Introduction: Holospinal epidural abscesses (HEA) affecting the cervical, thoracic, and lumbar spine are rare. We present the largest ever reported series of HEA cases.
Methods: Billing records were queried for patients from 2011-2016 with diagnosis codes for spinal abscess. Charts were reviewed to find patients with HEA, totaling 8 patients. Information was collected on medical history, blood and epidural pathogens, symptoms at presentation, abscess location, presence of mass effect, surgical procedures, treatment regimens, and neurological outcomes.
Results: Eight patients with HEA were treated at our institution in the past five years; all underwent surgery. One (12.5%) underwent laminectomy of the entire spinal column, one (12.5%) had focal laminectomies at the area of mass effect, and six (75%) underwent skip laminectomies. Half required reoperation at other levels. Ultimately, five (62.5%) had decompression in all three regions of the spine, two had thoracolumbar decompressions, and one underwent cervical decompression. Average number of laminectomies was 8.6. Neurologically, 50% of patients improved, 37.5% remained stable, and 12.5% worsened. There was no difference in outcome between patients who underwent skip versus panspinal laminectomies. No differences in outcomes were noted in timing from presentation to surgery (median 5.3 hours), location of mass effect, dorsal versus ventral abscesses, or initial symptoms.Of the four patients who had cervical laminectomy without fusion, two developed post-laminectomy kyphosis requiring fusion.
Conclusions: There was no difference in outcomes between skip versus panspinal laminectomies for HEA. Most patients ultimately required decompression of their cervical, thoracic, and lumbar spines, suggesting that doing this in the first operation would be beneficial. Cervical instability occurred in half the patients who underwent cervical laminectomies without fusion, and there were no adverse outcomes in the patients who were fused in the setting of infection. Thus, one may consider performing instrumented fusion up front in these cases.
Patient Care: 1) This data demonstrates that skip laminectomies for the treatment of holospinal epidural abscess are sufficient, without necessity for laminectomies of the entire spinal column.
2) The data suggests that cervical instability following cervical laminectomies may warrant upfront fusion at the time of decompression.
3) Performing decompression at the cervical, thoracic, and lumbar spines at the initial surgery for evacuation of panspinal epidural abscess may minimize subsequent neurological decline and returns to the operating room.
Learning Objectives: 1) Describe the importance of upfront multi-level skip laminectomies for treatment of panspinal epidural abscess
2) Discuss in small groups the consideration for upfront posterior cervical fusion following cervical laminectomy for evacuation of epidural abscess
3) Identify the most effective treatment for panspinal epidural abscess