How Best to Manage the Spinal Epidural Abscess? A Current Systematic Review.
BACKGROUND
A spinal epidural abscess is a medical emergency. Despite urgent surgical intervention and adjuvant antibiotic therapy, neurologic prognosis remains variable and guarded. The optimal approach to managing this condition is debated with substantial variability in clinical practice, dependent on patient demographic and pretreatment neurologic status as well as radiologic appearance.


METHODS
A systematic search in MEDLINE and similar databases was conducted for literature published from 1990 to 2015 using the search term "spinal epidural abscess", limiting the search results to human studies published in the English language. Case series that consisted of fewer than 10 patients were excluded. The evidence strength was graded according to the Grades of Recommendation Assessment, Development, and Evaluation criteria.


RESULTS
The search yielded 1843 patients from 34 retrospective case series. Ten studies compared surgical and medical management, with no significant difference in patients with good outcome (odds ratio, 0.65; P = 0.11) or neurologic improvement (odds ratio, 1.11; P = 0.69). However, failure rates after initial medical management requiring surgical intervention ranged from 10% to 50%. Three of 4 studies evaluating timing of surgery reported large effect sizes for neurologic outcome if early surgery was performed (P < 0.01). Other prognostic factors from a neurologic perspective included admission neurologic status, patient age, and diabetes mellitus.


CONCLUSIONS
Surgery with adjuvant antibiotics remains the optimal treatment for the neurologically symptomatic patient with spinal epidural abscess. If antibiotic therapy alone is considered for the neurologically intact patient, we recommend interdisciplinary medical and surgical consultations with an in-depth dialogue on the potential for failure in isolated medical management and the recommendation for close neurologic monitoring.
Department of Surgery, University of Toronto, Toronto, Canada.
Suganth
S
Suppiah
Department of Surgery, University of Toronto, Toronto, Canada.
Ying
Y
Meng
Department of Surgery, University of Toronto, Toronto, Canada; Division of Neurosurgery, Toronto Western Hospital, Toronto, Canada; Toronto Western Research Institute, Toronto, Canada.
Michael G
MG
Fehlings
Department of Surgery, University of Toronto, Toronto, Canada; Division of Neurosurgery, Toronto Western Hospital, Toronto, Canada; Toronto Western Research Institute, Toronto, Canada.
Eric M
EM
Massicotte
Department of Surgery, University of Toronto, Toronto, Canada; Division of Orthopedic Surgery, Sunnybrook Hospital, Toronto, Canada; Sunnybrook Research Institute, Toronto, Canada.
Albert
A
Yee
Department of Surgery, University of Toronto, Toronto, Canada; Division of Neurosurgery, Toronto Western Hospital, Toronto, Canada; Techna Research Institute, Toronto, Canada. Electronic address: mohammed.shamji@uhn.ca.
Mohammed F
MF
Shamji
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019072:Antibiotic Prophylaxis / Q000401:mortality* / Q000706:statistics & numerical data; D015984:Causality; D003131:Combined Modality Therapy / Q000401:mortality; D015897:Comorbidity; D019299:Decompression, Surgical / Q000401:mortality* / Q000706:statistics & numerical data; D020802:Epidural Abscess / Q000401:mortality* / Q000601:surgery*; D019317:Evidence-Based Medicine; D006801:Humans; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000401:mortality* / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000401:mortality*; D015995:Prevalence; D012307:Risk Factors; D015996:Survival Rate; D016896:Treatment Outcome; D055815:Young Adult
Spinal epidural abscess