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Kreutzträger M, Lübstorf T, Ekkernkamp A, Blex C, Schwab JM, Kopp MA, Auhuber T, Wüstner G, Liebscher T. Spinal infection with intraspinal abscess or empyema and acute myelopathy: comparative analysis of diagnostics, therapy, complications and outcome in primary care. Eur J Trauma Emerg Surg 2022; 48:4745-4754. [PMID: 35657387 PMCID: PMC9712376 DOI: 10.1007/s00068-022-02001-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 05/06/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION This study on pyogenic spinal infections with intraspinal epidural involvement (PSI +) compared the outcome of patients with spinal cord injury (SCI) to those without (noSCI) taking diagnostic algorithm, therapy, and complications into account. METHODS Patients were enrolled in an ambispective study (2012-2017). Diagnostic and therapeutic algorithms, complications, and neurological outcome were analyzed descriptively. Survival was analyzed applying Kaplan-Meier method and Cox regression. RESULTS In total, 134 patients with a median (IQR) age of 72 (61-79) years were analyzed. Baseline characteristics were similar between the SCI (n = 55) and noSCI (n = 79). A higher percentage of endocarditis (9% vs. 0%; p = 0.03) was detected in the noSCI group. The majority (81%) received combinatorial therapy including spinal surgery and antibiotic treatment. The surgery complication rate was 16%. At discharge, improvement in neurologic function was present in 27% of the SCI patients. Length of stay, duration of ventilation and the burden of disease-associated complications were significantly higher in the SCI group (e.g., urinary tract infection, pressure ulcers). Lethality risk factors were age (HR 1.09, 95% CI 1.02-1.16, p = 0.014), and empyema/abscess extension (≥ 3 infected spinal segments, HR 4.72, 95% CI 1.57-14.20, p = 0.006), dominating over additional effects of Charlson comorbidity index, SCI, and type of treatment. The overall lethality rate was 11%. CONCLUSION PSI + are associated with higher in-hospital mortality, particularly when multiple spinal segments are involved. However, survival is similar with (SCI) or without myelopathy (noSCI). If SCI develops, the rate of disease complications is higher and early specialized SCI care might be substantial to reduce complication rates.
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Affiliation(s)
- Martin Kreutzträger
- Treatment Centre for Spinal Cord Injuries, BG Hospital Unfallkrankenhaus Berlin, Trauma Hospital Berlin, Warener Straße 7, 12683, Berlin, Germany.
- Department of Neurology and Experimental Neurology, Spinal Cord Injury Research, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Tom Lübstorf
- Department of Neurology and Experimental Neurology, Spinal Cord Injury Research, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Axel Ekkernkamp
- Trauma Surgery and Orthopedics Clinic, BG Hospital Unfallkrankenhaus, Berlin, Germany
| | - Christian Blex
- Department of Neurology and Experimental Neurology, Spinal Cord Injury Research, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jan M Schwab
- Department of Neurology and Experimental Neurology, Spinal Cord Injury Research, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Spinal Cord Injury Division, Department of Neurology, Belford Center for Spinal Cord Injury, The Ohio State University, Wexner Medical Center, Columbus, OH, 43210, USA
- Department of Neuroscience, The Neurological Institute, The Ohio State University, Wexner Medical Center, Columbus, OH, 43210, USA
- Department of Physical Medicine and Rehabilitation, The Neurological Institute, The Ohio State University, Wexner Medical Center, Columbus, OH, 43210, USA
| | - Marcel A Kopp
- Department of Neurology and Experimental Neurology, Spinal Cord Injury Research, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, QUEST - Center for Transforming Biomedical Research, Berlin, Germany
| | - Thomas Auhuber
- Medical Management, Trauma Hospital Berlin, Berlin, Germany
- University of the German Statutory Accident Insurance (HGU), Bad Hersfeld, Germany
| | - Grit Wüstner
- BG Hospital Unfallkrankenhaus Berlin, Berlin, Germany
| | - Thomas Liebscher
- Treatment Centre for Spinal Cord Injuries, BG Hospital Unfallkrankenhaus Berlin, Trauma Hospital Berlin, Warener Straße 7, 12683, Berlin, Germany
- Department of Neurology and Experimental Neurology, Spinal Cord Injury Research, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Pomponio MK, Khan IS, Evans LT, Simmons NE, Ball PA, Ryken TC, Hong J. Association between interhospital transfer and increased in-hospital mortality in patients with spinal epidural abscesses. Spine J 2022; 22:921-926. [PMID: 35017053 DOI: 10.1016/j.spinee.2022.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 11/30/2021] [Accepted: 01/03/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spinal epidural abscess (SEA) is an uncommon yet serious infection, associated with significant morbidity and mortality. Patients diagnosed with SEA often require surgical interventions or critical care services that are not available at community hospitals and are therefore transferred to tertiary care centers. Little is known about the effects of interhospital transfer on acute outcomes for patients with SEA. PURPOSE To study the effects of interhospital transfer on acute outcomes for patients with SEA. STUDY DESIGN Cross sectional analysis using the 2009 to 2017 National Inpatient Sample (NIS). PATIENT SAMPLE Using the 2009 to 2017 NIS, we identified cases of SEA using ICD, Ninth, or Tenth Revision diagnosis codes 324.1 & G06.1. OUTCOME MEASURES Our primary endpoint was in hospital mortality. METHODS The association between interhospital transfer and inpatient mortality was assessed using multivariable logistic regression to adjust for potential covariates. Patient and hospital factors associated with interhospital transfer were assessed in a secondary analysis. RESULTS A total of 21.5% of patient with SEA were treated after transfer from another hospital. After adjusting for covariates, those who presented after transfer had higher odds of death during hospitalization (OR: 1.51, 95% CI 1.27-1.78, p<.001). Transferred patients were significantly more likely to live in rural communities (11.4 % vs. 5.3 % for nontransferred patients). CONCLUSIONS Interhospital transfer, which occurred more frequently in patients from rural hospitals, was associated with death even after controlling for disease severity. Addressing healthcare delivery disparities across the US, including across the rural-urban spectrum, will require better understanding of the observed increased mortality of interhospital transfer as a preventable source of in-hospital mortality for SEA.
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Affiliation(s)
- Maria K Pomponio
- Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road Hanover, NH 03755, USA
| | - Imad S Khan
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Linton T Evans
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Nathan E Simmons
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Perry A Ball
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Timothy C Ryken
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Jennifer Hong
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA.
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A case report of an atypical presentation of pyogenic erector spinae abscess. Asian J Surg 2022; 45:2157-2158. [DOI: 10.1016/j.asjsur.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 04/29/2022] [Accepted: 05/06/2022] [Indexed: 11/17/2022] Open
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Laws EJ, Sánchez L, Beltran E, Domínguez E, Ekiri AB, Brocal J, De Risio L. Multicenter Study of Clinical Presentation, Treatment, and Outcome in 41 Dogs With Spinal Epidural Empyema. Front Vet Sci 2022; 9:813316. [PMID: 35330611 PMCID: PMC8940254 DOI: 10.3389/fvets.2022.813316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/18/2022] [Indexed: 11/25/2022] Open
Abstract
There is limited information on canine spinal epidural empyema (SEE). The aim of this multicenter retrospective study is to describe the clinical presentation and outcome of dogs undergoing spinal surgery or conservative management for SEE. Forty-one dogs met the inclusion criteria; the SEE was treated surgically in 17 dogs and conservatively in 24 dogs. Two dogs underwent spinal surgery after failure of conservative management, meaning that 19 dogs in total had spinal surgery. Long-term (i.e., >6 months) follow-up was available in 35 dogs (19 conservatively treated and 16 surgically treated dogs). Recovery to a functional pet status was achieved in 15/19 (78.9%) conservatively treated and 12/16 (75%) surgically treated dogs. There was no significant difference (p = 1.000) in long-term outcome between conservatively and surgically treated dogs (78.9 and 75%, respectively). However, significantly more surgically treated dogs were non-ambulatory at presentation (9/17 vs. 5/24, p = 0.048) compared with conservatively treated dogs. This study suggests that conservative treatment may be appropriate for dogs with SEE that are ambulatory at presentation and that surgically treated dogs generally have good outcomes. Age may be a negative prognostic indicator as dogs with poor long-term outcomes were significantly older than dogs with a good long-term outcome (p = 0.048). A larger prospective randomized study may provide further insight on treatment and outcome of SEE in dogs.
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Affiliation(s)
- Emma J. Laws
- Linnaeus Veterinary Limited, Solihull, United Kingdom
- *Correspondence: Emma J. Laws
| | - Lluís Sánchez
- Neurology/Neurosurgery Service, Willows Veterinary Centre and Referral Centre, Linnaeus Veterinary Limited, Solihull, United Kingdom
| | - Elsa Beltran
- Neurology/Neurosurgery Service, Queen Mother Hospital for Animals, Royal Veterinary College, Potters Bar, United Kingdom
| | - Elisabet Domínguez
- Diagnostic Imaging Service, Anicura ARS Hospital Veterinari, Barcelona, Spain
| | - Abel B. Ekiri
- Department of Veterinary Epidemiology and Public Health, School of Veterinary Medicine, University of Surrey, Guildford, United Kingdom
| | - Josep Brocal
- Neurology/Neurosurgery Service, Anderson Moores, Linnaeus Veterinary Limited, Winchester, United Kingdom
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Bazán PL, Adaro JCS, Ciccioli NM, Adaro AOG, Gonzalez RAA. MORPHOLOGICAL ASPECT OF PYOGENIC SPINAL EPIDURAL ABSCESSES. PART I. COLUNA/COLUMNA 2022. [DOI: 10.1590/s1808-185120222101260738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT Background: Pyogenic Spinal Epidural Abscess (PSEA) is difficult to diagnose and can have devastating consequences. Magnetic Resonance Imaging (MRI) has high sensitivity and specificity, which are further increased with the use of contrast. There are several classifications of vertebral infectious processes, with emphasis on spondylodiscitis. Objective: To analyze the morphological parameters and their reproducibility; and to analyze different resonance imaging sequences. Methods: Using an image database, a morphological classification of PSEA was planned, with five parameters: Region (R), indicating the upper and lower limits of the abscess; Location (U), indicating whether the abscess is anterior or posterior within the canal; Compromise (C), meningeal or content of the structures; Association (A), discitis, osteomyelitis or both; and Perivertebral (P), anterior, lateral or posterior extravertebral abscess. The first three parameters give an idea of the volume of the PSEA, while the last two give the related infectious foci. Thirty-five cases were analyzed using Kappa’s coefficient. Results: The global intra- and interobserver reproducibility was Kappa 0.81. The results for each parameter were as follows: R=0.95, U=0.92, C=0.66, A=0.70 and P=0.80. The first three give a notion of volume and the last two relate to the presence of vertebral infectious foci outside the canal. T2 weighted MRI with contrast was found to be the most effective imaging sequence. Conclusion: The morphological classification is simple to use, with excellent reproducibility. The parameters with the highest reproducibility were region and location, with values >0.92. The addition of gadolinium contrast increased the sensitivity of the diagnosis; the use of sagittal and axial images in T2-MRI was the most sensitive imaging sequence. Evidence Level III; Original.
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Affiliation(s)
- Pedro Luis Bazán
- HIGA San Martín de La Plata, Argentina; Hospital Italiano de La Plata, Argentina; Instituto de Diagnóstico La Plata, Argentina
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Nguyen LD, Vo TT, Tran CV, Hoang TTT, Vu PX, To KD, Doan HTN, Nguyen AD. Case Report: Epidural Abscess Following Obstetric Epidural Anesthesia in Vietnam. Int Med Case Rep J 2021; 14:301-305. [PMID: 34012298 PMCID: PMC8128129 DOI: 10.2147/imcrj.s301536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/17/2021] [Indexed: 11/23/2022] Open
Abstract
Epidural abscess after obstetric epidural anesthesia occurs infrequently and may result in severe morbidity. We report a clinical case of an epidural abscess in Vietnam. A 31-year-old woman who was in labor was admitted to our hospital and given epidural anesthesia indicated to relieve labor pain. After three hours of anesthesia, cesarean section was indicated for the patient due to signs of fetal failure, the epidural catheter was then used to relieve pain for the first 48 hours postoperatively. On post-partum day 5 she presented with high fever of 39-40°C, fatigue, stimulation, dyspnea, and lumbar pain. The patient then suffered from sepsis and lower limb paralysis. She was diagnosed with epidural abscess based on the MRI of the lumbar spine. The abscess was treated by surgery for draining and appropriate antibiotics with a satisfactory outcome as she completely recovered her motor function and stable health status.
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Affiliation(s)
| | | | | | | | | | - Kha Dong To
- School of Medicine, Vietnam National University Ho Chi Minh City, Ho Chi Minh City, Vietnam
- Vietnam National University Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | | | - Anh Duy Nguyen
- Hanoi Obstetrics and Gynecology Hospital, Hanoi, Vietnam
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Onyima C, Chinn M, Chin M. Epidural abscess after lumbar medial branch blocks in a patient on disease-modifying anti-rheumatic drug and corticosteroid. Reg Anesth Pain Med 2021; 46:923-925. [PMID: 33963083 DOI: 10.1136/rapm-2021-102656] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/10/2021] [Accepted: 04/15/2021] [Indexed: 02/03/2023]
Affiliation(s)
- Chiemeka Onyima
- Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Moshe Chinn
- Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - May Chin
- Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Talamonti G, Colistra D, Crisà F, Cenzato M, Giorgi P, D'Aliberti G. Spinal epidural abscess in COVID-19 patients. J Neurol 2020; 268:2320-2326. [PMID: 32910251 PMCID: PMC7482053 DOI: 10.1007/s00415-020-10211-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 08/29/2020] [Accepted: 09/02/2020] [Indexed: 12/17/2022]
Abstract
Objective To report the peculiarity of spinal epidural abscess in COVID-19 patients, as we have observed an unusually high number of these patients following the outbreak of SARS-Corona Virus-2. Methods We reviewed the clinical documentation of six consecutive COVID-19 patients with primary spinal epidural abscess that we surgically managed over a 2-month period. These cases were analyzed for what concerns both the viral infection and the spinal abscess. Results The abscesses were primary in all cases indicating that no evident infective source was found. A primary abscess represents the rarest form of spinal epidural abscess, which is usually secondary to invasive procedures or spread from adjacent infective sites, such as spondylodiscitis, generally occurring in patients with diabetes, obesity, cancer, or other chronic diseases. In all cases, there was mild lymphopenia but the spinal abscess occurred regardless of the severity of the viral disease, immunologic state, or presence of bacteremia. Obesity was the only risk factor and was reported in two patients. All patients but one were hypertensive. The preferred localizations were cervical and thoracic, whereas classic abscess generally occur at the lumbar level. No patient had a history of pyogenic infection, even though previous asymptomatic bacterial contaminations were reported in three cases. Conclusion We wonder about the concentration of this uncommon disease in such a short period. To our knowledge, cases of spinal epidural abscess in COVID-19 patients have not been reported to date. We hypothesize that, in our patients, the spinal infection could have depended on the coexistence of an initially asymptomatic bacterial contamination. The well-known COVID-19-related endotheliitis might have created the conditions for retrograde bacterial invasion to the correspondent spinal epidural space. Furthermore, spinal epidural abscess carries a significantly high morbidity and mortality. It is difficult to diagnose, especially in compromised COVID-19 patients but should be kept in mind as early diagnosis and treatment are crucial.
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Affiliation(s)
- G Talamonti
- Departments of Neurosurgery, ASST Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.
| | - Davide Colistra
- Departments of Neurosurgery, ASST Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Francesco Crisà
- Departments of Neurosurgery, ASST Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.,Università Di Milano, Milan, Italy
| | - Marco Cenzato
- Departments of Neurosurgery, ASST Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Pietro Giorgi
- Department of Orthopedics, ASST Niguarda, Milan, Italy
| | - Giuseppe D'Aliberti
- Departments of Neurosurgery, ASST Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
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To the Editor. Spine (Phila Pa 1976) 2020; 45:E304. [PMID: 32032341 DOI: 10.1097/brs.0000000000003366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Kim MS, Jeong TY, Cheong YS, Jeon YW, Lim SY, Kang SS, Kim IN, Chang TB, Seong HH, Hwang BM. Effect of epidural corticosteroid injection on magnetic resonance imaging findings. Korean J Pain 2017; 30:281-286. [PMID: 29123623 PMCID: PMC5665740 DOI: 10.3344/kjp.2017.30.4.281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 08/25/2017] [Accepted: 09/19/2017] [Indexed: 01/31/2023] Open
Abstract
Background Magnetic resonance imaging (MRI) of the spine is the preferred diagnostic tool for pathologic conditions affecting the spine. However, in patients receiving epidural corticosteroid injection (ESI) for treatment of spinal diseases, there is a possibility of misreading of MR images because of air or fluid in the epidural space after the injection. Therefore, we defined the characteristics of abnormal changes in MRI findings following an ESI in patients with low back pain. Methods We reviewed the medical records of 133 patients who underwent MRI of the lumbar spine within 7 days after ESI between 2006 and 2015.All patients were administered an ESI using a 22-gauge Tuohy needle at the lumbar spine through the interlaminar approach. The epidural space was identified by the loss of resistance technique with air. Results The incidences of abnormal changes in MRI findings because of ESI were 54%, 31%, and 25% in patients who underwent MRI at approximately 24 h, and 2 and 3 days after ESI, respectively. Abnormal MRI findings included epidural air or fluid, needle tracks, and soft tissue changes. Epidural air, the most frequent abnormal finding (82%), was observed in 41% of patients who underwent MRI within 3 days after injection. Abnormal findings due to an ESI were not observed in MR images acquired 4 days after ESI or later. Conclusions Pain physicians should consider the possibility of abnormal findings in MR images acquired after epidural injection using the interlaminar approach and the loss of resistance technique with air at the lumbar spine.
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Affiliation(s)
- Min Soo Kim
- Department of Anesthesiology and Pain Medicine, Institute of Medical Sciences, Kangwon National University Hospital, School of Medicine, Chuncheon, Korea
| | - Tae Yoon Jeong
- Department of Anesthesiology and Pain Medicine, Institute of Medical Sciences, Kangwon National University Hospital, School of Medicine, Chuncheon, Korea
| | - Yu Seon Cheong
- Department of Anesthesiology and Pain Medicine, Institute of Medical Sciences, Kangwon National University Hospital, School of Medicine, Chuncheon, Korea
| | - Young Wook Jeon
- Department of Radiology, Institute of Medical Sciences, Kangwon National University Hospital, School of Medicine, Chuncheon, Korea
| | - So Young Lim
- Department of Anesthesiology and Pain Medicine, Institute of Medical Sciences, Hallym University Hospital, School of Medicine, Chuncheon, Korea
| | - Seong Sik Kang
- Department of Anesthesiology and Pain Medicine, Institute of Medical Sciences, Kangwon National University Hospital, School of Medicine, Chuncheon, Korea
| | - In Nam Kim
- Department of Anesthesiology and Pain Medicine, Institute of Medical Sciences, Kangwon National University Hospital, School of Medicine, Chuncheon, Korea
| | - Tsong Bin Chang
- Department of Anesthesiology and Pain Medicine, Institute of Medical Sciences, Kangwon National University Hospital, School of Medicine, Chuncheon, Korea
| | - Hyun Ho Seong
- Department of Anesthesiology and Pain Medicine, Institute of Medical Sciences, Kangwon National University Hospital, School of Medicine, Chuncheon, Korea
| | - Byeong Mun Hwang
- Department of Anesthesiology and Pain Medicine, Institute of Medical Sciences, Kangwon National University Hospital, School of Medicine, Chuncheon, Korea
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Cupler ZA, Anderson MT, Stancik TJ. Thoracic Spondylodiscitis Epidural Abscess in an Afebrile Navy Veteran: A Case Report. J Chiropr Med 2017; 16:246-251. [PMID: 29097956 DOI: 10.1016/j.jcm.2017.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 02/13/2017] [Accepted: 03/28/2017] [Indexed: 12/17/2022] Open
Abstract
Objective The purpose of this case study was to describe the differential diagnosis of a thoracic epidural abscess in a Navy veteran who presented to a chiropractic clinic for evaluation and management with acupuncture within a Veterans Affairs Medical Center. Clinical Features An afebrile 59-year-old man with acute thoracic spine pain and chronic low back pain presented to the chiropractic clinic at a Veterans Affairs Medical Center for consideration for acupuncture treatment. Intervention and Outcome The veteran elected to trial acupuncture once per week for 4 weeks. A routine thoracic magnetic resonance imaging scan without gadolinium detected a space-occupying lesion after the patient failed to attain 50% reduction of pain within 2 weeks with conservative care. The patient was diagnosed with a multilevel thoracic spondylodiscitis epidural abscess and was treated same day with emergency debridement and laminectomy of T7-8 with a T6-9 fusion. The patient had complete recovery without neurological compromise and completed an antibiotic regimen for 6 weeks. Conclusion A Navy veteran with acute thoracic spine and chronic low back pain appeared to respond initially but failed to achieve clinically meaningful outcomes. Follow-up advanced imaging detected a thoracic spondylodiscitis epidural abscess. Early diagnosis and immediate intervention are important to preserving neurological function and limiting morbidity in cases of spondylodiscitis epidural abscess.
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Affiliation(s)
- Zachary A Cupler
- Physical Medicine & Rehabilitative Services, VA Butler Healthcare, Butler, Pennsylvania
| | - Michael T Anderson
- Physical Medicine & Rehabilitative Services, VA Butler Healthcare, Butler, Pennsylvania
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Park SH, Ryu WS. Ventriculitis Associated with Extended Spectrum Beta-Lactamase Producing Klebsiella pneumoniae after Acupuncture. JOURNAL OF NEUROCRITICAL CARE 2017. [DOI: 10.18700/jnc.170011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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DePasse JM, Ruttiman R, Eltorai AEM, Palumbo MA, Daniels AH. Assessment of malpractice claims due to spinal epidural abscess. J Neurosurg Spine 2017; 27:476-480. [PMID: 28498071 DOI: 10.3171/2016.12.spine16814] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spinal epidural abscesses (SEAs) can be difficult to diagnose and may result in neurological compromise or even death. Delays in diagnosis or treatment may worsen the prognosis. While SEA presents a high risk for litigation, little is known about the medicolegal ramifications of this condition. An enhanced understanding of potential legal implications is important for practicing spine surgeons, emergency medicine physicians, and internists. METHODS The VerdictSearch database, a large legal-claims database, was queried for "epidural abscess"-related legal cases. Demographic and clinical data were examined for all claims; any irrelevant cases or cases with incomplete information were excluded. The effects of age of the plaintiff, sex of the plaintiff, presence of a known infection, resulting paraplegia or quadriplegia, delay in diagnosis, and delay in treatment on the proportion of plaintiff rulings and size of payments were assessed. RESULTS In total, 56 cases met the inclusion criteria. Of the 56 cases, 17 (30.4%) were settled, 22 (39.3%) resulted in a defendant ruling, and 17 (30.4%) resulted in a plaintiff ruling. The mean award for plaintiff rulings was $5,277,468 ± $6,348,462 (range $185,000-$19,792,000), which was significantly larger than the mean award for cases that were settled out of court, $1,914,265 ± $1,313,322 (range $100,000-$4,500,000) (p < 0.05). The mean age of the plaintiffs was 47.0 ± 14.4 years; 23 (41.1%) of the plaintiffs were female and 33 (58.9%) were male. The proportion of plaintiff verdicts and size of monetary awards were not affected by age or sex (p > 0.49). The presence of a previously known infection was also not associated with the proportion of plaintiff verdicts or indemnity payments (p > 0.29). In contrast, juries were more likely to rule in favor of plaintiffs who became paraplegic or quadriplegic (p = 0.03) compared with plaintiffs who suffered pain or isolated weakness. Monetary awards for paraplegic or quadriplegic patients were also significantly higher (p = 0.003). Plaintiffs were more likely to win if there was a delay in diagnosis (p = 0.04) or delay in treatment (p = 0.006), although there was no difference in monetary awards (p > 0.57). Internists were the most commonly sued physician (named in 13 suits [23.2%]), followed by emergency medicine physicians (named in 8 [14.3%]), and orthopedic surgeons (named in 3 [5.4%]). CONCLUSIONS This investigation is the largest examination of legal claims due to spinal epidural abscess to date. The proportion of plaintiff verdicts was significantly higher in cases in which the patient became paraplegic or quadriplegic and in cases in which there was delay in diagnosis or treatment. Additionally, paralysis is linked to large sums awarded to the plaintiff. Nonsurgeon physicians, who are often responsible for initial diagnosis, were more likely to be sued than were surgeons.
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Affiliation(s)
- J Mason DePasse
- Division of Spine Surgery, Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Roy Ruttiman
- Division of Spine Surgery, Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Adam E M Eltorai
- Division of Spine Surgery, Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Mark A Palumbo
- Division of Spine Surgery, Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Alan H Daniels
- Division of Spine Surgery, Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Hammer A, Wolff D, Geißdörfer W, Schrey M, Ziegler R, Steiner HH, Bogdan C. A spinal epidural abscess due to Streptobacillus moniliformis infection following a rat bite: case report. J Neurosurg Spine 2017; 27:92-96. [PMID: 28430048 DOI: 10.3171/2016.12.spine161042] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The authors describe the case of a 40-year-old man suffering from an epidural abscess in the thoracic spine due to a rarely isolated pathogen, Streptobacillus moniliformis, the causative agent of rat bite fever. Besides diffuse abdominal pain, ataxia, paresthesia, hypesthesia, and enhanced reflexes of the lower extremities, the patient suffered from a decreased sensation of bladder filling. His history was also positive for a rat bite 6 weeks earlier. Magnetic resonance imaging showed an epidural, space-occupying lesion compressing the spinal cord at the vertebral levels of T6-8. Neurosurgery revealed an epidural abscess, which was drained via laminectomy (T-7) and excision of the ligamentum flavum (T6-8). The etiological agent S. moniliformis was identified by 16S rRNA-based polymerase chain reaction and sequencing as well as by culture and mass spectrometry. Treatment with penicillin G led to complete resolution of the abscess and clinical recovery of the patient, who regained his bladder-filling sensation and free walking ability. This case demonstrates that careful attention to the patient's history is essential in suspecting unusual bacterial pathogens as the cause of an epidural abscess and initiating the optimal diagnostic procedure and antimicrobial therapy.
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Affiliation(s)
- Alexander Hammer
- Department of Neurosurgery, Paracelsus Medical University, Nürnberg
| | - Dorit Wolff
- Mikrobiologisches Institut-Klinische Mikrobiologie, Immunologie und Hygiene, Friederich-Alexander-Universität Erlangen-Nürnberg, Universitätsklinikum Erlangen, Erlangen, Germany ; and
| | - Walter Geißdörfer
- Mikrobiologisches Institut-Klinische Mikrobiologie, Immunologie und Hygiene, Friederich-Alexander-Universität Erlangen-Nürnberg, Universitätsklinikum Erlangen, Erlangen, Germany ; and
| | - Michael Schrey
- Department of Neurosurgery, Paracelsus Medical University, Nürnberg
| | - Renate Ziegler
- Institut für Klinikhygiene, Medizinische Mikrobiologie und Klinische Infektiologie, Universitätsinstitut der Paracelsus Medizinischen Privatuniversität, Nürnberg, Germany
| | | | - Christian Bogdan
- Mikrobiologisches Institut-Klinische Mikrobiologie, Immunologie und Hygiene, Friederich-Alexander-Universität Erlangen-Nürnberg, Universitätsklinikum Erlangen, Erlangen, Germany ; and
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Tardieu GG, Fisahn C, Loukas M, Moisi M, Chapman J, Oskouian RJ, Tubbs RS. The Epidural Ligaments (of Hofmann): A Comprehensive Review of the Literature. Cureus 2016; 8:e779. [PMID: 27752405 PMCID: PMC5063636 DOI: 10.7759/cureus.779] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The epidural space contains the internal vertebral venous plexus, adipose, and other connective tissues. In the anatomical literature, there are nonspecific descriptions of varying fibrous connective tissue bands in the epidural space, mainly mentioned in the lumbar region, that tether the dural sac to the posterior longitudinal ligament, the vertebral canal, and the ligamentum flavum. These ligaments have been termed as Hofmann’s ligaments. This review expands on the anatomy and function of Hofmann’s ligaments, increasing the awareness of their presence and serves as an impetus for further study of their histology, innervation, and function.
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Affiliation(s)
| | - Christian Fisahn
- Orthopedic Surgery, Swedish Neuroscience Institute ; Department of Trauma Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
| | | | - Marc Moisi
- Seattle Science Foundation ; Neurological Surgery, Wayne State University
| | - Jens Chapman
- Orthopedics Spine Surgery, Swedish Neuroscience Institute
| | - Rod J Oskouian
- Neurosurgery, Complex Spine, Swedish Neuroscience Institute
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