Is there a difference in neurologic outcome in medical versus early operative management of cervical epidural abscesses?

Background context: The ideal management of cervical spine epidural abscess (CSEA), medical versus surgical, is controversial. The medical failure rate and neurologic consequences of delayed surgery are not known.

Purpose: The purpose of this study is to assess the neurologic outcome of patients with CSEA managed medically or with early surgical intervention and to identify the risk factors for medical failure and the consequences of delayed surgery.

Study design/setting: Retrospective electronic medical record (EMR) review.

Patient sample: Sixty-two patients with spontaneous CSEA, confirmed with advanced imaging, from a single tertiary medical center from January 5 to September 11.

Outcome measures: Patient data were collected from the EMR with motor scores (MS) (American Spinal Injury Association 0-100) recorded pre/posttreatment. Three treatment groups emerged: medical without surgery, early surgery, and those initially managed medically but failed requiring delayed surgery.

Methods: Inclusion criteria: spontaneous CSEA based on imaging and intraoperative findings when available, age >18 years, and adequate EMR documentation of the medical decision-making process. Exclusion criteria: postoperative infections, Pott disease, isolated discitis/osteomyelitis, and patients with imaging findings suggestive of CSEA but negative intraoperative findings and cultures.

Results: Of the 62 patients included, 6 were successfully managed medically (Group 1) with MS increase of 2.3 points (standard deviation [SD] 4.4). Thirty-eight patients were treated with early surgery (Group 2) (average time to operating room 24.4 hours [SD 19.2] with average MS increase 11.89 points [SD 19.5]). Eighteen failed medical management (Group 3) requiring delayed surgery (time to OR 7.02 days [SD 5.33]) with a net MS drop of 15.89 (SD 24.9). The medical failure rate was 75%. MS change between early and delayed surgery was significant (p<.001) favoring early surgery. Risk factors and laboratory data did not predict medical failure or posttreatment MS because of the high number of medical failures when abscess involves the cervical epidural space.

Conclusions: Early surgery results in improved posttreatment MS compared with medical failure and delayed surgery. In our patients, the failure rate of medical management was high, 75%. Based on our results, we recommend early surgical decompression for all CSEA.