Timing in Surgical Evacuation of Spinal Epidural Abscesses
Timing in Surgical Evacuation of Spinal Epidural Abscesses
Object. One often overlooked aspect of spinal epidural abscesses (SEAs) is the timing of surgical management. Limited evidence is available correlating earlier intervention with outcomes. Spinal epidural abscesses, once a rare diagnosis carrying a poor prognosis, are steadily becoming more common, with one recent inpatient meta-analysis citing an approximate incidence of 1 in 10,000 admissions with a mortality approaching 16%. One key issue of contention is the benefit of rapid surgical management of SEA to maximize outcomes. Timing of surgical management is definitely one overlooked aspect of care in spinal infections. Therefore, the authors performed a retrospective analysis in which they evaluated patients who underwent early (evacuation within 24 hours) versus delayed surgical intervention (> 24 hours) from the point of diagnosis, in an attempt to test the hypothesis that earlier surgery results in improved outcomes.
Methods. A retrospective review of a prospectively maintained adult neurosurgical database from 2009 to 2011 was conducted for patients with the diagnostic heading: epidural abscess, infection, osteomyelitis, osteodiscitis, spondylodiscitis, and abscess. The primary end point for each patient was neurological grade, measured as an American Spinal Injury Association Impairment Scale grade using hospital inpatient records on admission and discharge. Patients were divided into early surgical (< 24 hours) and delayed surgical cohorts.
Results. Eighty-seven consecutive patients were identified (25 females; mean age 55.5 years, age range 18–87 years). Fifty-four patients received surgery within 24 hours of admission (mean time from admission to incision, 11.2 hours), and 33 underwent surgery longer than 24 hours (mean 59 hours) after admission. Of the 54 patients undergoing early surgery 45 (85%) had a neurological deficit, whereas in the delayed surgical group 21 (64%) of 33 patients presented with a neurological deficit (p = 0.09). Patients in the delayed surgery cohort were significantly older by 10 years (59.6 vs 51.8 years, p = 0.01). With regard to history of prior revision, body mass index, intravenous drug abuse, tobacco use, prior radiation therapy, diabetes, chronic systemic infection, and prior osteomyelitis, there were no significant differences. There was no significant difference between early and delayed surgery groups in neurological grade on presentation, discharge, or location of epidural abscess. The most common organism isolated was Staphylococcus aureus (n = 51, 59.3%). The incidence of methicillin-resistant S. aureus was 21% (18 of 87).
Conclusions. Evacuation within 24 hours appeared to have a relative advantage over delayed surgery with regard to discharge neurological grade. However, due to a limited, variable sample size, a significant benefit could not be shown. Further subgroup analyses with larger populations are required.
Spinal epidural abscesses (SEAs), once a rare diagnosis carrying a poor prognosis, are steadily becoming more common, with a recent inpatient meta-analysis citing an approximate incidence of 1 in 10,000 admissions. Once thought to be widely fatal, the mortality of SEA has been reportedly as high as 16%. Further contributing to the morbidity is the rising prevalence of highly virulent organisms such as methicillin-resistant Staphylococcus aureus (MRSA), attributed to the rise in intravenous drug abuse, chronic antibiotic use, and hemodialysis. Two key issues of contention have been the need for early surgical management of an SEA to maximize outcomes and the benefit of surgical over medical management in the form of intravenous antibiotics. Recently, relatively large published retrospective series have found no additional benefit added by early surgical evacuation to antibiotic treatment. However, early surgical management of cervical and thoracic epidural abscesses continues to be common practice, especially in the face of progressive neurological deterioration.
Timing of surgical management is one overlooked aspect of care in spinal infections. Limited prospective data are available regarding the management of this disease. The presence of a purulent bacterial empyema or phlegmon in the epidural space overlying the spinal cord is considered as a surgical emergency. This perceived risk is largely due to pathological studies demonstrating diffuse thrombosis of the underlying vasculature in rabbits, published almost 30 years ago. In the present study, we present a large surgical series of spinal decompression for SEA in the adult population, in an attempt to test the hypothesis that earlier surgery correlates with improved outcomes.
Abstract and Introduction
Abstract
Object. One often overlooked aspect of spinal epidural abscesses (SEAs) is the timing of surgical management. Limited evidence is available correlating earlier intervention with outcomes. Spinal epidural abscesses, once a rare diagnosis carrying a poor prognosis, are steadily becoming more common, with one recent inpatient meta-analysis citing an approximate incidence of 1 in 10,000 admissions with a mortality approaching 16%. One key issue of contention is the benefit of rapid surgical management of SEA to maximize outcomes. Timing of surgical management is definitely one overlooked aspect of care in spinal infections. Therefore, the authors performed a retrospective analysis in which they evaluated patients who underwent early (evacuation within 24 hours) versus delayed surgical intervention (> 24 hours) from the point of diagnosis, in an attempt to test the hypothesis that earlier surgery results in improved outcomes.
Methods. A retrospective review of a prospectively maintained adult neurosurgical database from 2009 to 2011 was conducted for patients with the diagnostic heading: epidural abscess, infection, osteomyelitis, osteodiscitis, spondylodiscitis, and abscess. The primary end point for each patient was neurological grade, measured as an American Spinal Injury Association Impairment Scale grade using hospital inpatient records on admission and discharge. Patients were divided into early surgical (< 24 hours) and delayed surgical cohorts.
Results. Eighty-seven consecutive patients were identified (25 females; mean age 55.5 years, age range 18–87 years). Fifty-four patients received surgery within 24 hours of admission (mean time from admission to incision, 11.2 hours), and 33 underwent surgery longer than 24 hours (mean 59 hours) after admission. Of the 54 patients undergoing early surgery 45 (85%) had a neurological deficit, whereas in the delayed surgical group 21 (64%) of 33 patients presented with a neurological deficit (p = 0.09). Patients in the delayed surgery cohort were significantly older by 10 years (59.6 vs 51.8 years, p = 0.01). With regard to history of prior revision, body mass index, intravenous drug abuse, tobacco use, prior radiation therapy, diabetes, chronic systemic infection, and prior osteomyelitis, there were no significant differences. There was no significant difference between early and delayed surgery groups in neurological grade on presentation, discharge, or location of epidural abscess. The most common organism isolated was Staphylococcus aureus (n = 51, 59.3%). The incidence of methicillin-resistant S. aureus was 21% (18 of 87).
Conclusions. Evacuation within 24 hours appeared to have a relative advantage over delayed surgery with regard to discharge neurological grade. However, due to a limited, variable sample size, a significant benefit could not be shown. Further subgroup analyses with larger populations are required.
Introduction
Spinal epidural abscesses (SEAs), once a rare diagnosis carrying a poor prognosis, are steadily becoming more common, with a recent inpatient meta-analysis citing an approximate incidence of 1 in 10,000 admissions. Once thought to be widely fatal, the mortality of SEA has been reportedly as high as 16%. Further contributing to the morbidity is the rising prevalence of highly virulent organisms such as methicillin-resistant Staphylococcus aureus (MRSA), attributed to the rise in intravenous drug abuse, chronic antibiotic use, and hemodialysis. Two key issues of contention have been the need for early surgical management of an SEA to maximize outcomes and the benefit of surgical over medical management in the form of intravenous antibiotics. Recently, relatively large published retrospective series have found no additional benefit added by early surgical evacuation to antibiotic treatment. However, early surgical management of cervical and thoracic epidural abscesses continues to be common practice, especially in the face of progressive neurological deterioration.
Timing of surgical management is one overlooked aspect of care in spinal infections. Limited prospective data are available regarding the management of this disease. The presence of a purulent bacterial empyema or phlegmon in the epidural space overlying the spinal cord is considered as a surgical emergency. This perceived risk is largely due to pathological studies demonstrating diffuse thrombosis of the underlying vasculature in rabbits, published almost 30 years ago. In the present study, we present a large surgical series of spinal decompression for SEA in the adult population, in an attempt to test the hypothesis that earlier surgery correlates with improved outcomes.
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