Predictors of Failure for Nonoperative Management of Spinal Epidural Abscess

Abstract

Study Design: Retrospective cohort study. Objectives: The aim of this study is to identify predictive factors associated with failure of nonoperative management of spinal epidural abscess (SEA). Methods: Between January 2007 and January 2017, there were 97 patients 18 years or older treated for SEA at a tertiary referral center. Of these, 58 were initially managed nonoperatively. Details on presenting complaint, laboratory parameters, radiographic evaluation, demographics, comorbidities, and neurologic status (Frankel grades A-E) were collected. Success of treatment was defined as eradication of infection with no requirement for further antimicrobial therapy. Diagnosis of SEA was made via evaluation of imaging and intraoperative findings. Patients with repeat presentation of SEA, children, and those who were transferred for immediate surgical decompression were excluded. Results: Fifty-eight patients initially treated nonoperatively were included. Of these, 21 failed nonoperative management and required surgical intervention. The mean age was 60 years, 66% male, and 19% of Maori ethnicity. Abscess location was predominantly dorsal, and in the lumbar region (53%). Multivariate analysis identified Maori ethnicity, multifocal sepsis, and elevated white cell count as predictors of failure of nonoperative management. With 1 predictor the risk of failure was 44%. In the presence of 2 predictive variables, failure rate increased to 60%, and if all 3 variables were present, patients had a 75% risk of failure. Conclusion: Thirty-six percent of patients treated nonoperatively failed nonoperative management—the failure rate was significantly increased in patients with multifocal sepsis, in patients with elevated white cell count, and in patients of Maori ethnicity.

Cervical Epidural Abscess

“…The classic presentation of spinal epidural abscess is the triad of spinal pain, fever, and neurological deficit; however, diagnosis may be difficult because only 8% to 15% of patients present with the full triad 3,5 . Diagnosis must be made as early as possible as delayed management and increased neurological symptoms are associated with lower success of interventions 11,12 . Treatment options usually include antibiotics, or a combination of antibiotics and surgical management, such as drainage, debridement, and instrumentation 4,9,12,13 …”

“…3,5 Diagnosis must be made as early as possible as delayed management and increased neurological symptoms are associated with lower success of interventions. 11,12 Treatment options usually include antibiotics, or a combination of antibiotics and surgical management, such as drainage, debridement, and instrumentation. 4,9,12,13 An additional difficulty in the diagnosis of epidural abscess is the limitation of imaging modalities.…”

Letter to the Editor Regarding “Predictors of Failure for Nonoperative Management of Spinal Epidural Abscess” by Hunter et al

“…Borislav Kitov, MD, PhD 1 , Tanya Kitova, MD, PhD, DMSc 1,2 , Ivo Kehayov, MD, PhD 1 , and Polina Angelova, MD 1 We have read with great interest the article by Hunter et al entitled "Predictors of Failure for Nonoperative Management of Spinal Epidural Abscess." 1 The spinal epidural abscess (SEA) is rare but insidious disease. Recently, the mortality varies from 1,8% to 25%.…”

“…We have read with great interest the article by Hunter et al entitled “Predictors of Failure for Nonoperative Management of Spinal Epidural Abscess.” 1 …”

Early Reduction in C-Reactive Protein Following Treatment for Spinal Epidural Abscess: A Potential Treatment Guide

“…Elevated inflammatory markers such as C-reactive protein (CRP) and white cell count (WCC) have been shown to predict failure of non-operative management in multiple studies. [6][7][8] The trend of certain laboratory markers has also been studied in the setting of pyogenic spinal column infection with elevated CRP at 14 days post treatment onset for vertebral osteomyelitis considered a poor prognostic indicator. 9 Monitoring laboratory values provides an opportunity for clinicians to consider the disease response to treatment decisions.…”