Neurosurg Focus
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Delayed or inappropriate treatment of spinal epidural abscess (SEA) can lead to serious morbidity or death. It is a rare event with significant variation in its causes, anatomical locations, and rate of progression. Traditionally the treatment of choice has involved emergency surgical evacuation and a prolonged course of antibiotics tailored to the offending pathogen. Recent publications have advocated antibiotic treatment without surgical decompression in select patient populations. Clearly defining those patients who can be safely treated in this manner remains in evolution. The authors review the current literature concerning the treatment and outcome of SEA to make recommendations concerning what population can be safely triaged to nonoperative management and the optimal timing of surgery. ⋯ Patients who are unable to undergo an operation, have a complete spinal cord injury more than 48 hours with low clinical or radiographic concern for an ascending lesion, or who are neurologically stable and lack risk factors for failure of medical management may be initially treated with antibiotics alone and close clinical monitoring. If initial medical management is to be undertaken the patient should be made aware that delayed neurological deterioration may not fully resolve even after prompt surgical treatment. Patients deemed good surgical candidates should receive their operation as soon as possible because the rate of clinical deterioration with SEA is notoriously unpredictable. Although patients tend to recover from neurological deficits after treatment of SEA, the time point when a neurological injury becomes irreversible is unknown, supporting emergency surgery in those patients with acute findings.
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The medical management of discitis and osteomyelitis with long-term antibiotic therapy and bracing usually results in eradicated infection. Surgical management is appropriate when medical management fails and in some cases with pyogenic deformity or neurological deficit. The success of surgery depends on adequate debridement of the necrotic infected disc and vertebral body, along with anterior column reconstruction and vertebral stabilization. Debridement is typically performed via an anterior retroperitoneal approach, which can necessitate mobilization of the great vessels for proper exposure. Mobilization can be technically difficult and lead to vascular injury. The purpose of this study was to evaluate an alternative technique for the surgical treatment of lumbar discitis and osteomyelitis using a direct lateral retroperitoneal approach, which allows for thorough debridement and anterior column reconstruction while avoiding the need to mobilize the great vessels. ⋯ The direct lateral approach for the surgical treatment of lumbar discitis and osteomyelitis allows for thorough debridement and spinal reconstruction without the need to mobilize the great vessels. This technique effectively eradicated infection in all cases, with reasonable blood loss and no vascular injuries. This approach should be considered as an alternative to the open anterior approach. The authors recommend posterior instrumentation to prevent the development of kyphosis.
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One often overlooked aspect of spinal epidural abscesses (SEAs) is the timing of surgical management. Limited evidence is available correlating earlier intervention with outcomes. Spinal epidural abscesses, once a rare diagnosis carrying a poor prognosis, are steadily becoming more common, with one recent inpatient meta-analysis citing an approximate incidence of 1 in 10,000 admissions with a mortality approaching 16%. One key issue of contention is the benefit of rapid surgical management of SEA to maximize outcomes. Timing of surgical management is definitely one overlooked aspect of care in spinal infections. Therefore, the authors performed a retrospective analysis in which they evaluated patients who underwent early (evacuation within 24 hours) versus delayed surgical intervention (> 24 hours) from the point of diagnosis, in an attempt to test the hypothesis that earlier surgery results in improved outcomes. ⋯ Evacuation within 24 hours appeared to have a relative advantage over delayed surgery with regard to discharge neurological grade. However, due to a limited, variable sample size, a significant benefit could not be shown. Further subgroup analyses with larger populations are required.
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Vertebral osteomyelitis has been reported to occur in approximately 0.2-2 cases per 100,000 annually. Elevated laboratory values such as erythrocyte sedimentation rate and C-reactive protein suggest inflammatory etiologies. Different imaging modalities, from radiography and CT scanning to nuclear medicine imaging and contrastenhanced MRI, can be employed to evaluate for osteomyelitis. Although MRI has a strong sensitivity and specificity for vertebral osteomyelitis, obtaining histological and microbiological samples remains the gold standard in diagnosis. Therapy can be geared toward the specific pathogen cultured, thereby preventing the need surgical intervention in the majority of cases. However, recent reports have questioned the percentage yield of image-guided percutaneous biopsy even when there is a high clinical suspicion for vertebral osteomyelitis. ⋯ Image-guided percutaneous biopsy for vertebral osteomyelitis demonstrates an extremely low probability of identifying specific microbes. Blood or urine cultures concurrently identified culprit pathogens in 50% of positive biopsy cultures. Therefore, in only 8 (9.5%) of 84 biopsies did the biopsy results provide additional information to clinicians as to the pathological microorganism present and how treatment might need to be adjusted.