating room (odds ratio [OR] 1.892), with the difference primarily accounted for by cervical spine operations. Additionally, fusion patients had significantly greater rates of blood transfusion. Infection was the most common reason for reoperation in both populations. Both laminectomy and laminectomy with fusion effectively treat SEA, but addition of fusion is associated with significantly higher rates of transfusion and perioperative return to the operating room. In operative situations where either procedure is reasonable, surgeons should consider that fusion nearly doubles the odds of reoperation in the short-term, and weigh this risk against the benefit of added stability. 3.

Recent Developments in the Treatment of Spinal Epidural Abscesses.

Spinal epidural abscess (SEA) is a serious condition that can be challenging to diagnose due to nonspecific symptomology and delayed presentation. Despite this, it requires prompt recognition and management in order to prevent permanent neurologic sequelae. Several recent studies have improved our understanding of SEA. Herein, we summarize the recent literature from the past 10 years relevant to SEA diagnosis, management and outcome. While surgical care remains the mainstay of treatment, a select subset of SEA patients may be managed without operative intervention. Multidisciplinary management involves internal medicine, infectious disease, critical care, and spine surgeons in order to optimize care.

Medical treatment of a spinal epidural abscess with neurologic deficits.

In spite of advances in medical knowledge, imaging techniques, and surgical interventions, the diagnosis and treatment of spinal epidural abscess remains a challenge. The diagnosis is often elusive, but achieving diagnosis prior to the onset of neurological deficits is essential to preserving the vital neurological function. Traditionally, urgent surgical decompression and drainage remain the mainstay therapy for spinal epidural abscess. In recent years, with the improvement of antibiotics, conservative treatment with adequate antibiotics has been proposed as an effective method in selective patients. We report a case of spinal epidural abscess in a 50-year-old man, who complained of progressive weakness of lower extremities for 4 days before admission. After conservative treatment with antibiotics alone, the patient recovered uneventfully from previous neurological deficits. The relevant literature is also reviewed.

Treatment of Spinal Epidural Abscess and Predisposing Factors of Motor Weakness: Experience with 48 Patients.

ObjectiveSpinal epidural abscess (SEA) can be fatal if untreated, so early diagnosis and treatment are essential. We conducted a retrospective study to define its clinical features and evaluate the risk factors of motor weakness.MethodsWe retrospectively analyzed the medical records and images of patients with SEA who had been hospitalized in our institute from January 2005 to June 2012. Pyogenic SEA patients were categorized as patients without motor weakness (Group A) and with motor weakness (Group B). Abscess volume was measured using the Gamma-Plan program. Intervertebral foramen height and posterior disc height were measured to evaluate degree of spinal stenosis.ResultsOf 48 patients with pyogenic SEA, 33 (68%) were treated surgically, and 15 (32%) were treated with antibiotics. Eleven patients had weakness and abscess volume was unrelated to motor weakness. Old age, 'spare room' (abscess volume subtracted from spinal volume) and intervertebral foramen height and posterior disc height were statistically significant. Among the 48 patients, 43 (85%) had good outcome and erythrocyte sedimentation rate (ESR) was the only meaningful prognostic factor (p=0.014). The cut-off value of ESR was 112mm/h with 80% sensitivity and 79% specificity and had borderline significance (p=0.062).ConclusionSEA needs emergent diagnosis and treatment. Motor weakness is the most important factor in treatment decision. By careful image reading, early surgical treatment can be an option for selected patients with severe spinal stenosis for prevent motor weakness. Inflammatory markers, especially ESR, are valuable to identify worsening of SEA.

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.

Spinal and Intracranial Epidural Abscess

Presentation, epidemiology, diagnosis and treatment of spinal epidural abscess (SEA) and intracranial epidural abscess (ICEA) are reviewed by researchers at The John's Hopkins University School of Medicine, Baltimore, MD, and Universidad de Santander, Columbia.

広範囲に及んだ硬膜外膿ようの治療経験

We experienced two cases of wide-range spinal epidural abscess after an epidural block. In one case, the abscess spread from Th8/9 to C3/4, and in the other the abscess spread from L5 to Th2/3.We performed emergency operation on both cases but paralysis remained. In the treatment of spinal epidural abscess, early diagnosis and the timing of the operation are important because paralysis can deteriorate suddenly and the abscess may spread.

Spinal Epidural Abscess

Treatment of spinal epidural abscess has been based on surgical debridement. Medical treatment with antibiotics has been proposed as an alternative, but data on its efficacy are limited. The purpose of this study was to determine the early clinical outcome of medical treatment. This is a retrospective review of 52 patients with a spinal epidural abscess who were treated at our institution. Medical treatment was selected if no systemic sepsis was present and the neurologic examination was normal or stable (radiculopathy or signs of partial cord compression present for more than 72 hours before admission without deterioration). Twenty-nine patients had medical treatment and 23 patients were treated surgically. Medical treatment resulted in good or excellent early neurologic outcome in 24 of 29 patients (83%) at a median followup of 2 months. Three patients (11%) had failed medical treatment and required surgery and one patient (3%) who had severe comorbidities died. Staphylococcus aureus was the most common infectious pathogen, isolated in 28 of 36 positive cultures (78%). Medical treatment is a viable alternative to surgery for selected patients with a spinal epidural abscess. However, close clinical followup is essential and surgical decompression should be done when neurologic deterioration or development of systemic sepsis is observed.

Spinal Epidural Abscess Successfully Treated with Percutaneous, Computed Tomography-guided, Needle Aspiration and Parenteral Antibiotic Therapy: Case Report and Review of the Literature

We describe a case of a posterior spinal epidural abscess that was successfully treated with percutaneous, computed tomography-guided, needle aspiration and parenteral antibiotic therapy. A 48-year-old man experienced acute pain in the paralumbar region for 1 week, followed by gait disturbance and micturition difficulty. Laboratory studies demonstrated leukocytosis and hyperglycemia. Blood cultures yielded Staphylococcus aureus. Magnetic resonance imaging scans of the thoracolumbar spine revealed a posterior spinal epidural abscess located between L2 and the lower cervical spine. The patient's low back pain persisted despite 10 days of antibiotic therapy. Therefore, percutaneous, computed tomography-guided, needle aspiration was performed. The low back pain was relieved dramatically and immediately after the procedure. The spinal epidural abscess completely resolved after 6 weeks of antibiotic treatment. Surgical decompression and antibiotic therapy are the treatments of choice for patients with spinal epidural abscesses. Selected patients may be treated nonsurgically. Rarely, percutaneous drainage of the abscess has been reported to be helpful. Our case suggests that percutaneous, computed tomography-guided, needle aspiration might be a rational alternative to surgical decompression for treatment of spinal epidural abscesses.

Pyogenic Spinal Epidural Abscess

Pyogenic Spinal Epidural Abscess