Although these infections are usually monomicrobial,^17,29,36,37 broad-spectrum antibiotic therapy covering S. aureus, E. coli, and P. aeruginosa should be initiated early after blood cultures are obtained,^38,39 and urgent infectious disease consultation should be sought.

In most instances, vancomycin combined with a cephalosporin having antipseudomonal activity (ceftazidime or cefepime) or meropenem is indicated until culture results can provide information to tailor therapy.⁴⁰ In selected cases in which the patient does not have risk factors for nosocomial drug-resistant organisms, empiric therapy with nafcillin (or oxacillin), combined with a third-generation cephalosporin (ceftriaxone or cefotaxime) may be appropriate.⁴⁰ Regardless of antibiotic selection, the duration of treatment is usually a minimum of 4-6 weeks.^7,40

Trial Therapies

Nonsurgical treatment is a viable option for selected patients, including poor surgical candidates, those with bleeding tendencies, lack of neurological deficits, or complete paralysis for more than 3 days.⁷ Those patients with large abscesses extending from the cervical to the lumbar segments may also be candidates for conservative treatment.^13,41

In general, the most important prerequisite for nonsurgical treatment is that the diagnosis must be made before the initial onset of neurological deficits.¹² Close, continued monitoring is essential to ensure immediate surgical intervention at the first sign of deterioration.⁴² The rarity of SEA overall precludes a prospective randomized trial that would elucidate the role of medical versus surgical treatment of SEA.⁴²

Specific treatment options, however, are not determined by the emergency physician, who should consider all cases of SEA neurosurgical emergencies.²⁹

Hyperbaric oxygen (HBO) has been used to treat a variety of infected and hypoperfused wounds.⁴³ Although the mechanism by which HBO acts as a beneficial adjunct in treating SEA is not completely understood, it is thought to enhance the direct bactericidal or bacteriostatic effect of antibiotics.⁴³ There is anecdotal evidence of a cervical epidural abscess managed conservatively with HBO and antibiotics after initial treatment failure from antibiotics alone.⁴³ HBO has also been used in conjunction with laminectomy.⁴⁴

Prognosis

Prior to the 1930s, most patients with SEA died. The mortality of SEA dropped from 34% in the period of 1954-1960 to about 15%^7,45,46 in 1991-1997. Complete recovery can be expected in about 45% of patients,⁷ but permanent neurologic sequelae remain common.

The duration of neurologic impairment has a significant influence on outcome. Not surprisingly, the longer the duration of symptoms such as bowel/bladder dysfunction or paralysis, the poorer the prognosis.⁴⁷ The most significant factor contributing to duration of symptoms is delay in diagnosis, with the most common misdiagnosis being meningitis, followed by intervertebral disk prolapse, urinary tract infection, and vertebral osteomyelitis.⁷