What are we waiting for? An argument for early surgery for spinal epidural abscesses

In the article: Timing and prognosis of surgery for spinal epidural abscess (SEA): A review, Epstein raises one major point; it is imperative that spinal surgeons "take back decision-making" from our medical cohorts and reinstitute early surgery (<24 h) to better treat SEAs.

Spine surgeons recognize the clinical triad (e.g., fever [50%], spinal pain [92-100%], and neurological deficits [47%]) for establishing the diagnosis of an SEA. We also appreciate the multiple major risk factors for developing SEA; diabetes (15-30%), elevated white blood cell count (>12.5), high C-reactive protein (>115), positive blood cultures, radiographic cord compression, and significant neurological deficits (e.g., 19-45%).

Recognizing these risk factors should prompt early open surgery (<24 h from the onset of a neurological deficit). Open surgery better defines the correct/multiple organisms present, and immediately provides adequate/thorough neurological decompression (with fusion if unstable). Although minimally invasive surgery may suffice in select cases, too often it provides insufficient biopsy/culture/irrigation/decompression. Most critically, nonsurgical options result in unacceptably high failure rates (e.g., 41-42.5-75% requiring delayed surgery), while risking permanent paralysis (up to 22%), and death (up to 25%).

As spine surgeons, we need to "take back decision-making" from our medical cohorts and advocate for early surgery to achieve better outcomes for our patients. Why should anyone accept the >41-42.5 to up to the 75% failure rate that accompanies the nonsurgical treatment of SEA, much less the >25% mortality rate?