THE CANADIAN JOURNAL OF NEUROLOGICAL SCIENCES Diagnosis and Management of Spinal Epidural Abscess

Twenty-five patients with spinal epidural abscess were treated at the University of Western Ontario hospitals between July 1980 and July 1990. There were eighteen males (72%) and seven females (28%), with a median age of 60 years. Concurrent illness resulting in immunocompromise was present in 60%. Eleven presented with complete myelopathy, thirteen had limb weakness, and one had no neurological deficit. In twenty cases the abscess consisted of frankly purulent material, while in five the epidural collection consisted of chronic granulation tissue. Staphylococcus aureus was isolated in 64% of the abscesses. Twenty-seven surgical procedures were performed on 21 patients. Ten cases occurred in the cervical spine (40%), seven in the thoracic spine (28%), three in both the cervical and thoracic spine (12%) and five in the lumbosacral spine (20%). Fourteen patients (56%) retained or recovered ambulation and there were five deaths (20%). The progression from back and radicular pain to weakness and eventual paralysis continues to be characteristic of spinal epidural infection. Morbidity and mortality remain unacceptably high because of delay in diagnosis and treatment. Magnetic resonance imaging is the radiological investigation of choice for the diagnosis of spinal epidural abscess. Prompt intervention, before the development of severe neurological deficits, can improve outcome. Immediate surgical drainage combined with antibiotics remains the treatment of choice. RESUME: Diagnostic et traitement de I'abces epidural spinal. Vingt-cinq patients avec abces epidural spinal ont et6 traites dans des hopitaux de l'Universite de l'ouest de l'Ontario entre juillet 1980 et juillet 1990. Vingt-huit etaient des hommes (72%) et sept etaient des femmes (28%), l'age median etant de 60 ans. Une maladie coexistante responsable d'un deficit immunitaire 6tait presente chez 60% des cas. Onze presentaient une myelopathic complete, treize avaient de la faiblesse au niveau des membres et un n'avait pas de deficit neurologique. Chez vingt cas, le contenu de I'abces etait franchement purulent, alors que chez cinq la collection etait composee de tissu de granulation chronique. Du staphylocoque dore a ete isole de 64% des abces. On a procede a vingt-sept interventions chirurgicales chez vingtet-un patients. Dix cas sont survenus au niveau du rachis cervical (40%), sept au niveau du rachis dorsal (28%), trois au niveau du rachis cervical et dorsal (12%) et cinq au niveau du rachis lombosacre (20%). Quatorze patients (56%) ont conserve ou recouvre la marche et il y a eu cinq deces (20%). La progression de la douleur dorsale et radiculaire a la faiblesse et a la paralysie eventuelle demeure caracteristique des infection epidurales spinales. La morbidite et la mortalite demeurent inacceptablement elevees a cause du retard a poser le diagnostic et a etablir le traitement. L'imagerie par resonance magnetique est 1'investigation radiologique de choix pour le diagnostic de I'abces Epidural spinal. Une intervention rapide, avant l'apparition de deficits neurologiques severes, peut ameliorer Tissue. Le drainage chirurgical immediat combine a l'antibiotherapie demeurent le traitement de choix. Can. J. Neurol. Sci. 1992; 19:180-187 Infection involving the spinal epidural space is a neurosurgical problem of considerable importance. Dandy studied the anatomy of the epidural space and described the clinical features and management of pyogenic infections involving this region. Although effective surgical and antimicrobial therapy is available, delay in diagnosis and treatment continue to result in high morbidity and mortality." Twenty-five cases of spinal epidural abscess were treated at our institution between July 1980 and July 1990. The present study reviews their presentation and outcome, in order to emphasize the importance of early recognition of this disorder and to present current epidemiological and microbiological trends. A grading scheme based on clinical status at the time of presentation is proposed, and the impact of magnetic resonance imaging (MRI) on diagnosis is discussed. MATERIAL AND METHODS This study examines 25 cases of spinal epidural abscess treated by the Division of Neurosurgery at the University of From the Brain Research Laboratories, Clinical Investigational Unit, Division of Neurosurgery, Department of Clinical Neurological Sciences, University of Western Ontario, London Received August 14, 1991. Accepted in final form December 4, 1991 Reprint requests to: Dr. Gary Redekop, Division of Neurosurgery, Department of Clinical Neurological Sciences, The University of Western Ontario, London, Ontario, Canada N6A 5A5