In a study by Davis et al., residual weakness remained in 37% of SEA patients (91% of whom had suffered a diagnostic delay).25 SEA patients without paralysis preoperatively or whose paralysis had developed less than 36 hours before the operation had better prognoses with respect to survival and recovery of function.²² In contrast, no patients with paralysis developing 48 hours or more before surgical decompression showed recovery of neurologic function.²²

Better outcomes are found in younger patients or those with thecal sac compression less than 50%. The prognosis is also better if the abscess is located in the lumbosacral region, likely because of less nerve root compression in this location compared to the direct cord compression that occurs in the cervical or thoracic spine.⁴⁷ Patients with anteriorly located SEA have an increased risk of osteomyelitis, with a resulting worse prognosis.⁴⁷

Conclusion

Nearly every publication on spinal epidural abscess emphasizes timely treatment to avoid or reduce permanent neurological disability. Risk factor assessment along with a thorough physical examination may afford a better screening strategy than simply using the presence of the “classic triad” for identification of SEA patients. This underscores the importance of considering SEA in high-risk patients and initiating a workup in the emergency department to avoid potentially catastrophic delays.

In summary, “The problem with spinal epidural abscesses is not the treatment, but its early diagnosis.”⁴⁸

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