Operative treatment of spinal epidural abscesses does not improve outcomes in older patients


Owoicho Adogwa (Division of Neurosurgery, Department of Surgery, Duke University Medical Center, Durham, USA) and others report, in the Journal of Neurosurgery: Spine, that the combination of early surgical decompression and intravenous antimicrobial therapy does not improve clinical outcomes in patients aged ≥50 years with a spinal epidural abscess compared with intravenous antimicrobial therapy alone.

Adogwa et al write that spinal epidural abscesses are “rare but serious” infections that often require emergency neurosurgical intervention to avoid permanent neurological deficits. They add that treatment options include laminectomy (to allow surgical drainage and decompression), CT-guided percutaneous aspiration, prolonged antibiotic therapy or a combination of these approaches. However, according to Adogwa et al, whether prolonged antibiotic in combination with surgery is superior to prolonged antibiotic alone is unknown. Furthermore, no published studies have investigated treatment options for spinal epidural abscesses in patients aged ≥50 years—even though increasing age is a known risk factor for poor prognosis. The authors write: “We feel it is necessary to examine data from an older population in isolation to help guide clinical decision making for these patients. Therefore, this study retrospectively analysed cases of spinal epidural abscesses in patients aged 50 years or older, treated at our institution over the past 15 years.”

During the time period of the study (1999–2013), 82 patients aged ≥50 years were treated for a spinal epidural abscesses at the authors’ institution (Duke University Medical Center). All patients underwent T-guided aspiration or blood culture and either received a prolonged course of antibiotics (alone) or a combination of surgical decompression and prolonged antibiotics. The indications for surgery were neurological deficit or progressive spinal deformity (even in the absence of neurological deficit), with 30 (37%) patients undergoing surgery.

At a mean follow-up point of 41.38±86.48 weeks, 12 patients had a good outcome—with seven in the operative group vs. five in the non-operative group (p=0.03). There were no significant differences in the number of patients who worsened after treatment (two in the operative group vs. one in the non-operative group; p=0.53) or the number of patients who died (nine vs. 11 respectively; p=0.43). However, Adogwa et al did find (in a multivariate analysis) that increasing baseline level of pain, the presence of paraplegia or quadriplegia on initial presentation, and a dorsally located abscess were independent poor predictors of treatment outcome (regardless of what the treatment was).

They concluded: “Our study suggests that in patients aged 50 years or older, early surgical decompression combined with intravenous antimicrobial therapy was not associated with superior clinical outcomes when compared with intravenous antimicrobial therapy.”

Adogwa told Spinal News International: “The implications of this study is that in elderly patients with spinal epidural abscesses who have low functional reserve and several co-morbid medical conditions, early surgical decompression and intravenous antimicrobial therapy was not superior to intravenous antimicrobial therapy alone. This suggests that, absent of impending neurological deterioration, intravenous antibiotic therapy should be the first-line treatment for older patients with spinal epidural abscesses and re-assuring neurological examination.”