Elsevier

Surgical Neurology

Volume 52, Issue 2, August 1999, Pages 189-197
Surgical Neurology

Spine
Spinal epidural abscess: contemporary trends in etiology, evaluation, and management

https://doi.org/10.1016/S0090-3019(99)00055-5Get rights and content

Abstract

BACKGROUND

Despite advances in neuroimaging and neurosurgical treatment, spinal epidural abscess remains a challenging problem; early diagnosis is often difficult and treatment is delayed. Optimal management is unclear, and morbidity and mortality are significant. To define contemporary trends in etiology and management, and establish diagnostic and therapeutic guidelines, we reviewed our 10-year experience with spinal epidural abscess.

METHODS

We examined medical records, laboratory data, radiological (CT and MRI) studies, and operative reports from 75 cases of spinal epidural abscess between 1983 and 1992. Demographic characteristics, frequency, clinical features, pathogens, risk factors, surgical and medical treatment, and outcome were analyzed.

RESULTS

We found a significant increase in the frequency of spinal epidural abscess over the 10-year period (p-value = 0.0195). Intravenous drug abuse was present in 28 patients (33%), diabetes mellitus in 22 patients (27%), and prior spinal surgery in 11 patients (17%). Back pain, progressive neurologic deficit, and low grade fever remained the distinguishing diagnostic features. Erythrocyte sedimentation rate was elevated in 48 of 50 patients (95%); peripheral leukocyte count was elevated in 45 patients (60%). MRI was the most effective technique for diagnosing spinal epidural abscess, revealing or suggesting the diagnosis in all 59 patients (100%) studied. Sites of spinal epidural abscess were equally distributed along the spinal axis. Staphylococcus aureus was the predominant organism (67% of patients, with 15% having a methicillin-resistant strain); 8% of patients had Streptococcal species. Most patients had open surgical drainage followed by prolonged antibiotic treatment; 22 patients were managed with antibiotics alone; 50 patients (66%) had a good clinical outcome after treatment. Multiple medical problems, prior spinal surgery, and methicillin-resistant Staphylococci were correlated with a significantly worse outcome.

CONCLUSIONS

The frequency of diagnosis of spinal epidural abscess is increasing. To prevent serious morbidity and mortality, early diagnosis is essential. Patients with localized back pain who are at risk for developing such abscesses or who have an increased erythrocyte sedimentation rate and/or neurologic deficit should have an immediate MRI scan with contrast enhancement. Surgical drainage and prolonged antibiotic use are the cornerstones of treatment, although selected patients may be treated conservatively.

Section snippets

Clinical material and methods

From January 1, 1983 to December 31, 1992, a total of 74,477 patients were admitted to the University of Maryland Medical Systems. Seventy-five patients with SEA were identified by a computerized search of discharge diagnoses. The medical records, laboratory data, hospital notes, radiological studies, and operative reports of all patients with SEA were carefully reviewed.

Patients with manifestations for less than 2 weeks before admission were considered to have an acute presentation. Those

Patient demographics

We identified 75 cases (48 male (64%); 27 female (36%); age range 3 months to 83 years; mean age, 50.7 years) of spinal epidural abscess (0.1% of all hospital admissions during the study period). Yearly frequency of SEA revealed a significant increase (least squares regression method, p = 0.0195) in incidence after December 1988 (Figure 1).

Microbiology

Staphylococcus aureus was the predominant pathogen isolated in 50 (67%) patients; 11 (15%) cases showed methicillin-resistant Staphylococcal species. Five

Discussion

Spinal epidural abscess poses a formidable problem to the practicing physician in both diagnosis and treatment. The morbidity and mortality associated with this condition remain significant. In the present series, 8 of 75 patients died and 17 had fair to poor outcome, highlighting the need for prompt diagnosis and initiation of appropriate therapy. With rapid intervention, excellent outcome (50 of 75 patients in the present study) can be achieved and morbidity avoided.

Conclusions

Given our extensive experience with SEA, we propose the following recommendations to all physicians who encounter patients who may harbor this potentially devastating disease:

1. For all high risk patients the following clinical presentations should prompt an urgent MRI (or CT myelogram when MRI is not available): neurologic deficit and focal back pain; neurologic deficit with unexplained fever; neurologic deficit with elevated ESR; severe focal back pain with fever; severe focal back pain with

Acknowledgements

This work was presented at the European Congress of Neurological Surgeons, Berlin, Germany, May 11–15, 1995, and also at the International Congress of Neurological Surgeons. Amsterdam, Netherlands, July 4–9, 1997. We thank Dr. Pamela Talalay and Ritu Goel for assistance in preparing this article.

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