＜Editors' Choice＞ Treatment strategy for upper cervical epidural abscess: a literature review

We aimed to determine available evidences in the literature regarding surgical approaches and methods, timing of surgical interventions, duration of perioperative antibiotics, and duration of nonsurgical treatments (antibiotics administration) in patients with upper cervical (occiput-C2) epidural abscess (UCEA). We performed a literature review of the articles on surgical interventions and antibiotic therapy to treat UCEA, searching the PubMed database for relevant articles published in the English language (as of March 2020). In total, 53 patients with UCEA were identified. Permanent limb paralysis or death was observed in 1/15 (6.7%) patients who received the transoral approach and 2/15 (13.3%) patients who received the transcervical approach, 1/26 (3.8%) patients who underwent surgery before the onset of paralysis, and 2/4 (50.0%) patients who underwent surgery after the onset of paralysis. In 85%-89% of cases, antibiotic administration was continued for 6-12 weeks, which was determined by the confirmation of reduced inflammatory response and/or abscess disappearance on imaging. Differences in surgical approaches may not be associated with the incidence of permanent limb paralysis or death. Surgical interventions before limb paralysis onset are recommended in UCEA patients. In perioperative and nonoperative treatments, antibiotic administration for 6-12 weeks may be supported based on the confirmation of reduced inflammatory response and/or abscess disappearance on imaging. Further investigations are needed.