Surgical Management of Spinal Epidural Abscess in Elderly Patients: A Comparative Analysis Between Patients 65-79 Years and ≥80 Years with 3-Year Follow-Up.

BACKGROUND: Recently, the incidence of pyogenic vertebral osteomyelitis with spinal epidural abscess (SEA) has increased. However, the most appropriate surgical management remains debatable, especially for older patients. This study aimed to compare the clinical course in older patients aged between 65 and 79 years and those 80 years or older undergoing surgery for SEA. METHODS: Data on patient demographics, surgical characteristics, complications, hospital clinical course, and 90-day mortality of patients diagnosed with pyogenic vertebral osteomyelitis and SEA between September 2005 and December 2021 were collected. Comorbidities were assessed using the age-adjusted Charlson comorbidity index. RESULTS: We enrolled 45 patients aged 65-79 years and 32 patients ≥80 years. Patients ≥80 years had significantly higher rates of Charlson comorbidity index (9.2 ± 2.4) than younger patients (6.5 ± 2.5; P < 0.001). Arterial hypertension, renal failure, and dementia were significantly more prevalent in octogenarians (P < 0.05). Patients aged ≥80 years had a significantly longer length of hospitalization, while the intensive care unit stay was similar between groups. In-hospital mortality was significantly greater in those ≥80 years (n = 3, 9.4% vs. n = 0, 0.0%; P = 0.029), whereas no differences in 90-day mortality or 30-day readmission were observed. In the second-stage analysis, significant improvements in blood infection parameters and neurologic status were detected in both groups. Of adverse events, pneumonia occurred significantly more frequently in patients aged ≥80 years. CONCLUSIONS: Surgical management leads to significant improvements in both laboratory and clinical parameters in older patients. Nevertheless, a personalized medical approach is mandatory in frail patients, especially octogenarians. A clear discussion regarding the potential risk is unambiguously recommended.

Predictors of reoperation after surgery for spinal epidural abscess.

BACKGROUND CONTEXT: Spinal epidural abscess is a rare but severe condition with high rates of postoperative adverse events. PURPOSE: The objective of the study was to identify independent prognostic factors for reoperation using two datasets: an institutional and national database. STUDY DESIGN/SETTING: Retrospective Review. PATIENT SAMPLE: Database 1: Review of five medical centers from 1993 to 2016. Database 2: The National Surgical Quality Improvement Program (NSQIP) was queried between 2012 and 2016. OUTCOME MEASURES: Thirty-day and ninety-day reoperation rate. METHODS: Two independent datasets were reviewed to identify patients with spinal epidural abscesses undergoing spinal surgery. Multivariate analyses were used to determine independent prognostic factors for reoperation while including factors identified in bivariate analyses. RESULTS: Overall, 642 patients underwent surgery for a spinal epidural abscess in the institutional cohort, with a 90-day unplanned reoperation rate of 19.9%. In the NSQIP database, 951 patients were identified with a 30-day unplanned reoperation rate of 12.3%. On multivariate analysis in the NSQIP database, cervical spine abscess was the only factor that reached significance for 30-day reoperation (OR=1.71, 95% CI=1.11-2.63, p=.02, Area under the curve (AUC)=0.61). On multivariate analysis in the institutional cohort, independent prognostic factors for 30-day reoperation were: preoperative urinary incontinence, ventral location of abscess relative to thecal sac, cervical abscess, preoperative wound infection, and leukocytosis (AUC=0.65). Ninety-day reoperation rate also found hypoalbuminemia as a significant predictor (AUC=0.66). CONCLUSION: Six novel independent prognostic factors were identified for 90-day reoperation after surgery for a spinal epidural abscess. The multivariable analysis fairly predicts reoperation, indicating that there may be additional factors that need to be uncovered in future studies. The risk factors delineated in this study through the use of two large cohorts of spinal epidural abscess patients can be used to improve preoperative risk stratification and patient management.

High risk and low prevalence diseases: Spinal epidural abscess.

INTRODUCTION: Spinal epidural abscess (SEA) is a rare but serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE: This review highlights the pearls and pitfalls of SEA, including presentation, initial evaluation, and management in the emergency department (ED) based on current evidence. DISCUSSION: SEA is a suppurative infection and infectious disease emergency that may result in significant morbidity and even mortality. It is a challenging diagnosis due to its range of risk factors and variety of presentations with up to 90% of patients misdiagnosed on their first ED visit. Factors associated with increased risk of SEA include immunocompromise, bacteremia, contiguous infection (e.g., psoas muscle abscess, osteomyelitis, skin infection), and spinal instrumentation. However, the absence of risk factors cannot be used to exclude SEA. The classic triad of back pain, fever, and neurologic deficit occurs in less than 8% of cases, though back pain is a common presenting symptom. Up to half of patients experience a neurologic abnormality, but fever is absent in 50%. Laboratory assessment may assist with inflammatory markers elevated in the majority of cases. Diagnosis includes magnetic resonance imaging with and without contrast and blood cultures, and management includes spinal specialist consultation and antibiotic therapy. CONCLUSIONS: An understanding of SEA can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Morbidity and Mortality of Spinal Epidural Abscess in End-Stage Renal Disease Patients: A Case-Control Study.

BACKGROUND: Spinal epidural abscess (SEA) is an uncommon and highly morbid infection of the epidural space. End-stage renal disease (ESRD) patients are known to be at increased risk of developing SEA; however, there are no studies that have described the risk factors and outcomes of SEA in ESRD patients utilizing the United States Renal Data System (USRDS). METHODS: To determine risk factors, morbidity, and mortality associated with SEA in ESRD patients, a retrospective case-control study was conducted using the USRDS. ESRD patients diagnosed with SEA between 2005 and 2010 were identified, and logistic regression was performed to examine correlates of SEA, as well as risk factors associated with mortality in SEA-ESRD patients. RESULTS: The prevalence of SEA amongst ESRD patients was 0.39% (n = 1,697). Patients with SEA were more likely to be male [adjusted Odds Ratio (OR) = 1.22], black (OR = 1.19), diabetic (OR = 1.26), with catheter access (OR = 1.29), and less likely to be ≥65 years old (OR = 0.64). Osteomyelitis, bacteremia/septicemia, MRSA, and endocarditis were all significantly associated with increased risk of SEA (OR = 1.54-5.14). Age ≥65 years (HR = 1.45), urinary tract infections (HR = 1.26), decubitus ulcers (HR=1.37), and post-SEA paraplegia (HR = 1.25) were significantly associated with mortality among those with SEA. CONCLUSIONS: As described in previous literature, risk factors for SEA included infections, diabetes, and indwelling catheters. Additionally, clinicians should be aware of the risk factors for mortality in SEA-ESRD patients. As the largest study of SEA to date, our report identifies important risk factors for SEA in ESRD patients, and novel data regarding their mortality-associated risk factors.

Spinal epidural abscess in COVID-19 patients.

OBJECTIVE: To report the peculiarity of spinal epidural abscess in COVID-19 patients, as we have observed an unusually high number of these patients following the outbreak of SARS-Corona Virus-2. METHODS: We reviewed the clinical documentation of six consecutive COVID-19 patients with primary spinal epidural abscess that we surgically managed over a 2-month period. These cases were analyzed for what concerns both the viral infection and the spinal abscess. RESULTS: The abscesses were primary in all cases indicating that no evident infective source was found. A primary abscess represents the rarest form of spinal epidural abscess, which is usually secondary to invasive procedures or spread from adjacent infective sites, such as spondylodiscitis, generally occurring in patients with diabetes, obesity, cancer, or other chronic diseases. In all cases, there was mild lymphopenia but the spinal abscess occurred regardless of the severity of the viral disease, immunologic state, or presence of bacteremia. Obesity was the only risk factor and was reported in two patients. All patients but one were hypertensive. The preferred localizations were cervical and thoracic, whereas classic abscess generally occur at the lumbar level. No patient had a history of pyogenic infection, even though previous asymptomatic bacterial contaminations were reported in three cases. CONCLUSION: We wonder about the concentration of this uncommon disease in such a short period. To our knowledge, cases of spinal epidural abscess in COVID-19 patients have not been reported to date. We hypothesize that, in our patients, the spinal infection could have depended on the coexistence of an initially asymptomatic bacterial contamination. The well-known COVID-19-related endotheliitis might have created the conditions for retrograde bacterial invasion to the correspondent spinal epidural space. Furthermore, spinal epidural abscess carries a significantly high morbidity and mortality. It is difficult to diagnose, especially in compromised COVID-19 patients but should be kept in mind as early diagnosis and treatment are crucial.

Outcome of Surgical Treatment of Spontaneous Spinal Epidural Abscesses for a 10-year Period.

INTRODUCTION: Spinal epidural abscess is uncommon but potentially debilitating infection. Delay in early diagnosis may be associated with increased morbidity and mortality despite recent advances in medicine. AIM: To present the clinical course and outcome of treatment of spontaneous spinal epidural abscesses. MATERIALS AND METHODS: Thirty-four patients (20 men and 14 women) with clinical, neuroimaging and/or histological data for spinal epidural abscess were treated at the Clinic of Neurosurgery at St George University Hospital, Plovdiv, Bulgaria, for the period 2009-2018. RESULTS: The average age of patients was 62 years (21-76 years) and the ratio of men to women was 1.4:1. All patients (100%) presented with vertebralgia, 13 patients (38.2%) had additional radiculalgia, and 10 patients (29.4%) presented with sensory or motor deficit. The duration of complaints varied from 4 to 180 days. At hospital admission, only 9 patients (26.4%) had intact neurological status. The most common localization of the spinal epidural abscess was in the lumbar and lumbosacral area (52.9%), concomitant spondylodiscitis was present in 31 patients (91.2%). Twenty-four patients (70.6%) underwent emergency surgery within 24 hours, and the rest had planned surgery. Decompressive interlaminotomy or hemilaminectomy was performed in 9 patients (26.5%). The remaining 25 patients (73.5%) underwent laminectomy, in 15 patients (44.1%) it was combined with posterior pedicle screw fixation. After the treatment, 23 patients (67.6%) had a good outcome, the remaining 11 (32.4%) had a poor outcome, and 3 patients died (8.8%). CONCLUSION: In patients with spinal epidural abscess, emergency surgery is the treatment method of choice. It allows decompression of neural structures, correction of the spinal deformity, segmental stabilization and rapid mobilization of patients.

Evaluating new paralysis, mortality, and readmission among subgroups of patients with spinal epidural abscess: A latent class analysis.

BACKGROUND: Spinal epidural abscess (SEA) is increasing in incidence; this not-to-miss diagnosis can cause significant morbidity and mortality, particularly if diagnoses are delayed. While some risk factors for SEA and subsequent mortality have been identified, the SEA patient population is clinically heterogeneous and sub-populations have not yet been characterized in the literature. The primary objective of this project was to identify characteristics of subgroups of patients with SEA. The secondary objective was to identify associations between subgroups and three clinical outcomes: new onset paralysis, in-hospital mortality, and 180-day readmission. METHODS: Demographics and comorbid diagnoses were collected for patients diagnosed with SEA at an academic health center between 2015 and 2019. Latent class analysis was used to identify clinical subgroups. Chi-squared tests were used to compare identified subgroups with clinical outcomes. RESULTS: We identified two subgroups of patients in our analysis. Group 1 had a high rate of medical comorbidities causing immunosuppression, requiring vascular access, or both. Group 2 was characterized by a high proportion of people with substance use disorders. Patients in Group 2 were more likely to be readmitted within 6 months than patients in Group 1 (p = 0.03). There was no difference between groups in new paralysis or mortality. DISCUSSION: While prior studies have examined the SEA patient population as a whole, our research indicates that there are at least two distinct subgroups of patients with SEA. Patients who are younger, with substance use disorder diagnoses, may have longer hospital courses and are at higher risk of readmission within six months. Future research should explore how to best support patients in both groups, and additional implications for subgroup classification on health outcomes, including engagement in care.

Risk factors for residual neurologic deficits after surgical treatment for epidural abscess in the thoracic or lumbar spine.

BACKGROUND CONTEXT: Spinal epidural abscess (SEA) can cause neurologic deficits and needs urgent surgical intervention. Many clinical factors had been proposed to predict surgical outcomes in patients with SEA, but the predictive radiographic risk factors for residual neurologic deficits were not addressed sufficiently. PURPOSE: To analyze the clinical and radiographic risk factors for residual neurologic deficit in patients with SEA after surgical intervention of the thoracic or lumbar spine. STUDY DESIGN/SETTING: A retrospective consecutive case series. PATIENT SAMPLE: From January 2005 through December 2014, 53 patients with primary SEA, confirmed by culture or histopathology, in the thoracic or lumbar spine who underwent posterior-only approach surgery at our hospital. OUTCOME MEASURES: Neurologic status was assessed using the Frankel grading system preoperatively, postoperatively, and at final follow-up. METHODS: The patients were allocated into two groups based on the presence of postoperative residual neurologic deficits. Patients' demographic, clinical, and factors based on magnetic resonance imaging (MRI) were analyzed for their influence on residual neurologic deficits. Clinical factors included age, sex, diabetes, comorbidities, pathogens, affected spinal levels, the interval between onset of symptoms to surgery, preoperative neurologic status, presence of cauda equina syndrome, and surgical procedures. MRI factors included the distribution of abscesses within the spinal canal, presence of ring enhancement, presence of paravertebral abscess or psoas abscess, canal compromise anteroposterior (AP) ratio and cross-sectional area ratio, abscess length, and abscess thickness. RESULTS: Thirty-five of the 53 patients (66%) had preoperative neurologic deficits, and 21 of 53 patients (40%) had postoperative residual neurologic deficits. Patients' neurologic status improved significantly after the surgery (p<.001). Risk factors including age, diabetes, cauda equina syndrome, presence of anterior with posterior (A+P) dural abscess, canal compromise AP ratio, cross-sectional area ratio, abscess length, and abscess thickness were significantly correlated with postoperative residual neurologic deficits. In multivariate logistic regression analysis, age ≥70 years, preoperative cauda equina syndrome, abscess length ≥5.5 cm and abscess thickness ≥0.8 cm were the four most significant factors related to residual neurologic deficits. CONCLUSIONS: In patients with SEA of the thoracic and lumbar spine, age ≥70 years, preoperative cauda equina syndrome, abscess length ≥5.5 cm and abscess thickness ≥0.8 cm were the most significant preoperative risk factors for residual neurologic deficits after surgery.

Injection Drug Use in Patients With Spinal Epidural Abscess: Nationwide Data, 2000 to 2013.

STUDY DESIGN: Retrospective review of the Healthcare Cost and Utilization Project National Inpatient Sample, 2000 to 2013. OBJECTIVE: To determine the proportion of spinal epidural abscess (SEA) cases that were related to injection drug use (IDU) and to compare length of stay, leaving against medical advice, paralysis, cauda equina syndrome, radiculitis, and in-hospital mortality between SEA cases with and without IDU. SUMMARY OF BACKGROUND DATA: The US opioid epidemic impacts all aspects of healthcare, including spinal surgeons. Although injection drug use (IDU) is a risk factor for spinal epidural abscess (SEA), IDU among SEA patients and its effect on clinical outcomes is not well understood. METHODS: Cases aged 15 to 64 with principal diagnosis of SEA were classified as IDU-related (IDU-SEA) or non-IDU-related (non-IDU-SEA) using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for illicit drug use and hepatitis C. We determined the proportion of SEA patients with IDU and compared length of stay, leaving against medical advice, paralysis, cauda equina syndrome, radiculitis, and in-hospital mortality between IDU-SEA and non-IDU-SEA patients. RESULTS: From 2000 to 2013, there were 20,425 admissions with a principal diagnosis of SEA (95% confidence interval (CI), 19,281-21,568); 19.1% were associated with IDU (95% CI, 17.7%-20.5%). The proportion of white IDU-SEA cases increased by 2.4 percentage points annually (95% CI, 1.4-3.4). After adjusting for age, sex, and race, IDU-SEA patients stayed a mean of 6.7 more days in the hospital (95% CI, 5.1-8.2) and were 4.8 times more likely to leave against medical advice (95% CI, 2.9-8.0). Mean hospital charges for IDU-SEA patients were $31,603 higher (95% CI: $20,721-$42,485). Patients with IDU-SEA were less likely to have cauda equina syndrome (adjusted odds ratio, 0.48, 95% CI, 0.26-0.87). CONCLUSION: IDU-SEA patients stay in the hospital longer and more often leave against medical advice. Providers and hospitals may benefit from exploring how to better facilitate completion of inpatient treatment and achieve superior outcomes. LEVEL OF EVIDENCE: 3.

Low Back Pain in the Emergency Department: Prevalence of Serious Spinal Pathologies and Diagnostic Accuracy of Red Flags.

BACKGROUND: Very little evidence is available on the prevalence of serious spinal pathologies and the diagnostic accuracy of red flags in patients presenting to the emergency department (ED). This systematic review aims to investigate the prevalence of serious spinal pathologies and the diagnostic accuracy of red flags in patients presenting with low back pain to the ED. METHODS: We systematically searched MEDLINE, PUBMED, EMBASE, Cochrane Library, and SCOPUS from inception to January 2019. Two reviewers independently reviewed the references and evaluated methodological quality. RESULTS: We analyzed 22 studies with a total of 41,320 patients. The prevalence of any requiring immediate/urgent treatment was 2.5%-5.1% in prospective and 0.7%-7.4% in retrospective studies (0.0%-7.2% for vertebral fractures, 0.0%-2.1% for spinal cancer, 0.0%-1.9% for infectious disorders, 0.1%-1.9% for pathologies with spinal cord/cauda equina compression, 0.0%-0.9% for vascular pathologies). Examples of red flags which increased the likelihood for a serious condition were suspicion or history of cancer (spinal cancer); intravenous drug use, indwelling vascular catheter, and other infection site (epidural abscess). CONCLUSION: We found a higher prevalence of serious spinal pathologies in the ED compared to the reported prevalence in primary care settings. As the diagnostic accuracy of most red flags was reported only by a single study, further validation in high-quality prospective studies is needed.

High risk clinical characteristics for pyogenic spinal infection in acute neck or back pain: Prospective cohort study.

OBJECTIVE: To identify clinical characteristics associated with pyogenic spinal infection among adults presenting to a community emergency department (ED) with neck or back pain. A secondary objective was to describe the frequency of these characteristics among patients with spinal epidural abscess (SEA). METHODS: We conducted a prospective cohort study in a community ED enrolling adults with neck or back pain in whom the ED provider had clinical concern for pyogenic spinal infection. Study phase 1 (Jan 2004-Mar 2010) included patients with and without pyogenic spinal infection. Phase 2 (Apr 2010-Aug 2018) included only patients with pyogenic spinal infection. We performed univariate and multivariate analyses for association of clinical characteristics with pyogenic spinal infection. RESULTS: We enrolled 232 and analyzed 223 patients, 89 of whom had pyogenic spinal infection. The median age was 55 years and 102 patients (45.7%) were male. The clinical characteristics associated with pyogenic spinal infection on multivariate analysis of study phase 1 included recent soft tissue infection or bacteremia (OR 13.5, 95% CI 3.6 to 50.7), male sex (OR 5.0, 95% CI 2.5 to 10.0), and fever in the ED or prior to arrival (OR 2.8, 95% CI 1.3 to 6.0). Among patients with SEA (n = 61), 49 (80.3%) had at least one historical risk factor, 12 (19.7%) had fever in the ED, and 8 (13.1%) had a history of intravenous drug use. CONCLUSION: Male sex, fever, and recent soft tissue infection or bacteremia were associated with pyogenic spinal infection in this prospective ED cohort.

Development of a machine learning algorithm for prediction of failure of nonoperative management in spinal epidural abscess.

BACKGROUND CONTEXT: Data regarding risk of failure of nonoperative management in spinal epidural abscess (SEA) are limited. Given the potential for deterioration with treatment failure, a tool that predicts the probability of failure would be of great clinical utility. PURPOSE: We primarily aim to build a machine learning model using independent predictors of nonoperative management failure. Secondarily, we aim to develop an open-access web-based application that provides a patient-specific probability of treatment failure. STUDY DESIGN/SETTING: Retrospective, case-control study. PATIENT SAMPLE: Patients 18 years or older diagnosed with SEA at 2 academic medical centers and 3 community hospitals. OUTCOME MEASURES: Failure of nonoperative management. METHODS: This is a retrospective cohort study of 367 patients with SEA initially managed nonoperatively between 1993 and 2016. The primary outcome was failure of nonoperative management defined as neurologic deterioration, worsened back and/or radicular pain, or persistent symptoms despite initiation of antibiotic therapy. Five machine learning algorithms were developed and assessed by discrimination, calibration, and overall performance. RESULTS: Ninety-nine (27%) patients failed nonoperative management. Factors determined for prediction of nonoperative management were: motor deficit, diabetes, ventral component of abscess relative to thecal sac, history of compression or pathologic vertebral fracture, sensory deficit, active malignancy, and involvement of 3 or more vertebral levels. The elastic-net penalized logistic regression model was chosen as the final model given its superior discrimination, calibration, and overall model performance. This model was incorporated into an open access web application. CONCLUSION: By building a discriminative and well-calibrated model in a user-friendly and open-access digital interface, we hope to provide a prognostic tool that can be used to inform clinical decision-making in real-time.

Outcomes of additional instrumentation in elderly patients with pyogenic vertebral osteomyelitis and previous spinal instrumentation.

BACKGROUND CONTEXT: In patients with pyogenic vertebral osteomyelitis (PVO) and previous instrumentation requiring surgical treatment, a decision must be made between a less-invasive noninstrumented surgery, including retaining the previous instrumentation, or a more invasive additional instrumented surgery involving the complete removal of the infected tissue and firm restabilization. PURPOSE: To evaluate the clinical outcomes of using additional instrumentation in patients with PVO and previous instrumentation and determine the significant risk factors related to recurrent infection. STUDY DESIGN/SETTING: Retrospective cohort study (case control study). PATIENT SAMPLE: PVO patients with previous instrumentation. OUTCOME MEASURES: Recurrence of PVO and mortality. METHODS: Patients were divided into two groups (instrumented or noninstrumented) according to the presence or absence of additional instrumentation. The baseline characteristics, infection profile, and treatment outcomes were compared between the two groups, and a multivariate logistic regression analysis was performed to identify the risk factors for infection recurrence. RESULTS: A total of 187 postoperative patients with PVO and previous spinal instrumentation were included. There were no significant differences in the baseline characteristics except the presence of a titanium cage. Surgery for additional instrumentation in patients with PVO and previous instrumentation showed similar rates of infection recurrence and mortality compared with noninstrumented surgery despite a larger number of involved vertebral levels and greater incidence of epidural abscesses. However, instrumented patients with PVO and previous instrumentation who experienced infection recurrence had worse clinical outcomes than those of the noninstrumented patients with PVO. Severe medical comorbidities, the presence of a psoas abscess, and methicillin-resistant Staphylococcus aureus infection were associated with a higher risk of infection recurrence. CONCLUSIONS: Surgery for additional instrumentation in patients with PVO and previous instrumentation showed similar rates of infection recurrence and mortality to those who underwent noninstrumented surgery despite a larger number of involved vertebral levels and an increased frequency of epidural abscesses.

Update on spinal epidural abscess.

PURPOSE OF REVIEW: Spinal epidural abscess (SEA) is still a rare but potentially very morbid infection of the spine. In recent years, the incidence has risen sharply but the condition remains a medical conundrum wrought with unacceptably long diagnostic delays. The outcome depends on timely diagnosis and missed opportunities can be associated with catastrophic consequences. Management and outcomes have improved over the past decade. This review focuses on risk factors and markers that can aid in establishing the diagnosis, the radiological characteristics of SEA on MRI and their clinical implications, as well as the importance of establishing clear indications for surgical decompression. RECENT FINDINGS: This once exclusively surgically managed entity is increasingly treated conservatively with antimicrobial therapy. Patients diagnosed in a timely fashion, prior to cord involvement and the onset of neurologic deficits can safely be managed without decompressive surgery with targeted antimicrobial therapy. Patients with acute cord compression and gross neurologic deficits promptly undergo decompression. The greatest therapeutic dilemma remains the group with mild neurological deficits. As failure rates of delayed surgery approach 40%, recent research is focused on predictive models for failure of conservative SEA management. In addition, protocols are being implemented with some success, to shorten the diagnostic delay of SEA on initial presentation. SUMMARY: SEA is a potentially devastating condition that is frequently missed. Protocols are put in place to facilitate early evaluation of back pain in patients with red flags with appropriate cross-sectional imaging, namely contrast-enhanced MRI. Efforts for establishing clear-cut indications for surgical decompression of SEA are underway.

Fungal spinal epidural abscess: a case series of nine patients.

BACKGROUND CONTEXT: Fungal spinal epidural abscess (FSEA) is a rare entity with high morbidity and mortality. Reports describing the clinical features, diagnosis, treatment, and outcomes of FSEA are scarce in the literature. PURPOSE: This study aimed to describe the clinical features, diagnosis, treatment, and outcomes of FSEA. STUDY DESIGN: This study is designed as a retrospective clinical case series. PATIENT SAMPLE: A continuous series of patients with the diagnosis of FSEA who presented at our institution from 1993 to 2016. METHODS: We reviewed the electronic medical records of patients with SEA who were treated within our hospital system from 1993 to 2016. We only included SEA cases that were due to fungi. We also reviewed FSEA cases in the English language literature from 1952 to 2017 to analyze the features of FSEA. RESULTS: From a database of 1,053 SEA patients, we identified 9 patients with FSEA. Aspergillus fumigatus was isolated from 2 (22%) patients, and Candida species were isolated from 7 (78%). Focal spine pain, neurologic deficit, and fever were demonstrated in 89%, 50%, and 44% of FSEA cases, respectively. Five of nine cases involved the thoracic spine, and eight were located anterior to the thecal sac. Three cases had fungemia, six had long symptom duration (>2 weeks) prior to presentation, seven had concurrent immunosuppression, and eight had vertebral osteomyelitis. Additionally, one case had residual motor deficit at last follow-up, one had S1 sensory radicular symptoms, two suffered recurrent FSEA, two died within hospitalization, and two died within 90 days after discharge. CONCLUSIONS: In summary, the classic diagnostic triad (focal spine pain, neurologic deficit, and fever) is not of great clinical utility for FSEA. Biopsy, intraoperative tissue culture, and blood culture can be used to diagnose FSEA. The most common pathogens of FSEA are Aspergillus and Candida species. Therefore, empiric treatment for FSEA should cover these species while definitive identification is pending. FSEA is found in patients with poor baseline health status, which is the essential reason for its high mortality.

Methicillin-resistant Staphylococcus aureus intracranial abscess: An analytical series and review on molecular, surgical and medical aspects.

PURPOSE: Intracranial abscess caused by methicillin-resistant Staphylococcus aureus (MRSA) is rare and unexplored. The aim of the present study is to examine the prevalence, clinical and molecular characteristics, treatment options and outcome of MRSA intracranial abscess over a period of 6 years. PATIENTSAND METHODS: A total of 21 patients were included in this retrospective study. The demographic and clinical details of all the patients were collected. Molecular typing including staphylococcal cassette chromosome mec typing, spa typing and polymerase chain reaction of Panton-Valentine leucocidin toxin (PVL) gene for the latter 6 isolates was performed. RESULTS: The paediatric population was the most affected group (33.3%). The primary route of infection was post-operative/trauma in 7 (33.3%) cases. All the patients were treated surgically either by aspiration or excision. Fifteen (71%) patients received anti-MRSA treatment with vancomycin or linezolid, where linezolid-treated patients showed better prognosis. Of the 11 patients who were on follow-up, unfavourable outcome was observed in 3 (27.3%) cases and 8 (72.7%) cases improved. The molecular typing of six isolates revealed four community-associated (CA) MRSA, one each of livestock-associated (LA) and healthcare-associated MRSA with PVL gene noted in all. CONCLUSION: We propose that timely diagnosis, surgical intervention and appropriate anti-MRSA treatment would contribute to better outcome. The occurrence of CA-MRSA and LA-MRSA infection in the central nervous system signifies the threat from the community and livestock reservoir, thus drawing attention towards surveillance and tracking to understand the epidemiology and implement infection control measures.

Incidence, Morbidity, and Surgical Outcomes of Complex Spinal Inflammatory Syndromes in Adults.

BACKGROUND: Spondylodiscitis is a rare inflammatory syndrome affecting intervertebral discs and adjacent vertebral bodies. Without appropriate therapy, serious complications, such as secondary spinal epidural abscess (SEA), may prolong recovery time. In this study, we compared the main characteristics of our cohort of patients with spondylodiscitis with those of patients reported in the international literature and analyzed the impact of complications associated with spondylodiscitis on clinical outcomes. METHODS: We designed a retrospective study based on the database of the National Institute of Clinical Neurosciences, Hungary, between 2008 and 2015. We collected 78 patients suffering from primary spondylodiscitis or primary spinal epidural abscess. Based on the main clinical characteristics of our population (demographic features, initial symptoms, concurrent diseases, laboratory findings, microbiological diagnosis, therapy and clinical outcome) we constructed a database. Odds ratio (OR) counting was used to define the correlation between etiology and stage of recovery. RESULTS: We found a mild increase in the incidence of spondylodiscitis compared with international standards, and main demographic and clinical characteristics in concordance with international trends. Primary, noncomplicated spondylodiscitis had the best outcome results (OR, 1.25), and complicated spondylodiscitis had the worst, as well as the lowest OR for total recovery (0.6). CONCLUSIONS: The clinical characteristics of our study cohort did not differ from the international trends. Primary, noncomplicated spondylodiscitis has the highest odds for absolute recovery. Secondary spinal epidural abscess exacerbates ongoing spondylodiscitis, and thus should be considered a poor prognostic factor for spondylodiscitis. Early diagnosis and treatment may prevent serious complications and provide better outcomes.

The time-sensitive challenge of diagnosing spinal epidural abscess in the emergency department.

Spinal epidural abscess (SEA) is a rare but devastating condition. Entry of infectious contents into the epidural space occurs via contiguous infected tissue, hematogenous spread, or iatrogenic inoculation. Traditionally, emergency providers are taught to assess for the "classic triad" of spinal pain, fever, and neurological deficits, but this constellation of findings is seen in only 10-15% of cases. Delays in diagnosis and treatment of this condition directly correspond to worse, and often debilitating, outcomes for these patients. This review will demonstrate the challenges of diagnosing SEA, describe key diagnostic pitfalls, and present a model and framework for its evaluation. The authors conducted a systematic review in PubMed and Google Scholar for articles describing the emergency medicine evaluation and management of spinal epidural abscess dating from 1996 to 2016. Of the initial 219 articles found, 18 articles were selected based on their relevancy to emergency medicine. Lower back pain is a common chief complaint, whereas SEA is a rare condition and may not be anticipated. The "classic triad" of SEA symptoms presents infrequently. Moreover, the early symptoms of back pain and fever are non-specific, and patients seek medical attention at varying stages of disease progression. Once the more conspicuous and wide-ranging neurological symptoms develop, they are often irreversible. In fact, final outcomes correlate with the severity and duration of symptoms before surgery. Furthermore, discovering these late neurological symptoms can be particularly difficult in bed-bound and chronically ill patients. MRI is the best diagnostic imaging tool for SEA. Early diagnosis is the major prognostic factor for favorable outcome of SEA, and yet, making this diagnosis in the emergency department (ED) has proved challenging. Shifting from a "classic triad" screening to a risk factor-based model of evaluation represents the current optimal strategy for diagnosing SEA. An algorithm incorporating the most recent data is provided.

Spinal Epidural Abscess: A Series of 101 Cases.

BACKGROUND: Spinal epidural abscesses are uncommon but potentially devastating infections that often elude early diagnosis. An increasing incidence has been suggested; however, few contemporary data are available regarding risk factors and epidemiologic trends over time. METHODS: A retrospective study of spinal epidural abscesses from 2004 to 2014 at a large academic hospital was conducted. Cases were identified using International Classification of Diseases, Ninth Revision (ICD-9) code 324.1, and a review of medical and radiographic records was performed to confirm each case. Data collected included sociodemographics, medical history, suspected route of infection, treatments, and outcome. RESULTS: The incidence was 5.1 cases for each 10,000 admissions, with no significant changes during the study period. The route of infection was identified in 52% of cases, with bacteremia as the most common (26%), followed by recent surgery/procedure (21%) and spinal injection (6%). An identifiable underlying risk factor was present in 84% of cases, most commonly diabetes and intravenous drug use. A causative organism was identified in 84% of cases, most commonly Staphylococcus aureus; methicillin-resistant isolates accounted for 25% of S. aureus cases. All cases received intravenous antibiotic therapy, and 73% underwent a drainage procedure. Fifteen percent had an adverse outcome (8% paralysis and 7% death). CONCLUSIONS: The incidence of spinal epidural abscesses may be increasing, with the present study demonstrating a ≥5-fold higher rate compared with historical data. Although the outcome in most cases was favorable, spinal epidural abscesses continue to cause substantial morbidity and mortality and should remain a "not to be missed diagnosis."