Abstract & Commentary
Commentary by Stan Deresinski, MD, FACP, Editor of Infectious Disease Alert, Clinical Professor of Medicine, Stanford, and Associate Chief of Infectious Diseases, Santa Clara Valley Medical Center.
Source: Siddiq F, et al. Medical vs surgical management of spinal epidural abscess. Arch Intern Med 2004;164:2409-2412.
Researchers reviewed the management of 60 episodes of spinal epidural abscess in 57 patients seen during a 14-year period ending in 2002. The lumbar or lumbosacral region was involved in 54%, the thoracic in 18%, and the cervical in 28%. The number of vertebral levels involved was 1-8, with more than two vertebral levels involved in 45% of patients.
Blood cultures were positive in 26 (46%) patients, and abscess cultures were positive in 36 (63%). Staphylococcus aureus was recovered from 34 patients (60%), coagulase negative staphylococci from five (9%), streptococci from nine (16%), Enterococcus faecalis from three (5%), Actinomycetes from four (7%), and other organisms from eight (14%).
All patients received antibiotic therapy. Surgical decompression was performed in the management of 28 (47%) of episodes, and computerized tomography (CT)-guided percutaneous needle aspiration in seven (12%), while medical management alone was administered in 25 (42%) of episodes.
Neurologic impairment was present at presentation of approximately half of all episodes, and was marked in 11. Complete recovery was achieved in 43 (72%) episodes, while an additional ten (17%) were left with only minimal residual weakness. Recovery rates were similar regardless of the management mode. Only neurologic impairment at presentation was associated with a poor outcome. Complete recovery was achieved in only 17 of 30 (57%), with impairment at the outset of therapy, compared with 93% in those without initial impairment. Even in those with neurological complications at presentation, there was no significant difference noted in outcomes when surgical and non-surgical management were compared.
Commentary
The management of spinal epidural abscess has evolved during the last two decades, with the most important change being the recognition that not all patients require surgery for a successful outcome. The most generally agreed upon approach has been to intervene surgically only in patients with a neurological deficit resulting from the infection. Thus, patients presenting with a deficit as the consequence of cord compression are referred for urgent decompression. Those without an initial deficit are examined carefully several times daily for evidence of its appearance, an event that triggers referral for a decompressive procedure. In any case, antibiotic therapy is prolonged, although the duration is somewhat arbitrary, since there is no good clinical evidence upon which to base a recommendation regarding duration. The necessary duration of therapy, however, is likely to be longer in cases in which osteomyelitis and/or diskitis are present than when they are absent.
The mode of decompression also has evolved with the recognition that many spinal epidural abscesses can be drained successfully using percutaneous CT-guided aspiration.1 This procedure was, in fact, used successfully in seven of seven episodes in this series. When successful, this mode of decompression, as well as of specimen acquisition for microbiological studies, has an obvious advantage over surgical decompression.
Accepting the implications of the report by Siddiq and colleagues at face value would, however, indicate that the approach to management described above results in unnecessary surgery in many patients. Siddiq and colleagues conclude that surgery is not required in most instances, even in patients presenting with a neurological complication of the infection. However, clinical experience has led to observations of sometimes apparently dramatic results from decompression, including the resolution of tetraplegia in some patients with epidural abscess involving the cervical spine.2 Not all spinal cord complications in patients with this problem are amenable to surgical intervention or to percutaneous aspiration because myelopathy may result from compression and/or thrombosis of spinal vasculature in the absence of cord compression.3
The retrospective nature of this study, patient heterogeneity, and small sample size all contribute to a wariness concerning its conclusions. I continue to believe that patients who develop a neurological deficit as the result of cord compression should be considered candidates for decompression, especially if this can be achieved by percutaneous drainage. I also continue to believe that an important key to a successful outcome is early recognition of this infection, since delayed diagnosis is associated with increased risk of permanent neurological deficit.4
References
1. Lyu RK, et al. Spinal epidural abscess successfully treated with percutaneous, computed tomography-guided, needle aspiration and parenteral antibiotic therapy: Case report and review of the literature. Neurosurgery 2002;51:509-512.
2. Young WF, et al. Reversal of tetraplegia in patients with cervical osteomyelitis—epidural abscess using anterior debridement and fusion. Spinal Cord 2001; 39:538-540.
3. van de Warrenburg BP, et al. Myelopathy due to spinal epidural abscess without cord compression: A diagnostic pitfall. Clin Neuropathol 2004;23:102-106.
4. Davis DP, et al. The clinical presentation and impact of diagnostic delays on emergency department patients with spinal epidural abscess. J Emerg Med 2004;26: 285-291.
Researchers reviewed the management of 60 episodes of spinal epidural abscess in 57 patients seen during a 14-year period ending in 2002.
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