Management of cervical spine epidural abscess: a systematic review

Background: Cervical spinal epidural abscess (CSEA) is a localized infection between the thecal sac and cervical spinal column which may result in neurological deficit and death if inadequately treated. Two treatment options exist: medical management and surgical intervention. Our objective was to analyze CSEA patient outcomes in order to determine the optimal method of treatment. Methods: An electronic literature search for relevant case series and retrospective reviews was conducted through June 2016. Data abstraction and study quality assessment were performed by two independent reviewers. A lack of available data led to a post hoc decision not to perform meta-analysis of the results; study findings were synthesized qualitatively. Results: 927 studies were identified, of which 11 were included. Four studies were ranked as good quality, and seven ranked as fair quality. In total, data from 173 patients were included. Mean age was 55 years; 61.3% were male. Intravenous drug use was the most common risk factor for CSEA development. Staphylococcus aureus was the most commonly cultured pathogen. 140 patients underwent initial surgery, an additional 18 patients were surgically treated upon failure of medical management, and 15 patients were treated with antibiotics alone. Conclusion: The rates of medical management failure described in our review were much higher than those reported in the literature for thoracolumbar spinal epidural abscess patients, suggesting that CSEA patients may be at a greater risk for poor outcomes following nonoperative treatment. Thus, early surgery appears most viable for optimizing CSEA patient outcomes. Further research is needed in order to corroborate these recommendations.

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The indications and timing for operative management of spinal epidural abscess: literature review and treatment algorithm

Neurosurgical FOCUS ◽

10.3171/2014.6.focus14261 ◽

2014 ◽

Vol 37 (2) ◽

pp. E8 ◽

Cited By ~ 42

Author(s):

Alexander Tuchman ◽

Martin Pham ◽

Patrick C. Hsieh

Keyword(s):

Literature Review ◽

Medical Management ◽

Epidural Abscess ◽

Nonoperative Management ◽

Treatment Algorithm ◽

Case Series ◽

Spinal Epidural Abscess ◽

Pubmed Database ◽

Cord Injury ◽

Spinal Epidural

Object Delayed or inappropriate treatment of spinal epidural abscess (SEA) can lead to serious morbidity or death. It is a rare event with significant variation in its causes, anatomical locations, and rate of progression. Traditionally the treatment of choice has involved emergency surgical evacuation and a prolonged course of antibiotics tailored to the offending pathogen. Recent publications have advocated antibiotic treatment without surgical decompression in select patient populations. Clearly defining those patients who can be safely treated in this manner remains in evolution. The authors review the current literature concerning the treatment and outcome of SEA to make recommendations concerning what population can be safely triaged to nonoperative management and the optimal timing of surgery. Methods A PubMed database search was performed using a combination of search terms and Medical Subject Headings, to identify clinical studies reporting on the treatment and outcome of SEA. Results The literature review revealed 28 original case series containing at least 30 patients and reporting on treatment and outcome. All cohorts were deemed Class III evidence, and in all but two the data were obtained retrospectively. Based on the conclusions of these studies along with selected smaller studies and review articles, the authors present an evidence-based algorithm for selecting patients who may be safe candidates for nonoperative management. Conclusions Patients who are unable to undergo an operation, have a complete spinal cord injury more than 48 hours with low clinical or radiographic concern for an ascending lesion, or who are neurologically stable and lack risk factors for failure of medical management may be initially treated with antibiotics alone and close clinical monitoring. If initial medical management is to be undertaken the patient should be made aware that delayed neurological deterioration may not fully resolve even after prompt surgical treatment. Patients deemed good surgical candidates should receive their operation as soon as possible because the rate of clinical deterioration with SEA is notoriously unpredictable. Although patients tend to recover from neurological deficits after treatment of SEA, the time point when a neurological injury becomes irreversible is unknown, supporting emergency surgery in those patients with acute findings.

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14. Surgical vs. Medical Management of Spinal Epidural Abscess: A Single Center 10 Year Experience

The Spine Journal ◽

10.1016/j.spinee.2009.08.019 ◽

2009 ◽

Vol 9 (10) ◽

pp. 7S

Author(s):

Isaac Karikari ◽

Ciaran Powers ◽

Renee Reynolds ◽

Ankit Mehta ◽

Robert Isaacs

Keyword(s):

Medical Management ◽

Epidural Abscess ◽

Spinal Epidural Abscess ◽

Single Center ◽

Spinal Epidural

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Medical and surgical management of spinal epidural abscess: a systematic review

Neurosurgical FOCUS ◽

10.3171/2014.6.focus14127 ◽

2014 ◽

Vol 37 (2) ◽

pp. E4 ◽

Cited By ~ 65

Author(s):

Leopold Arko ◽

Eric Quach ◽

Vincent Nguyen ◽

Daniel Chang ◽

Vishad Sukul ◽

...

Keyword(s):

Risk Factors ◽

Surgical Management ◽

Medical Therapy ◽

Medical Management ◽

Epidural Abscess ◽

Nonoperative Treatment ◽

Spinal Epidural Abscess ◽

Nonsurgical Management ◽

Significant Difference ◽

Spinal Epidural

Object Spinal epidural abscess (SEA) is a rare condition that has previously been treated with urgent surgical decompression and antibiotics. Recent availability of MRI makes early diagnosis possible and allows for the nonoperative treatment of SEA in select patients. The first retrospective review of medically and surgically managed SEA was published in 1999, and since that time several other retrospective institutional reports have been published. This study reviews these published reports and compares pooled data with historical treatment data. Methods A PubMed keyword and Boolean search using (“spinal epidural abscess” OR “spinal epidural abscesses” AND [management OR treatment]) returned 429 results. Filters for the English language and publications after 1999 were applied, as the first study comparing operative and nonoperative management was published that year. Articles comparing operative to nonoperative treatment strategies for SEA were identified, and the references were further reviewed for additional articles. Studies involving at least 10 adult patients (older than 18 years) were included. Case reports, studies reporting either medical or surgical management only, studies not reporting indications for conservative management, or studies examining SEA as a result of a specific pathogen were excluded. Results Twelve articles directly comparing surgical to nonsurgical management of SEA were obtained. These articles reported on a total of 1099 patients. The average age of treated patients was 57.24 years, and 62.5% of treated patients were male. The most common pathogens found in blood and wound cultures were Staphylococcus aureus (63.6%) and Streptococcus species (6.8%). The initial treatment was surgery in 59.7% of cases and medical therapy in 40.3%. This represented a significant increase in the proportion of medically managed patients in comparison with the historical control prior to 1999 (p < 0.05). Patients with no neurological deficits were significantly more likely to be treated medically than surgically (p < 0.05). There was no statistically significant difference overall between surgical and nonsurgical management, although several risk factors may predict failure of medical management. Conclusions . Since the first reports of nonoperative treatment of SEA, there has been a substantial trend toward treating neurologically intact patients with medical management. Nevertheless, medical therapy fails in a fair number of cases involving patients with specific risk factors, and patients with these risk factors should be closely observed in consideration for surgery. Further research may help identify patients at greater risk for failure of medical therapy.

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Fungal spinal epidural abscess: a case series of nine patients

The Spine Journal ◽

10.1016/j.spinee.2018.08.001 ◽

2019 ◽

Vol 19 (3) ◽

pp. 516-522 ◽

Cited By ~ 6

Author(s):

Huiliang Yang ◽

Akash A. Shah ◽

Sandra B. Nelson ◽

Joseph H. Schwab

Keyword(s):

Epidural Abscess ◽

Case Series ◽

Spinal Epidural Abscess ◽

Spinal Epidural

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Spinal epidural abscess complicating chemotherapy in patients with leukemia

Neurosurgical FOCUS ◽

10.3171/foc.2005.18.1.11 ◽

2005 ◽

Vol 18 (1) ◽

pp. 1-4 ◽

Cited By ~ 2

Author(s):

Laura Moschettoni ◽

Agazio Menniti ◽

Giovanni Liccardo ◽

Pierpaolo Lunardi

Keyword(s):

Surgical Treatment ◽

Medical Treatment ◽

Epidural Abscess ◽

Treatment Options ◽

Spinal Epidural Abscess ◽

Basic Facts ◽

Spinal Epidural

The authors reviewed the basic facts about infections that complicate chemotherapy, and found that a difference exists between those that are medically treated, for which several standard protocols have been adopted, and infections amenable to surgical treatment, such as spinal epidural abscess, which are managed according to the experience at individual institutions. The authors believe that patients with leukemia who manifest a spinal epidural abscess should always be surgically treated when the infection occurs between the induction and remission phases, whereas medical treatment options can be considered for spinal epidural abscesses occurring at the end of the chemotherapy course.

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Inappropriate medical management of spinal epidural abscess

Annals of the Rheumatic Diseases ◽

10.1136/ard.60.3.218 ◽

2001 ◽

Vol 60 (3) ◽

pp. 218-222 ◽

Cited By ~ 22

Author(s):

P Harrington

Keyword(s):

Medical Management ◽

Epidural Abscess ◽

Spinal Epidural Abscess ◽

Spinal Epidural

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The Prognostic Accuracy of Suggested Predictors of Failure of Medical Management in Patients With Nontuberculous Spinal Epidural Abscess

Global Spine Journal ◽

10.1177/2192568217719437 ◽

2017 ◽

Vol 8 (3) ◽

pp. 279-285 ◽

Cited By ~ 2

Author(s):

Alexandra Stratton ◽

Peter Faris ◽

Kenneth Thomas

Keyword(s):

Medical Management ◽

Prediction Models ◽

Epidural Abscess ◽

Care Center ◽

Tertiary Care ◽

White Blood Cells ◽

Spinal Epidural Abscess ◽

Icd 10 ◽

Spinal Epidural ◽

Prediction Criteria

Study Design: Retrospective cohort study. Objectives: To test the external validity of the 2 published prediction criteria for failure of medical management in patients with spinal epidural abscess (SEA). Methods: Patients with SEA over a 10-year period at a tertiary care center were identified using ICD-10 (International Classification of Diseases, 10th Revision) diagnostic codes; electronic and paper charts were reviewed. The incidence of SEA and the proportion of patients with SEA that were treated medically were calculated. The rate of failure of medical management was determined. The published prediction models were applied to our data to determine how predictive they were of failure in our cohort. Results: A total of 550 patients were identified using ICD-10 codes, 160 of whom had a magnetic resonance imaging–confirmed diagnosis of SEA. The incidence of SEA was 16 patients per year. Seventy-five patients were found to be intentionally managed medically and were included in the analysis. Thirteen of these 75 patients failed medical management (17%). Based on the published prediction criteria, 26% (Kim et al) and 45% (Patel et al) of our patients were expected to fail. Conclusions: Published prediction models for failure of medical management of SEA were not valid in our cohort. However, once calibrated to our cohort, Patel’s model consisting of positive blood culture, presence of diabetes, white blood cells >12.5, and C-reactive protein >115 was the better model for our data.

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Incidence and risk factors for failed medical management of spinal epidural abscess: a systematic review and meta-analysis

Journal of Neurosurgery Spine ◽

10.3171/2016.6.spine151249 ◽

2017 ◽

Vol 26 (1) ◽

pp. 81-89 ◽

Cited By ~ 16

Author(s):

Alexandra Stratton ◽

Karla Gustafson ◽

Kenneth Thomas ◽

Matthew T. James

Keyword(s):

Risk Factors ◽

Systematic Review ◽

Medical Management ◽

Epidural Abscess ◽

Meta Analysis ◽

Original Data ◽

Primary Objective ◽

Spinal Epidural Abscess ◽

Consensus Definition ◽

Spinal Epidural

OBJECTIVE Spinal epidural abscess (SEA) is a life-threatening infection. It is uncertain whether medical versus surgical treatment is the ideal initial approach for neurologically intact patients with SEA. Recent evidence demonstrates that initial medical management is increasingly common; however, patients who ultimately require surgery after failed medical management may have a worse prognosis than those whose treatment was initially surgical. The primary objective of this study was to establish the current incidence of failed medical management for SEA. The secondary aim was to identify risk factors associated with the failure of medical management. METHODS The authors conducted a systematic review and meta-analysis by searching electronic databases (MEDLINE, Embase, CINAHL, and PubMed), recent conference proceedings, and reference lists of relevant articles. Studies that reported original data on consecutive adult patients with SEA treated medically were eligible for inclusion. RESULTS Twelve studies met the inclusion criteria, which included a total of 489 medically treated patients with SEA. Agreement on articles for study inclusion was very high between the reviewers (kappa 0.86). In a meta-analysis, the overall pooled risk of failed medical management was 29.3% (95% CI 21.4%–37.2%) and when medical to surgical crossover was used to define failure the rate was 26.3% (95% CI 13.0%–39.7%). Only 6 studies provided data for analysis by intended treatment, with a pooled estimate of 35.1% (95% CI 15.7%–54.4%) of failed medical management. Two studies reported predictors of the failure of medical management. CONCLUSIONS Although the incidence of failed medical management of SEA was relatively common in published reports, estimates were highly heterogeneous between studies, thus introducing uncertainty about the frequency of this risk. A consensus definition of failure is required to facilitate comparison of failure rates across studies.

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