Mortality, complication risk, and total charges after the treatment of epidural abscess

Risk Factors for Readmission Following Surgical Decompression for Spinal Epidural Abscesses: An Analysis of 4595 Patients

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

The study aimed to (1) compare baseline demographics of patients undergoing surgery for SEA who were/were not readmitted; (2) identify risk factors for 90-day readmissions; and (3) quantify 90-day episode-of-care health care costs.

BACKGROUND

Spinal epidural abscess (SEA), while rare, occurring ~2.5-5.1/10,000 admissions, may lead to permanent neurologic deficits and mortality. Definitive treatment often involves surgical intervention via decompression.

METHODS

A search of the PearlDiver database from 2010 to 2021 for patients undergoing decompression for SEA identified 4595 patients. Cohorts were identified through the International Classification of Disease, Ninth Revision (ICD-9), ICD-10, and Current Procedural Terminology codes. Baseline demographics of patients who were/were not readmitted within 90 days following decompression were aggregated/compared, identifying factors associated with readmission. Using Bonferroni correction, a P -value<0.001 was considered statistically significant.

RESULTS

Readmission within 90 days of surgical decompression occurred in 36.1% (1659/4595) of patients. While age/gender were not associated with readmission rate, alcohol use disorder, arrhythmia, chronic kidney disease, ischemic heart disease, and obesity were associated with readmission. Readmission risk factors included fluid/electrolyte abnormalities, obesity, paralysis, tobacco use, and pathologic weight loss ( P <0.0001). Mean same-day total costs ($17,920 vs. $8204, P <0.001) and mean 90-day costs ($46,050 vs. $15,200, P <0.001) were significantly higher in the readmission group.

CONCLUSION

A substantial proportion of patients (36.1%) are readmitted within 90 days following surgical decompression for SEA. The top 5 risk factors in descending order are fluid/electrolyte abnormalities, pathologic weight loss, tobacco use, pre-existing paralysis, and obesity. This study highlights areas for perioperative medical optimization that may reduce health care utilization.

Long-term survivability of surgical and nonsurgical management of spinal epidural abscess

BACKGROUND CONTEXT

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.

PURPOSE

This study aims to determine the long-term survival of patients who underwent surgical and nonsurgical management for SEA.

STUDY DESIGN

Retrospective cohort study.

PATIENT SAMPLE

A total of 250 consecutive SEA patients.

OUTCOME MEASURES

Survival and mortality rates, complications.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

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

BACKGROUND/CONTEXT

In 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.

PURPOSE

To describe patterns and associated factors impacting long-term quality of life following treatment of spinal epidural abscess.

STUDY DESIGN/SETTING

Multicenter cohort study at two urban academic tertiary referral centers and two community centers.

PATIENT SAMPLE

Adult patients treated for a spinal epidural abscess.

OUTCOME MEASURES

EuroQoL 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).

METHODS

Eligible 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.

RESULTS

Sixty-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.

CONCLUSIONS

We 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 EVIDENCE

Level III, cohort study.

Utility of the LACE index to assess risk of mortality and readmission in patients with spinal infections

Retrospective cohort study. To assess the utility of the LACE index for predicting death and readmission in patients with spinal infections (SI). SIs are severe conditions, and their incidence has increased in recent years. The LACE (Length of stay, Acuity of admission, Comorbidities, Emergency department visits) index quantifies the risk of mortality or unplanned readmission. It has not yet been validated for SIs. LACE indices were calculated for all adult patients who underwent surgery for spinal infection between 2012 and 2021. Data were collected from a single academic teaching hospital. Outcome measures included the LACE index, mortality, and readmission rate within 30 and 90 days. In total, 164 patients were analyzed. Mean age was 64.6 (± 15.1) years, 73 (45%) were female. Ten (6.1%) patients died within 30 days and 16 (9.8%) died within 90 days after discharge. Mean LACE indices were 13.4 (± 3.6) and 13.8 (± 3.0) for the deceased patients, compared to 11.0 (± 2.8) and 10.8 (± 2.8) for surviving patients (p = 0.01, p < 0.001), respectively. Thirty-seven (22.6%) patients were readmitted ≤ 30 days and 48 (29.3%) were readmitted ≤ 90 days. Readmitted patients had a significantly higher mean LACE index compared to non-readmitted patients (12.9 ± 2.1 vs. 10.6 ± 2.9, < 0.001 and 12.8 ± 2.3 vs. 10.4 ± 2.8, p < 0.001, respectively). ROC analysis for either death or readmission within 30 days estimated a cut-off LACE index of 12.0 points (area under the curve [AUC] 95% CI, 0.757 [0.681-0.833]) with a sensitivity of 70% and specificity of 69%. Patients with SI had high LACE indices that were associated with high mortality and readmission rates. The LACE index can be applied to this patient population to predict the risk of early death or unplanned readmission.

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

Background

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.

Methods

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.

Results

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.

Conclusions

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 of Evidence

Level III; Observational Cohort study.

Keeping It Simple: Developing a Prognostic Tool for Spinal Epidural Abscess

STUDY DESIGN

A retrospective study.

OBJECTIVE

To develop a prognostic score for mortality and treatment failure in Spinal epidural abscess (SEA), based on simplicity and multidimensional assessment principles.

METHODS

One-hundred-fifty patients were reviewed. Variables assessed included comorbidities, functional status, clinical presentation, Frankel classification, and biochemical and radiological parameters. The main outcomes were the 90-day mortality and treatment failure, corresponding to any intensification of the initial treatment plan. Variables were sorted out with a factorial analysis. Logistic regressions were performed, and the new score was derived from the coefficients. ROC curves with Area Under Curve, calibration plots, and cross-validation were performed.

RESULTS

Forty-three patients (29%) had treatment failure, and 15 died (10%) by 90 days. Factorization created 3 groups: Comorbidities (C), Severity (S), and Function (F). For 90-day mortality, Odds ratios were 1.20 (P = .0002), 1.15, (P = .03), 1.36, (P < 10-4) for C, S, F, respectively. The new score 'CSF' had 1 point per item, ranging from zero to 3. OR increased by 1.2/point for 90-day mortality (P < 10-4), AUC was .86. For failures OR increased by 1.15/point (P = .014), AUC was .58, and increased to .64 for patients who survived after 90 days, probably due to competing risks.

CONCLUSIONS

Comorbidities, Severity, and Function is a new simplistic tool, easy to use in daily practice; its performances were excellent for 90-day mortality, and acceptable for failures. Simple tools are more likely to be adopted into practice. External validation of this technique is desirable.

Failure to rescue as a patient safety indicator for neurosurgical patients: are we there yet? A systematic review

Failure to rescue (FTR) is a standardized patient safety indicator (PSI-04) developed by the Agency for Healthcare Research and Quality (AHRQ) to assess the ability of a healthcare team to prevent mortality following a major complication. However, FTR rates vary and are impacted by non-modifiable individual patient characteristics such as baseline frailty. This raises concerns regarding the validity of FTR as an objective quality metric, as not all patients have the same baseline frailty level, or physiological reserve, to recover from major complications. Literature from other surgical specialties has identified flaws in FTR and called for risk-adjusted metrics. Currently, knowledge of factors influencing FTR and its subsequent implementation in neurosurgical patients are limited. The present review assesses trends in FTR utilization to assess how FTR performs as an objective neurosurgery quality metric. This review then proposes how FTR may be best modified to optimize use in neurosurgical patients. A PubMed search was performed to identify articles published until August 9, 2023. Studies that reported FTR as an outcome in patients undergoing neurosurgical procedures were included. A qualitative assessment was performed using the Newcastle Ottawa Scale (NOS). The initial search revealed 1232 citations. After a title and abstract screen, followed by a full text screen, 12 studies met criteria for inclusion. These articles measured FTR across a total of 764,349 patients undergoing neurosurgical procedures. Five studies analyzed FTR with regard to hospital characteristics, and three studies utilized patient characteristics to predict FTR. All studies were considered high quality based on the NOS. Modifications in criteria to measure FTR are necessary since FTR depends on patient characteristics like frailty. This would allow for the incorporation of risk-adjusted FTR metrics that would aid in clinical decision making in neurosurgical patients.

A clinical prediction model to differentiate tuberculous spondylodiscitis from pyogenic spontaneous spondylodiscitis

BACKGROUND

Microbiological diagnosis of tuberculous spondylodiscitis (TS) and pyogenic spontaneous spondylodiscitis (PS) is sometime difficult. This study aimed to identify the predictive factors for differentiating TS from PS using clinical characteristics, radiologic findings, and biomarkers, and to develop scoring system by using predictive factors to stratify the probability of TS.

METHODS

A retrospective single-center study. Demographics, clinical characteristics, laboratory findings and radiographic findings of patients, confirmed causative pathogens of PS or TS, were assessed for independent factors that associated with TS. The coefficients and odds ratio (OR) of the final model were estimated and used to construct the scoring scheme to identify patients with TS.

RESULTS

There were 73 patients (51.8%) with TS and 68 patients (48.2%) with PS. TS was more frequently associated with younger age, history of tuberculous infection, longer duration of symptoms, no fever, thoracic spine involvement, ≥3 vertebrae involvement, presence of paraspinal abscess in magnetic-resonance-image (MRI), well-defined thin wall abscess, anterior subligamentous abscess, and lower biomarker levels included white blood cell (WBC) counts, erythrocyte-sedimentation-rate (ESR), neutrophil fraction, and C-reactive protein (all p < 0.05). Multivariate logistic regression analysis revealed significant predictors of TS included WBC ≤9,700/mm3 (odds ratio [OR] 13.11, 95% confidence interval [CI] 4.23-40.61), neutrophil fraction ≤78% (OR 4.93, 95% CI 1.59-15.30), ESR ≤92 mm/hr (OR 4.07, 95% CI 1.24-13.36) and presence of paraspinal abscess in MRI (OR 10.25, 95% CI 3.17-33.13), with an area under the curve of 0.921. The scoring system stratified the probability of TS into three categories: low, moderate, and high with a TS prevalence of 8.1%, 29.6%, and 82.2%, respectively.

CONCLUSIONS

This prediction model incorporating WBC, neutrophil fraction counts, ESR and presence of paraspinal abscess accurately predicted the causative pathogens. The scoring scheme with combination of these biomarkers and radiologic features can be useful to differentiate TS from PS.

Clinical phenotyping of spondylodiscitis and isolated spinal epidural empyema: a 20-year experience and cohort study

Background

The incidence of spondylodiscitis (SD) and isolated spinal epidural empyema (ISEE) has been increasing in the last decades, but the distinct differences between both entities are poorly understood. We aimed to evaluate the clinical phenotypes and long-term outcomes of SD and ISEE in depth.

Methods

We performed a chart review and analyzed data from our cohorts of consecutive SD and ISEE patients who were treated and assessed in detail for demographic, clinical, imaging, laboratory, and microbiologic characteristics at a university neurosurgical center in Germany from 2002 to 2021. Between-group comparisons were performed to identify meaningful differences in both entities.

Results

We included 208 patients (72 females: age 75 [75 32-90] y vs. 136 males: 65 [23-87] y, median [interquartile range], p < 0.001), of which 142 (68.3%) had SD and 66 (31.7%) had ISEE. Patients with SD were older than ISEE (ISEE: 62 y vs. SD: 70 y, p = 0.001). While SD was more common in males than females (males: n = 101, 71.1% vs. females: n = 41, 28.9%, p < 0.001), there was no sex-related difference in ISEE (males: n = 35, 53.0% vs. females: n = 31, 47.0%, p = 0.71). Obesity was more frequent in ISEE than in SD (ISEE: n = 29, 43.9% vs. SD: n = 37, 26.1%, p = 0.016). However, there were no between-group differences in rates of diabetes and immunodeficiency. In the entire study population, a causative pathogen was identified in 192 (92.3%) patients, with methicillin-susceptible staphylococcus aureus being most frequent (n = 100, 52.1%) and being more frequent in ISEE than SD (ISEE: n = 43, 65.2% vs. SD: n = 57, 40.1%, p = 0.003). SD and ISEE occurred most frequently in the lumbar spine, with no between-group differences (ISEE: n = 25, 37.9% vs. SD: n = 65, 45.8%, p = 0.297). Primary infectious sources were identified in 145 patients (69.7%) and among this skin infection was most common in both entities (ISEE: n = 14, 31.8% vs. SD: n = 25, 24.8%, p = 0.418). Furthermore, epidural administration was more frequent the primary cause of infection in ISEE than SD (ISEE: n = 12, 27.3% vs. SD: n = 5, 4.9%, p < 0.001). The most common surgical procedure in SD was instrumentation (n = 87, 61%) and in ISEE abscess evacuation (n = 63, 95%). Patients with ISEE displayed lower in-hospital complication rates compared to SD for sepsis (ISEE: n = 12, 18.2% vs. SD: n = 94, 66.2%, p < 0.001), septic embolism (ISEE: n = 4/48 cases, 8.3% vs. SD: n = 52/117 cases, 44.4%, p < 0.001), endocarditis (ISEE: n = 1/52 cases, 1.9% vs. SD: n = 23/125 cases, 18.4%, p = 0.003), relapse rate (ISEE: n = 4/46, 8.7% vs. SD: n = 27/92, 29.3%, p = 0.004), and disease-related mortality (ISEE: n = 1, 1.5% vs. SD: n = 11, 7.7%, p = 0.108). Patients with SD showed prolonged length of hospital stay (ISEE: 22 [15, 30] d vs. SD: 38 [29, 53] d, p < 0.001) and extended intensive care unit stay (ISEE: 0 [0, 4] d vs. SD: 3 [0, 12] d, p < 0.002).

Conclusions

Our 20-year experience and cohort analysis on the clinical management of SD and ISEE unveiled distinct clinical phenotypes and outcomes in both entities, with ISEE displaying a more favorable disease course with respect to complications and relapse rates as well as disease-related mortality.

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.

Patients Follow-up for Spinal Epidural Abscess as a Critical Treatment Plan Consideration

INTRODUCTION

 Spinal epidural abscess (SEA) is a rare process with significant risk for morbidity and mortality. Treatment includes an extended course of antibiotics with or without surgery depending on the clinical presentation. Both non-operative and surgically treated patients require close follow-up to ensure the resolution of the infection without recurrence and/or progression of neurologic deficits. No previous study has looked specifically at follow-up in the SEA population, but the review of the literature does show evidence of varying degrees of difficulty with follow-up for this patient population.

METHODS

 This retrospective review looked at follow-up for 147 patients with SEA at a single institution from 2012 to 2021. Statistical analyses were performed to assess differences between groups of surgical versus non-surgical patients and those with adequate versus inadequate follow-up.

RESULTS

Sixty-two of 147 (42.2%) patients had inadequate follow-up (less than 90 days) with their surgical team, and 112 of 147 (76.2%) patients had inadequate follow-up (less than 90 days) with infectious disease (ID). The primary statistically significant difference between patients with adequate versus inadequate follow-up was found to be surgical status with those treated surgically more likely to have adequate follow-up than those treated non-operatively.

CONCLUSION

Improved follow-up in surgical patients should be considered as a factor when deciding on surgical versus non-operative treatment in the SEA patient population. Extra efforts coordinating follow-up care should be made for SEA patients.

External validation of a predictive algorithm for in-hospital and ninety-day mortality after spinal epidural abscess

BACKGROUND CONTEXT

Mortality in patients with spinal epidural abscess (SEA) remains high. Accurate prediction of patient-specific prognosis in SEA can improve patient counseling as well as guide management decisions. There are no externally validated studies predicting short-term mortality in patients with SEA.

PURPOSE

The purpose of this study was to externally validate the Skeletal Oncology Research Group (SORG) stochastic gradient boosting algorithm for prediction of in-hospital and 90-day postdischarge mortality in SEA.

STUDY DESIGN/SETTING

Retrospective, case-control study at a tertiary care academic medical center from 2003 to 2021.

PATIENT SAMPLE

Adult patients admitted for radiologically confirmed diagnosis of SEA who did not initiate treatment at an outside institution.

OUTCOME MEASURES

In-hospital and 90-day postdischarge mortality.

METHODS

We tested the SORG stochastic gradient boosting algorithm on an independent validation cohort. We assessed its performance with discrimination, calibration, decision curve analysis, and overall performance.

RESULTS

A total of 212 patients met inclusion criteria, with a short-term mortality rate of 10.4%. The area under the receiver operating characteristic curve (AUROC) of the SORG algorithm when tested on the full validation cohort was 0.82, the calibration intercept was -0.08, the calibration slope was 0.96, and the Brier score was 0.09.

CONCLUSIONS

With a contemporaneous and geographically distinct independent cohort, we report successful external validation of a machine learning algorithm for prediction of in-hospital and 90-day postdischarge mortality in SEA.

Surgery combined with antibiotics for thoracic vertebral Escherichia coli infection after acupuncture: A case report

BACKGROUND

Acupuncture is relatively popular worldwide, but an unregulated operation can easily lead to infections. The purpose of this report was to analyze a clinical case of surgery combined with the use of antibiotics for the treatment of thoracic vertebral infection by Escherichia coli (E. coli) after acupuncture.

CASE SUMMARY

A 63-year-old male was diagnosed with E. coli infection in the thoracic vertebra after acupuncture. His fever and pain did not improve after treatment with broad-spectrum antibiotics for 10 d. Thus, debridement of the infected area and biopsy were decided. The final pathology confirmed the diagnosis of vertebral infection by E. coli. The patient underwent anterior and posterior thoracic vertebral debridement and internal fixation surgery combined with the use of sensitive antibiotics. He had no fever or backache 3 mo postoperatively.

CONCLUSION

In this report, we first considered antibiotic treatment for the patient with septic spinal infection, but the effect was not obvious. Interventional surgery was combined with the use of sensitive antibiotics to relieve backache, and good clinical results were achieved. Furthermore, acupuncture practitioners should pay attention to hygienic measures.

Spinal infection with intraspinal abscess or empyema and acute myelopathy: comparative analysis of diagnostics, therapy, complications and outcome in primary care

INTRODUCTION

This study on pyogenic spinal infections with intraspinal epidural involvement (PSI +) compared the outcome of patients with spinal cord injury (SCI) to those without (noSCI) taking diagnostic algorithm, therapy, and complications into account.

METHODS

Patients were enrolled in an ambispective study (2012-2017). Diagnostic and therapeutic algorithms, complications, and neurological outcome were analyzed descriptively. Survival was analyzed applying Kaplan-Meier method and Cox regression.

RESULTS

In total, 134 patients with a median (IQR) age of 72 (61-79) years were analyzed. Baseline characteristics were similar between the SCI (n = 55) and noSCI (n = 79). A higher percentage of endocarditis (9% vs. 0%; p = 0.03) was detected in the noSCI group. The majority (81%) received combinatorial therapy including spinal surgery and antibiotic treatment. The surgery complication rate was 16%. At discharge, improvement in neurologic function was present in 27% of the SCI patients. Length of stay, duration of ventilation and the burden of disease-associated complications were significantly higher in the SCI group (e.g., urinary tract infection, pressure ulcers). Lethality risk factors were age (HR 1.09, 95% CI 1.02-1.16, p = 0.014), and empyema/abscess extension (≥ 3 infected spinal segments, HR 4.72, 95% CI 1.57-14.20, p = 0.006), dominating over additional effects of Charlson comorbidity index, SCI, and type of treatment. The overall lethality rate was 11%.

CONCLUSION

PSI + are associated with higher in-hospital mortality, particularly when multiple spinal segments are involved. However, survival is similar with (SCI) or without myelopathy (noSCI). If SCI develops, the rate of disease complications is higher and early specialized SCI care might be substantial to reduce complication rates.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Predictors of reoperation after surgery for spinal epidural abscess

BACKGROUND CONTEXT

Spinal epidural abscess is a rare but severe condition with high rates of postoperative adverse events.

PURPOSE

The objective of the study was to identify independent prognostic factors for reoperation using two datasets: an institutional and national database.

STUDY DESIGN/SETTING

Retrospective Review.

PATIENT SAMPLE

Database 1: Review of five medical centers from 1993 to 2016. Database 2: The National Surgical Quality Improvement Program (NSQIP) was queried between 2012 and 2016.

OUTCOME MEASURES

Thirty-day and ninety-day reoperation rate.

METHODS

Two independent datasets were reviewed to identify patients with spinal epidural abscesses undergoing spinal surgery. Multivariate analyses were used to determine independent prognostic factors for reoperation while including factors identified in bivariate analyses.

RESULTS

Overall, 642 patients underwent surgery for a spinal epidural abscess in the institutional cohort, with a 90-day unplanned reoperation rate of 19.9%. In the NSQIP database, 951 patients were identified with a 30-day unplanned reoperation rate of 12.3%. On multivariate analysis in the NSQIP database, cervical spine abscess was the only factor that reached significance for 30-day reoperation (OR=1.71, 95% CI=1.11-2.63, p=.02, Area under the curve (AUC)=0.61). On multivariate analysis in the institutional cohort, independent prognostic factors for 30-day reoperation were: preoperative urinary incontinence, ventral location of abscess relative to thecal sac, cervical abscess, preoperative wound infection, and leukocytosis (AUC=0.65). Ninety-day reoperation rate also found hypoalbuminemia as a significant predictor (AUC=0.66).

CONCLUSION

Six novel independent prognostic factors were identified for 90-day reoperation after surgery for a spinal epidural abscess. The multivariable analysis fairly predicts reoperation, indicating that there may be additional factors that need to be uncovered in future studies. The risk factors delineated in this study through the use of two large cohorts of spinal epidural abscess patients can be used to improve preoperative risk stratification and patient management.

C-reactive Protein-to-albumin Ratio in Spinal Epidural Abscess: Association with Post-treatment Complications

INTRODUCTION

Spinal epidural abscess (SEA) is a complex medical condition with high morbidity and healthcare costs. Clinical presentation and laboratory data may have prognostic value in forecasting morbidity and mortality. C-reactive protein-to-albumin ratio (CAR) demonstrates promise for the prediction of adverse events in multiple orthopaedic and nonorthopaedic surgical conditions. We investigated the relationship between CAR and outcomes after treatment of SEA.

METHODS

We retrospectively evaluated adult patients treated within a single healthcare system for a diagnosis of SEA (2005 to 2017). Laboratory and clinical data included age at diagnosis, sex, race, body mass index, smoking status, history of intravenous drug use, Charlson Comorbidity Index, and CAR. The primary outcome was the occurrence of any complication; mortality and readmissions were considered secondarily. We used logistic regression to determine the association between baseline CAR and outcomes, adjusting for confounders.

RESULTS

We included 362 patients with a 90-day mortality rate of 13.3% and a 90-day complication rate of 47.8%. A reduced complication rate was observed in the lowest decile of CAR values compared with the remaining 90% of patients, a threshold value of 2.5 (27.0% versus 50.2%; odds ratio [OR] 2.66, 95% confidence interval [CI] 1.22 to 5.81). CAR values in the highest two deciles experienced significantly increased odds of complications compared with the lowest decile (80th: OR 3.44; 95% CI 1.25 to 9.42; 90th: OR 3.28; 95% CI 1.19 to 9.04).

DISCUSSION

We found elevated CAR to be associated with an increased likelihood of major morbidity in SEA. We suggest using a CAR value of 2.5 as a threshold for enhanced surveillance and recognizing patients with values above 73.7 as being at exceptional risk of morbidity.

LEVEL OF EVIDENCE

Level III observational cohort study.

Risk factors for surgical intervention in patients with primary spinal infection on initial presentation

OBJECTIVE

Treatment of primary spinal infection includes medical management with or without surgical intervention. The objective of this study was to identify risk factors for the eventual need for surgery in patients with primary spinal infection on initial presentation.

METHODS

From January 2010 to July 2019, 275 patients presented with primary spinal infection. Demographic, infectious, imaging, laboratory, treatment, and outcome data were retrospectively reviewed and collected. Thirty-three patients were excluded due to insufficient follow-up (≤ 90 days) or death prior to surgery.

RESULTS

The mean age of the 242 patients was 58.8 ± 13.6 years. The majority of the patients were male (n = 130, 53.7%), White (n = 150, 62.0%), and never smokers (n = 132, 54.5%). Fifty-four patients (22.3%) were intravenous drug users. One hundred fifty-four patients (63.6%) ultimately required surgery while 88 (36.4%) never needed surgery during the duration of follow-up. There was no significant difference in age, gender, race, BMI, or comorbidities between the surgery and no-surgery groups. On univariate analysis, the presence of an epidural abscess (55.7% in the no-surgery group vs 82.5% in the surgery group, p < 0.0001), the median spinal levels involved (2 [interquartile range (IQR) 2-3] in the no-surgery group vs 3 [IQR 2-5] in the surgery group, p < 0.0001), and active bacteremia (20.5% in the no-surgery vs 35.1% in the surgery group, p = 0.02) were significantly different. The cultured organism and initial laboratory values (erythrocyte sedimentation rate, C-reactive protein, white blood cell count, creatinine, and albumin) were not significantly different between the groups. On multivariable analysis, the final model included epidural abscess, cervical or thoracic spine involvement, and number of involved levels. After adjusting for other variables, epidural abscess (odds ratio [OR] 3.04, 95% confidence interval [CI] 1.64-5.63), cervical or thoracic spine involvement (OR 2.03, 95% CI 1.15-3.61), and increasing number of involved levels (OR 1.16, 95% CI 1.01-1.35) were associated with greater odds of surgery. Fifty-two surgical patients (33.8%) underwent decompression alone while 102 (66.2%) underwent decompression with fusion. Of those who underwent decompression alone, 2 (3.8%) of 52 required subsequent fusion due to kyphosis. No patient required hardware removal due to persistent infection.

CONCLUSIONS

At time of initial presentation of primary spinal infection, the presence of epidural abscess, cervical or thoracic spine involvement, as well as an increasing number of involved spinal levels were potential risk factors for the eventual need for surgery in this study. Additional studies are needed to assess for risk factors for surgery and antibiotic treatment failure.

A scoring system for the preoperative evaluation of prognosis in spinal infection: the MSI-20 score

BACKGROUND CONTEXT

Spinal infection (SI) is a life-threatening condition and its treatment remains challenging. Recent studies have supported early and aggressive surgery, but mortality still reaches 5% to 10% and it remains unclear, if an aggressive surgical strategy also applies for severely sick patients.

PURPOSE

The aim of this analysis was to generate an assessment score to predict mortality of SI in order to facilitate decision-making.

STUDY DESIGN

Retrospective risk factor analysis.

PATIENT SAMPLE

Two hundred fifty-two patients were retrospectively analyzed.

OUTCOME MEASURES

Physiologic measures, functional measures.

METHODS

Diagnosis was based on clinical presentation, imaging findings and inflammatory markers. Factors associated with mortality were identified by multivariate analysis, weighted according to their relative risk ratio (RR) and included in the novel assessment score.

RESULTS

Eight parameters were included: (1) BMI, (2) ASA score, (3) presence of sepsis, (4) age-adjusted Charlson Comorbidity Index, (5) presence and degree of renal failure, (6) presence of hepatopathy, (7) neurological deficits and (8) CRP levels at diagnosis. Each parameter was assigned a certain range of points, resulting in a maximum total score of 20. The mortality in spinal infection (MSI-20) score - indicating poorer status with higher values - was obtained for each patient and correlated with mortality.

CONCLUSION

An MSI-20 score of 11 or more points seems to identify the small group of patients being "too sick to undergo surgery," while early surgery can be recommended in the remainder (MSI-20 ≤10). Our results need to be confirmed in prospective studies, but may give guidance for indicating surgery even in rather sick and comorbid patients.

Does Operative Management of Epidural Abscesses Increase Healthcare Expenditures up to 1 Year After Treatment?

BACKGROUND

The incidence of spinal epidural abscesses is increasing. What is more, they are associated with high rates of morbidity and mortality. Advances in diagnostic imaging and antibiotic therapies have made earlier diagnosis and nonoperative management feasible in appropriately selected patients. Nonoperative treatment also has the advantage of lower immediate healthcare charges; however, it is unknown whether initial nonoperative care leads to higher healthcare charges long term.

QUESTIONS/PURPOSES

(1) Does operative intervention generate higher charges than nonoperative treatment over the course of 1 year after the initial treatment of spinal epidural abscesses? (2) Does the treatment of spinal epidural abscesses in people who actively use intravenous drugs generate higher charges than management in people who do not?

METHODS

This retrospective comparative study at two tertiary academic centers compared adult patients with spinal epidural abscesses treated operatively and nonoperatively from January 2016 through December 2017. Ninety-five patients were identified, with four excluded for lack of billing data and one excluded for concomitant intracranial abscess. Indications for operative management included new or progressive motor deficit, lack of response to nonoperative treatment including persistent or progressive systemic illness, or initial sepsis requiring urgent source control. Of the included patients, 52% (47 of 90) received operative treatment with no differences in age, gender, BMI, and Charlson comorbidity index between groups, nor any difference in 30-day all-cause readmission rate, 1-year reoperation rate, or 2-year mortality. Furthermore, 29% (26 of 90) of patients actively used intravenous drugs and were younger, with a lower BMI and lower Charlson comorbidity index, with no differences in 30-day all-cause readmission rate, 1-year reoperation rate, or 2-year mortality. Cumulative charges at the index hospital discharge and 90 days and 1 year after discharge were compared based on operative or nonoperative management and secondarily by intravenous drug use status. Medical records, laboratory results, and hospital billing data were reviewed for data extraction. Demographic factors including age, gender, region of abscess, intravenous drug use, and comorbidities were extracted, along with clinical factors such as symptoms and ambulatory function at presentation, spinal instability, intensive care unit admission, and complications. The primary outcome was charges associated with care at the index hospital discharge and 90 days and 1 year after discharge. All covariates extracted were included in this analysis using negative binomial regression that accounted for confounders and the nonparametric nature of charge data. Results are presented as an incidence rate ratio with 95% confidence intervals.

RESULTS

After adjusting for demographic and clinical variables such as age, gender, BMI, ambulatory status, presence of mechanical instability, and intensive care unit admission among others, we found higher charges for the group treated with surgery compared with those treated nonoperatively at the index admission (incidence rate ratio [IRR] 1.62 [95% CI 1.35 to 1.94]; p < 0.001) and at 1 year (IRR 1.36 [95% CI 1.10 to 1.68]; p = 0.004). Adjusted analysis also showed that active intravenous drug use was also associated with higher charges at the index admission (IRR 1.57 [95% CI 1.16 to 2.14]; p = 0.004) but no difference at 1 year (IRR 1.11 [95% CI 0.79 to 1.57]; p = 0.55).

CONCLUSION

Multidisciplinary teams caring for patients with spinal epidural abscesses should understand that the decreased charges associated with selecting nonoperative management during the index admission persist at 1 year with no difference in 30-day readmission rates, 1-year reoperation rates, or 2-year mortality. On the other hand, patients with active intravenous drug use have higher index admission charges that do not persist at 1 year, with no difference in 30-day readmission rates, 1-year reoperation rates, or 2-year mortality. These results suggest possible economic benefit to nonoperative management of epidural abscesses without increases in readmission or mortality rates, further tipping the scale in an evolving framework of clinical decision-making. Future studies should investigate if these economic implications are mirrored on the patient-facing side to determine whether any financial burden is shifted onto patients and their families in nonoperative management.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Gender-Specific Differences in Presentation and Management of Spinal Infection: A Single-Center Retrospective Study of 159 Cases

STUDY DESIGN

A retrospective single-center analysis of 159 cases.

OBJECTIVE

To investigate differences between male and female patients, as spinal infection (SI) represents a life-threatening condition and numerous factors may facilitate the course and outcome of SI, including patients' age and comorbidities, as well as gender. To date, no comparative data investigating sex differences in SI is available. Thus, the purpose of the present retrospective trial was to investigate differences between male and female patients.

METHODS

A total of 159 patients who were treated for a spinal infection between 2010 and 2016 at our department were included in the analysis. The patients were categorized into 2 groups based on gender. Evaluation included magnetic resonance imaging, laboratory values, clinical outcome, and conservative/operative management.

RESULTS

Male patients suffered from SI significantly more often than female patients (n = 101, 63.5% vs n = 58, 36.5%, P = .001). However, female patients were initially affected more severely, as infection parameters were significantly higher (P = .032) and vertebral destruction was more serious (P = .018). Furthermore, women suffered from intraoperative complications more often (P = .024) and received erythrocyte concentrates more frequently (P = .01). Nevertheless, mortality rates and outcome were comparable. Pain scales were significantly higher in female patients at 12-month follow-up (P = .042).

CONCLUSION

Although male patients show a higher incidence for SI, the course of disease and the management is more challenging in female patients. Nevertheless, outcome after 12 months is comparably good. Underlying mechanisms may include a better immune response and dissimilar effects of antibiotic treatment in women. Pain management in female patients is still unsatisfactory after 12 months.

Early surgery may lower mortality in patients suffering from severe spinal infection

PURPOSE

Spinal infection (SI) is a life-threatening condition and treatment remains challenging. Numerous factors influence the outcome of SI and both conservative and operative care can be applied. As SI is associated with mortality rates between 2 and 20% even in developed countries, the purpose of the present study was to investigate the occurrence and causes of death in patients suffering from SI.

METHODS

A retrospective analysis was performed on 197 patients, categorized into two groups according to their outcome: D (death) and S (survival). The diagnosis was based on clinical and imaging (MRI) findings. Data collected included demographics, clinical characteristics, comorbidities, infection parameters, treatment details, outcomes, and causes of death.

RESULTS

The number of deaths was significantly higher in the conservative group (n = 9/51, 18%) compared with the operative counterpart (n = 8/146, 6%; p = 0.017). Death caused by septic multiorgan failure was the major cause of fatalities (n = 10/17, 59%) followed by death due to cardiopulmonary reasons (n = 4/17, 24%). The most frequent indication for conservative treatment in patients of group D included "highest perioperative risk" (n = 5/17, 29%).

CONCLUSION

We could demonstrate a significantly higher mortality rate in patients solely receiving conservative treatment. Mortality is associated with number and type of comorbidities, but also tends to be correlated with primarily acquired infection. As causes of death are predominantly associated with a septic patient state or progression of disease, our data may call for an earlier and more aggressive treatment. Nevertheless, prospective clinical trials will be mandatory to better understand the pathogenesis and course of spinal infection, and to develop high quality, evidence-based treatment recommendations.

Spinal Epidural Abscess: Diagnosis, Management, and Outcomes

An infection of the spinal epidural space, spinal epidural abscess (SEA) is a potentially devastating entity that is rising in incidence. Its insidious presentation, variable progression, and potential for precipitous neurologic decline make diagnosis and management of SEA challenging. Prompt diagnosis is key because treatment delay can lead to paralysis or death. Owing to the nonspecific symptoms and signs of SEA, misdiagnosis is alarmingly common. Risk factor assessment to determine the need for definitive MRI reduces diagnostic delays compared with relying on clinical or laboratory findings alone. Although decompression has long been considered the benchmark for SEA, considerable risk associated with spinal surgery is noted in an older cohort with multiple comorbidities. Nonoperative management may represent an alternative in select cases. Failure of nonoperative management is a feared outcome associated with motor deterioration and poor clinical outcomes. Recent studies have identified independent predictors of failure and residual neurologic dysfunction, recurrence, and mortality. Importantly, these studies provide tools that generate probabilities of these outcomes. Future directions of investigation should include external validation of existing algorithms through multi-institutional collaboration, prospective trials, and incorporation of powerful predictive statistics such as machine learning methods.

Impact of Cirrhosis on Morbidity and Mortality After Spinal Fusion

STUDY DESIGN

Retrospective large database study.

OBJECTIVE

To determine the impact of cirrhosis on perioperative outcomes and resource utilization in elective spinal fusion surgery.

METHODS

Elective spinal fusion hospitalizations in patients with and without cirrhosis were identified using ICD-9-CM codes between the years of 2009 and 2011 using the Nationwide Inpatient Sample database. Main outcome measures were in-hospital neurologic, respiratory, cardiac, gastrointestinal, renal and urinary, pulmonary embolism, wound-related complications, and mortality. Length of stay and inpatient costs were also collected. Multivariable logistic regressions were conducted to compare the in-hospital outcomes of patients with and without cirrhosis undergoing spinal fusion.

RESULTS

A total of 1 214 694 patients underwent elective spinal fusions from 2009 to 2011. Oh these, 6739 were cirrhotic. Cirrhosis was a significant independent predictor for respiratory (odds ratio [OR] = 1.43, confidence interval [CI] 1.29-1.58; P < .001), gastrointestinal (OR = 1.72, CI 1.48-2.00; P < .001), urinary and renal (OR = 1.90, CI 1.70-2.12; P < 0.001), wound (OR = 1.36, CI 1.17-1.58; P < 0.001), and overall inpatient postoperative complications (OR = 1.43, CI 1.33-1.53; P < .001). Cirrhosis was also independently associated with significantly greater inpatient mortality (OR = 2.32, CI 1.72-3.14; P < .001). Cirrhotic patients also had significantly longer lengths of stay (5.35 vs 3.35 days; P < .001) and inpatient costs ($36 738 vs $29 068; P < .001).

CONCLUSIONS

Cirrhosis is associated with increased risk of perioperative complications, mortality and greater resource utilization. Cirrhotic patients undergoing spinal fusion surgeries should be counseled on these increased risks. Current strategies for perioperative management of cirrhotic patients undergoing spinal fusion surgery need improvement.

What Is the Financial Impact of Orthopaedic Sequelae of Intravenous Drug Use on Urban Tertiary-care Centers?

BACKGROUND

Orthopaedic sequelae such as skin and soft-tissue abscesses are frequent complications of intravenous drug use (IVDU) and comprise many of the most common indications for emergency room visits and hospitalizations within this population. Urban tertiary-care and safety-net hospitals frequently operate in challenging economic healthcare environments and are disproportionately tasked with providing care to this largely underinsured patient demographic. Although many public health initiatives have been instituted in recent years to understand the health impacts of IVDU and the spreading opioid epidemic, few efforts have been made to investigate its economic impact on healthcare systems. The inpatient treatment of orthopaedic sequelae of IVDU is a high-cost healthcare element that is critically important to understand within the current national context of inflationary healthcare costs.

QUESTIONS/PURPOSES

(1) What were the total healthcare costs incurred and total hospital reimbursements received in the treatment of extraspinal orthopaedic sequelae of IVDU? (2) What were the total healthcare costs incurred and total hospital reimbursements received in the treatment of spinal orthopaedic sequelae of IVDU? (3) How did patient insurance status effect the economic burden of orthopaedic sequelae of IVDU?

METHODS

An internal departmental record of all successive patients requiring inpatient treatment of orthopaedic sequelae of IVDU was initiated at Boston Medical Center (Boston, MA, USA) in 2012 and MetroHealth Medical Center (Cleveland, OH, USA) in 2015. A total of 412 patient admissions between 2012 to 2017 to these two safety-net hospitals (n = 236 and n = 176, respectively) for orthopaedic complications of IVDU were included in the study. These sequelae included cellulitis, cutaneous abscess, bursitis, myositis, tenosynovitis, septic arthritis, osteomyelitis, and epidural abscess. Patients were included if they were older than 18 years of age, presented to the emergency department for management of a musculoskeletal infection secondary to IVDU, and required inpatient orthopaedic treatment during their admission. Exclusion criteria included all patients presenting with a musculoskeletal infection not directly secondary to active IVDU. Patients presenting with an epidural abscess (Boston Medical Center, n = 36) were evaluated separately to explore potential differences in costs within this subgroup. A robust retrospective financial analysis was performed using internal financial databases at each institution which directly enumerated all true hospital costs associated with each patient admission, independent of billed hospital charges. All direct, indirect, variable, and fixed hospital costs were individually summed for each hospitalization, constituting a true "bottom-up" micro-costing approach. Labor-based costs were calculated through use of time-based costing; for instance, the cost of nursing labor care associated with a patient admission was determined through ascription of the median hospital cost of a registered nurse within that department (that is, compensation for salary plus benefits) to the total length of nursing time needed by that patient during their hospitalization. Primary reimbursements reflected the true monetary value received by the study institutions from insurers and were determined through the total adjusted payment for each inpatient admission. All professional fees were excluded. A secondary analysis was performed to assess the effect of patient insurance status on hospital costs and reimbursements for each patient admission.

RESULTS

The mean healthcare cost incurred for the treatment of extraspinal orthopaedic sequelae of IVDU was USD 9524 ± USD 1430 per patient admission. The mean hospital reimbursement provided for the treatment of these extraspinal sequelae was USD 7678 ± USD 1248 per patient admission. This resulted in a mean financial loss of USD 1846 ± USD 1342 per patient admission. The mean healthcare cost incurred at Boston Medical Center for the treatment of epidural abscesses secondary to IVDU was USD 44,357 ± USD 7384 per patient. Hospital reimbursements within this subgroup were highly dependent upon insurance status. The median (range) reimbursement provided for patients possessing a unique hospital-based nonprofit health plan (n = 4) was USD 103,016 (USD 9022 to USD 320,123), corresponding to a median financial gain of USD 24,904 (USD 2289 to USD 83,079). However, the mean reimbursement for all other patients presenting with epidural abscesses (n = 32) was USD 30,429 ± USD 5278, corresponding to a mean financial loss of USD 5768 ± USD 4861. A secondary analysis demonstrated that treatment of extraspinal orthopaedic sequelae of IVDU for patients possessing Medicaid insurance (n = 309) resulted in a financial loss of USD 2813 ± USD 1593 per patient admission. Conversely, treatment of extraspinal orthopaedic sequelae for patients possessing non-Medicaid insurance (n = 67) generated a mean financial gain of USD 2615 ± USD 1341 per patient admission.

CONCLUSIONS

Even when excluding all professional fees, the inpatient treatment of orthopaedic sequelae of IVDU resulted in substantial financial losses driven primarily by high proportions of under- and uninsured people within this patient population. These financial losses may be unsustainable for medical centers operating in challenging economic healthcare landscapes. The development of novel initiatives and support of existing programs aimed at mitigating the health-related and economic impact of IVDU must remain a principal priority of healthcare providers and policymakers in coming years. Advocacy for the expansion of Medicaid accountable care organizations and national syringe service programs (SSPs), and the development of specialized outpatient wound and abscess clinics at healthcare centers may help to substantially alleviate the economic burden of the orthopaedic sequelae of IVDU.

LEVEL OF EVIDENCE

Level, IV, economic and decision analyses.

Evaluating new paralysis, mortality, and readmission among subgroups of patients with spinal epidural abscess: A latent class analysis

Background

Spinal epidural abscess (SEA) is increasing in incidence; this not-to-miss diagnosis can cause significant morbidity and mortality, particularly if diagnoses are delayed. While some risk factors for SEA and subsequent mortality have been identified, the SEA patient population is clinically heterogeneous and sub-populations have not yet been characterized in the literature. The primary objective of this project was to identify characteristics of subgroups of patients with SEA. The secondary objective was to identify associations between subgroups and three clinical outcomes: new onset paralysis, in-hospital mortality, and 180-day readmission.

Methods

Demographics and comorbid diagnoses were collected for patients diagnosed with SEA at an academic health center between 2015 and 2019. Latent class analysis was used to identify clinical subgroups. Chi-squared tests were used to compare identified subgroups with clinical outcomes.

Results

We identified two subgroups of patients in our analysis. Group 1 had a high rate of medical comorbidities causing immunosuppression, requiring vascular access, or both. Group 2 was characterized by a high proportion of people with substance use disorders. Patients in Group 2 were more likely to be readmitted within 6 months than patients in Group 1 (p = 0.03). There was no difference between groups in new paralysis or mortality.

Discussion

While prior studies have examined the SEA patient population as a whole, our research indicates that there are at least two distinct subgroups of patients with SEA. Patients who are younger, with substance use disorder diagnoses, may have longer hospital courses and are at higher risk of readmission within six months. Future research should explore how to best support patients in both groups, and additional implications for subgroup classification on health outcomes, including engagement in care.

Spinal epidural abscess in COVID-19 patients

Objective

To report the peculiarity of spinal epidural abscess in COVID-19 patients, as we have observed an unusually high number of these patients following the outbreak of SARS-Corona Virus-2.

Methods

We reviewed the clinical documentation of six consecutive COVID-19 patients with primary spinal epidural abscess that we surgically managed over a 2-month period. These cases were analyzed for what concerns both the viral infection and the spinal abscess.

Results

The abscesses were primary in all cases indicating that no evident infective source was found. A primary abscess represents the rarest form of spinal epidural abscess, which is usually secondary to invasive procedures or spread from adjacent infective sites, such as spondylodiscitis, generally occurring in patients with diabetes, obesity, cancer, or other chronic diseases.

In all cases, there was mild lymphopenia but the spinal abscess occurred regardless of the severity of the viral disease, immunologic state, or presence of bacteremia. Obesity was the only risk factor and was reported in two patients. All patients but one were hypertensive. The preferred localizations were cervical and thoracic, whereas classic abscess generally occur at the lumbar level. No patient had a history of pyogenic infection, even though previous asymptomatic bacterial contaminations were reported in three cases.

Conclusion

We wonder about the concentration of this uncommon disease in such a short period. To our knowledge, cases of spinal epidural abscess in COVID-19 patients have not been reported to date. We hypothesize that, in our patients, the spinal infection could have depended on the coexistence of an initially asymptomatic bacterial contamination. The well-known COVID-19-related endotheliitis might have created the conditions for retrograde bacterial invasion to the correspondent spinal epidural space.

Furthermore, spinal epidural abscess carries a significantly high morbidity and mortality. It is difficult to diagnose, especially in compromised COVID-19 patients but should be kept in mind as early diagnosis and treatment are crucial.

The Prognostic Value of Laboratory Markers and Ambulatory Function at Presentation for Post-Treatment Morbidity and Mortality Following Epidural Abscess

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To develop a comprehensive understanding of the prognostic value of laboratory markers on morbidity and mortality following epidural abscess.

SUMMARY OF BACKGROUND DATA

Spinal epidural abscess is a serious medical condition with high rates of morbidity. The value of laboratory data in forecasting morbidity and mortality after epidural abscess remains underexplored.

METHODS

We obtained clinical data on patients treated for epidural abscess at two academic centers from 2005 to 2017. Our primary outcome was the development of one or more complications within 90-days of presentation, with mortality a secondary measure. Primary predictors included serum albumin, serum creatinine, platelet-lymphocyte ratio, and ambulatory status at presentation. We used multivariable logistic regression techniques to adjust for confounders. The most parsimonious set of variables influencing both complications and mortality were considered to be clinically significant. These were then examined individually and in combination to assess for synergy along with model-discrimination and calibration. We performed internal validation with a bootstrap procedure using sampling with replacement.

RESULTS

We included 449 patients in this analysis. Complications were encountered in 164 cases (37%). Mortality within 1-year occurred in 39 patients (9%). Regression testing determined that serum albumin, serum creatinine, and ambulatory status at presentation were clinically important predictors of outcome, with albumin more than 3.5 g/dL, creatinine less than or equal to 1.2 mg/dL, and independent ambulatory function at presentation considered favorable characteristics. Patients with no favorable findings had increased likelihood of 90-day complications (odds ratio [OR] 5.43; 95% confidence intervals [CI] 1.98, 14.93) and 1-year mortality (OR 8.94; 95% CI 2.03, 39.37). Those with one favorable characteristic had greater odds of complications (OR 4.00; 95% CI 2.05, 7.81) and mortality (OR 5.71; 95% CI 1.60, 20.43).

CONCLUSION

We developed a nomogram incorporating clinical and laboratory values to prognosticate outcomes after treatment for epidural abscess. The results can be used in shared-decision making and counseling.

LEVEL OF EVIDENCE

3.

Spinal Epidural Abscess: A Review of Presentation, Management, and Medicolegal Implications

Spinal epidural abscess (SEA) is a rare condition associated with significant morbidity and mortality. Despite advances in diagnostic medicine, early recognition of SEAs remains elusive. The vague presentation of the disease, coupled with its numerous risk factors, the diagnostic requirement for obtaining advanced imaging, and the necessity of specialized care constitute extraordinary challenges to both diagnosis and treatment of SEA. Once diagnosed, SEAs require urgent or emergent medical and/or surgical management. As SEAs are a relatively rare pathology, high-quality data are limited and there is no consensus on their optimal management. This paper focuses on presenting the treatment modalities that have been successful in the management of SEAs and providing a critical assessment of how specific SEA characteristics may render one infection more amenable to primary surgical or medical interventions. This paper reviews the relevant history, epidemiology, clinical presentation, radiology, microbiology, and treatment of SEAs and concludes by addressing the medicolegal implications of delayed treatment of the disease.

Spinal epidural abscesses - The role for non-operative management: A systematic review

BACKGROUND

Spinal Epidural Abscesses (SEAs) are traditionally seen as a surgical emergency. However, SEAs can be discovered in entirely asymptomatic patients. This presents a dilemma for the attending clinician as to whether to subject these patients to significant surgery. This systematic review updates the evidence surrounding the efficacy of non-operative SEA management by means of intravenous antibiotics ± radiologically-guided aspiration.

AIMS

1. To assess failure rates of medical therapy for SEA. The absolute definition of 'failure' used by the study was recorded, and comparisons made. 2. To review of risk factors for success/failure of medical treatment for SEA.

METHODS

A database search with the MESH term 'epidural abscess' and keywords ['treatment' OR 'management'] were used.

RESULTS

14 studies were included. The number of SEA patients managed non-operatively ranged from 19 to 142. There was significant heterogeneity across the studies. Pooled Failure of Medical Therapy (FMT) (defined as any poor outcome) was 29.40%. When FMT = mortality the pooled rate was 11.49%. Commonly cited risk factors for FMT included acute neurological compromise, diabetes mellitus, increasing age and Staphylococcus aureus.

CONCLUSION

SEA will always be a condition mostly managed surgically. Despite this, there is growing evidence that non-operative management can be possible in the correct patients. The key is in patient selection - patients with any of the above-mentioned risk factors have the potential to deteriorate further on medical treatment and have a worse outcome than if they had undergone emergency surgery straight away. Ongoing research will hopefully further investigate this crucial step.

Prognostic value of laboratory values in older patients with cervical spine fractures

OBJECTIVES

To understand the prognostic value of laboratory markers at presentation on post-treatment survival of patients 50 and older following cervical spine fracture.

PATIENTS AND METHODS

We obtained clinical data on patients 50 and older treated for cervical spine fracture in a single healthcare system (2006-2016). Our primary outcome consisted of 1-year mortality, with mortality within 3-months of presentation considered secondarily. Our primary predictors included serum glucose, serum creatinine, platelet-lymphocyte ratio (PLR) and neutrophil-lymphocyte ratio (NLR) at presentation. We used multivariable logistic regression to adjust for confounding from sociodemographic and clinical characteristics. Point estimates and 95 % confidence intervals (CI) from the final model were refined using Bayesian regression techniques.

RESULTS

We included 1781 patients in this analysis, with an average age of 75.3 (SD 12.0). The mortality rate at 3-months was 12 % and 17 % at 1-year. In multivariable testing, neither elevated PLR or NLR were significant predictors of 1-year mortality. Elevated serum creatinine was associated with increased mortality at 1-year (OR 1.89; 95 % CI 1.30, 2.74), as was hyperglycemia (OR 1.50; 95 % CI 1.06, 2.13). Elevated serum creatinine remained influential (OR 1.64; 95 % CI 1.06, 2.54) on mortality at 3-months.

CONCLUSIONS

This is the first study to evaluate laboratory values at presentation in conjunction with survival following cervical fractures. The results can be used to help forecast natural history and in expectation management. They may also help formulate treatment plans, especially when the need for surgical intervention is not clearly defined.

Readmission after spinal epidural abscess management in urban populations: a bi-institutional study

OBJECTIVE

The incidence of spinal epidural abscess (SEA) is rising, yet there are few reports discussing readmission rates or predisposing factors for readmission after treatment. The aims of the present study were to determine the rate of 90-day readmission following medical or surgical treatment of SEA in an urban population, identify patients at increased risk for readmission, and delineate the principal causes of readmission.

METHODS

Neurosurgery records from two large urban institutions were reviewed to identify patients who were treated for SEA. Patients who died during admission or were discharged to hospice were excluded. Univariate analysis was performed using chi-square and Student t-tests to identify potential predictors of readmission. A multivariate logistic regression model, controlled for age, body mass index, sex, and institution, was used to determine significant predictors of readmission.

RESULTS

Of 103 patients with identified SEA, 97 met the inclusion criteria. Their mean age was 57.1 years, and 56 patients (57.7%) were male. The all-cause 90-day readmission rate was 37.1%. Infection (sepsis, osteomyelitis, persistent abscess, bacteremia) was the most common cause of readmission, accounting for 36.1% of all readmissions. Neither pretreatment neurological deficit (p = 0.16) nor use of surgical versus medical management (p = 0.33) was significantly associated with readmission. Multivariate analysis identified immunocompromised status (p = 0.036; OR 3.5, 95% CI 1.1-11.5) and hepatic disease (chronic hepatitis or alcohol abuse) (p = 0.033; OR 2.9, 95% CI 1.1-7.7) as positive predictors of 90-day readmission.

CONCLUSIONS

The most common indication for readmission was persistent infection. Readmission was unrelated to baseline neurological status or management strategy. However, both hepatic disease and baseline immunosuppression significantly increased the odds of 90-day readmission after SEA treatment. Patients with these conditions may require closer follow-up upon discharge to reduce overall morbidity and hospital costs associated with SEA.

Development of machine learning algorithms for prediction of mortality in spinal epidural abscess

BACKGROUND CONTEXT

In-hospital and short-term mortality in patients with spinal epidural abscess (SEA) remains unacceptably high despite diagnostic and therapeutic advancements. Forecasting this potentially avoidable consequence at the time of admission could improve patient management and counseling. Few studies exist to meet this need, and none have explored methodologies such as machine learning.

PURPOSE

The purpose of this study was to develop machine learning algorithms for prediction of in-hospital and 90-day postdischarge mortality in SEA.

STUDY DESIGN/SETTING

Retrospective, case-control study at two academic medical centers and three community hospitals from 1993 to 2016.

PATIENTS SAMPLE

Adult patients with an inpatient admission for radiologically confirmed diagnosis of SEA.

OUTCOME MEASURES

In-hospital and 90-day postdischarge mortality.

METHODS

Five machine learning algorithms (elastic-net penalized logistic regression, random forest, stochastic gradient boosting, neural network, and support vector machine) were developed and assessed by discrimination, calibration, overall performance, and decision curve analysis.

RESULTS

Overall, 1,053 SEA patients were identified in the study, with 134 (12.7%) experiencing in-hospital or 90-day postdischarge mortality. The stochastic gradient boosting model achieved the best performance across discrimination, c-statistic=0.89, calibration, and decision curve analysis. The variables used for prediction of 90-day mortality, ranked by importance, were age, albumin, platelet count, neutrophil to lymphocyte ratio, hemodialysis, active malignancy, and diabetes. The final algorithm was incorporated into a web application available here: https://sorg-apps.shinyapps.io/seamortality/.

CONCLUSIONS

Machine learning algorithms show promise on internal validation for prediction of 90-day mortality in SEA. Future studies are needed to externally validate these algorithms in independent populations.

Health Care Utilization and Payments of Postoperative and Drug Abuse-Related Spinal Infections

STUDY DESIGN

Retrospective analysis of data extracted from the MarketScan database (2000-2016) using International Classification of Diseases (ICD)-9, ICD-10, and Current Procedural Terminology-4 codes.

OBJECTIVE

Evaluate the economic costs and health care utilization associated with spine infections.

SUMMARY OF BACKGROUND DATA

Spinal infections (SI) are associated with significant morbidity and mortality. A recent spike in SI is attributed to the drug abuse epidemic. Management of SI represents a large burden on the health care system.

METHODS

We assessed payments and outcomes at the index hospitalization, 1-, 3-, 6-, and 12-month follow up. Outcomes assessed included length of stay, complications, operation rates, and health care utilization. Outcomes were compared between cohorts with spinal infections: (1) with prior surgery, (2) drug abuse, and (3) without previous exposure to surgery or drug abuse, denoted as control.

RESULTS

We identified 43,972 patients; 15.6% (N = 6847) of patients underwent prior surgery, 3.8% (N = 1,668) were previously expose to drug abuse while 80.6% fell into the control group. Both the postsurgical and drug abuse groups longer hospital stay compared with the control cohort (5 d vs. 4 d, P < 0.0001). Exposure to IV drug abuse was associated with increased risk of complications compared with the control group (43% vs. 38%, P < 0.0001). Payments at 1-month follow-up were significantly (P < 0.0001) higher among the postsurgical group compared with both groups. However, at 12-months follow-up, payments were significantly (P < 0.0001) higher in the drug abuse group compared with both groups. Only postsurgical infections were associated with higher number of surgical interventions both at presentation and 1 year follow up.

CONCLUSION

SI following surgery or IV drug abuse are associated with higher payments, complication rates, and longer hospital stays. Drug abuse related SI are associated with the highest complication rates, readmissions, and overall payments at 1 year of follow up despite the lower rate of surgical interventions.

LEVEL OF EVIDENCE

3.

High Prevalence of Multifocal Spine Infections Involving the Cervical and Thoracic Regions: A Case for Imaging the Entire Spine

Objective

Pyogenic spinal infections account for 2%–4% of orthopaedic infections. They are often difficult to diagnose, resulting in a delay in diagnosis. Risk factors for orthopaedic and spinal infection are well-documented in the literature, yet there is a paucity of studies examining risk factors specifically for multifocal spinal infections. The objective of this study was to identify predictors of multifocal spinal infections in comparison to unifocal spinal infections.

Methods

The medical records, imaging studies, and bacteriology data of 20 patients treated surgically for pyogenic spinal infection over 6 years at a tertiary referral center were reviewed and analyzed after receiving Institutional Review Board approval. Univariate and multivariate analyses were performed to identify factors associated with a multifocal spinal infection.

Results

Seven patients (35%) had multifocal infections. Three were bifocal, and 4 were trifocal. Patients with surgically treated cervical or thoracic spinal infections had a high rate of concomitant multifocal spinal infections (71% and 83%, respectively). Other potential predictors (e.g., patient age, body mass index, magnetic resonance image findings, etc.) did not reach statistical significance. Each of the multifocal infections involved the lumbar spine.

Conclusion

In this study, the spinal region was the only statistically significant risk factor for multifocal infection. Patients who are diagnosed with a spinal infection that requires operative treatment should have their entire spine evaluated with magnetic resonance imaging to detect multifocal involvement promptly.

Assessment of postoperative outcomes in spinal epidural abscess following surgical decompression

BACKGROUND CONTEXT

A spinal epidural abscess (SEA) is a serious condition that may be managed with antibiotics alone or with decompressive surgery combined with antibiotics.

PURPOSE

The objectives of this study were to assess the clinical outcomes of SEA after surgical management and to identify the patient-level factors that are associated with outcomes following surgical decompression and removal of SEA.

STUDY DESIGN/SETTING

Retrospective chart review analysis.

PATIENT SAMPLE

An analysis of 154 consecutive patients who initially presented to a tertiary-care, academic medical center with SEA, and were subsequently treated with surgery between 2010 and 2015 was performed.

OUTCOME MEASURES

Postoperative predischarge American Spinal Injury Association Impairment Scale (AIS) scores, 6-month follow-up encounter AIS scores, need for revision surgery, and mortality during SEA surgery were the primary outcomes.Physiological Measures: AIS scores.

METHOD

Fisher's exact and Wilcoxon rank-sum tests were used to assess the associations between patient-level factors and surgical outcomes. Moreover, an interactive, predictive model for postoperative predischarge AIS score was developed using a proportional odds regression model. There was no funding secured for this study and there is no conflict of interest-associated biases.

RESULTS

One hundred fifty-four patients (mean age of 58 years) were treated using surgical decompression in addition to antibiotics. The majority of patients were Caucasian (81%) and male (61%). No intraoperative mortality was reported. A second SEA surgery was performed in 8% of patients. A comparison of the preoperative and postoperative predischarge AIS scores showed that 49% of patients maintained a score of E or improved, while 45% remained at their preoperative status and 6% worsened. Among a subset of patients (n=36; 23%) for whom a 6-month follow-up encounter occurred, 75% maintained an AIS score of E or improved, 19% remained at their preoperative status, and 6% worsened. Both the presence and longer duration of preoperative paresis was associated with an increased risk of remaining at the same AIS score or worsening at the predischarge encounter (both p< .001). A predictive model for predischarge AIS scores was developed based on several patient characteristics.

CONCLUSIONS

Surgical decompression can contribute to improving or maintaining AIS scores in a high percentage of SEA patients. The presence and duration of preoperative paresis are prognostic for poorer outcomes and suggest that rapid surgical intervention before paresis develops may lead to improved postoperative outcomes. Our modeling tool enables an estimation of probabilities of patients' predischarge condition.

Recent Increase in the Rate of Spinal Infections May be Related to Growing Substance-use Disorder in the State of Washington: Wide Population-based Analysis of the Comprehensive Hospital Abstract Reporting System (CHARS) Database

STUDY DESIGN

Epidemiological study.

OBJECTIVE

The aim of this study was to evaluate trends in the incidence of spinal infections (SI) and the possible role of substance use disorder (SUD) as a key associated factor.

SUMMARY OF BACKGROUND DATA

SI pose major diagnostic and therapeutic challenge in developed countries, resulting in substantial morbidity and mortality. With an estimated incidence of up to 1:20,000, recent clinical experiences suggest that this rate may be rising.

METHODS

To evaluate a possible change in trend in the proportion of SI, we searched the Washington state Comprehensive Hospital Abstract Reporting System (CHARS) data during a period of 15 years. We retrieved ICD-9 and 10 codes, searching for all conditions that are regarded as SI (discitis, osteomyelitis, and intraspinal abscess), as well as major known SI-related risk factors.

RESULTS

We found that the proportion of SI among discharged patients had increased by around 40% during the past 6 years, starting at 2012 and increasing steadily thereafter. Analysis of SI-related risk factors within the group of SI revealed that proportion of SUD and malnutrition had undergone the most substantial change, with the former increasing >3-fold during the same period.

CONCLUSION

Growing rates of drug abuse, drug dependence, and malnutrition throughout the State of Washington may trigger a substantial increase in the incidence of spinal infections in discharged patients. These findings may provide important insights in planning prevention strategies on a broader level.

LEVEL OF EVIDENCE

4.

[Modern radiological diagnostics in spine surgery]

BACKGROUND

Radiological imaging is important in the preoperative diagnosis of many forms of spinal pathology and plays a fundamental role in the assessment of p.o. effects, which can be verified on the spinal column as well as on the surrounding soft tissues, depending on the imaging method used.

AIM

The article provides an overview of the current status and possibilities of radiological diagnostic methods for the verification of possibly recommended spine surgery in the context of degenerative, inflammatory-infectious, post-traumatic or p.o. pathologies and changes in the spine: X‑rays, computed tomography (CT), magnetic resonance imaging (MRI). The supplementary nuclear medicine procedures (scintigraphy, PET[-CT], SPECT, etc.) which may be required for special questions are not discussed.

MATERIAL AND METHODS

The merits and limitations of the techniques used in the investigation of advanced degenerative spinal pathologies and post-traumatic conditions are discussed, with multidetector CT being the focus of attention in spinal clearance for traumatic injuries. In most cases of spinal infection, MRI images, as a central diagnostic tool, show typical findings such as destruction of adjacent endplates, bone marrow and intervertebral disc abnormalities, and paravertebral or epidural abscesses. However, it is not always easy to diagnose a spinal infection, especially if atypical MR patterns of infectious spondylitis are present. Knowledge of them means misdiagnosis and improper treatment can be avoided.

RESULTS

It is shown that high-quality modern radiological examinations are essential for diagnosis and p.o. management, as these provide answers to the main questions in the treatment: Is the entity/injury stable or unstable, acute or old, benign or malign; is there a myelopathy or p.o. complication?

DISCUSSION

The main indications for p.o. diagnostic imaging, difficulties such as metal artefact formation, and potential pitfalls are analyzed. Entity-specific radiological image patterns, imaging algorithms and differential diagnostic peculiarities are presented and discussed based on current literature and selected case studies.

Albumin and Spinal Epidural Abscess: Derivation and Validation in Two Independent Data Sets

BACKGROUND

None of the existing prognostic scoring systems for spinal epidural abscess (SEA) include albumin despite albumin's established role in inflammation, nutrition, lipid peroxidation, and regulation of apoptosis. The purpose of the present study was to determine the prognostic value of albumin in SEA.

METHODS

We performed a retrospective, case-control study of 2 independent data sets: patients with SEA in an institutional population and patients in the National Surgical Quality Improvement Program (NSQIP). Bivariate analyses and multivariate analyses were used to determine whether albumin is an independent prognostic factor for survival in both data sets.

RESULTS

For the 1053 patients with SEA in the institutional cohort, the 90-day postdischarge mortality was 134 (12.7%). Overall, 633 (60.1%) underwent surgery in the initial admission, with a 30-day postoperative mortality rate of 5.5% (n = 35). For the 1154 patients with SEA in the NSQIP database, the 30-day postoperative mortality rate was 3.6% (n = 42). The rate of 90-day postdischarge mortality in the institutional cohort for patients with albumin <2.3 g/dL was 25.1%. In contrast, the rate for patients with albumin >3.3 g/dL was 4.5%. On multivariate analysis of the NSQIP database, hypoalbuminemia was an independent prognostic factor for 30-day postoperative mortality. On multivariate analysis of the institutional cohort, hypoalbuminemia remained a prognostic factor for 90-day postdischarge mortality.

CONCLUSION

Albumin was validated as an independent prognostic factor in patients with SEA. The lack of this marker in existing scoring systems underscores the need for updated models to optimize risk stratification and shared decision-making before surgery.

Musculoskeletal Infections in the Emergency Department

Bone and joint infections are potentially limb-threatening or even life-threatening diseases. Emergency physicians must consider infection when evaluating musculoskeletal complaints, as misdiagnosis can have significant consequences. Patients with bone and joint infections can have heterogeneous presentations with nonspecific signs and symptoms. Staphylococcus aureus is the most commonly implicated microorganism. Although diagnosis may be suggested by physical examination, laboratory testing, and imaging, tissue sampling for Gram stain and microbiologic culture is preferable, as pathogen identification and susceptibility testing help optimize long-term antibiotic therapy. A combination of medical and surgical interventions is often necessary to effectively manage these challenging infections.

Development of Predictive Algorithms for Pre-Treatment Motor Deficit and 90-Day Mortality in Spinal Epidural Abscess

BACKGROUND

Spinal epidural abscess is a high-risk condition that can lead to paralysis or death. It would be of clinical and prognostic utility to identify which subset of patients with spinal epidural abscess is likely to develop a motor deficit or die within 90 days of discharge.

METHODS

We identified all patients ≥18 years of age who were admitted to our hospital system with a diagnosis of spinal epidural abscess during the period of 1993 to 2016. Explanatory variables were collected retrospectively. Bivariate and multivariable logistic regression was performed using these variables to identify independent predictors of motor deficit and 90-day mortality. Nomograms were then constructed to quantify the risk of these outcomes.

RESULTS

Of the 1,053 patients we identified with spinal epidural abscess, 362 presented with motor weakness. One hundred and thirty-four patients died within 90 days of discharge, inclusive of those who died during hospitalization. Multivariable logistic regression yielded 8 independent predictors of pre-treatment motor deficit and 8 independent predictors of 90-day mortality. We constructed nomograms that generated a probability of pre-treatment motor deficit or 90-day mortality on the basis of the presence of these factors.

CONCLUSIONS

By quantifying the risk of pre-treatment motor deficit and 90-day mortality, our nomograms may provide useful prognostic information for the treatment team. Timely treatment of neurologically intact patients with a high risk of developing a motor deficit is necessary to avoid residual motor weakness and improve survival.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of Levels of Evidence.

What low back pain is and why we need to pay attention

Low back pain is a very common symptom. It occurs in high-income, middle-income, and low-income countries and all age groups from children to the elderly population. Globally, years lived with disability caused by low back pain increased by 54% between 1990 and 2015, mainly because of population increase and ageing, with the biggest increase seen in low-income and middle-income countries. Low back pain is now the leading cause of disability worldwide. For nearly all people with low back pain, it is not possible to identify a specific nociceptive cause. Only a small proportion of people have a well understood pathological cause-eg, a vertebral fracture, malignancy, or infection. People with physically demanding jobs, physical and mental comorbidities, smokers, and obese individuals are at greatest risk of reporting low back pain. Disabling low back pain is over-represented among people with low socioeconomic status. Most people with new episodes of low back pain recover quickly; however, recurrence is common and in a small proportion of people, low back pain becomes persistent and disabling. Initial high pain intensity, psychological distress, and accompanying pain at multiple body sites increases the risk of persistent disabling low back pain. Increasing evidence shows that central pain-modulating mechanisms and pain cognitions have important roles in the development of persistent disabling low back pain. Cost, health-care use, and disability from low back pain vary substantially between countries and are influenced by local culture and social systems, as well as by beliefs about cause and effect. Disability and costs attributed to low back pain are projected to increase in coming decades, in particular in low-income and middle-income countries, where health and other systems are often fragile and not equipped to cope with this growing burden. Intensified research efforts and global initiatives are clearly needed to address the burden of low back pain as a public health problem.

Management of spinal infection: a review of the literature

Spinal infection (SI) is defined as an infectious disease affecting the vertebral body, the intervertebral disc, and/or adjacent paraspinal tissue and represents 2–7% of all musculoskeletal infections. There are numerous factors, which may facilitate the development of SI including not only advanced patient age and comorbidities but also spinal surgery. Due to the low specificity of signs, the delay in diagnosis of SI remains an important issue and poor outcome is frequently seen. Diagnosis should always be supported by clinical, laboratory, and imaging findings, magnetic resonance imaging (MRI) remaining the most reliable method. Management of SI depends on the location of the infection (i.e., intraspinal, intervertebral, paraspinal), on the disease progression, and of course on the patient’s general condition, considering age and comorbidities. Conservative treatment mostly is reasonable in early stages with no or minor neurologic deficits and in case of severe comorbidities, which limit surgical options. Nevertheless, solely medical treatment often fails. Therefore, in case of doubt, surgical treatment should be considered. The final result in conservative as well as in surgical treatment always is bony fusion. Furthermore, both options require a concomitant antimicrobial therapy, initially applied intravenously and administered orally thereafter. The optimal duration of antibiotic therapy remains controversial, but should never undercut 6 weeks. Due to a heterogeneous and often comorbid patient population and the wide variety of treatment options, no generally applicable guidelines for SI exist and management remains a challenge. Thus, future prospective randomized trials are necessary to substantiate treatment strategies.

The Risks of Hepatitis C in Association With Cervical Spinal Surgery: Analysis of Radiculopathy and Myelopathy Patients

STUDY DESIGN

Retrospective review.

OBJECTIVE

To investigate rates of in-hospital postsurgical complications among hepatitis C-infected patients after cervical spinal surgery in comparison with uninfected patients and determine independent risk factors.

SUMMARY OF BACKGROUND DATA

Studying hepatitis C virus (HCV) as a possible risk factor for cervical spine postoperative complications is prudent, given the high prevalence of cervical spondylosis and HCV in older patients. Spine literature is limited with respect to the impact of chronic HCV upon complications after surgery.

MATERIALS AND METHODS

Patients who underwent cervical spine surgery for cervical radiculopathy (CR) or cervical myelopathy (CM) from 2005 to 2013 were retrospectively reviewed using the Nationwide Inpatient Sample database. Patients were divided into CR and CM groups, with comparative subgroup analysis of HCV and no-HCV patients. Univariate analysis compared demographics and complications. Binary logistic stepwise regression modeling identified any independent outcome predictors (covariates: age, sex, Deyo score, and surgical approach).

RESULTS

In total, 227,310 patients (HCV: n=2542; no-HCV: n=224,764) were included. From 2005 to 2013, HCV infection prevalence among all cervical spinal fusion cases increased from 0.8% to 1.2%. HCV patients were more likely to be African American or Hispanic and have Medicare and/or Medicaid (all P<0.001). Overall complication rates among HCV patients with CR or CM increased, specifically related to device (CR: 3.1% vs. 1.9%; CM: 2.9% vs. 1.3%), hematoma/seroma (CR: 1.1% vs. 0.4%; CM: 1.8% vs. 0.8%), and sepsis (CR: 0.4% vs. 0.1%; CM: 1.1% vs. 0.5%) (all P≤0.001). Among CR and CM patients, HCV significantly predicted increased complication rates [odds ratio (OR): 1.268; OR: 1.194], hospital stay (OR: 1.738; OR: 1.861), and hospital charges (OR: 1.516; OR: 1.732; all P≤0.044).

CONCLUSIONS

HCV patients undergoing cervical spinal surgery were found to have increased risks of postoperative complications and increased risk associated with surgical approach. These findings should augment preoperative risk stratification and counseling for HCV patients and their spine surgeons.

LEVEL OF EVIDENCE

Level III.

Thoracic Spondylodiscitis Epidural Abscess in an Afebrile Navy Veteran: A Case Report

Objective

The purpose of this case study was to describe the differential diagnosis of a thoracic epidural abscess in a Navy veteran who presented to a chiropractic clinic for evaluation and management with acupuncture within a Veterans Affairs Medical Center.

Clinical Features

An afebrile 59-year-old man with acute thoracic spine pain and chronic low back pain presented to the chiropractic clinic at a Veterans Affairs Medical Center for consideration for acupuncture treatment.

Intervention and Outcome

The veteran elected to trial acupuncture once per week for 4 weeks. A routine thoracic magnetic resonance imaging scan without gadolinium detected a space-occupying lesion after the patient failed to attain 50% reduction of pain within 2 weeks with conservative care. The patient was diagnosed with a multilevel thoracic spondylodiscitis epidural abscess and was treated same day with emergency debridement and laminectomy of T7-8 with a T6-9 fusion. The patient had complete recovery without neurological compromise and completed an antibiotic regimen for 6 weeks.

Conclusion

A Navy veteran with acute thoracic spine and chronic low back pain appeared to respond initially but failed to achieve clinically meaningful outcomes. Follow-up advanced imaging detected a thoracic spondylodiscitis epidural abscess. Early diagnosis and immediate intervention are important to preserving neurological function and limiting morbidity in cases of spondylodiscitis epidural abscess.

Spinal infections in older people: an analysis of demographics, presenting features, microbiology and outcomes

BACKGROUND

Clinical features of infection can become more atypical as we age. Spinal infections can be insidious, and timely diagnosis and treatment are essential to prevent adverse outcomes.

AIMS

To explore differences in presentation and outcomes between younger and older patients with bacterial spinal infections.

METHODS

Clinical, microbiological and radiological information was collected for patients with spinal infections (spondylodiscitis, vertebral osteomyelitis, septic discitis, facet joint septic arthritis and spinal epidural abscess) at a single metropolitan hospital between January 2008 and January 2015. Patients were excluded if they were under 18 years of age or if clinical and imaging findings were inconsistent with the diagnosis. Presenting features, investigations and outcomes were compared for patients ≥65 (older) or <65 (younger) years old.

RESULTS

Of 53 identified patients, 34 (64%) were classified as older, with more males in both older (65%) and younger (79%) groups. Older patients presented later (median symptom duration 13 vs 4 days, P = 0.016). Back pain was nearly ubiquitous. Older patients presented less commonly with fevers (38 vs 63%) and rigors (24 vs 42%) but more commonly with hypotension (18 vs 5%), delirium (24 vs 11%), higher median inflammatory marker levels and variable microbiological findings, although these differences were not statistically significant. They had longer median lengths of stay (24 vs 14 days) and a higher likelihood of death or failure of medical treatment (HR 9.34, P = 0.031). Radicular pain was associated with poor outcome (HR 3.29, P = 0.046).

CONCLUSION

Older patients with spinal infections present later, with higher inflammatory markers and fewer typical infective symptoms and signs; these may contribute to poorer outcomes. A low threshold for promptly investigating older patients with new or worsening back pain should be set.

The impact of hepatitis C virus infection on 90-day outcomes following major orthopaedic surgery: a propensity-matched analysis

INTRODUCTION

The impact of hepatitis C virus (HCV) infection on outcomes following major orthopaedic interventions, such as joint arthroplasty or spine surgery, has not been effectively studied in the past. Most prior studies are impaired by small samples, limited surveillance for adverse events, or the potential for selection bias to confound results. In this context, we sought to evaluate the impact of HCV infection on 90-day outcomes following joint arthroplasty or spine surgery using propensity-matched techniques.

MATERIALS AND METHODS

This study utilized 2006-2014 claims from TRICARE insurance. Adults who received spine surgical procedures, total knee and hip arthroplasty were identified. Covariates included demographic factors, a diagnosis of HCV and medical co-morbidities defined by International Classification of Disease-9th revision (ICD-9) code. Outcomes consisted of 30- and 90-day mortality, complications and readmission. A propensity score was used to balance the cohorts with logistic regression techniques employed to determine the influence of HCV infection on post-operative outcomes.

RESULTS

The propensity-matched cohort consisted of 2262 patients (1131 with and without HCV). Following logistic regression, patients with HCV were found to have increased odds of 30-day complications (OR 1.87; 95% CI 1.33, 2.64; p < 0.001), 90-day complications (OR 1.55; 95% CI 1.16, 2.08; p = 0.003) and 30-day readmission (OR 1.46; 95% CI 1.04, 2.05; p = 0.03).

CONCLUSION

HCV infection was found to increase the risk of complication and readmission following spine surgery and total joint arthroplasty. Patients should be counseled on their increased risk prior to surgery. Health systems that treat a higher percentage of patients with HCV need to consider the increased risk of complications and readmission when negotiating with insurance carriers.

Incidence, Morbidity, and Surgical Outcomes of Complex Spinal Inflammatory Syndromes in Adults

BACKGROUND

Spondylodiscitis is a rare inflammatory syndrome affecting intervertebral discs and adjacent vertebral bodies. Without appropriate therapy, serious complications, such as secondary spinal epidural abscess (SEA), may prolong recovery time. In this study, we compared the main characteristics of our cohort of patients with spondylodiscitis with those of patients reported in the international literature and analyzed the impact of complications associated with spondylodiscitis on clinical outcomes.

METHODS

We designed a retrospective study based on the database of the National Institute of Clinical Neurosciences, Hungary, between 2008 and 2015. We collected 78 patients suffering from primary spondylodiscitis or primary spinal epidural abscess. Based on the main clinical characteristics of our population (demographic features, initial symptoms, concurrent diseases, laboratory findings, microbiological diagnosis, therapy and clinical outcome) we constructed a database. Odds ratio (OR) counting was used to define the correlation between etiology and stage of recovery.

RESULTS

We found a mild increase in the incidence of spondylodiscitis compared with international standards, and main demographic and clinical characteristics in concordance with international trends. Primary, noncomplicated spondylodiscitis had the best outcome results (OR, 1.25), and complicated spondylodiscitis had the worst, as well as the lowest OR for total recovery (0.6).

CONCLUSIONS

The clinical characteristics of our study cohort did not differ from the international trends. Primary, noncomplicated spondylodiscitis has the highest odds for absolute recovery. Secondary spinal epidural abscess exacerbates ongoing spondylodiscitis, and thus should be considered a poor prognostic factor for spondylodiscitis. Early diagnosis and treatment may prevent serious complications and provide better outcomes.

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.