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Predictors of Failure of Nonoperative Management of Spinal Epidural Abscesses

Sang Do Kim, M.D.

Spinal epidural abscess has been traditionally treated with urgent surgical decompression followed by long-term intravenous antibiotics. Cases of successful medical management of select patients have been recently reported.

This is a case-control retrospective study analyzing the management of spinal epidural abscesses admitted to Partners Healthcare from 1993 to 2011. In particular, we investigate the role of medical management in spinal epidural abscesses and their outcomes.

355 patients (214 males to 141 females) with average age of 60 years (range, 18 to 94) with spinal epidural abscess were admitted that met our inclusion criteria. 100 patients were treated with long-term intravenous (IV) antibiotics and 255 patients were treated with surgical decompression followed by long-term IV antibiotics. Overall mortality was 8.7% during the initial hospitalization and 11.3% within 90 days of admission. Diabetes, alcohol abuse and intravenous were the most significant risk factors. The offending pathogen was staphylococcus species 78.7% of the time. There was 94.5% concordance between blood cultures and surgical wound cultures. Comparing outcomes of medical management, 73 patients were successfully treated with antibiotics. Twelve deaths resulted from nonoperative management, and 42 patients failed initial medical management and underwent surgical decompression. Univariate analysis identified age, neurologic status, diabetes, epidural abscess above the level of the conus medullaris and circumferential epidural abscesses as significant risk factors for failure. Multivariate analysis identified neurologic impairment of incomplete or complete spinal cord injury as the most significant risk factor, along with age greater than 65 years, diabetes, and methicillin resistant staphylococcus aureus (MRSA) as independent risk factors for failure of medical management. Algorithm for probability of failed antibiotic management of spinal epidural abscess predicted 99% probability of failure for patient older than 65 years with diabetes with MRSA infection presenting with a neurologic impairment.

Spinal epidural abscesses have high risk for failure with medical management alone. Risk stratification for failure of medical treatment based on independent risk factors is presented.