Cervical subdural empyema following acupuncture

Spontaneous lumbar intraspinal subdural abscess: a case report

BACKGROUND

Subdural spinous abscess is a rare pathology that carries significant morbidity if not diagnosed and treated early; of the cases reported in the literature, very few are genuinely spontaneous in nature.

CASE PRESENTATION

Here we demonstrate the case of an otherwise entirely fit and well 56-year-old White, British female presenting with low back pain, bilateral sciatica and sensate urinary retention; lumbar subdural spinous abscess was diagnosed on urgent magnetic resonance imaging and the patient was successfully managed with surgical evacuation and prolonged antibiotic therapy. The patient made a full neurological recovery and was followed-up in the outpatient setting 12 weeks following her initial surgery; she was pain free with normal inflammatory markers and a normal neurological examination. There have been no further consultations and a telephone call at 20 weeks confirmed that she remains well.

CONCLUSIONS

This is the second case reported in the literature of a genuinely spontaneous subdural spinous abscess, which was successfully managed with surgical evacuation following prompt diagnosis. This highlights the need to ensure infective pathologies are kept at the back of one's mind even in the most unlikely circumstances, and that excellent outcomes can be achieved with early surgical intervention.

Surgical Outcome of Spinal Subdural Abscesses: A Report of Four Consecutive Patients and Brief Review of the Literature

BACKGROUND AND STUDY AIMS

 Spinal subdural abscesses (SSAs) are rare and have a poor prognosis, especially when they are diagnosed late. In the literature, most cases of SSAs have been reported as case reports and small case series. In this study, we aimed to evaluate the surgical outcomes of four consecutive SSA patients.

MATERIAL AND METHODS

 In this retrospective study, we reviewed the medical charts of four SSA patients who underwent surgical intervention at two neurosurgical centers from September 2012 to September 2019.

RESULTS

 Our series comprised four patients (three females and one male) with SSA (intradural-extramedullary) who were treated surgically. Holocord SSA was observed in two patients. The mean age was 15.1 ± 17.1 years. Unsteady gait and weakness of legs was the presenting symptom in all patients. The mean preoperative course was 5.3 ± 3.4 weeks. The causative pathogens were methicillin-resistant Staphylococcus aureus (MRSA), Escherichia coli, and Mycobacterium tuberculosis. In the fourth case, the pathogen was non-M. tuberculosis. In the 44th postoperative month, the patient underwent surgery for an intramedullary abscess. The causative pathogen was E. coli. Except for one adolescent male who was paraplegic at presentation, improvement was observed in all patients at their last follow-up after 54.0 ± 35.9 months after surgery.

CONCLUSION

 Early diagnosis and urgent surgical intervention are essential for a good prognosis in SSA cases. We recommend drainage followed by appropriate antibiotics.

Unusual case of spinal subdural empyema with ventriculitis managed conservatively with lumbar drain

It has long been believed that spinal subdural empyemas (SDEs) with neurological symptoms result in death if operative intervention is not performed. We present a case of addressing an extensive spinal SDE with a minimally invasive procedure: a bedside lumbar drain. Our patient is a 67-year-old man with medical history significant for type I diabetes who presented 2 weeks after a right shoulder steroid injection with septic arthritis. An MRI was obtained for back pain which revealed spinal SDE from the cervical to lumbosacral spine. Given patient's acute sepsis, haemodynamic instability, and extent of empyema, we placed a lumbar drain for decompression. The patient had a prolonged complicated hospital course. Imaging 2 months later revealed interval decrease in the spinal SDE. Although this severe septic event left the patient with significant deficits, he was able to return to ambulation without surgical intervention.

Unusual intracranial suppuration: illustrative cases

BACKGROUND

Intracranial suppuration (ICS) is a rare complication that can arise from various disease processes and is composed of brain abscess, extradural empyema, and subdural empyema. Although significant progress has been achieved with antibiotics, neuroimaging, and neurosurgical technique, ICS remains a serious neurosurgical emergency. An uncommon presentation of ICS is sterile ICS, which has yet to be fully elucidated by clinicians. The authors present 2 cases of unusual sterile ICS: a sterile subdural empyema and a sterile brain abscess.

OBSERVATIONS

Both patients underwent surgical treatment consisting of craniotomy to evacuate the pus collection. The blood cultures from both the patients, the collected empyema, and the thick capsule from the brain abscess were sterile. However, the necrotic brain tissue surrounding the abscess contained inflammatory cells. The authors’ review of the literature emphasizes the rarity of sterile ICS and substantiates the necessity for additional studies to explore this field.

LESSONS

Sterile ICS is a disease entity that warrants further investigation to determine appropriate treatment to improve patient outcomes. This study highlights the paucity of data available regarding sterile ICS and supports the need for future studies to uncover the etiology of sterile ICS to better guide management of this condition.

Pediatric Spinal Subdural Abscesses: A Report of Three Consecutive Patients

BACKGROUND

Despite technological advances in medical treatment, the prognosis of the rarely reported spinal subdural abscesses (SSAs) has remained a serious entity largely unaffected, especially when they are diagnosed late. In this study, the authors aimed to present the surgical outcomes of 3 consecutive pediatric patients with SSA.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of pediatric patients with spinal lesions who underwent surgery at 2 neurosurgical centers spanning 7 years, from 2012 to 2019. All pediatric patients who were diagnosed with SSA (n = 3) were selected as the core sample for this study.

RESULTS

Three pediatric patients (2 females and 1 male) with SSA were surgically treated. Holocord SSA was observed in 1 patient. The mean age was 7.1 ± 7.7 years. The most common presenting symptoms were gait disturbance and weakness of lower extremities (100%). The mean preoperative course was 5.7 ± 4.0 weeks. The causative pathogens were Escherichia coli (E. coli) and M. tuberculosis. In the 2nd case, the pathogen was non-tuberculosis mycobacterium in the extramedullary abscess. In the 44th postoperative month, she underwent surgery for intramedullary abscess. The causative pathogen was E. coli. Except for 1 male adolescent who presented with severe clinical status (paraplegic), the improvement was observed in all patients at their last follow-up after 50.3 ± 43.5 months of average.

CONCLUSIONS

Drainage followed by appropriate antibiotics is the optimal treatment for SSAs. Early diagnosis and urgent surgical treatment are essential for a good prognosis. All surgically treated SSA patients with neurological deficits were rehabilitated with physical therapy postoperatively.

Acupuncture-Induced Cranial Epidural Abscess: Case Report and Review of the Literature

BACKGROUND

Acupuncture is a common form of alternative medicine that is used for pain control among other modalities of treatment. It is a relatively safe procedure, but complications, including those of infectious etiology, may still occur.

CASE DESCRIPTION

A 47-year-old immunosuppressed woman presented with fever, altered level of consciousness, dysphasia, and a left occipital subgaleal fluctuant mass after acupuncture for headaches in the same area. Imaging demonstrated subgaleal and epidural collection localized in the left occipital region. She underwent urgent surgical evacuation of both collections. Cultures from intraoperative specimens grew Streptococcus anginosus. The patient started targeted antibiotic treatment leading to complete recovery.

CONCLUSIONS

To our knowledge, this is the first report of intracranial abscess after acupuncture. Given the worldwide application of this alternative treatment, physicians, acupuncturists, and the general public should be aware of the possibility of this rare but serious complication.

Thoracic Spondylodiscitis Epidural Abscess in an Afebrile Navy Veteran: A Case Report

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.

Spinal subdural abscess following repeat lumbar microdiscectomy: A case report of imaging findings for a rare infection

Spinal subdural abscess is a rare central nervous system infection with just over a hundred cases reported. It is much less common than spinal epidural abscess. While most case reports have focused on route of infection and treatment options, there have not been any reports that focused on the unique MRI findings of spinal subdural abscess. We describe a case of spinal subdural abscess diagnosed by MRI in a 33-year-old male who presented with headaches after undergoing a microdiscectomy procedure, and review the underlying anatomic features of the spinal meninges which produce the appearance of a spinal subdural abscess.

An Acute Cervical Subdural Hematoma as the Complication of Acupuncture: Case Report and Literature Review

BACKGROUND

Several injuries in the cervical region as complications of acupuncture have been previously reported in the literature, including cord and medulla oblongata injuries, subdural empyema, and cervical hematoma. Spinal cord subdural hematoma is a rare condition mainly associated with coagulopathy, trauma, and iatrogenic procedures. We herein report an acute cervical subdural hematoma after cervical acupuncture for neck and shoulder pain.

CASE DESCRIPTION

A 74-year-old woman presented with progressive quadriparesis and sensory deficit after receiving acupuncture in the neck and shoulder. Magnetic resonance imaging of the cervical spine showed a subdural lesion that was a hyperintense mass in the T1-weighted and hypointense in T2-weighted images at the C4-C6 level, which proved to be an early subacute subdural hematoma. After surgical evacuation of the hematoma, the patient had significant neurologic improvement.

CONCLUSIONS

Although rare, cervical spinal cord hematomas are disastrous complications of cervical acupuncture. These procedures should be performed under direct observation of trained physicians with appropriate knowledge of cervical anatomy to avoid these complications.

Spinal Subdural Abscess Following Laminectomy for Symptomatic Stenosis: A Report of 2 Cases and Review of the Literature

BACKGROUND Spinal subdural abscesses, also known as empyemas, are rare infectious lesions, the exact incidence of which is unknown. Presentation is typically dramatic, with back pain, fever, motor, and sensory deficits. Rapid identification and surgical intervention with laminectomy, durotomy, and washout provides the best outcomes. While hematogenous spread of an extra-spinal infection is the most common cause of this condition, a significant number of cases result from iatrogenic mechanisms, including lumbar punctures, epidural injections, and surgery. CASE REPORT Here we present 2 cases: 1) an 87-year-old man with type 2 diabetes, schizophrenia, mild cognitive impairment, and symptomatic lumbar spinal stenosis and 2) a 62-year-old man with a prior L3-4 spinal fusion with symptomatic lumbar spinal stenosis. In both cases, patients underwent laminectomy for spinal stenosis and developed epidural abscess. Following successful drainage of the epidural abscess, they continued to be symptomatic, and repeat imaging revealed the presence of a subdural abscess that was subsequently evacuated. Case 1 had significant improvement with residual lower-extremity weakness, while Case 2 made a complete neurological recovery. CONCLUSIONS These cases illustrate patients at increased risk for developing this rare spinal infection, and demonstrate that rapid recognition and surgical treatment is key to cure and recovery. Review of the literature highlights pertinent risk factors and demonstrates nearly one-third of reported cases have an iatrogenic etiology. The cases presented here demonstrate that a subdural process should be suspected in any patient with intractable pain following treatment of an epidural abscess.

First Reported Case of Methicillin-Resistant Staphylococcus aureus Vertebral Osteomyelitis with Multiple Spinal and Paraspinal Abscesses Associated with Acupuncture

Acupuncture is one of the oldest medical procedures in the world and originated in China about 2,000 years ago. Acupuncture is a form of complementary medicine and has gained popularity worldwide in the last few decades. It is mainly used for the treatment of chronic pain. Acupuncture is usually considered a safe procedure but has been reported to cause serious complications including death. It has been associated with transmission of many viruses and bacteria. Two cases of Methicillin-Resistant Staphylococcus aureus have been reported recently following acupuncture therapy. We are reporting a case of a 57-year-old Korean female who developed vertebral osteomyelitis and intraspinal and paraspinal abscesses as a complication of acupuncture. Blood cultures, skin lesion culture, and body fluid culture yielded Methicillin-Resistant Staphylococcus aureus (MRSA). Good anatomical and medical knowledge, good hygiene standards, and proper acupuncture techniques should be followed to prevent the complications. Acupuncturists should consistently review the infection control guidelines to acupuncture. This case should raise awareness of such condition and hazards of presumably benign procedures such as acupuncture.

Retrospective study using MRI to measure depths of acupuncture points in neck and shoulder region

OBJECTIVES

There are safety issues associated with acupuncture treatment. Previous studies regarding needling depth of acupuncture points revealed inconsistent results due to vague depth definition, acupuncture point localisation and measuring tools. The objective of this study is to find and compare the differences of the mean depths of 11 acupuncture points in the neck and shoulder region between subjects, with variables including gender and body mass index (BMI).

SETTING

This study was conducted at a single medical center in Taiwan.

PARTICIPANTS

Three hundred and ninety-four participants were included in this study. Participants were grouped according to gender and BMI. Acupuncture points were localised by WHO standard and measured by MRI.

OUTCOME MEASURES

The distance from the needle insertion point (surface of the skin) to any tissues that would cause possible/severe complications.

RESULTS

Mean depths of 11 points were obtained in groups of different BMI and gender. Mean depths of all participants regardless of BMI and gender are as follows, in centimetres: GB21=5.6, SI14=5.2, SI15=8.8, GV15=4.9, GV16=4.6, GB20=5.0, ST9=1.6, SI16=1.8, SI17=2.4, TE16=3.1, LI18=1.3. Participants with higher BMI had greater measured depths in both gender groups. Male participants had larger mean depths than female participants regardless of BMI except in SI17 and LI18. When taking BMI into consideration, depths in male participants are greater than in female participants in most of the points except the following: GB21, TE16 in obesity group; ST9 in underweight and obesity group; SI16 in ideal body weight, overweight and obesity group; SI17, LI18 in each group.

CONCLUSIONS

Participants with higher BMI had greater measured depths and males tended to have greater depths in most of the points. Clinical practitioners are recommended to consider this information to prevent complications when applying acupuncture treatment to their patients.

Spinal subdural abscess following epidural steroid injection

The authors report the case of a 58-year-old man who presented with a cervicothoracolumbosacral spinal subdural abscess about a month after receiving an epidural steroid injection for management of low-back pain due to L5-S1 disc herniation. Although he presented with symptoms concerning for a spinal etiology, the subdural empyema was not evident on the initial MRI study and was observed on imaging 5 days later. This patient was successfully managed with surgical intervention and antibiotic treatment, and he is doing well more than 21 months after the operation. It is possible that a prior history of disc herniation or other spinal abnormality may increase a patient's risk of developing spinal subdural empyema. This case illustrates the risk of infection following spinal epidural steroid injections and the importance of early recognition and intervention to successfully treat an extensive subdural abscess.

Spinal subdural abscess: a rare complication of decubitus ulcer

Spinal subdural abscess (SSA) is an uncommon entity. The exact incidence is unknown, with very few cases reported in the literature. This condition may result in spinal cord compression, thus constituting a medical and neurosurgical emergency. The pathogenesis of SSA is not well-described, and the available knowledge is based on case observations only. There is only one case report that describes direct seeding from decubitus ulcers as a possible mechanism for development of SSA. We report a case of subacute onset of quadriplegia in a male patient, age 55 years, due to spinal cord compression from SSA and superimposed spinal subdural hematoma. The direct seeding from decubitus ulcers is thought to be the cause of infection in our patient. We present this case of SSA to elucidate and review the predisposing factors, pathogenesis, clinical presentation, diagnostic modalities, and treatment regarding management of this rare disorder.

Thoracolumbosacral spinal subdural abscess: magnetic resonance imaging appearance and limited surgical management

STUDY DESIGN

Case report and review of relevant literature.

OBJECTIVE

To report a rare case of a thoracolumbosacral spinal subdural abscess (SSA) and highlight the magnetic resonance imaging (MRI) appearance and surgical management.

SUMMARY OF BACKGROUND DATA

SSA is rare, as most intraspinal abscesses are epidural in location. Extensive thoracolumbosacral SSA has only rarely been reported. The MRI features and options for limited surgical management are not well described.

METHODS

A case report of SSA is presented and relevant literature is reviewed.

RESULTS

An elderly female presented with worsening back pain and sepsis. MRI demonstrated an extensive intraspinal abscess, extending from the upper thoracic spine to the sacrum. Both axial and sagittal images demonstrated a subdural location of the collection, with preservation of the dorsal epidural fat and mass effect on the spinal cord. Cord compression was most marked at the T8 level. Limited midthoracic laminectomies were performed. The epidural space seemed normal intraoperatively. A limited longitudinal durotomy yielded purulent fluid. After intraoperative irrigation, primary dural repair was performed. At 2-year follow-up, the patient had no clinical, radiographical, or laboratory evidence of residual or recurrent spinal infection.

CONCLUSION

Careful review of MRI can localize an intraspinal abscess to the subdural space. Even for extensive subdural collections, limited operative management can achieve excellent clinical outcome.

LEVEL OF EVIDENCE

N/A.

Adverse events of acupuncture: a systematic review of case reports

Acupuncture, moxibustion, and cupping, important in traditional Eastern medicine, are increasingly used in the West. Their widening acceptance demands continual safety assessment. This review, a sequel to one our team published 10 years ago, is an evaluation of the frequency and severity of adverse events (AEs) reported for acupuncture, moxibustion, and cupping between 2000 and 2011. Relevant English-language reports in six databases were identified and assessed by two reviewers. During this 12-year period, 117 reports of 308 AEs from 25 countries and regions were associated with acupuncture (294 cases), moxibustion (4 cases), or cupping (10 cases). Country of occurrence, patient's sex and age, and outcome were extracted. Infections, mycobacterial, staphylococcal, and others, were the main complication of acupuncture. In the previous review, we found the main source of infection to be hepatitis, caused by reusable needles. In this review, we found the majority of infections to be bacterial, caused by skin contact at acupoint sites; we found no cases of hepatitis. Although the route of infection had changed, infections were still the major complication of acupuncture. Clearly, guidelines such as Clean Needle Technique must be followed in order to minimize acupuncture AEs.

Chronic spinal subdural abscess mimicking an intradural-extramedullary tumor

Spinal subdural abscesses (SSA) are very rare disease. The etiologies of SSA are hematogenous spread, iatrogenic contamination, and local extension. Elevated WBC counts, ESR, and C-reactive protein are usually found in laboratory tests. But they are not sensitive indicators of SSA, especially chronic abscesses patient tend to have a less specific characteristic. We report the case of a healthy man with chronic subdural abscess referred to our hospital as an intradural-extramedullary (IDEM) tumor. The patient presented with voiding difficulty and pain in the back and left leg. In a contrast MRI scan, a rim-enhanced mass-like lesion was seen at the L5/S1 level. But adjacent ill-defined epidural fat enhancement that are unusual imaging manifestation for IDEM tumors was seen. He had no fever and normal WBC, ESR, and CRP. In addition, the patient had no previous infection history or other disease, but he did have an epidural block for back pain at another hospital 2 years previously. So, we repeated the MRI with a high-resolution 3-T scanner. The newly taken MR images in our hospital revealed a clear enlargement of lesion size compared to the previous MRI taken 1 week before in other hospital. We suspected a chronic spinal subdural abscess with recent aggravation and immediately performed surgical evacuation. In the surgical field, tensed dura was observed and pus was identified after opening the abscess capsule. Because chronic spinal subdural abscesses are difficult to diagnose, we could differentiate with IDEM tumor exactly and an exact history taking, contrast MRI are required.

Infections of the spinal subdural space in children: a series of 11 contemporary cases and review of all published reports. A multinational collaborative effort

INTRODUCTION

Positioned anatomically between the spinal epidural space and the intramedullary compartment, the spinal subdural space remains the least common area of localized infection in the central nervous system. Infectious processes of the subdural spinal space include subdural spinal empyema, subdural spinal abscess, infected spinal subdural cyst, and infectious spinal subdural cyst. To date, there has been no systematic review of these entities in children, with the cumulative knowledge of the pathophysiologic, microbiologic, and demographic characteristics of these infections relegated solely to few small series and case reports.

METHODS

A series of 11 recent cases culled from the collaboration of international authors are presented. In addition, an exhaustive MEDLINE search and manual review of the international literature was performed, identifying a total of 73 cases of spinal subdural infections in patients under the age of 21. Data of interest include the age, sex, signs, and symptoms at presentation, spinal location of infection, presence of spinal dysraphism, and other comorbidities, offending organism, treatment, outcome, and follow-up.

RESULTS

Patients ages ranged from 4 weeks to 20 years (mean, 6.5 years). Males outnumbered females by a ratio of 2:1. Over half (53 %) of spinal subdural infections in children were associated with spinal dysraphism or other congenital abnormalities of the spine. The commonest organism to infect the spinal subdural space in children is mycobacterium tuberculosis and the thoracic spinal region was most commonly infected.

CONCLUSIONS

The disease is usually treated surgically, although a more expectant approach consisting of antibiotics and observation has also been proposed.

Acupuncture: does it alleviate pain and are there serious risks? A review of reviews

Acupuncture is commonly used for pain control, but doubts about its effectiveness and safety remain. This review was aimed at critically evaluating systematic reviews of acupuncture as a treatment of pain and at summarizing reports of serious adverse effects published since 2000. Literature searches were carried out in 11 databases without language restrictions. Systematic reviews were considered for the evaluation of effectiveness and case series or case reports for summarizing adverse events. Data were extracted according to predefined criteria. Fifty-seven systematic reviews met the inclusion criteria. Four were of excellent methodological quality. Numerous contradictions and caveats emerged. Unanimously positive conclusions from more than one high-quality systematic review existed only for neck pain. Ninety-five cases of severe adverse effects including 5 fatalities were included. Pneumothorax and infections were the most frequently reported adverse effects. In conclusion, numerous systematic reviews have generated little truly convincing evidence that acupuncture is effective in reducing pain. Serious adverse effects continue to be reported. Numerous reviews have produced little convincing evidence that acupuncture is effective in reducing pain. Serious adverse events, including deaths, continue to be reported.

Cranial and spinal subdural empyema

Subdural empyema represents a loculated suppuration between the dura and the arachnoid. It has been described either intracranially or in the spinal canal, the latter localization being quite rare. It is a rare but serious illness with a declining mortality rate but rather frequent neurological sequelae. Morbidity and mortality in intracranial and spinal subdural empyema directly relate to the delay in diagnosis and therapy. The epidemiology, etiology, pathophysiology and symptoms of spinal subdural empyema and cranial subdural empyema are somewhat different, but brain and spinal subdural empyema are not always two different entities. An adequate treatment strategy should be selected on a case-by-case basis, especially for patients with a massive CNS involvement, where management represents a challenge.

[Cervical epidural abscess following lumbar epidural steroid injections]

A 49-year-old female with diabetes and chronic low back pain was treated with computed tomography-guided injections after years of unsuccessful pain management. Magnetic resonance imaging (MRI) demonstrated degenerative changes of the lumbar spine with disk herniation, facet joint degeneration, and instability of the presacral segment. Following epidural steroid injection, local infection and sepsis occurred and, finally, tetraparesis developed. A cervical epidural abscess was demonstrated on follow-up MRI and evacuation was performed. The patient survived severely handicapped. Legal proceedings were initiated against the radiologists. They were accused of causing damage to the patient. The plaint was defeated with special reference to the report and expertise of the neuroradiologic evidence.

Spinal Subdural Staphylococcus Aureus Abscess: case report and review of the literature

Background

Only 65 cases (including our case) of spinal subdural abscesses have been reported to the literature, mostly to the lumbar spine. Staphylococcus aureus is the most common bacterial. The symptoms are not caracteristic and contrast – enhanced magnetic resonance imaging scan (MRI) is the imaging method of choice. The early diagnosis is crucial for the prognosis of the patient.

Case presentation

We present a patient 75 years old who had a history of diabetes and suffered acute low back pain in the region of the lumbar spine for the last 4 days before his admission to the hospital. He also experienced lower leg weakness, fever and neck stiffness. After having a brain CT scan and a lumbar puncture the patient hospitalized with the diagnosis of meningitis. Five days after his admission the diagnosis of subdural abscess secured with contrast – enhanced MRI but meanwhile the condition of the patient impaired with respiratory failure and quadriplegia and he was admitted to the ICU. A laminectomy was performed eight days after his admission into the hospital but unfortunately the patient died.

Conclusion

Early diagnosis and treatment are very important for the good outcome in patients with subdural abscess. Although morbidity and mortality are very high, surgical and antibiotic treatment should be established as soon as possible after the diagnosis has secured.

[Spinal epidural empyema. Limited surgical treatment combined with continuous irrigation and drainage]

Epidural empyema of the spinal column is a rare, but in some cases devastating, disease. Surgery can be excessive or very limited. We want to report our results of combined therapy of limited surgical treatment and continuous irrigation with antibiotic solution and drainage. In the last 5 years we have operated on 12 patients (7 female, 5 male, median age: 61.5 years, range: 22-89 years) with spinal epidural empyema. All surviving patients were evaluated after 3 months including MRI. Six infections were caused by injections, two by spontaneous discitis, two by chronic systemic infections, and in two patients the cause remained unknown. In every case we implanted two catheters, one for irrigation with antibiotic solution and one for drainage. On average the catheters were used for 3 days. For evacuation in seven patients interlaminar fenestration in one, two, or three levels was enough. Only in one patient was a laminectomy performed. Five patients recovered totally, three partially, one did not recover at all, and three died. The autopsy of two dead patients showed complete healing of the operated area; they died because of lethal infections in other parts of their body. In only one case did a reoperation have to be done. The cause was an additional subdural empyema. In spite of the limited surgical procedure without relevant operative morbidity the reported method is an effective and safe therapy.

Acupuncture needles causing lumbar cerebrospinal fluid fistula

✓Acupuncture is a frequently used adjuvant treatment for chronic pain conditions. The authors report the case of a patient in whom the delayed migration of embedded acupuncture needles into the lumbar spinal canal caused the formation of a cerebrospinal fluid fistula and spine-related headache. The needles were safely removed surgically and the patient improved clinically.

Vascular and Parameningeal Infections of the Head and Neck

Vascular and parameningeal infections of the head and neck are rare but frequently life threatening. These infections include intracranial and extracranial septic venous thrombophlebitis, arterial mycotic aneurysms and erosions, subdural empyema, and epidural abscesses. They usually arise as complications of otogenic, oropharyngeal, or paranasal sinus infections, and management involves an aggressive combined medical-surgical approach.

Spinal subdural Staphylococcus aureus abscess: case report and review of the literature

Spinal subdural abscesses (SSA) are rare and to date only 57 cases have been reported. The exact incidence of the SSA is unknown. The most affected region is the thoraco-lumbar spine and the most common bacterial source is Staphylococcus aureus. The timing for magnetic resonance imaging is very important in these patients. Because early diagnosis and emergent treatment is vital to prevent the formation or progression of neurologic deficits.