Extensive Spinal Epidural Abscesses Resolved with Minimally Invasive Surgery: Two Case Reports and Review of the Recent Literature

Vertebral Candidiasis, the State of the Art: A Systematic Literature Review

OBJECTIVE

In recent years, Candida spondylodiscitis has represented an increasingly emerging disease in clinical practice. This condition requires long-term antibiotic therapy and sometimes surgical treatments. The main purpose of this study is to investigate the epidemiology, clinical and radiological aspects, treatment protocols, and outcomes of Candida-mediated vertebral osteomyelitis.

METHODS

A systematic review of the English literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.The research was conducted on Medline, Cochrane library, PubMed, and Scopus using as search terms "vertebral"; "spinal"; "infection"; "spondylodiscitis"; "discitis"; "osteomyelitis"; "Candida"; and "Candidosis." A case of vertebral candidiasis that was surgically managed was also reported.

RESULTS

In total, 88 articles were included in our systematic review. Including the reported case, our analysis covered 113 cases of vertebral candidiasis. Candida albicans was isolated in 64 cases (56.1%), Candida tropicalis in 21 (18.4%), Candida glabrata in 14 (12.3%), and Candida parapsilosis in five (4.4%). The mean duration of the follow-up was 395 days. Finally, 87 (82%) patients completely recovered, ten (9.4%) died, and nine (8.5%) reported sequelae.

CONCLUSION

This systematic review summarized the state of the art on vertebral candidiasis, describing data on its clinical features, diagnostic criteria and current limitations, and treatment alternatives and their outcomes.

The Surgical Management of Holospinal Epidural Abscess: A Case Report and Review on Catheter-Based Irrigation Techniques

Holospinal epidural abscess (HEA) is an extremely rare spinal infection involving the entire spine and is infrequently reported in the literature. Cases with evidence of spinal cord compression and consequent neurological deficit are typically managed with prompt surgical drainage and broad-spectrum antibiotics. Surgical intervention is often challenging because this condition is inherently associated with poor prognosis and serious complications, including death. During the surgical evacuation of the abscess, catheter-based irrigation must be adequately performed. In the majority of reported cases, the extent of the advancement of the epidural catheter is blindly assessed by the operating surgeon, increasing the risk of residual collections and subsequent persistent infection. Herein, we report a rare case of HEA that was successfully treated with surgical evacuation and skip laminectomies. We also describe a catheter-based technique that facilitates adequate irrigation, thereby ensuring the complete drainage of HEA in obscured perispinal areas, as well as the decompression of the spinal cord. Postoperative neurological examination exhibited marked improvement in motor function (compared with a baseline of complete quadriparesis), indicating the successful decompression of the spinal cord and neurological improvement.

Extensive Spinal Epidural Abscess Resulting in Complete Paraplegia Treated by Selective Laminectomies and Irrigation

Background

Spinal epidural abscess (SEA) is an uncommon clinical entity that is often subject to delayed diagnosis and suboptimal treatment. Untreated disease leads to compression of the spinal cord, resulting in devastating complications.

Case Presentation

A 56‐year‐old man visited our hospital for progressive lower back and lower extremity pain of several days' duration. Significant pyrexia (39.5°C) and elevated C‐reactive protein (89.2 mg/L) were detected during admission, but no positive neurological examination findings were observed. Magnetic resonance imaging revealed pyogenic discitis at L3–4. Despite the administration of directed antibiotic therapy, the patient's condition rapidly deteriorated, culminating in complete paraplegia secondary to an extensive SEA from L4 to C7. Emergency spinal decompression surgery was canceled due to his poor clinical condition and refusal of informed consent. After further deterioration, he consented to two‐level selective laminectomies and irrigation.

Conclusions

In contrast with prior case reports, this case illustrates the natural history of an extensive SEA during conservative and late surgical treatment. Early diagnosis and timely surgical decompression are of great importance for extensive SEA.

A Prospective Observational Clinical and Radiological Study of a Modular Bridging External Fixator for Unstable Distal Radius Fractures

Introduction:

Distal Radius Fractures (DRFs), with a reported annual incidence of 600,000, are common injuries treated by trauma surgeons. This prospective observational study aims to assess the efficacy of a modular external fixation system in the treatment of unstable distal radius fractures at 12-months follow-up.

Materials and methods:

Between December 2014 and December 2016, 35 patients (female: 21, male:14; mean age: 62.5), with unstable DRFs, treated with modular external fixation system, were selected for this prospective observational study. All the patients underwent clinical and radiological reviews at follow-up.

Results:

At 12-month follow-up, a mean DASH score of 15.73 and a mean PRWE score 20.10 were recorded. Mean radial inclination was 19.92°; mean ulnar variance was 1.12 mm and mean palmar inclination was 9.76°.

Conclusion:

Modular external fixator system revealed clinically and radiologically effective in the treatment of unstable and comminuted DRFs. Additional K-wires should be used to complement the fracture fixation, when there is unacceptable fragment reduction only with external fixator.

Skip hemilaminectomy for the treatment of holospinal epidural abscess: A single-center experience

Background:

Holospinal epidural abscesses (HEAs) are rare with potentially devastating consequences. Urgent bony decompression and abscess evacuation with long-term antibiotic therapy are typically the treatment of choice.

Methods:

We reviewed cases of holospinal HEAs operated on between 2009 and 2018. Variables studied included preoperative laboratories, CT/MR studies plus clinical and radiographic follow-up for between 34 and 60 postoperative months.

Results:

We utilized skip hemilaminectomies to minimize the risks of segmental instability. Targeted antibiotic therapy was also started immediately and maintained for 6 postoperative weeks. MR/CT studies documented full radiographic and neurological recovery between 6 and 12-months later.

Conclusion:

HEAs may be treated utilizing multilevel skip hemilaminectomies to help maintain spinal stability while offering adequate abscess decompression/resolution.

Disseminated Spinal Epidural Abscess in an Immunocompetent Individual: A Case Report and Review of the Literature

Spinal epidural abscess (SEA) is an uncommon pyogenic infection, localized between the dura mater and vertebral periosteum, leading to significant morbidity and mortality. SEA development is connected with medical comorbidities and risk factors facilitating bacterial dissemination; multiple factors are believed to play a role, including aging, increased alcohol abuse, use of intravenous drugs, a greater prevalence of medical comorbidities, and increased rates of spinal surgery that furthers iatrogenic spinal infection. Here, we have reported the first known case of disseminated SEA in an immunocompetent individual. A 33-year-old Japanese woman visited our hospital due to 1 week of continuous fever, low back pain, and numbness of the entire left lower limb. She was diagnosed with disseminated SEA by complete spine magnetic resonance imaging scan, of unknown origin. She was treated for 13 days with piperacillin-tazobactam, then for 16 days with levofloxacin tablets; ultimately, she recovered without treatment complications. This case highlights the complicated pathology, diagnosis, and treatment of SEA. In addition, this case suggests the need for a careful and detailed examination when encountering patients presenting with fever, low back pain even in an immunocompetent individual; we should thoroughly investigate, including further image investigations, bacteriological and pathologic examination.

Tailored minimally invasive tubular laminectomies for the urgent treatment of rare holocord spinal epidural abscess: case report and review of technique

Spinal abscesses that involve the full length of the spine, from the cervical to the sacral regions, are rare and account for approximately 1% of spinal epidural infections. Urgent surgical decompression combined with antibiotics treatment is usually recommended in these patients and selection of the most suitable surgical approach is tailored on the extent and location of the fluid collection. We present a rare case of holocord spinal epidural abscess treated with cervico-thoracic-lumbar tandem tubular decompressive laminectomies with alternating incisions, which were tailored on the preoperative sagittal and axial extension of the abscess. This minimally invasive procedure allowed for the successful drainage and decompression of the epidural space in an adult patient presenting with acute worsening tetraparesis. After the surgery the patient's neurological examination improved and follow up radiological studies confirmed the successful decompression of the epidural space. Tailoring not only the level but also the laterality of the tandem tubular approach, may be beneficial in minimizing soft tissues trauma, blood loss, operative time and need for more extensive surgical exposure, while successfully treating rare holospinal epidural infections. Minimally invasive tailored decompression of holocord spinal epidural abscesses should be considered as a surgical option in selected patients presenting with acute neurological symptoms.

Spontaneous Vertebral Aspergillosis, the State of Art: A Systematic Literature Review

Objective

Vertebral aspergillosis is quite rare conditions, often misdiagnosed, that requires long-term antibiotic therapy, and sometimes, surgical treatments. The present investigations were aimed to investigate the epidemiology, clinical-radiological aspects, treatment protocols, and outcomes of Aspergillus-mediated vertebral osteomyelitis.

Methods

A systematic review of the pertinent English literature according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed. The research was conducted on Cochrane library, MEDLINE, PubMed, and Scopus using as search-terms “Aspergillus,” “vertebral osteomyelitis,” “spondylodiscitis,” “spine infection.” A case of vertebral aspergillosis conservatively managed was also reported.

Results

Eighty-nine articles were included in our systematic review. Including the reported case, our analysis covered 112 cases of vertebral aspergillosis. Aspergillus fumigatus was isolated in 68 cases (61.2%), Aspergillus flavus in 14 (12.6%), Aspergillus terreus in 4 (3.6%), Aspergillus nidulans in 2 (1.8%). Seventy-three patients (65.7%) completely recovered at the last follow-up evaluation; in 7 patients (6.3%) radiological signs of chronic infection were reported, whereas 32 patients (28.8%) died during the follow-up.

Conclusion

This systematic review summarized the state of the art on vertebral aspergillosis, retrieving data on clinical features, diagnostic criteria and current limitations, treatment alternatives, and their outcomes.

Skipped vertebral spontaneous spondylodiscitis caused by Granulicatella adiacens: Case report and a systematic literature review

BACKGROUND

Granulicatella adiacens is a nutritional variant of streptococcus (NVS), which has been rarely reported as an etiologic agent in spondylodiscitis (SD).

MATERIAL AND METHODS

We report a case of a 51-year-old male with from chronic low-back pain associated with right sciatica and ipsilateral monoparesis. Spinal MRI showed radiological signs on L1-L2 and L5-S1 discs consistent with SD. We also performed a systematic review of the pertinent literature in order to retrieve all the key information regarding microbiological and clinical features.

RESULTS

Including our patients, seven cases with a mean age 56 ± 10.2 years were reported in English literature. Six patients were conservatively managed with antibiotic therapy (66%), whereas three with surgery in combination with antibiotics (33%). An endocarditis was associated in three cases, and a pacemaker infection in one. All patients received targeted antibiotic therapy resulting in a quick improvement of clinical symptoms with favorable outcome. Our case is the only with a skip spontaneous SD, which needed a surgical decompression due to the associated neurological symptoms.

CONCLUSIONS

This incidence of SD sustained by Granulicatella adiances could be underestimated due to their particular microbiological conditions requested for their cultures. However, this infection should be suspected in cases of culture-negative SD, especially when associated with endocarditis.

Spinal holocord epidural abscess evacuated with double thoracic interval laminectomy: a rare case report with literature review

Introduction

Holocord spinal cord epidural abscess is an uncommon condition that may result in serious neurological complications. Prompt diagnosis and early treatment is of paramount importance for an optimum clinical outcome. This case report describes a novel technique of interval laminectomy at two sites in the thoracic spine and surgical decompression with the help of infant feeding tubes in a case of holocord spinal epidural abscess (HSEA).

Case presentation

An 18-year-old male presented to the emergency department with high-grade fever and low back ache of 2 weeks duration and loss of bowel and bladder control for 4 days. Neurological examination revealed intact motor power and sensation in all four limbs at presentation; however, there was a rapid deterioration to complete quadriplegia within 24 h. A diagnosis of holocord epidural abscess was made. Emergent decompression via interval thoracic laminectomy was done and appropriate antimicrobial therapy was instituted. At 10 months of follow-up, the individual showed complete neurological recovery.

Discussion

The technique used in this case is unique with respect to the level of laminectomy and the manoeuvre employed for pus evacuation. Complete neurological and functional recovery was achieved despite complete paralysis pre-operatively. The outcome indicates that there may be good prognosis for individuals with HSEA accompanied with neurological deficit and emergent surgical decompression.