361 - Emergent Surgical Managment of Epidural Abscess: A Retrospective Study...

#361 Emergent Surgical Managment of Epidural Abscess: A Retrospective Study

General Session: Infections/Tumor

Presented by: J. Belding

Author(s):

J. Belding (1)
F. Christopher (1)

(1) University Hospitals of Cleveland, Orthopedics, Cleveland, OH, USA

Abstract

Introduction: Spinal epidural abscess is relatively rare clinical occurrence (less than 0.02 % incidence) but is associated with high morbidity and mortality if treatment is delayed (14% mortality in most series). Multiple risk factors including diabetes, IVDU, ESRD and previous infection have been described. Clinical outcomes are usually reasonable if diagnosis and treatment are initiated rapidly. We reviewed our surgical results over a seven year period to evaluate possible associations and predictive factors of post-operative outcomes.

Methods: A retrospective review of 24 patients with signs and symptoms consistent with an epidural abscess, septicemia and neurologic deficits of varying degrees was performed. Charts were reviewed for medical history, presenting symptoms, neurologic grade using the ASIA classification and laboratory values. Microbiology and pathology records were collected for speciation. Clinical follow-up was reviewed for bracing and time of antibiotic use. Odom scores were used for subjective measurement of postoperative outcome along with ASIA grading. Surgical data concerning number of levels involved and fusion type and material were reviewed and treatment option was based upon location of the majority of the abscess on MRI scan. Major complications were defined as early mortality (within 3 months), revision surgery for graft dislodgment or failure within 3 months, neurologic deterioration requiring repeat surgery, or repeat hospitalization for antibiotics. Statistical analysis was performed to evaluate the possible risk factors for persistent pain or major complication.

Results: There were 15 men and 9 women in the study with an average age of 60. The mean follow up length was 33.45 months. There was a variety of spinal levels involved. All patients measured had significant elevation in their inflammatory markers, but only 62.5% had elevated WBC. 70.8% of patients had positive intraoperative cultures, with half of these being MSSA. Most patients received 6 wks IV antibiotics except for those with TB and one whose culture remained negative. 14 patients underwent posterior decompression only, while 10 anterior fusion procedures were performed anteriorly, with a planned posterior staged fusion in one patient. All patients survived the immediate post-operative period, however major complications did occur in 33% of pts, with 4 mortalities. Only one of the patients who survived did not have significant improvement in ASIA score post-operatively. There was no recurrence of epidural abscess but two patients required readmission for IV antibiotics and one psoas abscess drainage. Those patients with diabetes did have a statistically higher rate of complications (p=0.0207) as well as those with ESRD (p=.0277). The duration of neurologic symptoms was not correlated with the development of a major complication (p=0.9639). ESR >80 was also not correlated with development of a major complication (p=0.1688). The number of levels involved in decompression was also evaluated and found not to be significantly correlated with either major complication or continued back pain (p= 0.1584).

Conclusions: Emergent surgical management with appropriate antibiotic treatment is still the most effective treatment modality for epidural abscess. Our review highlights the substantial morbidity of this diagnosis as well as points towards host factors as the most important determinant in outcomes rather than surgical options or specific presentation or bacteria.