Division of Neurosurgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina;
J Neurosurg Spine. 2014 Mar;20(3):344-9. doi: 10.3171/2013.11.SPINE13527. Epub 2013 Dec 20.
A spinal epidural abscess (SEA) is a rare but severe infection requiring prompt recognition and management. The incidence of SEA has doubled in the past decade, owing to an aging population and to increased use of spinal instrumentation and vascular access. The optimal management of SEAs in patients 50 years of age and older remains a matter of considerable debate. In an older patient population with multiple comorbidities, whether intravenous antibiotics alone or in combination with surgery lead to superior outcomes remains unknown. The present study retrospectively analyzes cases of SEAs, in patients 50 years of age and older, treated at Duke University Medical Center over the past 15 years.
Eighty-two patients underwent treatment for a spinal epidural abscess between 1999 and 2013. There were 46 men and 36 women, whose overall mean age (± SD) was 65 ± 8.58 years (range 50-82 years). The mean duration of clinical follow-up was 41.38 ± 86.48 weeks. Thirty patients (37%) underwent surgery for removal of the abscess, whereas 52 (63%) were treated more conservatively, undergoing CT-guided aspiration or receiving antibiotics alone based on the results of blood cultures. The correlation between pretreatment variables and outcomes was evaluated in a multivariate regression analysis.
Back pain and severe motor deficits were the most common presenting symptoms. Compared with baseline neurological status, the majority of patients (68%) reported being neurologically "better" or "unchanged." Twelve patients (15%) had a good outcome (7 [23%] treated operatively vs 5 [10%] treated nonoperatively, p = 0.03), while clinical status in 41 patients (50%) remained unchanged (10 [33%] treated operatively vs 31 [60%] treated nonoperatively, p = 0.01). Overall, 20 patients (25%) died (9 [30%] treated operatively vs 11 [21%] treated nonoperatively, p = 0.43). In a multivariate logistic regression model, an increasing baseline level of pain, the presence of paraplegia or quadriplegia on initial presentation, and a dorsally located SEA were independently associated with poor outcomes.
The results of the study suggest that in patients 50 years of age and older, early surgical decompression combined with intravenous antimicrobial therapy was not associated with superior clinical outcomes when compared with intravenous antimicrobial therapy alone.
脊柱硬膜外脓肿（SEA）是一种罕见但严重的感染，需要及时识别和处理。由于人口老龄化以及脊柱器械和血管通路的使用增加，SEA 的发病率在过去十年中翻了一番。对于 50 岁及以上的患者，SEA 的最佳治疗方法仍然存在很大争议。在患有多种合并症的老年患者中，单独使用静脉抗生素或联合手术是否会带来更好的结果尚不清楚。本研究回顾性分析了过去 15 年在杜克大学医学中心治疗的 50 岁及以上 SEA 患者。
1999 年至 2013 年间，82 例患者接受了脊柱硬膜外脓肿治疗。其中男 46 例，女 36 例，平均年龄（±标准差）为 65±8.58 岁（50-82 岁）。平均临床随访时间为 41.38±86.48 周。30 例（37%）患者因脓肿切除而行手术治疗，52 例（63%）患者接受更保守的治疗，根据血培养结果行 CT 引导下抽吸或单独使用抗生素。采用多变量回归分析评估治疗前变量与结局的相关性。
背痛和严重运动障碍是最常见的首发症状。与基线神经状态相比，大多数患者（68%）报告神经状态“更好”或“无变化”。12 例（15%）患者预后良好（7 例[23%]行手术治疗与 5 例[10%]非手术治疗，p=0.03），41 例（50%）患者临床状况无变化（10 例[33%]行手术治疗与 31 例[60%]非手术治疗，p=0.01）。总体而言，20 例（25%）患者死亡（9 例[30%]行手术治疗与 11 例[21%]行非手术治疗，p=0.43）。在多变量逻辑回归模型中，基线疼痛水平升高、初始表现为截瘫或四肢瘫痪以及脓肿位于背部与不良结局独立相关。
本研究结果表明，对于 50 岁及以上的患者，与单独静脉应用抗生素治疗相比，早期手术减压联合静脉应用抗菌药物治疗并不能带来更好的临床结局。
