Extensive spinal epidural abscess (SEA), characterized by multilevel or holospinal involvement, is an uncommon but potentially devastating spinal infection associated with significant neurological morbidity. Due to its rarity, optimal surgical management remains debated, with most evidence derived from case reports and small case series. We present an illustrative case of extensive SEA managed surgically and contextualize the management strategy through a review of the available literature. A 58-year-old male patient with an extensive SEA involving multiple spinal levels from cervical to lumbar presented with clinical and radiological features consistent with infection and neurological compromise. MRI demonstrated a multilevel epidural purulent collection from C2 to L3, requiring urgent surgical intervention. The patient underwent limited decompression via a single-level laminectomy combined with catheter-directed epidural irrigation to achieve adequate drainage while avoiding extensive multilevel laminectomies. Staphylococcus aureus was isolated from intraoperative samples, and targeted antimicrobial therapy was administered postoperatively for six weeks. The patient demonstrated neurological improvement following surgery and achieved complete recovery at follow-up. A systematic search of MEDLINE, EMBASE, Scopus, the Cochrane Library, and Google Scholar was conducted in accordance with the PRISMA 2020 guidelines. Studies published between 1991 and 2025 describing surgically treated extensive or holospinal SEA were included. Thirty-four studies met the inclusion criteria. Patients were predominantly male (approximately 70%), with diabetes mellitus being the most common comorbidity, and S. aureus the most frequently isolated pathogen (reported in approximately 60% of cases with microbiological data). Most reported cases utilized limited or skip decompression with catheter-directed epidural irrigation to minimize the need for extensive multilevel laminectomy, with neurological improvement reported in the majority of patients (greater than 80% across included studies). Extensive SEA can be effectively managed using targeted decompression combined with catheter-directed irrigation and prolonged antimicrobial therapy. This case highlights the feasibility of limited decompression strategies in achieving adequate abscess drainage while reducing surgical morbidity, though conclusions should be interpreted in the context of retrospective, heterogeneous case-level data.
Sher et al. (Tue,) studied this question.