Review Question - QID 213125

The patient's clinical history is most consistent with a cervical spine anterior epidural abscess with compression of the thecal sac. The most appropriate next step would be anterior decompression and fusion.

Spinal epidural abscesses are not uncommon in IV drug abusers, and can progress to cause neurologic symptoms. In addition to draining the abscess and debriding necrotic bone, vertebral body destruction and instability must be addressed with instrumentation and fusion, even in the face of infection. Prophylactic antibiotics should not be initiated until intraoperative cultures are obtained.

Tuchman et al. published a review of indications and timing for operative management of spinal epidural abscesses. They reported that the treatment of choice has traditionally involved emergency surgical evacuation and a prolonged course of antibiotics tailored to the offending pathogen. They present an evidence-based algorithm for selecting patients who may be safe candidates for nonoperative management. They concluded that the time point when a neurological injury becomes irreversible is unknown, and supported emergency surgery in those patients with acute findings.

Arko et al. published a systematic review of the medical and surgical management of spinal epidural abscesses. They reported that the most common pathogens found in blood and wound cultures were staphylococcus aureus and streptococcus species, and that patients without neurological deficits were significantly more likely to be treated medically than surgically. They recommended that patients with high risk factors should be carefully observed and should be highly considered for surgery.

Ju et al. performed a retrospective study to define clinical features and predisposing factors of motor weakness for patients with spinal epidural abscesses. They reported that, for pyogenic spinal epidural abscesses, 68% were treated surgically and 32% were treated medically with antibiotics. Greater than 80% of patients had good outcomes and ESR was the only significant prognostic factor. They concluded that motor weakness was the most important factor in the treatment algorithm and that early surgery should be performed for select patients with severe spinal stenosis to prevent motor weakness.

Figure A is a sagittal MRI depicting an anterior cervical epidural abscess with compression of neural elements. Figure B is an axial MRI at the C4-5 level.

Incorrect Answers:
Answer 1: The patient has neurological symptoms, necessitating drainage of the abscess. There is no literature to support surgical delay for intravenous steroids.
Answers 2 & 4: Broad spectrum antibiotics with possible IR-guided biopsy and culture would be indicated as cord level abscesses have an increased risk of progression.
Answer 5: The cervical epidural abscess is anterior, thus an anterior decompression and fusion would be most effective.