Spinal epidural abscess treatment [Neurosurgery Wiki]

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====== Spinal epidural abscess treatment ======

{{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1zcrKMCEYILmympl2UPpBcgMmsE0RWC7Z_c7AE7J0dMBO63sSF/?limit=15&utm_campaign=pubmed-2&fc=20240322035057}}

● [[Spinal epidural abscess]] may produce progressive [[myelopathy]], sometimes with precipitous [[deterioration]], therefore early
surgery has been advocated by some even if no neuro deficit.

● treatment: controversial. Many patients improve with [[antibiotic]]s alone, but some may deteriorate
precipitously


===== General information =====

Controversial. In most cases, treatment of [[spinal epidural abscess]] consists of early surgical [[evacuation]] combined with
[[antibiotic]]s as the treatment of choice. Argument: although there are reports of management with
antibiotics alone
((Morbidity from Acute Bacterial Spinal Epidural
Abscess using Computed Tomography and
Nonsurgical Treatment in Selected Patients. Ann
Neurol. 1985; 17:350–355))
((Mampalam TJ, Rosegay H, Andrews BT, et al.
Nonoperative Treatment of Spinal Epidural
Infections. J Neurosurg. 1989; 71:208–210))
((Hanigan WC, Asner NG, Elwood PW. Magnetic
Resonance Imaging and the Nonoperative
Treatment of Spinal Epidural Abscess. Surg Neurol.
1990; 34:408–413))
± immobilization,
((Cahill DW. Infections of the Spine. Contemp
Neurosurg. 1993; 15:1–8))
rapid and irreversible deterioration has occurred even in
patients treated with appropriate antibiotics who were initially neurologically intact
((Danner RL, Hartman BJ. Update of Spinal Epidural
Abscess: 35 Cases and Review of the Literature.
Rev Infect Dis. 1987; 9:265–274))
((Hlavin ML, Kaminski HJ, Ross JS, et al. Spinal
Epidural Abscess: A Ten-Year Perspective.
Neurosurgery. 1990; 27:177–184))
86% of
those who deteriorated were initially treated with antibiotics alone.
((Curry WT,Jr, Hoh BL, Amin-Hanjani S, et al. Spinal
epidural abscess: clinical presentation, management,
and outcome. Surg Neurol. 2005; 63:364–
71; discussion 371))

Therefore it has been recommended that nonsurgical management be reserved for the following patients 

1. those with prohibitive operative risk factors

2. involvement of an extensive length of the spinal canal

3. complete paralysis for > 3 days

To add fuel to the argument, in many cases, at the time of surgery, instead of a true [[abscess]], inflammatory [[tissue]] that is not easily or effectively debrided is encountered.
----
Although neurosurgical [[decompression]] is still the treatment of choice in the majority of cases, less invasive procedures (e.g. computed tomography-guided needle aspiration) or antimicrobial treatment alone can be applied in selected cases. The choice of the most appropriate therapy should be discussed immediately after a confirmed diagnosis in consultation with infectious disease, radiology and spinal surgery specialists. 

[[Spinal epidural abscess]]es usually are surgical emergencies because of concurrent neurologic deficits. 

Due to the rarity of this condition, there have been few randomized controlled trials to evaluate new treatment strategies, and most recommendations regarding treatment are based on case series studies often derived from the experiences at a single center
((Krishnamohan P, Berger JR. Spinal epidural abscess. Curr Infect Dis Rep. 2014 
Nov;16(11):436. doi: 10.1007/s11908-014-0436-7. PubMed PMID: 25230605.))

When an SEA is widespread, extensive decompression with laminectomy is often impossible, as it may subject the patient to very long operative times, extensive blood loss, and mechanical instability. A technique called "skip laminectomy" has been described in the literature, in which laminectomies are performed at the rostral and caudal ends of an abscess that spans 3-5 levels and a Fogarty catheter is used to mechanically drain the abscess, much like in an embolectomy. 

The optimal management of SEAs in patients 50 years of age and older remains a matter of considerable debate. In an older patient population with multiple comorbidities, whether intravenous antibiotics alone or in combination with surgery lead to superior outcomes remains unknown. 

Results of a study suggest that in patients 50 years of age and older, early surgical decompression combined with intravenous antimicrobial therapy was not associated with superior clinical outcomes when compared with intravenous antimicrobial therapy alone
((Adogwa O, Karikari IO, Carr KR, Krucoff M, Ajay D, Fatemi P, Perez EL, Cheng
JS, Bagley CA, Isaacs RE. Spontaneous spinal epidural abscess in patients 50
years of age and older: a 15-year institutional perspective and review of the
literature: clinical article. J Neurosurg Spine. 2014 Mar;20(3):344-9. doi:
10.3171/2013.11.SPINE13527. Epub 2013 Dec 20. Review. PubMed PMID: 24359002.)).

===== Surgery =====

[[Spinal epidural abscess surgery]].

===== Specific antibiotics =====

If organism and source unknown, [[staphylococcus aureus]] most likely. 

Empiric [[antibiotic]]s: 

● [[Ceftriaxone]] or [[cefepime]] (use when pseudomonas is a concern)

PLUS

● [[metronidazole]]

PLUS

● [[vancomycin]]:

○ until methicillin resistant S. aureus ([[MRSA]]) can be ruled out

○ once MRSA is ruled out a switch to synthetic [[penicillin]] (e.g. [[nafcillin]] or [[oxacillin]])

● ± [[rifampin]] PO

Modify antibiotics based on culture results or knowledge of source (e.g. IV drug abusers have a higher incidence of [[Gram]]-negative organisms).
----
IV [[cefazolin]] with oral [[probenecid]] may represent a once-daily IV treatment option for patients with methicillin-sensitive [[Staphylococcus aureus]] bacteremia and kidney disease
((Shah S, Golden M, Topal JE, McManus D. Intravenous (IV) cefazolin with oral
probenecid: A novel daily regimen for the management of Methicillin Sensitive
Staphylococcus aureus (MSSA) bacteremia in a patient with renal dysfunction.
IDCases. 2020 Jan 29;19:e00706. doi: 10.1016/j.idcr.2020.e00706. eCollection
2020. PubMed PMID: 32055441; PubMed Central PMCID: PMC7005544.
)).

===== References =====