Surgical vs. Non-operative management of Spinal Epidural Abscesses: a single center analysis

Introduction: Significant debate remains surrounding whether initial treatment modality for spinal epidural abscesses (SEA) should be surgical or nonsurgical. The insidious presentation, precipitous neurologic decline and nonspecific symptoms make diagnosis and management of SEA challenging. While nonoperative management of SEA can decrease risks associated with spinal surgery, especially for a cohort with advanced age and multiple comorbidities, failure of nonoperative management can lead to poor clinical outcomes. The objective of this report is to evaluate and characterize the management course of patients presenting with SEA.

Methods: A retrospective chart review was conducted of 45 patients with SEA at a single center between 2020-2023. Three different cohorts were defined based on their management course: initial recommendation for surgery (Group A), non-operative management (Group B), and initial recommendation for non-operative management which ultimately did require surgical intervention (Group C).

Results: The mean age of patients of cohorts A (46.8%, n=22), B (40.0%, n=18) and C (11.1%, n=5) were 56.7, 52.7 and 48.4. Median stay was 9.5, 10, and 11 days respectively. Of the total number of patients with initial non-operative management (n=23), 21.7% underwent surgery after medical management for an average of 9.8 days. Factors leading to switching patient management from non-operative to operative fell into three categories: antibiotic failure (80%), neurological deficit progression (40%), and patient election due to persistent pain (40%).

Conclusion : Our findings that after an average of 9.8 days, 20% of patients initially recommended for medical management required surgery suggest that vigilance should be maintained for patients presenting with SEA recommended for non-operative management. Further work is needed to elucidate factors associated with the conversion of medical to surgical treatment. Given SEA’s low incidence, multi institutional collaboration is a valuable next step to obtain generalizable assessments of operative vs non operative management courses.