Diagnostics, Management, and Outcomes in Patients with Pyogenic Spinal Intra- or Epidural Abscess.

ABSTRACT

BACKGROUND: Owing to the lack of evidence on the diagnostics, clinical course, treatment, and outcomes of patients with extremely rare spinal intradural abscess (SIA) and spinal epidural abscess (SEA), we retrospectively analyzed and compared a cohort of patients to determine the phenotyping of both entities. METHODS: Over a period of 20 years, we retrospectively analyzed the electronic medical records of 78 patients with SIA and SEA. RESULTS: The patients with SIA showed worse motor scores (MS scores) on admission (SIA 20 ± 26 vs. SEA 75 ± 34, p < 0.001), more often with an ataxic gait (SIA 100% vs. SEA 31.8%, p < 0.001), and more frequent bladder or bowel dysfunction (SIA 91.7% vs. SEA 27.3%, p < 0.001) compared to the SEA patients. Intraoperative specimens showed a higher diagnostic sensitivity in the SEA patients than the SIA patients (SIA 66.7% vs. SEA 95.2%, p = 0.024), but various pathogens such as Staphylococcus aureus (SIA 33.3% vs. SEA 69.4%) and Streptococci and Enterococci (SIA 33.3% vs. SEA 8.1%, p = 0.038) were detected in both entities. The patients with SIA developed sepsis more often (SIA 75.0% vs. SEA 18.2%, p < 0.001), septic embolism (SIA 33.3% vs. SEA 8.3%, p = 0.043), signs of meningism (SIA 100% vs. 18.5%, p < 0.001), ventriculitis or cerebral abscesses (SIA 41.7% vs. SEA 3.0%, p < 0.001), and pneumonia (SIA 58.3% vs. SEA 13.6%, p = 0.002). The mean MS score improved in both patient groups after surgery (SIA 20 to 35 vs. SEA 75 to 90); however, the SIA patients showed a poorer MS score at discharge (SIA 35 ± 44 vs. SEA 90 ± 20, p < 0.001). C-reactive protein (CrP) (SIA 159 to 49 vs. SEA 189 to 27) and leukocyte count (SIA 15 to 9 vs. SEA 14 to 7) were reduced at discharge. The SIA patients had higher rates of disease-related mortality (SIA 33.3% vs. SEA 1.5%, p = 0.002), had more pleural empyema (SIA 58.3% vs. SEA 13.6%, p = 0.002), required more than one surgery (SIA 33.3% vs. SEA 13.6%, p = 0.009), were treated longer with intravenous antibiotics (7 ± 4 w vs. 3 ± 2 w, p < 0.001) and antibiotics overall (12 ± 10 w vs. 7 ± 3 w, p = 0.022), and spent more time in the hospital (SIA 58 ± 36 vs. SEA 26 ± 20, p < 0.001) and in the intensive care unit (SIA 14 ± 18 vs. SEA 4 ± 8, p = 0.002). CONCLUSIONS: Our study highlighted distinct clinical phenotypes and outcomes between both entities, with SIA patients displaying a markedly less favorable disease course in terms of complications and outcomes.