====== Spinal epidural abscess surgery ======

see also [[Spinal epidural abscess treatment]].
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Goals are establishing [[diagnosis]] and causative organism, drainage of [[pus]] and debridement of [[granulation tissue]], and bony [[stabilization]] if necessary. Most [[spinal epidural abscess]]es are posterior to the [[dura]] and are approached with extensive [[laminectomy]]. For posteriorly located [[spinal epidural abscess]] and no evidence of [[vertebral osteomyelitis]], [[instability]] will usually not follow simple [[laminectomy]] and appropriate postoperative [[antibiotic]]s
((Rea GL, McGregor JM, Miller CA, et al. Surgical
Treatment of the Spontaneous Spinal Epidural
Abscess. Surg Neurol. 1992; 37:274–279)).

Thorough antibiotic irrigation is employed intraoperatively. Primary closure is often employed. Post-op drainage is not necessary in cases with only granulation tissue and no pus. For recurrent infections, reoperation and post-op suction-irrigation may be needed
((Garrido E, Rosenwasser RH. Experience with the
Suction-Irrigation Technique in the Management
of Spinal Epidural Infection. Neurosurgery. 1983;
12:678–679)).

Patients with associated [[vertebral osteomyelitis]] may develop [[instability]] after [[laminectomy]]
alone,
((Eismont FJ, Bohlman HH, Soni PL, et al. Pyogenic
and Fungal Vertebral Osteomyelitis with Paralysis.
J Bone Joint Surg. 1983; 65A:19–29))
especially if significant bony destruction is present. Thus for anterior SEA, usually with
osteomyelitis (especially Pott’s disease), a posterolateral extracavitary approach is utilized whenever
possible (to avoid transabdominal or transthoracic approach in these debilitated patients) with
the removal of devitalized bone usually followed by posterior [[instrumentation]] and [[fusion]]. Strut grafting with an [[autologous bone]] (rib or fibula) can be done acutely in [[Pott’s disease]] with little risk of graft infection. With purulent [[osteomyelitis]], metal [[hardware]] is not contraindicated ([[titanium]] is more resistant to harboring bacteria than stainless steel for several reasons, including the fact that titanium does not permit bacteria to form a glycocalyx on its surface), but bone grafting may run the risk of perpetuating the infection. In this situation, some surgeons use beads of calcium sulfate bone void filler impregnated with an antibiotic (e.g. Stimulan® Rapid Cure™ antibiotic beads).
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Biportal endoscopic spinal surgery may be an effective alternative to traditional open surgical decompression for the treatment of SEA
((Kang T, Park SY, Lee SH, Park JH, Suh SW. Spinal epidural abscess successfully
treated with biportal endoscopic spinal surgery. Medicine (Baltimore). 2019
Dec;98(50):e18231. doi: 10.1097/MD.0000000000018231. PubMed PMID: 31852084;
PubMed Central PMCID: PMC6922448.
)).
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Compared with surgical drainage, fluoroscopy-guided percutaneous epidural drainage is a less invasive treatment option for patients with a poor general condition
((Fujii M, Shirakawa T, Shime N, Kawabata Y. Successful treatment of extensive
spinal epidural abscess with fluoroscopy-guided percutaneous drainage: a case
report. JA Clin Rep. 2020 Jan 15;6(1):4. doi: 10.1186/s40981-020-0309-z. PubMed
PMID: 32026104; PubMed Central PMCID: PMC6967264.
))