- Department of Neuroscience, Winthrop Neuroscience, Winthrop University Hospital, Mineola, NY 11501, USA
Nancy E. Epstein
Department of Neuroscience, Winthrop Neuroscience, Winthrop University Hospital, Mineola, NY 11501, USA
DOI:10.4103/2152-7806.166894Copyright: © 2015 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Epstein NE. What are we waiting for? An argument for early surgery for spinal epidural abscesses. Surg Neurol Int 08-Oct-2015;6:
How to cite this URL: Epstein NE. What are we waiting for? An argument for early surgery for spinal epidural abscesses. Surg Neurol Int 08-Oct-2015;6:. Available from: http://surgicalneurologyint.com/surgicalint_articles/what-are-we-waiting-for-an-argument-for-early-surgery-for-spinal/
Background:In the article: Timing and prognosis of surgery for spinal epidural abscess (SEA): A review, Epstein raises one major point; it is imperative that spinal surgeons “take back decision-making” from our medical cohorts and reinstitute early surgery (
Methods:Spine surgeons recognize the clinical triad (e.g., fever [50%], spinal pain [92–100%], and neurological deficits [47%]) for establishing the diagnosis of an SEA. We also appreciate the multiple major risk factors for developing SEA; diabetes (15–30%), elevated white blood cell count (>12.5), high C-reactive protein (>115), positive blood cultures, radiographic cord compression, and significant neurological deficits (e.g., 19–45%).
Results:Recognizing these risk factors should prompt early open surgery (
Conclusion:As spine surgeons, we need to “take back decision-making” from our medical cohorts and advocate for early surgery to achieve better outcomes for our patients. Why should anyone accept the >41-42.5 to up to the 75% failure rate that accompanies the nonsurgical treatment of SEA, much less the >25% mortality rate?
Keywords: Avoid medical management, early surgery, high morbidity/mortality, spinal epidural abscesses, spine surgeons
The article: Timing and prognosis of surgery for spinal epidural abscess (SEA): A review raises one major point; Spine surgeons should perform early surgery for SEA, probably well before the 24 h mark following the onset of a neurological deficit, and should “take back decision-making” from our medical cohorts who too often promote nonsurgical management. Although much effort has been expended to identify the major risk factors prompting nonoperative management, such treatment has resulted in unacceptably high failure rates (e.g., 41-42,5 up to 75% requiring delayed surgery with often poor results), severe permanent morbidity (up to 22% risk of paralysis), and high mortality rates (3–25%).[
AS SPINE SURGEONS READILY RECOGNIZE THE CLINICAL TRIAD AND RISK FACTORS FOR SPINAL EPIDURAL ABSCESS, WHAT ARE WE WAITING FOR?
Spine surgeons certainly acknowledge the clinical triad (e.g., fever [50%], spinal pain [92–100%], and neurological deficits [47%]) required for establishing the diagnosis of a SEA.[
PYOGENIC AND NONPYOGENIC SPINAL INFECTIONS DIAGNOSED WITH DIFFUSION-WEIGHTED MAGNETIC RESONANCE IMAGING: ABSCESSES AND PUS COLLECTIONS
Newer MRI techniques enable us to better diagnose and treat/follow SEA. Moritani et al. noted that conventional MRI is typically utilized to diagnose SEA.[
Multiple risk factors should prompt early surgery (e.g., defined as within 24 h of the onset of a neurological deficit) versus late surgery (>24 h).[
Arko et al. noted that in the past SEA had typically (particularly prior to 1999) been managed with emergent surgery/decompression and antibiotic therapy.[
Another example of high nonsurgical failure rates for treating SEA comes from Kim et al. study in which 127 of 355 patients with SEA were managed nonsurgically; 54 (42.5%) failed nonoperative management requiring delayed surgery.[
In Patel et al., 127 consecutive patients with spontaneous SEA presented with the classic triad of pain (100%), fevers (50%), and weakness (47%); lesions were located ventrally (36%), dorsally (41%), or circumferentially (23%).[
Alton et al. evaluated the risks factors and neurological outcomes for 62 patients with cervical SEA treated with antibiotics alone (e.g., neurological deterioration) versus early surgery.[
Results of minimally invasive surgical procedures for spinal epidural abscess: Percutaneous endoscopy dilute betadine solution irrigation and percutaneous endoscopic lavage and drainage
The results of minimally invasive surgery (MIS) for SEA vary. Yang et al. evaluated the efficacy of percutaneous endoscopic epidural debridement of spondylodiscitis/SEA in 32 patients using “percutaneous endoscopy dilute betadine solution irrigation (PEDI)” (2005 to July 2010).[
Greater efficacy of open decompressions
The frequency of permanent neurological deficits with/without surgery for SEA remains high. Doutchi et al. noted a 22% incidence of permanent neurological deficits following SEA treated surgically or nonsurgically; deficits were greater where there was cervical involvement.[
The most common offending organism for SEA is MRSA, typically followed by MSSA. Early surgery is critical to avert sepsis which remains the leading causes of death. In Doutchi et al. series, the cause of osteomyelitis in 66% of cases was due to postoperative (18%) or hematogenous (48%) spread of organisms. Notably, just one organism was present in 92% of cases; Gram-positive bacteria (76% of cases), and Gram-negative bacilli in most of the remaining cases.[
As spinal surgeons, we need to “take back our surgical prerogative” and re-educate ourselves and our medical colleagues that SEA is a true neurosurgical emergency. We and our patients cannot afford the high failure rates attributed to the initial nonoperative management of SEA (e.g., a 41-42.5-75% failure rate) or the high mortality rates ranging up to 25%. As spine surgeons, we need to promptly diagnose and treat SEA before precipitous, unpredictable neurological decline/paralysis, and death occurs.
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Conflicts of interest
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