Isolated Staphylococcus aureus spinal epidural abscesses: severe initial neurological deficits do not predict worse...

Spinal epidural abscesses (SEA) are rare but severe infections with a risk of neurological sequelae. Data focusing specifically on Staphylococcus aureus SEA remain scarce, despite this pathogen being the leading cause. The prognosis of primary versus secondary SEA, and the role of medical versus surgical management remain debated. We aimed to describe the clinical, microbiological and therapeutic features of S. aureus SEA and to identify potential prognostic factors.

We conducted a retrospective review of S. aureus SEA managed in two French tertiary centers. Comparative analyses were performed between primary and secondary SEA, and between patients with favorable versus poor neurological outcomes.

Between May 2007 and June 2025, 65 patients were included, representing the largest cohort focusing exclusively on S. aureus SEA. Median age was 61 years (IQR 51-71), with a male predominance (63%). Intravenous drug use was frequent (16%). Most cases were secondary to spondylodiscitis (86%), while primary SEA accounted for 14% and were associated with more severe initial neurological deficits. A cutaneous portal of entry was associated with better outcomes, whereas implant-related infections and unidentified sources predicted poorer prognosis. Methicillin-resistant S. aureus showed a non-significant trend toward worse outcomes. Surgery was performed in 40% of patients, mainly in those with deficits. Among medically managed patients, 78% were alive without neurological sequelae at three months.

This study highlights clinical differences between primary and secondary SEA and the prognostic value of portal-of-entry identification. Conservative management appears effective in selected patients without neurological deficits, provided careful multidisciplinary monitoring is ensured.