An institutional series and contemporary review of bacterial spinal epidural abscess: current status and future directions

Surgical management of ventrally located cervical epidural abscess: A comparative analysis between patients aged 18-64 years and ≥65 years

Background

We aimed to compare the clinical course of patients aged 18-65 years and ≥65years who underwent anterior cervical discectomy and fusion (ACDF) or corpectomy for ventrally located CSEA.

Methods

Clinical and imaging data were retrospectively collected from the institutional database between September 2005 and December 2021.

Results

A total of 35 and 26 patients aged 18-64 and ≥ 65 years, respectively who were diagnosed with ventrally located CSEA were included. The overall mean age was 63.9 ± 3.2 years, with a predominance of the male sex (n = 43/61, 70.5%). Patients aged ≥65 years presented with significantly higher rates of comorbidities (10.3 ± 2.8), as indicated by the CCI, than their younger counterparts (18-64 years: 6.2 ± 2.6; p < 0.001). No differences in the surgical approach or characteristics were observed among the groups. Notably, patients aged ≥65 years had a significantly longer intensive care unit as well as overall hospital stay. In-hospital and 90-day mortality were similar across both groups. Following both types of surgery, a significant improvement was observed in the blood infection parameters and neurological status at discharge compared with the baseline measurements. Older age, higher rates of comorbidities, and higher grades of disability were significant predictors for mortality.

Conclusions

Emergency surgical evacuation should be undertaken for CSEA in the presence of acute neurological deterioration regardless of the age. Factors, such as age, comorbidities, and neurological status on admission appear to be important predictors of disease outcomes. However, the risk profile of younger patients should not be underestimated.

The Impact of Patient Characteristics on Outcomes of Surgically Managed Vertebral Osteomyelitis in the United States: Insights from a National Database Study

This study was conducted to assess the patient characteristics, types of treatment, and outcomes of patients who are surgically treated for vertebral osteomyelitis (VO) in the United States. VO can be treated with or without surgical intervention. Surgically treated cases of VO are associated with significant morbidity and mortality, and incur major healthcare costs. There are few studies assessing the characteristics and outcomes of patients with VO who are treated surgically, as well as the overall impact of surgically managed VO on the healthcare system of the United States. Utilizing the Nationwide Inpatient Sample (NIS) database, 44,401 patients were identified who underwent surgical treatment for VO over a fifteen year period. Severity of comorbidity burden was calculated using the Deyo Index (DI). Surgical approach and comorbidities were analyzed in regard to their impact on complications, mortality rate, LOS, and hospitalization charges. The incidence of surgical intervention for patients who had VO increased from 0.6 to 1.1 per U.S. persons over the study period. Surgically treated patients had a mean age of 56 years, were 75.8% white, were 54.5% male, 37.9% carried Medicare insurance, and they had a mean DI of 0.88. Anterior/posterior approach (OR: 3.53), thoracolumbar fusion (OR: 2.69), thoracolumbar fusion (OR: 19.94), and anterior/posterior approach (OR: 64.73) were the surgical factors that most significantly predicted any complication, mortality, increased LOS, and increased hospital charges, respectively (P < 0.001). The mean inflation-adjusted total hospital cost increased from $20,355 to $39,991 per patient over the study period. VO has been steadily increasing in the United States. Incidence and inflation-adjusted costs nearly doubled. Anterior/posterior approach and thoracolumbar fusion most significantly predicted negative outcomes. VO is associated with lengthy and expensive hospital stays resulting in a significant burden to patients and the healthcare system.

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.

Non-traumatic acute myelopathies: Clinical and imaging features in a real world emergency setting

OBJECTIVE

The aetiologic diagnosis of non-traumatic acute myelopathies (AMs), and their differentiation from other mimicking conditions (i.e. 'mimics'), are clinically challenging, especially in the emergency setting. Here, we sought to identify: (i) red flags suggesting diagnoses alternative to AMs and (ii) clinical signs and magnetic resonance imaging (MRI) features differentiating non-compressive from compressive AMs.

MATERIALS AND METHODS

We retrospectively retrieved MRI scans of spinal cord dictated at emergency room from January 2016 to December 2020 in the suspicion of AMs. Patients with traumatic myelopathies and those with subacute/chronic myelopathies (i.e. MRI scans acquired >48 h from symptom onset) were excluded from analysis.

RESULTS

Our search retrieved 105 patients; after excluding 16 cases of traumatic myelopathies and 14 cases of subacute/chronic myelopathies, we identified 30 cases with non-compressive AMs, 30 cases with compressive AMs and 15 mimics. The presence of pyramidal signs (p = 0.012) and/or pain (p = 0.048) correctly identified 88% of cases with AMs. We failed to identify clinical indicators for distinguishing non-compressive and compressive AMs, although cases with inflammatory AMs were younger than cases with all the remaining conditions (p < 0.05). Different MRI patterns could be described according to the final diagnosis: among non-compressive AMs, inflammatory lesions were more often posterior or central; vascular malformation had a fairly widespread distribution; spine ischaemia was more often central. Anterior or lateral compression were more often associated with neoplasms and disc herniation , whereas hemorrhages and infections produced spine compression on all sides.

CONCLUSION

We propose a simple clinical indicator (i.e. pyramidal signs and/or pain) to distinguish AMs from their mimics in an emergency setting. Urgent spinal cord MRI remains essential to discriminate compressive and non-compressive aetiologies.

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.

Case Report: A case of cervical spinal epidural abscess combined with cervical paravertebral soft tissue abscess

Background

Spinal epidural abscess (SEA) is a rare purulent infection of the central nervous system. Abscesses confined to the spinal canal can compress the spinal cord, causing nerve damage and even death in severe cases (1). Prompt diagnosis and treatment can relieve symptoms and prevent complications. To increase awareness of this rare disease, we report a case of a 58-year-old man with a cervical spinal epidural abscess combined with a soft tissue abscess in the neck and describe its clinical course, imaging feature, pathology, treatment, and patient prognosis.

Case description

A 58-year-old male Chinese patient was admitted to our hospital because of neck pain for 2 months, which worsened for 4 days. On the third day of admission, the muscle strength of the limbs decreased, and MRI of the spinal cord showed abnormal signal shadows in the spinal canal at the C1-C7 level and in the surrounding soft tissue on the right side of spine, suggesting the possibility of inflammatory lesions with local abscess formation. We immediately performed decompression of the spinal canal on the patient and performed incision and drainage of the cervical abscess. During the operation, we found a large amount of pus in the epidural space of the spinal canal, and there was a fistula between the cervical abscess and the epidural abscess of the spinal canal. The patient underwent continuous drainage and anti-infective treatment with sensitive antibiotics after operation. No recurrence of the abscess was observed and the patient recovered well.

Conclusion

Early diagnosis is the key to the treatment of SEA, so radiologists and neurosurgeons need to strengthen their understanding of this rare disease to avoid misdiagnosis. For SEA with definite diagnosis, decompression surgery should be performed in a timely manner when symptoms of nerve compression occur, continuous drainage should be performed after surgery, and sensitive antibiotics should be used for anti-infective treatment.

Methicillin-Resistant Staphylococcus aureus Spinal Epidural Abscess: Local and Systemic Case Management

Spinal epidural abscess (SEA) is a rare condition with complex pathophysiology and highly variable clinical presentation. While it is known to cause focal peripheral nerve symptoms such as muscle weakness, paresthesia, or pain, these are typically accompanied by complaints of back or spine pain and systemic symptoms indicative of infection. In our case, a 53-year-old male initially presented with unilateral pain and swelling in his right hand, with no fever at presentation and no complaints of back pain. Blood culture confirmed methicillin-resistant Staphylococcus aureus (MRSA)for which he was given vancomycin. The patient later endorsed back pain and diagnostic imaging revealed a spinal epidural abscess spanning the T5-T9 vertebrae. The abscess was drained, and vancomycin was placed in the subfascial and epifascial compartments. The hand was debrided in the same operation and showed no gross purulence. Two days after the procedure, intraoperative cultures remained negative, and the patient was subsequently managed with daptomycin.

Morbidity and Mortality of Spinal Epidural Abscess in End-Stage Renal Disease Patients: A Case-Control Study

BACKGROUND

Spinal epidural abscess (SEA) is an uncommon and highly morbid infection of the epidural space. End-stage renal disease (ESRD) patients are known to be at increased risk of developing SEA; however, there are no studies that have described the risk factors and outcomes of SEA in ESRD patients utilizing the United States Renal Data System (USRDS).

METHODS

To determine risk factors, morbidity, and mortality associated with SEA in ESRD patients, a retrospective case-control study was conducted using the USRDS. ESRD patients diagnosed with SEA between 2005 and 2010 were identified, and logistic regression was performed to examine correlates of SEA, as well as risk factors associated with mortality in SEA-ESRD patients.

RESULTS

The prevalence of SEA amongst ESRD patients was 0.39% (n = 1,697). Patients with SEA were more likely to be male [adjusted Odds Ratio (OR) = 1.22], black (OR = 1.19), diabetic (OR = 1.26), with catheter access (OR = 1.29), and less likely to be ≥65 years old (OR = 0.64). Osteomyelitis, bacteremia/septicemia, MRSA, and endocarditis were all significantly associated with increased risk of SEA (OR = 1.54-5.14). Age ≥65 years (HR = 1.45), urinary tract infections (HR = 1.26), decubitus ulcers (HR=1.37), and post-SEA paraplegia (HR = 1.25) were significantly associated with mortality among those with SEA.

CONCLUSIONS

As described in previous literature, risk factors for SEA included infections, diabetes, and indwelling catheters. Additionally, clinicians should be aware of the risk factors for mortality in SEA-ESRD patients. As the largest study of SEA to date, our report identifies important risk factors for SEA in ESRD patients, and novel data regarding their mortality-associated risk factors.

Preliminary clinical study: percutaneous lumbar discectomy combined with external drainage for treatment of intervertebral disc infections with epidural abscess

INTRODUCTION

Percutaneous lumbar discectomy (PLD) combined with external drainage (ED) is a new technique for the treatment of intervertebral disc infection with epidural abscess.

AIM

To discuss the feasibility, safety and efficacy of PLD and ED for the treatment of intervertebral disc infections with epidural abscess.

MATERIAL AND METHODS

We enrolled 12 patients who underwent intervertebral disc infections with epidural abscess. The clinical efficacy was evaluated by visual analog scale (VAS) and standard Macnab's evaluation. Postoperative computed tomography and magnetic resonance imaging were also used to evaluate the clinical efficacy.

RESULTS

The technical success rate is 100%. Preoperation mean VAS score was 8.18 ±0.98; 5.36 ±1.50 postoperation 1 month; 3.36 ±2.24 postoperation 6 months; 2.77 ±0.31 postoperation 12 months. The comparison of preoperation and postoperation VAS showed a significant difference (p < 0.05). According to standard Macnab's evaluation, of all 12 cases, postoperation 12 months - excellent 4 cases, good 7 cases, poor 1 case. The efficacy rate was 91.6%. No serious complications were recorded.

CONCLUSIONS

Percutaneous lumbar discectomy combined with external drainage may be a safe and efficacy method for the treatment of intervertebral disc infections with epidural abscess.

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.

Nontraumatic Spinal Cord Compression: MRI Primer for Emergency Department Radiologists

The occurrence of acute myelopathy in a nontrauma setting constitutes a medical emergency for which spinal MRI is frequently ordered as the first step in the patient's workup. The emergency department radiologist should be familiar with the common differential diagnoses of acute myelopathy and be able to differentiate compressive from noncompressive causes. The degree of spinal cord compression and presence of an intramedullary T2-hyperintense signal suggestive of an acute cord edema are critical findings for subsequent urgent care such as surgical decompression. Importantly, a delay in diagnosis may lead to permanent disability. In the spinal canal, compressive myelopathy can be localized to the epidural, intradural extramedullary, or intramedullary anatomic spaces. Effacement of the epidural fat and the lesion's relation to the thecal sac help to distinguish an epidural lesion from an intradural lesion. Noncompressive myelopathy manifests as an intramedullary T2-hyperintense signal without an underlying mass and has a wide range of vascular, metabolic, inflammatory, infectious, and demyelinating causes with seemingly overlapping imaging appearances. The differential diagnosis can be refined by considering the location of the abnormal signal intensity within the cord, the longitudinal extent of the disease, and the clinical history and laboratory findings. Use of a compartmental spinal MRI approach in patients with suspected nontraumatic spinal cord injury helps to localize the abnormality to an epidural, intradural extramedullary, or intramedullary space, and when combined with clinical and laboratory findings, aids in refining the diagnosis and determining the appropriate surgical or nonsurgical management.Online supplemental material is available for this article.^©RSNA, 2019.

Pyogenic discitis with an epidural abscess after cervical analgesic discography: A case report

BACKGROUND

Chronic neck pain is a common clinical problem. It has long been considered that degenerative cervical disc is an important source of chronic neck pain. In the clinic, cervical discography is thought to be a useful and safe method to distinguish aging discs from pathological discs, and the probability of complications caused by it is really rare. However, once complication occurs, it is likely to cause fatal consequences to patients. Therefore, accurate judgment and effective treatment are crucial.

CASE SUMMARY

A 45-year-old female was admitted to the department with a 5-year history of severe neck pain, dizziness, and tinnitus. In order to find the diseased disc, analgesic discography was performed on C4/5 and 6/7 discs successively. Unfortunately, Discitis with an epidural abscess was caused during the procedures. With the help of magnetic resonance imaging, an accurate diagnosis was made and an urgent anterior cervical operation was given subsequently. The patient ultimately recovered well.

CONCLUSION

Discitis with epidural abscess is a rare complication after cervical discography, which needs accurate diagnosis and effective antibiotic treatment.

The increasing frequency of intravenous drug abuse-associated spinal epidural abscesses: a case series

OBJECTIVEFew studies have been published specifically examining intravenous drug abuse (IVDA)-associated spinal epidural abscesses (SEAs), an unfortunate sequela of the opioid crisis in the United States. Here, the authors examined a series of patients with IVDA-associated SEAs in order to shed light on this challenging disease entity.METHODSThis study is a retrospective chart review of patients presenting with IVDA-associated SEAs at the authors' institution from 2013 to 2018, spanning the statewide implementation of opioid-prescribing restrictions.RESULTSA total of 45 patients presented with IVDA-associated SEAs; 46.5% presented with a neurological deficit. Thirty-one patients underwent surgery for neurological deficit, failure of medical therapy, or both. Nineteen surgical patients underwent a fusion procedure along with decompression. The complication rate was 41.9%, and the mortality rate was 6.7%. The average length of stay was 27.6 days. Patients who underwent surgery within 24 hours of onset of neurological symptoms trended toward more improvement in their American Spinal Cord Association Impairment Scale grade than those who did not (0.5 vs -0.2, p = 0.068). Methicillin-resistant Staphylococcus aureus was isolated as the causative pathogen in 57.8% of patients. Twenty-three patients (51.5%) kept their scheduled clinic follow-up appointments. Of the fusion patients with adequate follow-up, 5 showed bony arthrodesis and 3 had pseudarthrosis. The rate of IVDA-associated SEAs increased after opioid-prescribing restrictions were put in place, from 0.54 cases per month to 1.15 cases per month (p = 0.017).CONCLUSIONSPatients with IVDA-associated SEAs are challenging to treat, with high complication rates and poor follow-up. This disease is increasing in frequency, and opioid-prescribing restrictions did not slow that rise. Community outreach to promote prevention, early medical attention, and medication compliance would benefit this largely publicly funded patient population.

Cervical spinal epidural abscess following needle-knife acupotomy, with an initial presentation that mimicked an acute stroke: A case report

Introduction: A spinal epidural abscess is difficult to diagnose and it can sometimes mimic an acute ischemic stroke.Case presentation: We report a 69-year-old woman attended our emergency department because of gross hematuria for 1 week, with fever and bilateral flank pain. Two weeks earlier, she had received needle-knife acupotomy (a more invasive procedure than the traditional acupuncture) for chronic neck pain. Acute pyelonephritis was diagnosed; however, 4 h later, she developed weakness of both right limbs. Acute lacunar infarction was tentatively diagnosed. After admission, weakness of the left limbs developed, with a feeling of fullness and discomfort around the entire T6 dermatome with urinary retention. Neck magnetic resonance imaging showed extensive cervical epidural abscesses from C3 to T1. After an operation, her neck pain and the weakness of the four limbs gradually improved.Discussion: Spinal epidural abscess is a rare complication, and which should be considered for patients who have undergone invasive cervical procedures. Needle-knife acupotomy is a more invasive procedure than the traditional acupuncture. Conclusion: Although it is considered safe and effective for cervical spondylosis, it can be complicated by spinal infection. Careful disinfection should therefore be performed, and disposable needleknives should be used.

Brain and Spinal Epidural Abscess

PURPOSE OF REVIEW

Brain abscesses and spinal epidural abscesses are serious, potentially life-threatening infections of the central nervous system. This article outlines the clinical presentation, evaluation, and management of brain abscesses and spinal epidural abscesses, with a specific focus on bacterial infections.

RECENT FINDINGS

The overall incidence of brain abscesses has declined, in part because of fewer brain abscesses associated with otogenic infections. However, emerging patient populations at high risk for brain abscess include those with a history of penetrating head trauma, neurosurgery, or immunodeficiency. Improved mortality rates for brain abscess are attributable to modern diagnostic imaging, stereotactic-guided aspiration, and newer antimicrobials that readily penetrate into the central nervous system and abscesses. Brain MRI is more sensitive than CT for brain abscess, particularly in the early stages, but CT remains more widely available and can adequately identify potential abscesses and confirm response to treatment. With the advent of minimally invasive neurosurgical techniques, surgical excision is often employed only for posterior fossa, multiloculated, or superficial well-circumscribed abscesses. In select clinical scenarios, conservative medical management may be a safe alternative to a combined surgical and medical approach. Unlike brain abscess, the incidence of spinal epidural abscess is on the rise and has been attributed to higher prevalence of predisposing factors, including spinal procedures and instrumentation.

SUMMARY

Successful diagnosis and management of brain abscess and spinal epidural abscess requires a collaborative approach among neurologists, neurosurgeons, radiologists, and infectious disease physicians. The foundation of management of brain abscess includes surgical intervention for diagnostic purposes if a pathogen has not been identified or for decompression of larger abscesses or those with mass effect and significant surrounding edema; appropriate dosing and adequate duration of an antimicrobial regimen tailored to the presumptive source of infection and available culture data, and eradication of the primary source of infection. For spinal epidural abscesses, neurologic status at the time of presentation is directly related to outcomes, underscoring the importance of prompt recognition and intervention.

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.

Neurological Outcomes After Surgical or Conservative Management of Spontaneous Spinal Epidural Abscesses: A Systematic Review and Meta-Analysis of Data From 1980 Through 2016

STUDY DESIGN

This is a meta-analysis.

OBJECTIVE

Perform a systematic review and quantitative meta-analysis of neurological outcomes from all available spinal epidural abscess (SEA) literature published between 1980 and 2016.

SUMMARY OF BACKGROUND DATA

Current literature on SEAs lacks large-scale data characterizing prognostic factors and surgical indications.

MATERIALS AND METHODS

PubMed was queried for studies reporting neurological outcomes from patients undergoing conservative or surgical management for spontaneous SEA. Inclusion criteria included outcomes data measured ≥6 months after presentation, ≥10 human subjects, and diagnosis by magnetic resonance imaging or Computed tomography-myelogram. Where available, demographic data, abscess location, comorbidities, pretreatment neurological deficits, treatment methods, bacterial speciation, and complications were extracted from each study. Potential outcome predictors represented by continuous variables were compared using student t test and categorical variables were compared using the Pearson χ test. Variables identified as potentially associated with outcome (P≤0.05) were subjected to meta-analysis using Cochran-Mantel-Haenszel testing to calculate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

In total, 808 patients were analyzed from 20 studies that met inclusion criteria. 456 (56.3%) patients were treated with surgery and antibiotics, and 353 (43.7%) patients were managed with antibiotics alone. Neither surgical intervention (OR=1.01, 95% CI=0.40-2.59), lumbosacral location (OR=1.51, 95% CI=0.23-9.79), nor neurological deficit on presentation (OR=0.88, 95% CI=0.40-1.92) were significantly associated with good (stable or improved) or bad (worsened) neurological outcome, whereas delayed surgery was significantly associated with bad outcome (OR=0.01, 95% CI=0.02-0.62) and cervicothoracic location approached significance for predicting bad outcome (OR=0.41, 95% CI=0.15-1.09).

CONCLUSIONS

Current literature does not definitively support or oppose surgical intervention in all SEA cases. Therefore, until better evidence exists, the decision to operate must be made on an individual case-by-case basis with the goals of preventing neurological decline, obtaining source control after failed conservative treatment, or restoring spinal stability.

Challenges in diagnosis of spinal epidural abscess: A case report

RATIONALE

Spinal epidural abscess (SEA) is a rare condition that shows a high prevalence in immunocompromised patients. The clinical presentation of SEA includes the "classic triad" of pain, fever, and neurological dysfunction. However, these nonspecific features can lead to a high rate of misdiagnosis. SEA may lead to paralysis or even death; thus, prognosis of these patients remains unfavorable.

PATIENT CONCERNS

We report a case of a multilevel (T6-T12) SEA in a 22-year-old woman.

DIAGNOSIS

The patient was initially diagnosed with spinal tuberculosis at a local hospital based on a history of tuberculosis exposure, as well as radiography and computed tomography. Histopathological examination of the tissue resected during laminectomy confirmed the diagnosis of SEA in this patient.

INTERVENTIONS

The patient underwent multilevel laminectomy combined with long-term antibiotic therapy.

OUTCOMES

Physical examination performed 16 months postoperatively revealed that superficial and deep sensation was restored to normal levels in the lower extremities with improvement in the patient's motor function (muscle strength 2/5).

LESSONS

This case report indicates that whole spine magnetic resonance imaging is warranted in patients with SEA and that prompt surgical intervention is important at symptom onset. Long-term antibiotic therapy is also essential postoperatively.

Epidural Abscess: A Propensity Analysis of Surgical Treatment Strategies

STUDY DESIGN

Observational analysis of retrospectively collected data.

OBJECTIVE

A retrospective study was performed in order to compare the surgical profile of risk factors and perioperative complications for laminectomy and laminectomy with fusion procedures in the treatment of spinal epidural abscess (SEA).

SUMMARY OF BACKGROUND DATA

SEA is a highly morbid condition typically presenting with back pain, fever, and neurologic deficits. Posterior fusion has been used to supplement traditional laminectomy of SEA to improve spinal stability. At present, the ideal surgical strategy-laminectomy with or without fusion-remains elusive.

METHODS

Thirty-day outcomes such as reoperation and readmission following laminectomy and laminectomy with fusion in patients with SEA were investigated utilizing the American College of Surgeons National Quality Improvement Program database. Demographics and clinical risk factors were collected, and propensity matching was performed to account for differences in risk profiles between the groups.

RESULTS

Seven hundred thirty-eight patients were studied (608 laminectomy alone, 130 fusion). The fusion population was in worse health. The fusion population experienced significantly greater rate of return to the operating room (odds ratio [OR] 1.892), with the difference primarily accounted for by cervical spine operations. Additionally, fusion patients had significantly greater rates of blood transfusion. Infection was the most common reason for reoperation in both populations.

CONCLUSION

Both laminectomy and laminectomy with fusion effectively treat SEA, but addition of fusion is associated with significantly higher rates of transfusion and perioperative return to the operating room. In operative situations where either procedure is reasonable, surgeons should consider that fusion nearly doubles the odds of reoperation in the short-term, and weigh this risk against the benefit of added stability.

LEVEL OF EVIDENCE

3.

Etiology and Surgical Management of Cervical Spinal Epidural Abscess (SEA):: A Systematic Review

STUDY DESIGN

Systematic analysis and review.

OBJECTIVE

Evaluation of the presentation, etiology, management strategies (including both surgical and nonsurgical options), and neurological functional outcomes in patients with cervical spinal epidural abscess (SEA).

METHODS

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria were used to create a framework based on which articles pertaining to cervical SEA were chosen for review following a search of the Ovid and PubMed databases using the search terms "epidural abscess" and "cervical." Included studies needed to have at least 4 patients aged 18 years or older, and to have been published within the past 20 years.

RESULTS

Database searches yielded 521 potential articles in PubMed and 974 potential articles in Ovid. After review, 11 studies were ultimately identified for inclusion in this systematic review. Surgery appears to be a well-tolerated management strategy with limited complications for patients with cervical SEA. However, the quantity of data comparing medical and surgical treatment of cervical SEA is limited and the bulk of the data is derived from low quality studies.

CONCLUSION

Data reporting was heterogeneous among studies making it difficult to draw discrete conclusions. Early surgical intervention may be appropriate in selected patients with cervical epidural abscess, but it is not clear what distinguishes these patients from those who are successfully managed nonoperatively.

Spinal Epidural Abscess: A Series of 101 Cases

BACKGROUND

Spinal epidural abscesses are uncommon but potentially devastating infections that often elude early diagnosis. An increasing incidence has been suggested; however, few contemporary data are available regarding risk factors and epidemiologic trends over time.

METHODS

A retrospective study of spinal epidural abscesses from 2004 to 2014 at a large academic hospital was conducted. Cases were identified using International Classification of Diseases, Ninth Revision (ICD-9) code 324.1, and a review of medical and radiographic records was performed to confirm each case. Data collected included sociodemographics, medical history, suspected route of infection, treatments, and outcome.

RESULTS

The incidence was 5.1 cases for each 10,000 admissions, with no significant changes during the study period. The route of infection was identified in 52% of cases, with bacteremia as the most common (26%), followed by recent surgery/procedure (21%) and spinal injection (6%). An identifiable underlying risk factor was present in 84% of cases, most commonly diabetes and intravenous drug use. A causative organism was identified in 84% of cases, most commonly Staphylococcus aureus; methicillin-resistant isolates accounted for 25% of S. aureus cases. All cases received intravenous antibiotic therapy, and 73% underwent a drainage procedure. Fifteen percent had an adverse outcome (8% paralysis and 7% death).

CONCLUSIONS

The incidence of spinal epidural abscesses may be increasing, with the present study demonstrating a ≥5-fold higher rate compared with historical data. Although the outcome in most cases was favorable, spinal epidural abscesses continue to cause substantial morbidity and mortality and should remain a "not to be missed diagnosis."

Rehabilitation Outcomes in Spinal Abscess Patients With and Without a History of Intravenous Substance Abuse

OBJECTIVE

The aim of the study was to compare functional outcomes of acute inpatient rehabilitation for spinal epidural abscess patients with and without history of intravenous substance abuse.

DESIGN

This is a retrospective case series study in freestanding rehabilitation hospital.

METHODS

Charts of 28 spinal epidural abscess patients admitted from January 2012 to September 2015: 13 with intravenous substance abuse and 15 without intravenous substance abuse were reviewed. Both groups received standard-of-care rehabilitation. Statistical analyses of Functional Independence Measure scores were conducted using individual 2 (substance use) × 2 (rehabilitation status) repeated measures analysis of variance. Functional outcomes were defined by total Functional Independence Measure scores as well as motor and cognitive subsets. Length of stay and morphine equivalents were also compared.

RESULTS

There were no significant differences between the two groups. There was a significant main effect of treatment on total Functional Independence Measure scores (P < 0.001), Functional Independence Measure motor scores (P < 0.001), and Functional Independence Measure cognitive scores (P < 0.01) from admission to discharge. Subsequent Student's t tests revealed that the scores of both groups significantly improved on all Functional Independence Measure components. There were no group differences on length of stay and morphine equivalents at discharge.

CONCLUSIONS

Acute inpatient rehabilitation can effectively improve functional outcomes in spinal epidural abscess patients with or without intravenous substance abuse, even though these two patient groups can vary in clinical factors.

Cervical epidural analgesia complicated by epidural abscess: A case report and literature review

RATIONALE

Spinal epidural abscess is an uncommon complication in clinical practice. If the abscess is large enough, the patient will rapidly develop neurologic signs of spinal injury, and urgent neurosurgical intervention may be required.

PATIENT CONCERNS

Rapid and correct diagnosis and treatment is important for spinal epidural abscess complication.

DIAGNOSES

This report describes a cervical epidural abscess (CEA) caused by epidural analgesia, wherein the patient was punctured twice. A CEA was suspected based on the patient's significant neck pain and elevated white blood cell and neutrophil counts. A CEA from C6 to T8 was confirmed by magnetic resonance imaging scan.

INTERVENTIONS

The patient was treated with a combination of intravenous vancomycin and imipenem/cilastatin for more than 4 weeks.

OUTCOMES

After more than 2 weeks of intensive antibiotic treatment, the epidural abscess gradually diminished in size, the white blood cell count, neutrophil count, hyperallergic C-reactive protein (CRP), and general CRP decreased, and the patient's neck and back pain resolved. After more than 4 weeks of anti-inflammation therapy, the epidural abscess was completely absorbed, and there was no relapse during the 3-month follow-up period.

LESSONS

Although an effective combination of intravenous antibiotics can cure an epidural abscess, caution is warranted when performing epidural steroid injections in immunocompromised patients.

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.

A spinal epidural abscess due to Streptobacillus moniliformis infection following a rat bite: case report

The authors describe the case of a 40-year-old man suffering from an epidural abscess in the thoracic spine due to a rarely isolated pathogen, Streptobacillus moniliformis, the causative agent of rat bite fever. Besides diffuse abdominal pain, ataxia, paresthesia, hypesthesia, and enhanced reflexes of the lower extremities, the patient suffered from a decreased sensation of bladder filling. His history was also positive for a rat bite 6 weeks earlier. Magnetic resonance imaging showed an epidural, space-occupying lesion compressing the spinal cord at the vertebral levels of T6-8. Neurosurgery revealed an epidural abscess, which was drained via laminectomy (T-7) and excision of the ligamentum flavum (T6-8). The etiological agent S. moniliformis was identified by 16S rRNA-based polymerase chain reaction and sequencing as well as by culture and mass spectrometry. Treatment with penicillin G led to complete resolution of the abscess and clinical recovery of the patient, who regained his bladder-filling sensation and free walking ability. This case demonstrates that careful attention to the patient's history is essential in suspecting unusual bacterial pathogens as the cause of an epidural abscess and initiating the optimal diagnostic procedure and antimicrobial therapy.

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

OBJECTIVE

Recent studies have shown that in carefully selected patients, conservative treatment alone can be an option in the management of spinal epidural abscess (SEA). The aim of this study was to identify prognostic factors of outcome in patients with spontaneous SEA treated conservatively.

PATIENTS AND METHODS

A retrospective cohort study of all patients with spontaneous SEA treated with antibiotics alone from January 2012 to December 2015 was conducted in a 1200-bed tertiary referral center. Demographic, clinical, microbiological, and radiological characteristics were analyzed. Failure of medical treatment was defined as the need for delayed surgical intervention, no neurological improvement or deterioration, death due to the infection, or relapse after hospital discharge.

RESULTS

We identified 21 patients diagnosed with spontaneous SEA treated conservatively. Median age was 72 years and 10 patients were male. Eleven patients presented with radicular weakness and/or radicular sensory deficit, or incomplete cord injury. Inflammatory markers were markedly elevated in all patients. Thirteen patients were successfully treated with conservative treatment, while among 8 patients with treatment failure, 1 died due to the infection. Presence of serious neurological deficits and infection due to methicillin-resistant S. aureus (MRSA) were associated with failure of conservative treatment. Notably, neither the extension nor the location of the abscess on magnetic resonance imaging (MRI) was associated with failed medical management.

CONCLUSIONS

A significant proportion of patients with spontaneous SEA can respond to antibiotic treatment alone. However, in patients with infection due to MRSA or with severe neurological impairment, conservative management has an increased risk of failure.

Spinal angiolipomas: A puzzling case and review of a rare entity

Patients with spinal epidural abscesses (SEAs) may have a variable presentation. Such an infection has a typical appearance on magnetic resonance imaging (MRI) and enhances with gadolinium. We present a case that was a diagnostic challenge where pre- and intra-operative findings resulted in conflicting impressions. The mimicker was a spinal angiolipoma (SAL). The authors then provide a thorough review of this rare spinal neoplasm. A 55-year-old man presented with back pain, paresis, paresthesia, and urinary retention. MRI was indicative of a longitudinal epidural thoracic mass with a signal homogeneous to nearby fat, curvilinear vessels, and lack of enhancement. Although at emergent surgery, the lesion was found to contain abundant purulent material. Microbiology was positive for methicillin-resistant Staphylococcus aureus and consistent with SEA without evidence of neoplasia. While the imaging features were suggestive of an angiolipoma, the findings at surgery made SEA more likely, which were validated histopathologically. The diagnosis of SEA is often clear-cut, and the literature has reported only a few instances in which it masqueraded as another process such as lymphoma or myelitis. The case highlights SEA masquerading as an angiolipoma, and further demonstrates to clinicians that obtaining tissue diagnosis plays a crucial role diagnostically and therapeutically. SALs, on the other hand, are slow-growing tumors that can be infiltrating or noninfiltrating. They typically present with chronic symptoms and T1-MRI shows an inhomogeneous picture. Complete surgical excision is standard of care and patients tend to do well afterward.

Thoracic spinal epidural abscess caused by fishbone perforation: A case report and review of literature

RATIONALE

Ingestion of a fishbone is a common cause of esophageal injury, but spinal epidural abscess (SEA) is a rare condition due to the esophageal penetration by a swallowed fishbone. Prompt diagnosis can be seldom made owing to incomplete patient history taking and difficulties in imaging evidence identification.

PATIENT CONCERNS

We describe the case of a 62-year-old woman who was stuck in her throat by a fishbone, and complained of back pain, paresis of the lower limbs and fever, successively. To our knowledge, this is the first case report that we know of thoracic SEA caused by fishbone perforation.

DIAGNOSES

About 20 days after the onset of severe back pain, she was diagnosed with SEA based on the clinical presentation and imaging findings.

INTERVENTIONS

Antibiotic therapy and rehabilitation therapy were carried out afterwards. However, due to exacerbation of her condition, surgical intervention had to be taken eventually.

OUTCOMES

It is quite unfortunate for this patient to have a poor prognosis due to a delayed diagnosis and an improper management.

LESSONS

A number of lessons can be learnt from this case.

Spinal Epidural Abscess in Adults: A 10-Year Clinical Experience at a Tertiary Care Academic Medical Center

SEA incidence has increased more than three-fold over the past decade at a large, high-volume, academic medical center. This retrospective, case-control study identified several attributes that could inform the early recognition of this potentially highly morbid acute infection of the central nervous system.

Background. Delayed recognition of spinal epidural abscess (SEA) contributes to poor outcomes from this highly morbid and potentially lethal infection. We performed a case-control study in a regional, high-volume, tertiary care, academic medical center over the years 2005–2015 to assess the potential changing epidemiology, clinical and laboratory manifestations, and course of this disorder and to identify factors that might lead to early identification of SEA.

Methods. Diagnostic billing codes consistent with SEA were used to identify inpatient admissions for abstraction. Subjects were categorized as cases or controls based on the results of spinal imaging studies. Characteristics were compared using Fisher's exact or Kruskal-Wallis tests. All P values were 2-sided with a critical threshold of <.05.

Results. We identified 162 cases and 88 controls during the study period. The incidence of SEA increased from 2.5 to 8.0 per 10 000 admissions, a 3.3-fold change from 2005 to 2015 (P < .001 for the linear trend). Compared with controls, cases were significantly more likely to have experienced at least 1 previous healthcare visit or received antimicrobials within 30 days of admission; to have comorbidities of injection drug use, alcohol abuse, or obesity; and to manifest fever or rigors. Cases were also more likely to harbor coinfection at a noncontiguous site. When available, inflammatory markers were noted to be markedly elevated in cases. Focal neurologic deficits were seen with similar frequencies in both groups.

Conclusions. Based on our analysis, it appears that selected factors noted at the time of clinical presentation may facilitate early recognition of SEA.

Clinical features and inpatient rehabilitation outcomes of infection-related myelopathy

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVES

The objectives of this study were to determine clinical features of infection-related myelopathy (IRM) and functional outcomes compared with other nontraumatic and traumatic myelopathies.

SETTING

US academic inpatient rehabilitation unit.

METHODS

This was a 16-year retrospective review of patients with myelopathy discharged from inpatient rehabilitation between 1 January 1995 and 31 December 2010. Patients comprised three injury groups: IRM, nontraumatic myelopathy (NTM) and traumatic spinal cord injury (TSCI). Information collected includes demographic characteristics, functional data, length of stay, injury completeness and discharge destination. Primary outcome measures were change in Functional Independence Measure (FIM) and daily FIM change. For IRM, data were collected regarding injury characteristics, risk factors, presenting symptoms, neurologic impairment level and treatment.

RESULTS

Of the 1601 patients, 40 (2.5%) had IRM, 1105 (69.0%) had NTM and 456 (28.5%) had TSCI. IRM mean (s.d.) age was 58.6 (15.7) years (male gender, 72.5%). The majority in each group had incomplete injuries. IRM had longer lengths of stay (P<0.001), lower admission (P=0.001) and discharge (P=0.005) FIM scores and lower FIM daily change (P=0.002) than NTM. Degree of functional improvement was similar in all groups, and most patients in each group were discharged home. Infectious pathogens were bacterial (80.0%, n=32), viral (7.5%, n=3), tuberculous (7.5%, n=3), parasitic (2.5%, n=1) and multiple types (2.5%, n=1). The most common bacterial cause (65.6%) was Staphylococcus aureus.

CONCLUSIONS

Infectious etiologies comprise a small proportion of NTM but represent a unique entity with distinct recovery patterns and outcomes. These patients can achieve similar functional improvements as other NTM patients during inpatient rehabilitation, although over a longer period of time.

A rare case of multiple spinal epidural abscesses and cauda equina syndrome presenting to the emergency department following acupuncture

BACKGROUND

Acupuncture is a form of traditional Chinese medicine being increasingly used as complementary therapy in many countries. It is relatively safe and rarely associated with deep infections.

CASE PRESENTATION

In this case report, we describe a middle-aged Chinese patient who presented acutely to our emergency department with cauda equina syndrome secondary to acupuncture-related epidural abscesses, which were treated with surgical decompression and intravenous antibiotics. We also present a review of case reports of this rare condition in available literature.

CONCLUSION

Emergency physicians should be aware that spinal abscesses may occur after acupuncture, with a broad spectrum of clinical presentations. If a history of recent acupuncture over the symptomatic area is elicited, a high index of suspicion should be maintained and appropriate imaging performed to establish the diagnosis. Treatment is directed by a number of factors, such as severity and duration of neurological deficit and progression of symptoms.

How Best to Manage the Spinal Epidural Abscess? A Current Systematic Review

BACKGROUND

A spinal epidural abscess is a medical emergency. Despite urgent surgical intervention and adjuvant antibiotic therapy, neurologic prognosis remains variable and guarded. The optimal approach to managing this condition is debated with substantial variability in clinical practice, dependent on patient demographic and pretreatment neurologic status as well as radiologic appearance.

METHODS

A systematic search in MEDLINE and similar databases was conducted for literature published from 1990 to 2015 using the search term "spinal epidural abscess", limiting the search results to human studies published in the English language. Case series that consisted of fewer than 10 patients were excluded. The evidence strength was graded according to the Grades of Recommendation Assessment, Development, and Evaluation criteria.

RESULTS

The search yielded 1843 patients from 34 retrospective case series. Ten studies compared surgical and medical management, with no significant difference in patients with good outcome (odds ratio, 0.65; P = 0.11) or neurologic improvement (odds ratio, 1.11; P = 0.69). However, failure rates after initial medical management requiring surgical intervention ranged from 10% to 50%. Three of 4 studies evaluating timing of surgery reported large effect sizes for neurologic outcome if early surgery was performed (P < 0.01). Other prognostic factors from a neurologic perspective included admission neurologic status, patient age, and diabetes mellitus.

CONCLUSIONS

Surgery with adjuvant antibiotics remains the optimal treatment for the neurologically symptomatic patient with spinal epidural abscess. If antibiotic therapy alone is considered for the neurologically intact patient, we recommend interdisciplinary medical and surgical consultations with an in-depth dialogue on the potential for failure in isolated medical management and the recommendation for close neurologic monitoring.

Neurologic Complications, Reoperation, and Clinical Outcomes After Surgery for Vertebral Osteomyelitis

STUDY DESIGN

A consecutive retrospective cohort study from 2008 to 2013 at a single tertiary-care institution was conducted.

OBJECTIVE

The aim of the study was to characterize recovery from pain and neurologic deficit after surgery for vertebral osteomyelitis (VO), and identify incidence of postoperative adverse events.

SUMMARY OF BACKGROUND DATA

A minority of patients with VO require surgery. Although prior studies have characterized outcomes after medical management, the morbidity after surgery is poorly defined.

METHODS

The primary outcome was change from baseline in a Modified McCormick Scale (MMS, 1-5 scale), whereas secondary outcomes included reoperation and change in self-reported pain Visual Analog Scale (VAS, 0-10 scale). MMS and VAS were collected throughout the postoperative course as surrogates for neurologic function and degree of pain. Intraoperative, short-term postoperative (<30 d), and long-term neurologic complications were recorded. New-onset neurologic deficits in the postoperative period were considered neurologic complications.

RESULTS

Fifty patients were included; a majority (52%) presented with a neurologic deficit. The median length of follow-up was 18 months. A statistically significant improvement in MMS was observed by 12 months postoperatively, whereas an improvement in VAS was observed by 3 months. The mean improvement in MMS at last follow-up was 0.35, whereas the mean improvement in VAS was 3.40. One quarter of patients required reoperation. At 24 months postoperatively, 10% died, 26% underwent reoperation, 42% experienced a neurologic complication, and 60% experienced at least one of these 3 adverse events.

CONCLUSION

This is the first study to investigate neurologic complications, reoperation, and pain in a longitudinal manner after surgery for VO. We observed statistically significant improvements in MMS and VAS in the postoperative period. Despite these improvements, the 24-month incidence of overall adverse events was 60%. Patients and clinicians should be aware of the clinical improvement but high incidence of adverse events after surgical management of VO.

LEVEL OF EVIDENCE

4.

What are we waiting for? An argument for early surgery for spinal epidural abscesses

Background:

In the article: Timing and prognosis of surgery for spinal epidural abscess (SEA): A review, Epstein raises one major point; it is imperative that spinal surgeons “take back decision-making” from our medical cohorts and reinstitute early surgery (<24 h) to better treat SEAs.

Methods:

Spine surgeons recognize the clinical triad (e.g., fever [50%], spinal pain [92–100%], and neurological deficits [47%]) for establishing the diagnosis of an SEA. We also appreciate the multiple major risk factors for developing SEA; diabetes (15–30%), elevated white blood cell count (>12.5), high C-reactive protein (>115), positive blood cultures, radiographic cord compression, and significant neurological deficits (e.g., 19–45%).

Results:

Recognizing these risk factors should prompt early open surgery (<24 h from the onset of a neurological deficit). Open surgery better defines the correct/multiple organisms present, and immediately provides adequate/thorough neurological decompression (with fusion if unstable). Although minimally invasive surgery may suffice in select cases, too often it provides insufficient biopsy/culture/irrigation/decompression. Most critically, nonsurgical options result in unacceptably high failure rates (e.g., 41-42.5-75% requiring delayed surgery), while risking permanent paralysis (up to 22%), and death (up to 25%).

Conclusion:

As spine surgeons, we need to “take back decision-making” from our medical cohorts and advocate for early surgery to achieve better outcomes for our patients. Why should anyone accept the >41-42.5 to up to the 75% failure rate that accompanies the nonsurgical treatment of SEA, much less the >25% mortality rate?

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

Background:

The nonsurgical versus surgical management of spinal epidural abscesses (SEAs) remains controversial. Even with the best preoperative screening for multiple risk factors, high nonoperative failure rates are attended by considerable morbidity (e.g., irreversible paralysis) and mortality. Therefore, the focus remains on early surgery.

Methods:

Most papers promote early recognition of the clinical triad (e.g., fever [50%], spinal pain [92–100%], and neurological deficits [47%]) for SEA. They also identify SEA-related risk factors for choosing nonsurgical versus surgical approaches; advanced age (>65 or 80), diabetes (15–30%), cancer, intravenous drug abuse (25%), smoking (23%), elevated white blood cell count (>12.5), high C-reactive protein >115, positive blood cultures, magnetic resonance imaging/computed tomographic documented cord compression, and significant neurological deficits (e.g., 19–45%).

Results:

Surgical options include: decompressions, open versus minimally invasive biopsy/culture/irrigation, or fusions. Up to 75% of SEA involve the thoracolumbar spine, and 50% are located ventrally. Wound cultures are positive in up to 78.8% of cases and are often (60%) correlated with positive blood cultures. The most typical offending organism is methicillin resistant Staphylococcus aureus, followed by methicillin sensitive S. aureus. Unfortunately, the failure rates for nonoperative treatment of SEA remain high (e.g., 41–42.5%), contributing to significant morbidity (22% risk of permanent paralysis), and mortality (3–25%).

Conclusion:

The vast majority of studies advocated early surgery to achieve better outcomes for treating SEA; this avoids high failure rates (41–42.5%) for nonoperative therapy, and limits morbidity/mortality rates.

Catastrophic chest pain: blinded by cardiopulmonary disease

A 53-year-old man with a history of diabetic foot ulcer, osteomyelitis, coronary artery disease, hypertension and hyperlipidaemia, presented with chest pain of 3 weeks duration. Eleven days earlier, the patient had had a drug-eluting stent (DES) placed in a branch of the right coronary artery (RCA) after similar chest pain, leading to the findings of a positive nuclear stress test. Since discharge, he was not compliant with taking clopidegrel (Plavix), a concern for in-stent thrombosis with recurrent myocardial ischaemia; but work up was negative and medications were restarted. Within 24 h of admission, he developed bilateral flaccid leg weakness, urine retention and loss of sensation from the umbilicus level down. MRI revealed a T4-T6 epidural abscess. Emergent decompression laminectomy and abscess drainage was completed. Neurological symptoms improved hours after surgery with complete resolution of sensory deficits. Cultures grew Streptococcus sp., treated with intravenous nafcillin for 8 weeks. He regained leg strength with continued improvement seen in rehabilitation.