Kim Sang Do, Melikian Rojeh, Ju Kevin L, Zurakowski David, Wood Kirkham B, Bono Christopher M, Harris Mitchel B
Spine Center of Excellence, Cedars Sinai Medical Center, 444 S. San Vicente Blvd, Suite 901, Los Angeles, CA 90048, USA.
Department of Orthopaedics, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA.
Spine J. 2014 Aug 1;14(8):1673-9. doi: 10.1016/j.spinee.2013.10.011. Epub 2013 Oct 30.
The notion that all patients with spinal epidural abscess (SEA) require surgical decompression has been recently challenged by reports of successful medical management of select patients with SEA.
The purpose of this study was to identify the independent variables that determine success or failure of medical management of SEA.
STUDY DESIGN/SETTING: This was a retrospective, case-control study.
Patients 18 years or older with diagnosis of SEA admitted to our institution during the study period were included in the sample.
The outcome measure was successful management of SEA by eradication of the infection without worsening of neurologic deficits.
All patients admitted to our health-care system with a diagnosis of SEA from 1993 to 2011 were identified and the data were retrospectively collected. Patients 18 years or older diagnosed with SEA were included. Excluded were those with postsurgical SEA or phlegmon without an abscess and those with a complete spinal cord injury from SEA for longer than 48 hours.
A total of 355 patients with average age of 60 years met our inclusion criteria. Of the patients who initially underwent nonoperative treatment, 54 patients failed medical management and 73 patients were successfully treated without surgery. Univariate and multivariate analysis identified incomplete or complete spinal cord deficits as the most significant risk factor for failure of medical management. Age older than 65 years, diabetes, and methicillin-resistant Staphylococcus aureus (MRSA) were also independent risk factors for failure. An algorithm for probability of failed antibiotic management of spinal epidural abscess predicted 99% probability of failure for patients with all four of these risk factors.
SEA treated with medical management alone has a very high risk for failure if the patient is older than 65 years with diabetes, MRSA infection, or neurologic compromise. In the absence of these risk factors, nonoperative management of spinal epidural abscess may be considered as the initial line of treatment with close monitoring.
近期有报道称部分脊髓硬膜外脓肿（SEA）患者通过内科治疗取得成功，这对所有SEA患者均需手术减压的观点提出了挑战。
本研究旨在确定决定SEA内科治疗成败的独立变量。
研究设计/地点：这是一项回顾性病例对照研究。
研究期间在我院确诊为SEA且年龄在18岁及以上的患者纳入样本。
观察指标为通过根除感染且神经功能缺损无恶化来成功治疗SEA。
确定1993年至2011年我院医疗系统中所有诊断为SEA的患者，并回顾性收集数据。纳入年龄18岁及以上诊断为SEA的患者。排除术后SEA或无脓肿的蜂窝织炎患者以及SEA导致脊髓完全损伤超过48小时的患者。
共有355例平均年龄60岁的患者符合纳入标准。最初接受非手术治疗的患者中，54例内科治疗失败，73例未经手术成功治疗。单因素和多因素分析确定不完全或完全脊髓缺损是内科治疗失败的最显著危险因素。65岁以上、糖尿病和耐甲氧西林金黄色葡萄球菌（MRSA）感染也是失败的独立危险因素。脊髓硬膜外脓肿抗生素治疗失败概率算法预测，具有所有这四个危险因素的患者治疗失败概率为99%。
对于年龄大于65岁、患有糖尿病、MRSA感染或存在神经功能损害的患者，单纯内科治疗SEA失败风险极高。在不存在这些危险因素的情况下，脊髓硬膜外脓肿的非手术治疗可作为密切监测下的初始治疗方案。
