High risk and low prevalence diseases: Spinal epidural abscess

Pyogenic Vertebral Osteomyelitis

Vertebral osteomyelitis is a general term for a heterogenous group of spine infections involving the vertebral bone, intervertebral discs, and facet joints. These infections can often spread contiguously to adjacent paraspinal structures, including paravertebral muscles and the epidural space and frequently presents with nonspecific and indolent symptoms, which can delay diagnosis. Treatment can be arduous, requiring prolonged courses of antibiotics often combined with surgical debridement. This review focuses primarily on pyogenic vertebral osteomyelitis in adults, reviewing the pathophysiology, epidemiology, microbiology, diagnosis, and treatment of this infection.

Emergency medicine updates: Evaluation and diagnosis of sepsis and septic shock

INTRODUCTION

Sepsis and septic shock are common conditions evaluated and managed in the emergency department (ED), and these conditions are associated with significant morbidity and mortality. There have been several recent updates in the literature, including guidelines, on the evaluation and diagnosis of sepsis and septic shock.

OBJECTIVE

This is the first paper in a two-part series that provides emergency clinicians with evidence-based updates concerning sepsis and septic shock. This first paper focuses on evaluation and diagnosis of sepsis and septic shock.

DISCUSSION

The evaluation, diagnosis, and management of sepsis have evolved since the first definition in 1991. Current guidelines emphasize rapid diagnosis to improve patient outcomes. However, scoring systems have conflicting data for diagnosis, and sepsis should be considered in any patient with infection and abnormal vital signs, evidence of systemic inflammation (e.g., elevated white blood cell count or C-reactive protein), or evidence of end-organ dysfunction. The clinician should consider septic shock in any patient with infection and hypotension despite volume resuscitation or who require vasopressors to maintain a mean arterial pressure ≥ 65 mmHg. There are a variety of sources of sepsis but the most common include pulmonary, urinary tract, abdomen, and skin/soft tissue. Examples of other less common etiologies include the central nervous system (e.g., meningitis, encephalitis), spine (e.g., spinal epidural abscess, osteomyelitis), cardiac (e.g., endocarditis), and joints (e.g., septic arthritis). Evaluation may include biomarkers such as procalcitonin, C-reactive protein, and lactate, but these should not be used in isolation to exclude sepsis. Imaging is a key component of evaluation and should be based on the suspected source.

CONCLUSION

There have been several recent updates in the literature including guidelines concerning sepsis and septic shock; an understanding of these updates can assist emergency clinicians and improve the care of these patients.

An emergency medicine review: Multiple myeloma and its complications

INTRODUCTION

Multiple myeloma (MM) and its complications carry a high rate of morbidity and mortality.

OBJECTIVE

This review evaluates MM and its complications, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

MM is the second most common hematologic cancer and associated with monoclonal plasma cell proliferation. The presentation of MM varies, ranging from few symptoms to end organ injury and failure. The most common presenting findings include anemia, bone pain, renal injury, fatigue, hypercalcemia, and weight loss. While clinical outcomes have improved with known therapies, a variety of complications may occur. Anemia is the most common hematologic complication, though hyperviscosity syndrome, bleeding, and coagulopathy may occur. Renal injury is common, and hypercalcemia is the result of bone demineralization. Infection is a major cause of morbidity and mortality. Osteolytic bone disease is a significant feature of MM, present in 70 % of patients, which may result in pathologic and insufficiency fractures. The most serious neurologic complication includes spinal cord compression, and other neurologic complications include peripheral neuropathy and intracranial involvement. Cardiac toxicity may occur with MM therapies, and there is also increased risk of venous thromboembolism. Endocrine complications may also occur, including adrenal insufficiency and thyroid dysfunction.

CONCLUSIONS

An understanding of the complications of MM can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Epidural abscess formation after chemotherapy for breast cancer: a case report and literature review

Introduction

Spinal epidural abscess is a rare infectious lesion of the central nervous system. Here, we report a rare case of a thoracic suppurative epidural abscess in a female patient who developed incomplete paralysis of both lower limbs after chemotherapy for breast cancer. She underwent surgery and recovered well after surgery.

Case report

A 49-year-old female patient developed an epidural abscess after chemotherapy for breast cancer; she suffered sudden pain and paralysis in both lower limbs. Thoracic T9-T11 laminectomy, abscess removal, bone grafting, fusion, and internal fixation were performed. After the operation, the muscle strength in both lower limbs gradually recovered.

Discussion

This is the first reported case of an epidural abscess after chemotherapy for breast cancer. The disease progresses rapidly. During the literature review process, we found that timely removal of the epidural abscess, combined with the administration of appropriate antibiotics at the same time, is crucial for improved healing and successful treatment.

The Utility of Pre-Procedural Blood Tests in Neuraxial Blocks: A Retrospective Study in High-Risk Patients

Background/Objectives: The necessity and clinical utility of routine pre-procedural blood tests (PBTs) before neuraxial blockade remain controversial. This study evaluates the effectiveness of PBTs in identifying clinically significant conditions in an outpatient setting. Methods: This single-center retrospective study involved patients who received neuraxial blockades from January 2020 to August 2023. We extracted medical information and laboratory data from the electronic medical records during the pre-procedural period. Through a multivariate regression analysis, we identified patient factors associated with abnormal laboratory results. Results: Advanced age (OR, 1.021; p = 0.026) and a history of cancer (OR, 2.359; p = 0.016) were significantly associated with elevated CRP levels (>0.30 mg/dL). Severe hyperglycemia (≥200 mg/dL) was found in 24 patients (3.88%), with a history of cancer being a strong predictor (OR, 6.764; p < 0.001). No significant abnormalities were observed in PT or PTT. Reduced eGFR (<60 mL/min/1.73 m2) was detected in 8.62% of patients, despite no prior history of renal dysfunction. A multivariate analysis revealed that advanced age, hypertension, cancer, and coronary artery disease were significant predictors of abnormal PBT results, highlighting the importance of selective testing in high-risk patients. Conclusions: Routine PBTs are not universally required for all patients undergoing neuraxial blockade but can provide crucial information in high-risk populations. A selective testing approach based on individual risk factors is recommended to optimize patient safety and resource utilization. Future studies should aim to establish clear guidelines for targeted PBT use.

Are Dental Procedures Associated With Pyogenic Vertebral Osteomyelitis?

BACKGROUND

Dental procedures can lead to bacteremia and have been considered a potential risk factor for pyogenic vertebral osteomyelitis (PVO). However, data on the association between dental procedures and PVO are limited.

QUESTIONS/PURPOSES

(1) After controlling for relevant confounding variables, are dental procedures associated with an increased risk of PVO? (2) Does antibiotic prophylaxis before dental procedures effectively decrease the risk of PVO?

METHODS

A case-crossover study was conducted to investigate the association between dental procedures and PVO using a Japanese claims database. The advantage of this study design is that confounding factors that do not vary over time are automatically adjusted for, because cases act as their own controls. From April 2014 to September 2021, the database included 8414 patients who were hospitalized for PVO. Of these, 50% (4182 of 8414) were excluded because they had not undergone any dental procedures before the index date, a further 0.1% (10 of 8414) were excluded because they were younger than 18 years at the index date, and a further 7% (623 of 8414) were excluded because they did not have at least 20 weeks of continuous enrollment before the index date, leaving 43% (3599 of 8414) eligible for analysis here. The mean age was 77 ± 11 years, and 55% (1985 of 3599) were men. Sixty-five percent (2356 of 3599) of patients had a diagnosis of diabetes mellitus, and 42% (1519 of 3599) of patients had a diagnosis of osteoporosis. We compared the frequency of dental procedures between a 4-week hazard period before the admission date for PVO and two control periods, 9 to 12 weeks and 17 to 20 weeks before the admission date for PVO, within individuals. We calculated odds ratios and 95% confidence intervals using conditional logistic regression analysis.

RESULTS

Comparing the hazard and matched control periods within individuals demonstrated that dental procedures were not associated with an increased risk of PVO (OR 0.81 [95% CI 0.72 to 0.92]; p < 0.001). Additional analysis stratified by antibiotic prophylaxis use showed that antibiotic prophylaxis was not associated with a lower OR of developing PVO after dental procedures (with antibiotic prophylaxis: OR 1.11 [95% CI 0.93 to 1.32]; p < 0.26, without antibiotic prophylaxis: OR 0.72 [95% CI 0.63 to 0.83]; p < 0.001). Our sensitivity analyses, in which the exposure assessment interval was extended from 4 to 8 or 12 weeks and exposure was stratified by whether the dental procedure was invasive, demonstrated results that were consistent with our main analysis.

CONCLUSION

Dental procedures were not associated with an increased risk of subsequent PVO in this case-crossover study. The effectiveness of antibiotic prophylaxis was not demonstrated in the additional analysis that categorized exposure according to the use of antibiotic prophylaxis. Our results suggest that the association between dental procedures and PVO may have been overestimated. Maintaining good oral hygiene may be important in preventing the development of PVO. The indications for antibiotic prophylaxis before dental procedures should be reconsidered in view of the potential risk of adverse drug reactions to antibiotic prophylaxis and the emergence of drug-resistant pathogens. Larger randomized controlled trials are needed to confirm these findings and assess the role of antibiotic prophylaxis.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Implementation of an emergency department back pain clinical management tool on the early diagnosis and testing of spinal epidural abscess

BACKGROUND

Spinal epidural abscess (SEA) is a rare, catastrophic condition for which diagnostic delays are common. Our national group develops evidence-based guidelines, known as clinical management tools (CMT), to reduce high-risk misdiagnoses. We study whether implementation of our back pain CMT improved SEA diagnostic timeliness and testing rates in the emergency department (ED).

METHODS

We conducted a retrospective observational study before and after implementation of a nontraumatic back pain CMT for SEA in a national group. Outcomes included diagnostic timeliness and test utilization. We used regression analysis to compare differences before (January 2016-June 2017) and after (January 2018-December 2019) with 95% confidence intervals (CIs) clustered by facility. We graphed monthly testing rates.

RESULTS

In 59 EDs, pre versus post periods included 141,273 (4.8%) versus 192,244 (4.5%) back pain visits and 188 versus 369 SEA visits, respectively. After implementation, SEA visits with prior related visits were unchanged (12.2% vs. 13.3%, difference +1.0%, 95% CI -4.5% to 6.5%). Mean number of days to diagnosis decreased but not significantly (15.2 days vs. 11.9 days, difference -3.3 days, 95% CI -7.1 to 0.6 days). Back pain visits receiving CT (13.7% vs. 21.1%, difference +7.3%, 95% CI 6.1% to 8.6%) and MRI (2.9% vs. 4.4%, difference +1.4%, 95% CI 1.0% to 1.9%) increased. Spine X-rays decreased (22.6% vs. 20.5%, difference 2.1%, 95% CI -4.3% to 0.1%). Back pain visits receiving erythrocyte sedimentation rate or C-reactive protein increased (1.9% vs. 3.5%, difference +1.6%, 95% CI 1.3% to 1.9%).

CONCLUSIONS

Back pain CMT implementation was associated with an increased rate of recommended imaging and laboratory testing in back pain. There was no associated reduction in the proportion of SEA cases with a related prior visit or time to SEA diagnosis.

Silent spinal epidural abscess due to facet joint arthritis

Spinal epidural abscess (SEA) is an abscess that forms between the dura mater and vertebrae. SEA is characterized by back pain and neuropathy associated with fever, of which early diagnosis and treatment are necessary to avoid irreversible neurological sequelae. However, its diagnosis is often difficult because specific symptoms are rarely present in the early stages of the disease. A 25-month-old boy, healthy by nature and free of risk factors, was referred and admitted for fever symptoms only, without back pain or neurological symptoms. We focused on the residual activation of the coagulation-fibrinolytic system, which was contrary to the response to therapy, and were able to establish a diagnosis of SEA. After the initiation of antibiotics, the patient responded well to treatment and made a mild recovery without the need for surgical intervention. To date, there are no reported cases of SEA with only febrile symptoms without localized spinal cord tenderness. SEA is easily overlooked and should be considered in the differential diagnosis of pediatric fever of unknown origin. Although imaging studies have drawbacks, such as radiation exposure and sedation, they should be immediately performed if SEA is suspected.

High risk and low prevalence diseases: Adult bacterial meningitis

INTRODUCTION

Acute bacterial meningitis in adults is a rare but serious condition that carries a high rate of morbidity.

OBJECTIVE

This review highlights pearls and pitfalls of acute bacterial meningitis in adults, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Meningitis encompasses a broad spectrum of disease involving inflammation of the meninges and subarachnoid space. It classically presents with fever, nuchal rigidity, and altered mental status, but this triad is not present in all cases. Up to 95% of patients will have at least two of the following four cardinal symptoms: fever, nuchal rigidity, altered mental status, and headache. The most common bacterial etiologies are S. pneumoniae and N. meningitidis. Cerebrospinal fluid testing obtained by lumbar puncture remains the gold standard in diagnosis. Head computed tomography prior to lumbar puncture may not be necessary in most patients. Empiric treatment consists of vancomycin, ceftriaxone, and dexamethasone. Elevated intracranial pressure should be managed using established neurocritical care strategies.

CONCLUSION

A better understanding of the pearls and pitfalls of acute bacterial meningitis can assist emergency clinicians in pursuing its timely diagnosis and management.

Acute Spinal Epidural Abscess of the Cervical Spine Caused by Streptococcus constellatus Leads to Paraplegia in an Adult: A Case Report

The incidence of a spinal epidural abscess (SEA), which can cause serious neurological complications, is low; however, the incidence of SEA caused by Streptococcus is even lower, most of which are reported in the thoracolumbar spine and lumbosacral segment. We reported a case of cervical SEA caused by Streptococcus constellatus infection, resulting in paralysis of the patient. The acute onset of SEA in a 44-year-old male led to decreased upper limb muscle strength, lower limb paralysis, and loss of bowel and bladder function, and imaging and blood tests suggested pyogenic spondylitis. Emergency decompression surgery and antibiotic therapy were given, the patient gradually recovered, and the muscle strength of the lower limbs gradually improved. This case report suggests the importance of early decompressive surgery and effective antibiotic therapy.

Extensive spinal epidural abscess caused by Staphylococcus epidermidis: A case report and literature review

Background

Extensive spinal epidural abscess (SEA) is an exceptional and threatening condition that requires prompt recognition and proper management to avoid potentially disastrous complications. We aimed to find key elements of early diagnosis and rational treatments for extensive SEA.

Case presentation

A 70-year-old man complained of intense pain in the cervical-thoracic-lumbar spine that radiated to the lower extremity. Laboratory test results revealed a marked increase in all indicators of infection. The spinal magnetic resonance imaging (MRI) revealed a ventral SEA extending from C2 to L4. Owing to the patient's critical condition, laminectomy, drainage, and systemic antibiotic therapy were administered. And the multidrug-resistant Staphylococcus epidermidis was detected in the purulent material from this abscess.

Results

Postoperative MRI revealed diminished epidural abscess, and the clinical symptoms were dramatically and gradually relieved after two rounds of surgery and systemic antibiotic therapy involving the combination of ceftriaxone, linezolid, and rifampicin.

Conclusions

A comprehensive emergency assessment based on neck or back pain, neurological dysfunctions, signs of systemic infection, and MRI are important for early diagnosis of extensive SEA. Further, the combination of laminectomy, drainage, and systemic antibiotic therapy may be a rational treatment choice for patients with SEA, especially for extensive abscess or progressive neurological dysfunction.