General Session: Tumor, Trauma, and Infection

Presented by: N. Jain - View Audio/Video Presentation (Members Only)

Author(s):

Z. Denham(1), A. Bucca(1), J. Darnley(1), N. Jain(2), K. Stammen(1), R. Rauck(3), S. Virk(2), S. Khan(2)

(1) Ohio State University, Columbus, OH, United States
(2) Ohio State University, Orthopaedics, Columbus, OH, United States
(3) Hospital for Special Surgery, Orthopaedics, New York, NY, United States

Abstract

Background: Spinal epidural abscesses (SEA) affecting the cervical spine are exceedingly rare and little is reported in the literature pertaining to their incidence, epidemiology, and treatment trends. The purpose of this study was to determine the etiology and epidemiology of bacterial SEA involving the cervical spine and their treatment trends.

Methods: A retrospective chart review at an academic, tertiary hospital system was done from the medical center's data warehouse. Patients were included by the ICD-9 diagnosis code for intraspinal abscess (324.1) over a 10-year period from September, 2001 to September, 2011. Patients over 18 years old with cytopathologic or radiographic evidence of bacterial SEA in the cervical or cervicothoracic spine were included. Patient demographics, vertebral levels, signs and symptoms, risk factors, microorganisms, clinical status at admission and discharge, and treatment (medical vs. surgical) were recorded. Clinical status was recorded according to the following stages:
stage 1 = pain at affected spinal level;
stage 2 = back and nerve root pain radiating from involved spinal area;
stage 3 = motor weakness, sensory deficit or bladder/bowel dysfunction; and
stage 4 = paralysis.

Results: A total of 43 patients were diagnosed with a SEA involving the cervical spine and included in the study. Males made up 60% of the study population (n=26), and the average age was 55.1 ± 12.1 years (range 28-79). Locations of the SEA involving the cervical spine included 36 that were cervical (C1-C7) and 7 that were cervicothoracic (C1-T12). The average number of levels involved was 3.9 ± 2.7 (range 1-15). Patient presentation was as follows -
Stage 1 (33%),
Stage 2 (12%),
Stage 3 (37%) and
Stage 4 (19%).
Clinically relevant parameters included elevated erythrocyte sedimentation rate (60%), elevated white blood cell count (81%), and fever (49%). Risk factors included tobacco use (56%), concurrent non-spinal infection (37%), and diabetes mellitus (35%). The most common grown organisms were methicillin-resistant Staphylococcus aureus (44%) and methicillin-susceptible Staphylococcus aureus (23%). Fifteen patients were treated with antibiotics only (35%), and 28 were treated with both surgery and antibiotics (65%).

Conclusion: Spinal epidural abscesses involving the cervical spine are challenging to treat and manage. The majority of patients presented with some form of neural deficit. Tobacco use, non-spinal infections, and diabetes mellitus were found to be the biggest risk factors for spinal epidural abscesses of the cervical spine. Outcomes for a significant portion of patients treated non-operatively were poor.