Holospinal epidural abscess

Extensive Spinal Epidural Abscess: A Systematic Review of Risk Factors, Clinical Presentation, and Management with a Case Illustration

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.

A Machine Learning Algorithm for Predicting 6-Week Survival in Spinal Metastasis: An External Validation Study Using 2,768 Taiwanese Patients

INTRODUCTION

There are predictive algorithms for predicting 3-month and 1-year survival in patients with spinal metastasis. However, advance in surgical technique, immunotherapy, and advanced radiation therapy has enabled shortening of postoperative recovery, which returns dividends to the overall quality-adjusted life-year. As such, the Skeletal Oncology Research Group machine learning algorithm (SORG-MLA) was proposed to predict 6-week survival in patients with spinal metastasis, whereas its utility for patients treated with nonsurgical treatment was untested externally. This study aims to validate the survival prediction of the 6-week SORG-MLA for patients with spinal metastasis and provide the measurement of model consistency (MC).

METHODS

Discrimination using area under the receiver operating characteristic curve, calibration, Brier score, and decision curve analysis were conducted to assess the model's performance in the Taiwanese-based cohort. MC was also applied to detect the proportion of paradoxical predictions among 6-week, 3-month, and 1-year survival predictions. The long-term prognosis should not be better than the shorter-term prognosis in that of an individual.

RESULTS

The 6-week survival rate was 84.2%. The SORG-MLA retained good discrimination with an area under the receiver operating characteristic curve of 0.78 (95% confidence interval, 0.75 to 0.80) and good prediction accuracy with a Brier score of 0.11 (null model Brier score 0.13). There is an underestimation of the 6-week survival rate when the predicted survival rate is less than 50%. Decision curve analysis showed that the model was suitable for use over all threshold probabilities. MC showed suboptimal consistency between 6-week and 90-day survival prediction (78%).

CONCLUSIONS

The results of this study supported the utility of the algorithm. The online tool ( https://sorg-apps.shinyapps.io/spinemetssurvival/ ) can be used by both clinicians and patients in informative decision-making discussion before management of spinal metastasis.

Holospinal epidural abscess caused by Streptococcus anginosus group: a literature review

Spinal epidural abscess (SEA) usually extends over three to four vertebrae. We present a case of holospinal epidural abscess (HEA) caused by the Streptococcus anginosus group (SAG). A man in his 40s with a 2-week history of fever, back pain, and progressive tetraparesis was referred to us from the local hospital. MRI showed epidural fluid collection from C2 to S1. Blood and pus cultures revealed the presence of SAG. He was treated by emergency laminoplasty, epidural drainage and antibiotic treatment. After the 111st hospital day, his manual muscle test was shown to improve; hence, he was transferred for rehabilitation. According to the previous reports, we identified 12 cases of SEA extending from the cervical spine to the sacrum, including our case. For one-fourth of these cases, SAG was the causative organism of this rare SEA. Therefore, SAG should be considered causative organisms in HEA.

Management of Holospinal Epidural Abscess

Holospinal epidural abscess (HEA) is a rare condition that can cause extensive cord compression, necessitating prompt neurosurgical intervention for evacuation and drainage. Here we report the case of a 74-year-old male with HEA due to Cutibacterium acnes infection leading to headache, neck stiffness, and decreased mental acuity, successfully treated using segmental laminectomies in the cervical, thoracic, and lumbar spine.

Surgical management of an extensive spinal epidural abscess: illustrative cases

BACKGROUND

Extensive spinal epidural abscesses (SEAs) occupying three or more spinal regions are rare. This study aimed to address the key dilemma of surgical treatment for holospinal epidural abscesses, i.e., to determine the required scope of surgery and minimize surgical trauma with adequate purulent drainage.

OBSERVATIONS

Two patients with extensive SEAs were treated at the Neurosurgery Department of the Central Hospital of Ministry of Internal Affairs of Ukraine from 2018 to 2020. Both patients had a neurological deficit and general inflammatory response syndrome. Spinal magnetic resonance examinations were performed, showing that the first and second patients had extensive SEAs at T11/S1 and C2/L1, respectively. Both underwent minimally invasive abscess drainage via intra- and translaminar access at the most caudal point using an epidural silicone catheter in the cranial direction along the entire length of the abscess.

LESSONS

To achieve the key goal of extensive SEA treatment, i.e., to prevent the development of a persistent neurological deficit, immediate effective spinal canal decompression should be performed. Access method and scope should meet the requirements of spinal canal decompression and purulent content aspiration to the greatest possible extent while inducing minimal trauma.

Resolution of group B streptococcal panspinal epidural abscess in a patient with diabetes after treatment with ceftriaxone and linezolid

Panspinal epidural abscesses are an extremely rare yet potentially fatal condition. Whether cases are best managed surgically or medically is currently controversial. A 63-year-old patient with diabetes presented initially with abdominal pain, back pain, urinary retention and constipation. He subsequently developed fevers, radicular pain and new-onset weakness in the right leg. MRI confirmed a panspinal epidural abscess extending from C7 to L5, with group B Streptococcus (GBS) cultured on sampling. Due to the significant risks of surgery he was managed conservatively, initially with ceftriaxone, and subsequently in combination with linezolid. Repeat MRI 3 months after presentation revealed complete resolution of the abscess. This case illustrates how conservative management is a valid option for patients with this condition, and supports the use of synergistic linezolid in this scenario. It also highlights how some cases may not initially present with the classically described triad of fever, back pain and loss of neurological function.

Holospinal epidural abscess in elderly patient: A case presentation and review

Background:

Holospinal epidural abscess (HEA) is a rare pathological entity with significant morbidity and mortality rates. Here, we present a 74-year-old male with HEA treated with focal skip laminectomies and catheter irrigation.

Case Description:

A 74-year-old male presented with fever, neck/back pain, and slight weakness in his legs bilaterally (4/5). The patient underwent a magnetic resonance imaging (MRI) of the entire spine showing an epidural collection extending from C5-C6 to the L4-L5 levels. Laboratory studies revealed a leukocytosis and an elevated C-reaction protein level. Blood cultures were positive for methicillin-sensitive Staphylococcus aureus. The patient underwent skip laminectomies at C6 and C7; T2, T3, T5, T6, T8, T9, T10, and T12; and L3, L4, and L5 with catheter irrigation between these levels; this minimized the risk of postoperative kyphosis and instability. His postoperative course was uneventful. Other surgical approaches to HEA described in literature include laminectomy, focal laminectomies, and skip laminectomies.

Conclusion:

In this case of a holospinal HEA, skip laminectomies and catheter irrigation avoided neurological deterioration and delayed spinal instability in a 74-year-old male.

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

PURPOSE

An extensive spinal epidural abscess is a rare condition and causes significant morbidity and mortality. Few authors have described this uncommon entity, which requires early diagnosis and optimal treatment to avoid devastating complications. The purpose of this study was to evaluate a minimally invasive technique for treatment of an extensive spinal epidural abscess by describing two cases. Furthermore, we conducted a review of the recent literature on the management of this rare condition.

METHODS

We report two cases of spinal abscesses extending to the whole epidural space, successfully treated by use of a minimally invasive technique consisting of multilevel laminotomy and catheter irrigation to decompress and drain the epidural space.

RESULTS

This technique is able to decompress the spinal cord, isolate the pathogen and evacuate the abscess. No complications, late spine deformity or dura penetration were observed in our patients.

CONCLUSION

Urgent surgical decompression, in combination with long-term antibiotic treatment, is generally considered the treatment of choice for an extensive spinal epidural abscess. A minimally invasive technique can be very useful as a surgical option.

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

Introduction

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

Case presentation

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

Discussion

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

A case of panspinal epidural abscess that presented with meningeal irritation

Case

In rare cases, spinal epidural abscess involves the entire spine and can lead to neurological deficits and sepsis if treatment is delayed or suboptimal. A 65‐year‐old man was admitted with a diagnosis of bacterial meningitis. After admission, magnetic resonance imaging showed a spinal epidural abscess from the cervical to lumbar spine. Blood culture revealed Staphylococcus aureus. The patient was initially treated medically because he had no neurological deficits. Repeat blood culture remained positive and abscesses were found in the mediastinum and bilateral psoas muscles.

Outcome

Surgery was carried out and the patient's postoperative course was satisfactory.

Conclusion

Spinal epidural abscess can extensively affect the spine and may present with the symptoms of bacterial meningitis. It is essential to examine the entire spine and paraspinal regions and to treat early in cases of spinal epidural abscess.

Pan-spinal infection: a case series and review of the literature

BACKGROUND

Panspinal infection usually presents with fever, back pain, neurological deficit, and in advanced cases multi-organ failure and septic shock. The choice of treatment for panspinal infection is challenging because these patients are usually medically unstable with severe neurological compromise. The objective of this study is to review management and long term outcomes for patients with panspinal infection.

METHODS

A retrospective review of patients with panspinal infection treated in our center over a 5-year period [Jan 2010-Dec 2014] and a review of the current published literatures was undertaken.

RESULTS

We identified 4 patients with panspinal infection. One case was managed medically due to high perioperative risk, whilst the other three were managed surgically whilst on antibiotic therapy. All 3 cases managed surgically improved neurologically and infection subsided, whereas the patient managed medically did not change neurologically and infection subsided.

CONCLUSIONS

Patients with panspinal infection should be treated surgically unless the medical risk of surgery or anaesthesia is prohibitive.

Holospinal epidural abscess of the spinal axis: two illustrative cases with review of treatment strategies and surgical techniques

Despite the increasing prevalence of spinal infections, the subcategory of holospinal epidural abscesses (HEAs) is extremely infrequent and requires unique management. Panspinal imaging (preferably MRI), modern aggressive antibiotic therapy, and prompt surgical intervention remain the standard of care for all spinal axis infections including HEAs; however, the surgical decision making on timing and extent of the procedure still remain ill defined for HEAs. Decompression including skip laminectomies or laminoplasties is described, with varied clinical outcomes. In this review the authors present the illustrative cases of 2 patients with HEAs who were treated using skip laminectomies and epidural catheter irrigation techniques. The discussion highlights different management strategies including the role of conservative (nonsurgical) management in these lesions, especially with an already identified pathogen and the absence of mass effect on MRI or significant neurological defects. Among fewer than 25 case reports of HEA published in the past 25 years, the most important aspect in deciding a role for surgery is the neurological examination. Nearly 20% were treated successfully with medical therapy alone if neurologically intact. None of the reported cases had an associated cranial infection with HEA, because the dural adhesion around the foramen magnum prevented rostral spread of infection. Traditionally a posterior approach to the epidural space with irrigation is performed, unless an extensive focal ventral collection is causing cord compression. Surgical intervention for HEA should be an adjuvant treatment strategy for all acutely deteriorating patients, whereas aspiration of other infected sites like a psoas abscess can determine an infective pathogen, and appropriate antibiotic treatment may avoid surgical intervention in the neurologically intact patient.

Extensive spinal epidural abscess treated with "apical laminectomies" and irrigation of the epidural space: report of 2 cases

Spinal epidural abscess (SEA) is a rare but often devastating infection of the epidural space around the spinal cord. When an SEA is widespread, extensive decompression with laminectomy is often impossible, as it may subject the patient to very long operative times, extensive blood loss, and mechanical instability. A technique called "skip laminectomy" has been described in the literature, in which laminectomies are performed at the rostral and caudal ends of an abscess that spans 3-5 levels and a Fogarty catheter is used to mechanically drain the abscess, much like in an embolectomy. In this report of 2 patients, the authors present a modification of this technique, which they call "apical laminectomies" to allow for irrigation and drainage of an extensive SEA spanning the entire length of the vertebral column (C1-2 to L5-S1). Two patients presented with cervico-thoraco-lumbar SEA. Laminectomies were performed at the natural apices of the spine, namely, at the midcervical, midthoracic, and midlumbar spine levels. Next, a pediatric feeding tube was inserted in the epidural space from the thoracic laminectomies up toward the cervical laminectomy site and down toward the lumbar laminectomy site, and saline antibiotics were used to irrigate the SEA. Both patients underwent this procedure with no adverse effects. Their SEAs resolved both clinically and radiologically. Neither patient suffered from mechanical instability at 1 year after treatment. For patients who present with extensive SEAs, apical laminectomies seem to allow for surgical cure of the infectious burden and do not subject the patient to extended operating room time, an increased risk of blood loss, and the risk of mechanical instability.