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

Abstract

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.

Keywords: Medical management; neurological deficit; open surgery: Minimally invasive surgery; paraplegia; spinal epidural abscess; surgical decompression; timing.