Medical and Surgical Management of Spinal Epidural Abscess
A PubMed keyword and Boolean search using ("spinal epidural abscess" OR "spinal epidural abscesses" AND [management OR treatment]) returned 429 results (Fig. 1). Filters for the English language and publications after 1999 were applied, as the first study comparing operative and nonoperative management was published that year. After identifying articles comparing operative to nonoperative treatment strategies for SEA, the references within those articles were further reviewed for additional relevant articles. We included only adult (greater than 18 years of age) studies, as risk factors and management differ between adult and pediatric groups. We excluded case reports and small series of less than 10 patients for lack of power, for failure of these studies to track patients over time, and to reduce introduction of selection bias in our analysis. We did not find any randomized prospective trials comparing operative and nonoperative management. We did not find any studies that included only nonoperative management. We did not include studies of only operative management because those articles did not directly compare operative versus nonoperative management in the same series of patients. We also excluded study reports without indications for conservative management, as inclusion of these studies would introduce selection bias with unclear reasons for why patients were chosen for medical management. Studies examining SEA as a result of a specific pathogen were also excluded, as they did not represent the general cohort of patients presenting with SEA.
(Enlarge Image)
Figure 1.
Flow diagram depicting algorithm for article selection.
Data from the articles meeting our inclusion criteria were pooled and included demographic characteristics, risk factors, medical comorbidities, presenting features, pathogens, abscess location, management, and outcomes. If an abscess location spanned multiple cord segments, the location would be classified based on the most rostral segment involved. Patients were stratified into 2 groups based on their neurological presentation: patients without neurological deficit, with or without back pain (Group 1), and patients with neurological deficits, including radiculopathy, paresis, and paralysis, with or without back pain (Group 2). Patients were further stratified into whether they were treated operatively or medically. Papers reporting the number of treatment failures were noted and their data were combined. Reishaus and colleagues' analysis of the literature on SEA from 1954 to 1997 was used as a historical control for comparison. JMP pro 10 from SAS was used for all statistical calculations. A 2-sample test for equality of proportions without continuity correction was used to determine the variance of our aggregate data against the historical control. Fisher's exact test was used to determine the aggregate trend of whether patients would be treated operatively or medically based on their presenting neurological symptoms.
Methods
A PubMed keyword and Boolean search using ("spinal epidural abscess" OR "spinal epidural abscesses" AND [management OR treatment]) returned 429 results (Fig. 1). Filters for the English language and publications after 1999 were applied, as the first study comparing operative and nonoperative management was published that year. After identifying articles comparing operative to nonoperative treatment strategies for SEA, the references within those articles were further reviewed for additional relevant articles. We included only adult (greater than 18 years of age) studies, as risk factors and management differ between adult and pediatric groups. We excluded case reports and small series of less than 10 patients for lack of power, for failure of these studies to track patients over time, and to reduce introduction of selection bias in our analysis. We did not find any randomized prospective trials comparing operative and nonoperative management. We did not find any studies that included only nonoperative management. We did not include studies of only operative management because those articles did not directly compare operative versus nonoperative management in the same series of patients. We also excluded study reports without indications for conservative management, as inclusion of these studies would introduce selection bias with unclear reasons for why patients were chosen for medical management. Studies examining SEA as a result of a specific pathogen were also excluded, as they did not represent the general cohort of patients presenting with SEA.
(Enlarge Image)
Figure 1.
Flow diagram depicting algorithm for article selection.
Data from the articles meeting our inclusion criteria were pooled and included demographic characteristics, risk factors, medical comorbidities, presenting features, pathogens, abscess location, management, and outcomes. If an abscess location spanned multiple cord segments, the location would be classified based on the most rostral segment involved. Patients were stratified into 2 groups based on their neurological presentation: patients without neurological deficit, with or without back pain (Group 1), and patients with neurological deficits, including radiculopathy, paresis, and paralysis, with or without back pain (Group 2). Patients were further stratified into whether they were treated operatively or medically. Papers reporting the number of treatment failures were noted and their data were combined. Reishaus and colleagues' analysis of the literature on SEA from 1954 to 1997 was used as a historical control for comparison. JMP pro 10 from SAS was used for all statistical calculations. A 2-sample test for equality of proportions without continuity correction was used to determine the variance of our aggregate data against the historical control. Fisher's exact test was used to determine the aggregate trend of whether patients would be treated operatively or medically based on their presenting neurological symptoms.
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