Management of Neurologically Intact Patient with Cervical Epidural Abscess

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1 Management of Neurologically Intact Patient with Cervical Epidural Abscess Jason C. Eck, DO, MS Center for Sports Medicine & Orthopaedics Chattanooga, TN

2 Overview Pathophysiology and epidemiology of epidural abscesses Accepted indications for surgery Outcomes of conservative vs. surgical treatment Conclusions and recommendations

3 Pathophysiology & Epidemiology Collection of purulent material between the dura and the osteoligamentous spinal structures Bacteria gain entrance through hematogenous or contiguous spread or by other undetermined methods in up to 25% of cases 1 st described in 1761 by Morgagai 1 st surgical intervention for SEA in 1901 by Barth Most initial cases were fatal Baker AS et al. NEJM 1975 Feldenzer JA et al. Neurosurg 1987

4 Pathophysiology & Epidemiology Historical rates cases per 10,000 hospital admissions Higher rates at referral centers 12.5 cases per 10,000 hospital admissions Rates are increasing Doubled in last 20 years Overall mortality 5% Irreversible paralysis 22% Baker AS et al. NEJM 1975; Davis DP, et al. J Emerg Med 2004 Rigamonti D, et al. Surg Neurol 1999; Darouiche RO. NEJM 2006

5 Pathophysiology & Epidemiology Risk factors for development of SEA Elevated ESR Leukocytosis Bacteremia Sepsis IV drug use Diabetes mellitus Immunocompromise Malignancy Alcoholism Prior spine surgery Uncertain prognostic values of each of these

6 Pathophysiology & Epidemiology 50% patients initially misdiagnosed Clinical findings 75% neck or back pain 50% febrile 25% neurologic deficits Triad of back/neck pain, fever and neurologic deficit present in a minority with diagnostic sensitivity of only 8% Reihsaus E, et al. Neurosurg Rev 2000; Davis DP, et al. J Emerg Med 2004

7 Pathophysiology & Epidemiology Skip lesions in different regions of spine even more difficult to diagnose Occurred in 22 (9.4%) of 233 in large case-controlled study Three predictors identified for the presence of a skip lesion Delay in presentation at least 7 days Concomitant area of infection outside of the spine and paraspinous region ESR >95 mm/hr Predicted probability for skip lesion 73% with all 3 factors 13% for 2 factors 2% for 1 factor 0% for 0 factors Lu et al. Spine J 2015

8 Accepted Indications for Surgery Progressive neurologic deficit Structural collapse or deformity Failure of conservative treatment Failure to achieve a positive culture through biopsy or blood cultures

9 Conservative Approach for Some? Generally accepted that a certain subset of patients with SEA could be effectively managed without surgery Long-term culture-sensitive IV antibiotics Immobilization with brace Close clinical follow-up

10 Difficulty with Conservative Approach Determining which patients will develop a new neurologic deficit Once deficit occurs could be permanent Early surgery could have potentially prevented deficit from occurring Close clinical follow-up can be difficult in this patient population Poor compliance issues Will stable neurologic deficit progress or could it be improved with surgery If surgery is known to be effective is it ethical to delay surgical treatment that could lead to a worsening condition

11 Conservative Treatment vs. Surgery Arko et al. Neurosurg Focus 2014

12 Algorithm for Management Tuchman A., et al. Neurosurg Focus 2014

13 Conclusions SEA can be a potentially life threatening or paralyzing event The mainstay of treatment remains urgent surgical decompression and stabilization Surgery is required in cases of acute or progressive neurologic deficit, vertebral collapse or deformity, failure of conservative treatment, or failure to achieve adequate culture on biopsy

14 Conclusions Conservative management can consist of long-term culture-specific IV antibiotic therapy, immobilization in a brace, and close clinical follow-up Potential risk factors for disease progression include DM, MRSA infection, CRP >115, WBC >12.5, ring enhancement of abscess on MRI, and bacteremia. Neurologically intact patients without known risk factors for progression can be treated effectively without surgery

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