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Hugues Dokponou YC, Ontsi Obame FL, Mohcine S, Saad ME, Abderrahmane H, Imbunhe N, Mandour C, Gazzaz M. Extensive Spinal Epidural Abscess: A Systematic Review of Risk Factors, Clinical Presentation, and Management with a Case Illustration. World Neurosurg 2024; 189:273-284. [PMID: 38906469 DOI: 10.1016/j.wneu.2024.06.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 06/13/2024] [Accepted: 06/14/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND Extensive spinal epidural abscess (ESEA) is a rare clinical entity subject to delayed diagnosis, which can be explained by the extension of the epidural collection, thereby delaying the mass effect responsible for its clinical manifestations. METHODS We report a rare case of an extensive C7-T10 epidural abscess in a 54-year-old man treated with antibiotics, laminectomy, and abscess drainage. In addition, we conducted a systematic literature search according to the "Preferred Reporting Items for Systematic Reviews" guidelines. Relevant studies (1980-2023) reporting patients with ESEA were identified from PubMed databases. RESULTS A total of 48 studies reporting 55 patients were included in this study with a mean age of 55.7 ± 14.6 years with a male predominance of 61.8% (n = 34). The median duration of follow-up was 38 months (21.5-64.3). The mortality rate of ESEA was 1.8% for a 21.8% morbidity rate with 76.4% (n = 42) reported to have been improved after surgery. CONCLUSIONS Both single and multilevel laminectomy with abscess drainage for ESEA leads to patient recovery from this devastating condition. Evaluation of the outcome with data on time-to-Nadir and Nadir-to-surgery is needed to codify ESEA management.
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Affiliation(s)
| | | | - Salami Mohcine
- Department of Neurosurgery, Mohammed V Military Teaching Hospital, Rabat, Morocco
| | - Moussa Elmi Saad
- Department of Neurosurgery, Mohammed V Military Teaching Hospital, Rabat, Morocco
| | - Housni Abderrahmane
- Department of Neurosurgery, Mohammed V Military Teaching Hospital, Rabat, Morocco
| | - Napoleão Imbunhe
- Department of Neurosurgery, Mohammed V Military Teaching Hospital, Rabat, Morocco
| | - Cherkaoui Mandour
- Department of Neurosurgery, Mohammed V Military Teaching Hospital, Rabat, Morocco
| | - Miloud Gazzaz
- Department of Neurosurgery, Mohammed V Military Teaching Hospital, Rabat, Morocco
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Wu T, Liu D, Meng F, Lu J, Fan Z. Full-Endoscopic Transforaminal Debridement and Decompression for Brucellar Thoracic Spinal Epidural Abscess: A Minimally Invasive Alternative to Open Surgery. Orthop Surg 2024; 16:1480-1486. [PMID: 38664222 PMCID: PMC11144516 DOI: 10.1111/os.14051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 03/07/2024] [Accepted: 03/14/2024] [Indexed: 06/04/2024] Open
Abstract
OBJECTIVE Thoracic spinal epidural abscess (SEA) is a rare but dangerous condition, and traditional surgical methods are accompanied by extensive trauma and approach-related complications. Here we introduce the technique of full-endoscopic transforaminal debridement and decompression and evaluate its feasibility for treating brucellar thoracic SEA. METHODS We performed thoracic full-endoscopic transforaminal decompression and debridement on two patients with neurological deficits caused by brucellar SEA, which is mainly composed of granulation tissue rather than pus. Postoperative MRI was conducted to confirm the presence of any residual abscess compressing the nerves. Frankel grading was employed to assess the recovery of neurological function, and complications were documented. RESULTS There were no occurrences of dural tear, postoperative hematoma, or pulmonary complications. Their neurological function had significantly improved after surgery, and postoperative MRI confirmed no residual abscess compressing the spinal cord. During the 2-year follow-up, one patient achieved complete recovery (from Frankel-C to Frankel-E), while another patient improved from Frankel-A to Frankel-D. Neither patient experienced infection recurrence, instability, nor kyphotic deformity. CONCLUSION We described the novel application of transforaminal endoscopic surgery in brucellar thoracic granulomatous SEA and preliminarily indicated the feasibility of this technique as a minimally invasive alternative to open surgery.
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Affiliation(s)
- Tong Wu
- Department of OrthopedicsShengjing Hospital of China Medical UniversityShenyangChina
| | - Da Liu
- Department of OrthopedicsShengjing Hospital of China Medical UniversityShenyangChina
| | - Fan‐he Meng
- Department of OrthopedicsShengjing Hospital of China Medical UniversityShenyangChina
| | - Jing‐han Lu
- Department of OrthopedicsShengjing Hospital of China Medical UniversityShenyangChina
| | - Zheng Fan
- Department of OrthopedicsShengjing Hospital of China Medical UniversityShenyangChina
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Xiong GX, Nguyen A, Hering K, Schoenfeld AJ. Long-term quality of life and functional outcomes after management of spinal epidural abscess. Spine J 2024; 24:759-767. [PMID: 38072087 DOI: 10.1016/j.spinee.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/06/2023] [Accepted: 11/27/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND/CONTEXT In recent years, the incidence of spinal epidural abscesses (SEA) has tripled in number and nonoperative management has risen in popularity. While there has been a shift towards reserving surgical intervention for patients with focal neurologic deficits, a third of patients will still fail medical management and require surgical intervention. Failure to understand long-term quality of life and functional outcomes hinders effective decision making and prognostication. PURPOSE To describe patterns and associated factors impacting long-term quality of life following treatment of spinal epidural abscess. STUDY DESIGN/SETTING Multicenter cohort study at two urban academic tertiary referral centers and two community centers. PATIENT SAMPLE Adult patients treated for a spinal epidural abscess. OUTCOME MEASURES EuroQoL 5-Dimension 5L (EQ5D), Neuro-Quality of Life Lower Extremity - Mobility (Short Form; NeuroQoL-LE), Patient-Reported Outcomes Measurement Information System Physical Function (short form 4a; PROMIS PF), and PROMIS Global Mental Health score (PROMIS Mental). METHODS Eligible patients were enrolled and administered questionnaires. Multivariable analysis assessed the influence of ambulatory status on HRQL, adjusting for covariates including age, biologic sex, Charlson comorbidity index, intravenous drug use, management approach, and ASIA grade on presentation. RESULTS Sixty-one patients were enrolled (mean age 60.5 years, 46% male). Thirty-four patients (58%) underwent operative management. Mean standard deviation (SD) results for HRQL measures were: EQ5D 0.51 (0.37), EQ5D visual analogue scale 60.34 (25.11), NeuroQoL Lower extremity 41.47 (10.64), PROMIS physical function 39.49 (10.07), and PROMIS Global Mental Health 44.23 (10.36). Adjusted analysis demonstrated ambulatory status at presentation, and at 1 year, to be important drivers of HRQL, irrespective of other factors including IVDU and ASIA grade. Patients with independent ambulatory function at 1 year had mean EQ5D utility of 0.65 (95% CI 0.55, 0.75), whereas those requiring assistive devices saw a 49% decrease with mean EQ5D utility of 0.32 (0.14, 0.51). Ambulatory status was associated with global and physical function but did not impact overall health self-assessment or mental health scores. CONCLUSIONS We found that ambulatory status was the most important factor associated with long-term HRQL regardless of other factors such as ASIA grade or IVDU. Given prior literature demonstrating the protective effect of operative intervention on ambulatory function, this highlights ambulatory dysfunction as a potential indication for surgery and a marker of poor long-term prognosis, even in the absence of focal neurologic deficits. Our work also highlights the importance of optimized long-term rehabilitation strategies aimed to preserve ambulatory function in this high-risk population. LEVEL OF EVIDENCE Level III, cohort study.
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Affiliation(s)
- Grace X Xiong
- Harvard Combined Orthopaedic Residency Program, 55 Fruit St, Boston, MA 02114, USA
| | - Andrew Nguyen
- Harvard Medical School, 25 Shattuck St, Boston MA 02115, USA
| | - Kalei Hering
- Harvard Medical School, 25 Shattuck St, Boston MA 02115, USA
| | - Andrew J Schoenfeld
- Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston MA 02115, USA.
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Wang Y, Chen C, Peng L, Wang P. Fluoroscopy guided transpedicular abscess infusion and drainage in thoracic-lumbar spondylitis with prevertebral abscess. INTERNATIONAL ORTHOPAEDICS 2023; 47:2295-2300. [PMID: 37335315 DOI: 10.1007/s00264-023-05866-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/06/2023] [Indexed: 06/21/2023]
Abstract
PURPOSE To evaluate the effectiveness of fluoroscopy guided transpedicular abscess infusion and drainage in thoracic-lumbar spondylitis with prevertebral abscess. METHODS We retrospectively reviewed 14 patients with infectious spondylitis with prevertebral abscesses from January 2019 to December 2022. All patients underwent fluoroscopy guided transpedicular abscess infusion and drainage. Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), visual analog scale (VAS), Macnab criteria, and magnetic resonance imaging (MRI) were compared before and after the operation to evaluate clinical outcomes. RESULTS Among the 14 patients with prevertebral abscesses, 64.29% (9/14) involved the lumbar spine and 35.71% (5/14) involved the thoracic spine. The ESR, CRP, and VAS scores decreased from 87.34 ± 9.21, 93.01 ± 11.17, and 8.38 ± 0.97 preoperatively to 12.35 ± 1.61, 8.52 ± 1.19, and 2.02 ± 0.64 at the final follow-up, respectively. MRI at the final follow-up showed the disappearance of the prevertebral abscess compared with that in the preoperative group (66.95 ± 12.63 mm in diameter). Ten patients achieved an "excellent" outcome, while the remaining four patients obtained a "good" outcome according to the Macnab criteria. CONCLUSION Fluoroscopy guided transpedicular abscess infusion and drainage is a safe and minimally invasive procedure for the management of thoracic-lumbar spondylitis with a prevertebral abscess.
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Affiliation(s)
- Yuanhao Wang
- Department of Spine Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, China
| | - Cong Chen
- Department of Spine Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, China
| | - Lei Peng
- Department of Spine Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, China
| | - Peng Wang
- Department of Spine Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, China.
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Hijazi MM, Siepmann T, El-Battrawy I, Schröttner P, Podlesek D, Engellandt K, Schackert G, Juratli TA, Eyüpoglu IY, Filis A. The Efficacy of Daily Local Antibiotic Lavage via an Epidural Suction-Irrigation Drainage Technique in Spondylodiscitis and Isolated Spinal Epidural Empyema: A 20-Year Experience of a Single Spine Center. J Clin Med 2023; 12:5078. [PMID: 37568480 PMCID: PMC10420211 DOI: 10.3390/jcm12155078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 07/29/2023] [Accepted: 07/31/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Various treatment modalities are available for local antibiotic therapy in spondylodiscitis (SD) and isolated spinal epidural empyema (ISEE), but there is no evidence-based recommendation. Postoperative epidural suction-irrigation drainage (ESID) is thought to reduce bacterial load, which may prevent the development of relapse, wound healing, hematogenous spread, and systemic complications. We evaluated the efficacy of postoperative ESID over 20 years on disease progression and outcome in SD and ISEE. METHODS Detailed demographic, clinical, imaging, laboratory, and microbiological characteristics were examined in our cohorts of 208 SD and ISEE patients treated with and without ESID at a university spine center in Germany between 2002 and 2022. Between-group comparisons were performed to identify meaningful differences for the procedure. RESULTS We included data from 208 patients (142 SD, 68.3% vs. 66 ISEE, 31.7%) of whom 146 were ESID patients (87 SD, 59.6% vs. 59 ISEE, 40.4%) and 62 were NON-ESID patients (55 SD, 88.7% vs. 7 ISEE, 11.3%). ESID patients with SD showed more frequent SSI (ESID: 22, 25.3% vs. NON-ESID: 3, 5.5%, p = 0.003), reoperations due to empyema persistence or instability (ESID: 37, 42.5% vs. NON-ESID: 12, 21.8%, p = 0.012), and a higher relapse rate (ESID: 21, 37.5% vs. NON-ESID: 6, 16.7%, p = 0.037) than NON-ESID patients with SD. The success rate in NON-ESID patients with SD was higher than in ESID patients with SD (ESID: 26, 29.9% vs. NON-ESID: 36, 65.6%, p < 0.001). Multivariate binary logistic regression analysis showed that ESID therapy (p < 0.001; OR: 0.201; 95% CI: 0.089-0.451) was a significant independent risk factor for treatment failure in patients with SD. CONCLUSIONS Our retrospective cohort study with more than 20 years of experience in ESID technique shows a negative effect in patients with SD in terms of surgical site infections and relapse rate.
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Affiliation(s)
- Mido Max Hijazi
- Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Department of Neurosurgery, Division of Spine Surgery, Fetscherstrasse 74, 01307 Dresden, Germany; (D.P.); (G.S.); (T.A.J.); (I.Y.E.); (A.F.)
| | - Timo Siepmann
- Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Department of Neurology, Fetscherstrasse 74, 01307 Dresden, Germany;
| | - Ibrahim El-Battrawy
- Bergmannsheil University Hospitals Bergmannsheil, Ruhr University Bochum, Department of Cardiology, Bürkle de la Camp-Platz 1, 44789 Bochum, Germany;
| | - Percy Schröttner
- Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Institute for Microbiology and Virology, Fetscherstrasse 74, 01307 Dresden, Germany;
| | - Dino Podlesek
- Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Department of Neurosurgery, Division of Spine Surgery, Fetscherstrasse 74, 01307 Dresden, Germany; (D.P.); (G.S.); (T.A.J.); (I.Y.E.); (A.F.)
| | - Kay Engellandt
- Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Institute of Diagnostic and Interventional Neuroradiology, Fetscherstrasse 74, 01307 Dresden, Germany;
| | - Gabriele Schackert
- Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Department of Neurosurgery, Division of Spine Surgery, Fetscherstrasse 74, 01307 Dresden, Germany; (D.P.); (G.S.); (T.A.J.); (I.Y.E.); (A.F.)
| | - Tareq A. Juratli
- Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Department of Neurosurgery, Division of Spine Surgery, Fetscherstrasse 74, 01307 Dresden, Germany; (D.P.); (G.S.); (T.A.J.); (I.Y.E.); (A.F.)
| | - Ilker Y. Eyüpoglu
- Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Department of Neurosurgery, Division of Spine Surgery, Fetscherstrasse 74, 01307 Dresden, Germany; (D.P.); (G.S.); (T.A.J.); (I.Y.E.); (A.F.)
| | - Andreas Filis
- Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Department of Neurosurgery, Division of Spine Surgery, Fetscherstrasse 74, 01307 Dresden, Germany; (D.P.); (G.S.); (T.A.J.); (I.Y.E.); (A.F.)
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The pre-surgical role of halo-traction in patients with cervical infection associated with refractory kyphosis: a retrospective study. Sci Rep 2023; 13:479. [PMID: 36627377 PMCID: PMC9832031 DOI: 10.1038/s41598-023-27523-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 01/03/2023] [Indexed: 01/11/2023] Open
Abstract
To minimize surgical complications and staged procedures halo-traction is often used during deformity corrections. But the use of halo-traction in the treatment of refractory cervical kyphosis secondary to infections has never been reported. This study investigated the role of halo-traction in the treatment of cervical infection patients associated with refractory kyphosis. We retrospectively reviewed 48 patients with cervical infection associated with refractory kyphosis who were treated in our spine department. Patients were divided into two groups, the traction group (A) and the non-traction group (B). Group A underwent preoperative halo-traction followed by surgery, while group B underwent surgery alone. Between the two groups, we analyzed the kyphosis deformity correction, level of fusions, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), functional improvement by Neck disability index (NDI) score, and complications. Group A had a better correction of kyphosis deformity compared to group B (27.01 ± 11.54)0 versus (18.08 ± 10.04)0 (P = 0.01, Z = - 2.44). No statistically significant differences between the two groups in terms of functional improvement, level of fusions, ESR and CRP. Group B had 3 revision surgery cases. Preoperative halo-traction followed by surgery is superior in kyphosis correction in the treatment of patients with cervical infections with refractory kyphosis.
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Cao J, Fang J, Shao X, Shen J, Jiang X. Case Report: A case of cervical spinal epidural abscess combined with cervical paravertebral soft tissue abscess. Front Surg 2022; 9:967806. [PMID: 36277281 PMCID: PMC9581127 DOI: 10.3389/fsurg.2022.967806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 08/23/2022] [Indexed: 11/06/2022] Open
Abstract
Background Spinal epidural abscess (SEA) is a rare purulent infection of the central nervous system. Abscesses confined to the spinal canal can compress the spinal cord, causing nerve damage and even death in severe cases (1). Prompt diagnosis and treatment can relieve symptoms and prevent complications. To increase awareness of this rare disease, we report a case of a 58-year-old man with a cervical spinal epidural abscess combined with a soft tissue abscess in the neck and describe its clinical course, imaging feature, pathology, treatment, and patient prognosis. Case description A 58-year-old male Chinese patient was admitted to our hospital because of neck pain for 2 months, which worsened for 4 days. On the third day of admission, the muscle strength of the limbs decreased, and MRI of the spinal cord showed abnormal signal shadows in the spinal canal at the C1-C7 level and in the surrounding soft tissue on the right side of spine, suggesting the possibility of inflammatory lesions with local abscess formation. We immediately performed decompression of the spinal canal on the patient and performed incision and drainage of the cervical abscess. During the operation, we found a large amount of pus in the epidural space of the spinal canal, and there was a fistula between the cervical abscess and the epidural abscess of the spinal canal. The patient underwent continuous drainage and anti-infective treatment with sensitive antibiotics after operation. No recurrence of the abscess was observed and the patient recovered well. Conclusion Early diagnosis is the key to the treatment of SEA, so radiologists and neurosurgeons need to strengthen their understanding of this rare disease to avoid misdiagnosis. For SEA with definite diagnosis, decompression surgery should be performed in a timely manner when symptoms of nerve compression occur, continuous drainage should be performed after surgery, and sensitive antibiotics should be used for anti-infective treatment.
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Affiliation(s)
- Jun Cao
- Correspondence: Xuefei Shao Jun Cao Jincheng Fang
| | | | - Xuefei Shao
- Correspondence: Xuefei Shao Jun Cao Jincheng Fang
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8
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Chen CT, Wu MH, Huang TY, Li YY, Huang TJ, Lee CY, Lin CH, Lee CY. Anaerobic spondylodiscitis: a retrospective analysis. BMC Musculoskelet Disord 2022; 23:788. [PMID: 35978349 PMCID: PMC9382781 DOI: 10.1186/s12891-022-05749-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 08/09/2022] [Indexed: 11/20/2022] Open
Abstract
Background This retrospective study analyzed the clinical characteristics and outcomes of patients with anaerobic spondylodiscitis. Methods From a total of 382 patients with infectious spondylodiscitis, nine patients (2.4%; two male and seven female with an average age of 67 years) with anaerobic spondylodiscitis between March 2003 and March 2017 were analyzed. Results Most of the patients (77.8%) initially presented with afebrile back pain. Hematogenous spread occurred in seven patients and postoperative infection in two patients. Bacteroid fragilis was the most common pathogen isolated from three patients. Atypical radiographic characteristics, including a vertebral fracture with the preservation of disk height or coexisting spondylolytic spondylolisthesis, occurred in four patients with hematogenous anaerobic spondylodiscitis. The eradication rate of anaerobic infection was significantly higher in the patients with hematogenous infection than in those with postoperative infection (100% vs. 0%, p = 0.0476). Anaerobic spondylodiscitis accounted for 2.4% of cases of infectious spondylodiscitis and predominantly affected the female patients. Conclusions Diagnostic delay may occur because of atypical spinal radiographs if the patient reports only back pain but no fever. Anaerobic infection following elective spinal instrumentation has a higher recurrence rate.
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Affiliation(s)
- Chien-Ting Chen
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Meng-Huang Wu
- Department of Orthopedics, Taipei Medical University Hospital, No.252, Wu-hsing St., Taipei, 11031, Taiwan.,Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, No.250, Wu-hsing St., Taipei, 11031, Taiwan
| | - Tsung-Yu Huang
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yen-Yao Li
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Tsung-Jen Huang
- Department of Orthopedics, Taipei Medical University Hospital, No.252, Wu-hsing St., Taipei, 11031, Taiwan.,Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, No.250, Wu-hsing St., Taipei, 11031, Taiwan
| | - Chien-Yin Lee
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Che-Han Lin
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Ching-Yu Lee
- Department of Orthopedics, Taipei Medical University Hospital, No.252, Wu-hsing St., Taipei, 11031, Taiwan. .,Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, No.250, Wu-hsing St., Taipei, 11031, Taiwan. .,International Ph.D. Program for Cell Therapy and Regeneration Medicine, College of Medicine, Taipei Medical University, No.250, Wu-hsing St., Taipei, 11031, Taiwan.
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9
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Xiong GX, Crawford AM, Striano B, Lightsey HM, Nelson SB, Schwab JH. The NIMS framework: an approach to the evaluation and management of epidural abscesses. Spine J 2021; 21:1965-1972. [PMID: 34010684 DOI: 10.1016/j.spinee.2021.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 05/06/2021] [Accepted: 05/07/2021] [Indexed: 02/03/2023]
Affiliation(s)
- Grace X Xiong
- Harvard Combined Orthopaedic Residency Program, 55 Fruit St., Boston, MA, 02114
| | | | - Brendan Striano
- Harvard Combined Orthopaedic Residency Program, 55 Fruit St., Boston, MA, 02114
| | - Harry M Lightsey
- Harvard Combined Orthopaedic Residency Program, 55 Fruit St., Boston, MA, 02114
| | - Sandra B Nelson
- Division of Infectious Diseases, Massachusetts General Hospital, Bulfinch 130, 55 Fruit St., Boston, MA, 02114
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Yawkey 3A, 55 Fruit St., Boston, MA 02114.
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10
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Kim CY, Kim P, Ju CI, Kim SW. Treatment of Extensive Spinal Epidural Abscess with Skipped Laminotomy Using a Pediatric Feeding Tube: A Case Report. Korean J Neurotrauma 2021; 17:193-198. [PMID: 34760834 PMCID: PMC8558014 DOI: 10.13004/kjnt.2021.17.e18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Spinal epidural abscess (SEA) is an unusual form of spinal infection. Performing multilevel laminectomies is controversial in cases of extensive SEA considering the long surgical time and mechanical instability. Here, we report the case of an older woman with extensive SEA and poor general condition who was successfully treated with a less invasive treatment, namely skipped laminotomy using a pediatric feeding tube. A 79-year-old woman complained of progressive weakness in both legs, fever, and back pain. An extensive epidural abscess from the T3 to L5 vertebrae was observed on thoracic and lumbar magnetic resonance imaging (MRI). We performed skipped laminotomy at the T8 and T12 levels, and a 5-Fr pediatric feeding tube was advanced from the caudal level toward the rostral area and rostral level toward caudal level into the dorsal epidural space. Subsequently, regurgitation was performed with saline through the pediatric feeding tube at each level. Following this, to further irrigate the unexposed epidural abscess through laminotomy, the epidural space was washed by continuous irrigation, and the irrigation system was maintained for 48 hours. Follow-up MRI performed 3 weeks after the procedure confirmed near complete removal of the abscess in the thoracic spine, with a small residual abscess in the lumbar spine.
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Affiliation(s)
- Chang Yub Kim
- Department of Neurosurgery, College of Medicine, Chosun University, Gwangju, Korea
| | - Pius Kim
- Department of Neurosurgery, College of Medicine, Chosun University, Gwangju, Korea
| | - Chang Il Ju
- Department of Neurosurgery, College of Medicine, Chosun University, Gwangju, Korea
| | - Seok Won Kim
- Department of Neurosurgery, College of Medicine, Chosun University, Gwangju, Korea
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11
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Usuda D, Taki Y, Izumida T, Sangen R, Higashikawa T, Hatano E, Yokoyama M, Kasamaki Y. Disseminated Spinal Epidural Abscess in an Immunocompetent Individual: A Case Report and Review of the Literature. J Med Cases 2021; 11:417-425. [PMID: 34434354 PMCID: PMC8383548 DOI: 10.14740/jmc3603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 10/12/2020] [Indexed: 11/11/2022] Open
Abstract
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.
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Affiliation(s)
- Daisuke Usuda
- Department of General Medicine, Kanazawa Medical University Himi Municipal Hospital, 1130 Kurakawa, Himi-shi, Toyama-ken 935-8531, Japan.,Department of Infectious Diseases, Kanazawa Medical University, 1-1 Daigaku, Uchinada-machi, Ishikawa-ken 920-0293, Japan
| | - Yasuhiko Taki
- Department of Orthopedics, Kanazawa Medical University Himi Municipal Hospital, 1130 Kurakawa, Himi-shi, Toyama-ken 935-8531, Japan
| | - Toshihide Izumida
- Department of General Medicine, Kanazawa Medical University Himi Municipal Hospital, 1130 Kurakawa, Himi-shi, Toyama-ken 935-8531, Japan
| | - Ryusho Sangen
- Department of General Medicine, Kanazawa Medical University Himi Municipal Hospital, 1130 Kurakawa, Himi-shi, Toyama-ken 935-8531, Japan
| | - Toshihiro Higashikawa
- Department of Geriatric Medicine, Kanazawa Medical University Himi Municipal Hospital, 1130 Kurakawa, Himi-shi, Toyama-ken 935-8531, Japan
| | - Eiju Hatano
- Department of Orthopedics, Kanazawa Medical University Himi Municipal Hospital, 1130 Kurakawa, Himi-shi, Toyama-ken 935-8531, Japan
| | - Mitsuteru Yokoyama
- Department of Orthopedics, Kanazawa Medical University Himi Municipal Hospital, 1130 Kurakawa, Himi-shi, Toyama-ken 935-8531, Japan
| | - Yuji Kasamaki
- Department of General Medicine, Kanazawa Medical University Himi Municipal Hospital, 1130 Kurakawa, Himi-shi, Toyama-ken 935-8531, Japan
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Gaignard E, Bergeat D, Kieser D, Robin F, Meunier B. Fatal epidural abscess with meningitis: a rare complication of colorectal surgery. Acta Chir Belg 2021; 121:127-130. [PMID: 31311450 DOI: 10.1080/00015458.2019.1642596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Anastomotic leakage following colorectal surgery remains a frequent complication. We report a rare case of a fatal epidural abscess caused by a colo-epidural fistula complicating a laparoscopic proctectomy. CASE PRESENTATION A 62 year-old-man presented with weight loss, pelvic sepsis and neurological dysfunction four months after closing of the ileostomy following a laparoscopic proctectomy for a rectal adenocarcinoma one year ago. Cross-sectional imaging confirmed an epidural abscess caused by a chronic colorectal anastomotic leak. Systemic antibiotics and laparotomy with defunctioning pelvic loop colostomy were performed. Unfortunately, this management to control the major spinal infection failed. Epidural decompression and debridement was not possible due to his poor condition and the patient subsequently died. CONCLUSION Colo-epidural fistula can occur as a consequence of colorectal anastomotic leakage. Prior to frank neurology symptoms and sepsis, patients may present with only a low-grade fever. Without prompt and aggressive management of colo-epidural infection, this severe complication can lead to paraplegia and death.
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Affiliation(s)
- Elodie Gaignard
- Service de chirurgie hépatobiliaire et digestive, CHU, Rennes, France
- Faculté de Médecine, Université de Rennes 1, Rennes, France
| | - Damien Bergeat
- Service de chirurgie hépatobiliaire et digestive, CHU, Rennes, France
- Faculté de Médecine, Université de Rennes 1, Rennes, France
| | - David Kieser
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch School of Medicine, Christchurch, New Zealand
| | - Fabien Robin
- Service de chirurgie hépatobiliaire et digestive, CHU, Rennes, France
- Faculté de Médecine, Université de Rennes 1, Rennes, France
| | - Bernard Meunier
- Service de chirurgie hépatobiliaire et digestive, CHU, Rennes, France
- Faculté de Médecine, Université de Rennes 1, Rennes, France
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Cervical, Thoracic, and Lumbar Spine Epidural Abscess: Case Report and Literature Review. Case Rep Infect Dis 2020; 2020:8834589. [PMID: 33101744 PMCID: PMC7568137 DOI: 10.1155/2020/8834589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/17/2020] [Accepted: 09/22/2020] [Indexed: 11/30/2022] Open
Abstract
We report a case of a spinal epidural abscess (SEA) in a patient without significant risk factors. The patient was treated in an outpatient setting for one week for worsening back pain and subsequently admitted to the hospital for the treatment of sepsis and suspected SEA. An MRI obtained on admission showed an epidural abscess extending from the lower cervical to the upper lumbar region and accompanying paraspinal cervical and psoas abscesses. The patient was successfully treated with antibiotics based on the sensitivity of the surgical cultures received from a needle aspiration of the abscess. SEA has a low incidence; however, the number of cases is consistently rising over the last two decades. The outcome of SEA treatment is related to the duration of the process prior to intuition of the treatment. Patients with no neurological symptoms, or with symptoms lasting less than 36 h, have the best recovery rate. As the typical symptoms of SEA are seen in only 13% of cases, physicians should have a low threshold to order MRI in patients with back pain that is new or changed from the baseline. With the help of CT-guided aspiration for culture analysis, patients can be successfully treated conservatively using antibiotics in cases where neurological signs are absent.
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Dai G, Li S, Yin C, Sun Y, Xu D, Wang Z, Luan L, Hou J, Wang T. Studies on 11 Cases of Spinal Epidural Abscess and Literature Review. Infect Drug Resist 2020; 13:3325-3334. [PMID: 33061480 PMCID: PMC7532908 DOI: 10.2147/idr.s257398] [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: 04/08/2020] [Accepted: 09/04/2020] [Indexed: 01/23/2023] Open
Abstract
Objective In the present study, we aimed to describe the clinical features, diagnosis, treatment, and prognosis of spinal epidural abscess (SEA). Methods The complete clinical data of 11 SEA patients who were treated in our hospital system from January 2015 to June 2018 were retrospectively analyzed. Moreover, the clinical features, diagnosis, treatment, and prognosis of 642 SEA cases collected from the foreign literature from 2010 to 2019 were also investigated. Results Among our 11 SEA patients, nine cases had purulent inflammation, two cases had tuberculosis, two cases had infection caused by Staphylococcus aureus, one case had infection caused by Streptococcus constellatus, one case had infection caused by Klebsiella pneumoniae, five cases showed negative bacterial culture, and two cases had Mycobacterium tuberculosis. All 11 cases showed focal spinal pain, eight cases exhibited neurological deficits, and six cases experienced fever. Nine of the 11 cases involved the lumbosacral spine, one case involved the thoracic spine, and one case involved the cervical spine. Eight patients had a longer course of disease (>2 weeks), all 11 patients had vertebral osteomyelitis, and nine patients had intervertebral discitis. One patient had motor dysfunction of arms and legs, one patient had lower limb motor dysfunction, one patient had limb numbness, one patient experienced relapse after the conservative treatment, and one patient experienced relapse after the surgical treatment. The follow-up time was 15–24 months. Conclusion The classic diagnosis of triads (focal spine pain, neurological deficit, and fever) was less specific for SEA. MRI examination, blood culture, tissue culture, and biopsy could be used for the diagnosis for SEA. Suppuritis was a common cause of SEA. Early detection, early diagnosis and early treatment, as well as the selection of the most suitable treatment regimen based on comprehensive evaluation, played crucial roles in a better prognosis of SEA. There was no statistically significant difference in terms of the general condition, diagnosis, treatment and prognosis between the patients with negative and positive culture results (P>0.05). For SEA patient with negative culture, antibiotic treatment should be used empirically.
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Affiliation(s)
- Guohua Dai
- Affiliated Hospital of Qingdao University, Qingdao 266003, People's Republic of China
| | - Shuzhong Li
- Affiliated Hospital of Qingdao University, Qingdao 266003, People's Republic of China
| | - Chuqiang Yin
- Affiliated Hospital of Qingdao University, Qingdao 266003, People's Republic of China
| | - Yuanliang Sun
- Affiliated Hospital of Qingdao University, Qingdao 266003, People's Republic of China
| | - Derong Xu
- Affiliated Hospital of Qingdao University, Qingdao 266003, People's Republic of China
| | - Zhongying Wang
- Affiliated Hospital of Qingdao University, Qingdao 266003, People's Republic of China
| | - Liangrui Luan
- Affiliated Hospital of Qingdao University, Qingdao 266003, People's Republic of China
| | - Jianwen Hou
- Affiliated Hospital of Qingdao University, Qingdao 266003, People's Republic of China
| | - Ting Wang
- Affiliated Hospital of Qingdao University, Qingdao 266003, People's Republic of China
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Abstract
PURPOSE OF REVIEW Spinal epidural abscess (SEA) is still a rare but potentially very morbid infection of the spine. In recent years, the incidence has risen sharply but the condition remains a medical conundrum wrought with unacceptably long diagnostic delays. The outcome depends on timely diagnosis and missed opportunities can be associated with catastrophic consequences. Management and outcomes have improved over the past decade. This review focuses on risk factors and markers that can aid in establishing the diagnosis, the radiological characteristics of SEA on MRI and their clinical implications, as well as the importance of establishing clear indications for surgical decompression. RECENT FINDINGS This once exclusively surgically managed entity is increasingly treated conservatively with antimicrobial therapy. Patients diagnosed in a timely fashion, prior to cord involvement and the onset of neurologic deficits can safely be managed without decompressive surgery with targeted antimicrobial therapy. Patients with acute cord compression and gross neurologic deficits promptly undergo decompression. The greatest therapeutic dilemma remains the group with mild neurological deficits. As failure rates of delayed surgery approach 40%, recent research is focused on predictive models for failure of conservative SEA management. In addition, protocols are being implemented with some success, to shorten the diagnostic delay of SEA on initial presentation. SUMMARY SEA is a potentially devastating condition that is frequently missed. Protocols are put in place to facilitate early evaluation of back pain in patients with red flags with appropriate cross-sectional imaging, namely contrast-enhanced MRI. Efforts for establishing clear-cut indications for surgical decompression of SEA are underway.
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Endoscopic Transforaminal Drainage of a Ventrally Located Thoracic Epidural Abscess. World Neurosurg 2020; 139:268-273. [PMID: 32278818 DOI: 10.1016/j.wneu.2020.03.193] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 03/26/2020] [Accepted: 03/27/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND No formalized surgical treatment strategy exists for a thoracic epidural abscess. Although endoscopic approaches have been described for the treatment of spinal infections, this is the first report of an endoscopic transforaminal approach for the drainage of a thoracic/lumbar epidural abscess with placement of indwelling abscess drain. We present a novel use of a known endoscopic approach and describe a minimally invasive surgical option for ventrally located thoracic epidural abscesses. CASE DESCRIPTION A patient with ventrally located T5-L5 epidural abscess with cord compression was taken for endoscopic transforaminal drainage at the right T9-10 level. A drain was left in the abscess cavity and tunneled subcutaneously for continued postoperative drainage. Immediate postoperative radiographic results showed significant reduction in the abscess size. The patient tolerated the procedure well with return to neurologic baseline. CONCLUSIONS Endoscopic transforaminal drainage of ventrally located thoracic epidural abscess is a safe procedure that may be an option for patients with a purulent-filled abscess. This procedure should be considered an option to avoid more invasive procedures that would require decompression and possibly instrumented fusion.
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Tetsuka S, Suzuki T, Ogawa T, Hashimoto R, Kato H. Spinal Epidural Abscess: A Review Highlighting Early Diagnosis and Management. JMA J 2019; 3:29-40. [PMID: 33324773 PMCID: PMC7733760 DOI: 10.31662/jmaj.2019-0038] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 08/26/2019] [Indexed: 01/08/2023] Open
Abstract
Spinal epidural abscess (SEA) is still an uncommon but devastating infection of the spine. In recent years, a number of reported cases have risen. The most important prognostic factor for a favorable outcome is early diagnosis and appropriate treatment. However, a diagnosis of SEA is often delayed, particularly in the early stages of the disease before patients present with neurological symptoms. With enough knowledge of risk factors, clinical features, and appropriate diagnostic procedures, it may be possible to reduce diagnostic delay in the early stages of the disease. This review focuses on early diagnosis of SEA based on risk factors, presenting symptoms, and characteristic findings on magnetic resonance imaging (MRI), and also discusses the timing of surgical interventions. Traditionally, the symptoms of SEA are characterized by fever, back pain, and neurological symptoms, which are described as a classical triad of symptoms for this type of infection; but this collection of symptoms is seen in only about 10% of cases. However, most patients complain of severe localized lower back pain. Gadolinium-enhanced MRI is the most sensitive, specific, and beneficial imaging modality for establishing a diagnosis of SEA. Patients diagnosed prior to neurological deficits with a known causative microbial organism can be safely treated with antimicrobial therapy alone. However, about 30%–40% of the patients fail in conservative management without surgery. The best management and timing for surgical decompression in patients with or without mild neurological deficits should be established in the near future. Early diagnosis and management, before the occurrence of serious neurological symptoms, are the most important prognostic factors for good outcomes in patients with SEA. We proposed a simple algorithm for early diagnosis of SEA by selecting patients with severe back pain, leading to emergent MRI.
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Affiliation(s)
- Syuichi Tetsuka
- Department of Neurology, International University of Health and Welfare Hospital, Nasushiobara, Japan
| | - Tomohiro Suzuki
- Department of Neurology, International University of Health and Welfare Hospital, Nasushiobara, Japan
| | - Tomoko Ogawa
- Department of Neurology, International University of Health and Welfare Hospital, Nasushiobara, Japan
| | - Ritsuo Hashimoto
- Department of Neurology, International University of Health and Welfare Hospital, Nasushiobara, Japan
| | - Hiroyuki Kato
- Department of Neurology, International University of Health and Welfare Hospital, Nasushiobara, Japan
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Ross AB, Tang JY, Rosas HG, Bice MJ. Fluoroscopy-guided percutaneous needle aspiration of posterior epidural abscesses: a report of two cases. Spinal Cord Ser Cases 2019; 5:43. [PMID: 31632702 PMCID: PMC6786395 DOI: 10.1038/s41394-019-0190-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 04/04/2019] [Accepted: 05/02/2019] [Indexed: 12/04/2022] Open
Abstract
Introduction Spinal epidural abscesses are most commonly treated with surgical decompression and antibiotics or in specific instances managed medically with antibiotic therapy alone. Image-guided percutaneous aspiration as an alternative to surgery has only rarely been reported in the literature. Case presentation We report two cases of successful fluoroscopy-guided needle aspiration of posterior epidural abscesses. Case 1 is a 48-year-old man who presented with several days of escalating back pain and constitutional symptoms with MRI showing a posterior epidural abscess at L2-L3 causing spinal stenosis. The patient remained neurologically intact. Percutaneous needle aspiration of the collection provided dramatic pain relief with the aspirate growing methicillin sensitive Staphylococcus aureus. The patient made a full recovery on antibiotic therapy. Case 2 is an 81-year-old man who presented with worsening upper back pain and was found to have osteomyelitis/discitis with a large posterior epidural abscess in the thoracic spine. Needle drainage was performed with the sample growing Bacteroides fragilis. This patient also responded successfully to nonsurgical management with full recovery after appropriate antibiotic therapy. Discussion In carefully selected patients, image-guided needle aspiration of posterior epidural abscesses may be a viable and less invasive alternative to surgery.
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Affiliation(s)
- Andrew B. Ross
- Department of Radiology – Musculoskeletal Imaging and Intervention, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave. D4/330, Madison, WI 53792 USA
| | - Joseph Y. Tang
- Department of Radiology – Musculoskeletal Imaging and Intervention, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave. D4/330, Madison, WI 53792 USA
| | - Humberto G. Rosas
- Department of Radiology – Musculoskeletal Imaging and Intervention, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave. D4/330, Madison, WI 53792 USA
| | - Miranda J. Bice
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, USA
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