title: Independent predictors of failure of nonoperative management of spinal epidural abscesses.
abstract: BACKGROUND
  The notion that all patients with spinal epidural abscess (SEA) require surgical decompression has been recently challenged by reports of successful medical management of select patients with SEA.
  
  
  OBJECTIVE
  The purpose of this study was to identify the independent variables that determine success or failure of medical management of SEA.
  
  
  METHODS
  This was a retrospective, case-control study.
  
  
  METHODS
  Patients 18 years or older with diagnosis of SEA admitted to our institution during the study period were included in the sample.
  
  
  METHODS
  The outcome measure was successful management of SEA by eradication of the infection without worsening of neurologic deficits.
  
  
  METHODS
  All patients admitted to our health-care system with a diagnosis of SEA from 1993 to 2011 were identified and the data were retrospectively collected. Patients 18 years or older diagnosed with SEA were included. Excluded were those with postsurgical SEA or phlegmon without an abscess and those with a complete spinal cord injury from SEA for longer than 48 hours.
  
  
  RESULTS
  A total of 355 patients with average age of 60 years met our inclusion criteria. Of the patients who initially underwent nonoperative treatment, 54 patients failed medical management and 73 patients were successfully treated without surgery. Univariate and multivariate analysis identified incomplete or complete spinal cord deficits as the most significant risk factor for failure of medical management. Age older than 65 years, diabetes, and methicillin-resistant Staphylococcus aureus (MRSA) were also independent risk factors for failure. An algorithm for probability of failed antibiotic management of spinal epidural abscess predicted 99% probability of failure for patients with all four of these risk factors.
  
  
  CONCLUSIONS
  SEA treated with medical management alone has a very high risk for failure if the patient is older than 65 years with diabetes, MRSA infection, or neurologic compromise. In the absence of these risk factors, nonoperative management of spinal epidural abscess may be considered as the initial line of treatment with close monitoring.
authors.affiliation: Spine Center of Excellence, Cedars Sinai Medical Center, 444 S. San Vicente Blvd, Suite 901, Los Angeles, CA 90048, USA. Electronic address: sangdkim@gmail.com.
authors.forename: Sang Do
authors.initials: SD
authors.lastname: Kim
authors.affiliation: Department of Orthopaedics, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA.
authors.forename: Rojeh
authors.initials: R
authors.lastname: Melikian
authors.affiliation: Department of Orthopaedics, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA.
authors.forename: Kevin L
authors.initials: KL
authors.lastname: Ju
authors.affiliation: Department of Orthopaedics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA.
authors.forename: David
authors.initials: D
authors.lastname: Zurakowski
authors.affiliation: Department of Orthopaedics, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA.
authors.forename: Kirkham B
authors.initials: KB
authors.lastname: Wood
authors.affiliation: Department of Orthopaedics, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA.
authors.forename: Christopher M
authors.initials: CM
authors.lastname: Bono
authors.affiliation: Department of Orthopaedics, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA.
authors.forename: Mitchel B
authors.initials: MB
authors.lastname: Harris
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D016022:Case-Control Studies; D020806:Central Nervous System Bacterial Infections / Q000188:drug therapy* / Q000601:surgery; D019299:Decompression, Surgical; D020802:Epidural Abscess / Q000188:drug therapy* / Q000601:surgery; D005260:Female; D006801:Humans; D008297:Male; D055624:Methicillin-Resistant Staphylococcus aureus / Q000302:isolation & purification*; D008875:Middle Aged; D019233:Retreatment; D012189:Retrospective Studies; D012307:Risk Factors; D013203:Staphylococcal Infections / Q000188:drug therapy* / Q000601:surgery; D017211:Treatment Failure; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents
keywords: Decompression; Infection; Nonoperative Treatment; Outcomes; Risk factors; Spinal epidural abscess