title: Predicting patients with concurrent noncontiguous spinal epidural abscess lesions.
abstract: BACKGROUND
  Spinal epidural abscess (SEA) is a serious condition that can lead to significant morbidity and mortality if not expeditiously diagnosed and appropriately treated. However, the nonspecific findings that accompany SEAs often make its diagnosis difficult. Concurrent noncontiguous SEAs are even more challenging to diagnose because whole-spine imaging is not routinely performed unless the patient demonstrates neurologic findings that are inconsistent with the identified lesion. Failure to recognize a separate SEA can subject patients to a second operation, continued sepsis, paralysis, or even death.
  
  
  OBJECTIVE
  To formulate a set of clinical and laboratory predictors for identifying patients with concurrent noncontiguous SEAs.
  
  
  METHODS
  A retrospective, case-control study.
  
  
  METHODS
  Patients aged 18 years or older admitted to our institution during the study period who underwent entire spinal imaging and were diagnosed with one or more SEAs.
  
  
  METHODS
  The presence or absence of concurrent noncontiguous SEAs on magnetic resonance imaging or computed tomography (CT)-myelogram.
  
  
  METHODS
  A retrospective review was performed on 233 adults with SEAs who presented to our health-care system from 1993 to 2011 and underwent entire spinal imaging. The clinical and radiographic features of patients with concurrent noncontiguous SEAs, defined as at least two lesions in different anatomical regions of the spine (ie, cervical, thoracic, or lumbar), were compared with those with a single SEA. Multivariate logistic regression identified independent predictors for the presence of a skip SEA, and a prediction algorithm based on these independent predictors was constructed. Institutional review board committee approval was obtained before initiating the study.
  
  
  RESULTS
  Univariate and multivariate analyses comparing patients with skip SEA lesions (n=22) with those with single lesions (n=211) demonstrated significant differences in three factors: delay in presentation (defined as symptoms for ≥7 days), a concomitant area of infection outside the spine and paraspinal region, and an erythrocyte sedimentation rate of >95 mm/h at presentation. The predicted probability for the presence of a skip lesion was 73% for patients possessing all three predictors, 13% for two, 2% for one, and 0% for zero predictors. Receiver operating characteristic curve analysis, used to evaluate the predictive accuracy of the model, revealed a steep shoulder with an area under the curve of 0.936 (p<.001).
  
  
  CONCLUSIONS
  The proposed set of three predictors may be a useful tool in predicting the risk of a skip SEA lesion and, consequently, which patients would benefit from entire spinal imaging.
authors: Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA. Electronic address: kju@partners.org.
authors: Kevin L
authors: KL
authors: Ju
authors: Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA.
authors: Sang Do
authors: SD
authors: Kim
authors: Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA.
authors: Rojeh
authors: R
authors: Melikian
authors: Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA.
authors: Christopher M
authors: CM
authors: Bono
authors: Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA.
authors: Mitchel B
authors: MB
authors: Harris
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D016022:Case-Control Studies; D020802:Epidural Abscess / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000473:pathology; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D011859:Radiography; D012189:Retrospective Studies; D013131:Spine / Q000000981:diagnostic imaging / Q000473:pathology; D055815:Young Adult
keywords: Algorithm; Concurrent; Epidural abscess; Noncontiguous; Prediction; Skip lesion