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Selvamani BJ, Kalagara H, Volk T, Narouze S, Childs C, Patel A, Seering MS, Benzon HT, Sondekoppam RV. Infectious complications following regional anesthesia: a narrative review and contemporary estimates of risk. Reg Anesth Pain Med 2024:rapm-2024-105496. [PMID: 38839428 DOI: 10.1136/rapm-2024-105496] [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: 03/19/2024] [Accepted: 05/22/2024] [Indexed: 06/07/2024]
Abstract
INTRODUCTION Infectious complications following regional anesthesia (RA) while rare, can be devastating. The objective of this review was to estimate the risk of infectious complications following central neuraxial blocks (CNB) such as epidural anesthesia (EA), spinal anesthesia (SA) and combined spinal epidural (CSE), and peripheral nerve blocks (PNB). MATERIALS AND METHODS A literature search was conducted in PubMed, Embase and Cochrane databases to identify reference studies reporting infectious complications in the context of RA subtypes. Both prospective and retrospective studies providing incidence of infectious complications were included for review to provide pooled estimates (with 95% CI). Additionally, we explored incidences specifically associated with spinal anesthesia, incidences of central nervous system (CNS) infections and, the incidences of overall and CNS infections following CNB in obstetric population. RESULTS The pooled estimate of overall infectious complications following all CNB was 9/100 000 (95% CI: 5, 13/100 000). CNS infections following all CNB was estimated to be 2/100 000 (95% CI: 1, 3/100 000) and even rarer following SA (1/100 000 (95% CI: 1, 2/100 000)). Obstetric population had a lower rate of overall (1/100 000 (95% CI: 1, 3/100 000)) and CNS infections (4 per million (95% CI: 0.3, 1/100 000)) following all CNB. For PNB catheters, the reported rate of infectious complications was 1.8% (95% CI: 1.2, 2.5/100). DISCUSSION Our review suggests that the risk of overall infectious complications following neuraxial anesthesia is very rare and the rate of CNS infections is even rarer. The infectious complications following PNB catheters seems significantly higher compared with CNB. Standardizing nomenclature and better reporting methodologies are needed for the better estimation of the infectious complications.
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Affiliation(s)
| | - Hari Kalagara
- Department of Anesthesiology and Perioperative Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Samer Narouze
- Western Reserve Hospital Partners, Cuyahoga Falls, Ohio, USA
| | | | - Aamil Patel
- University of Iowa Health Care, Iowa City, Iowa, USA
| | | | - Honorio T Benzon
- Departments of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rakesh V Sondekoppam
- Department of Anesthesia, University of Iowa Healthcare, Iowa City, Iowa, USA
- Department of Anesthesia and Pain Medicine, University of Alberta Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
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Muacevic A, Adler JR. The Surgical Management of Holospinal Epidural Abscess: A Case Report and Review on Catheter-Based Irrigation Techniques. Cureus 2022; 14:e30437. [PMID: 36407233 PMCID: PMC9671263 DOI: 10.7759/cureus.30437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2022] [Indexed: 01/25/2023] Open
Abstract
Holospinal epidural abscess (HEA) is an extremely rare spinal infection involving the entire spine and is infrequently reported in the literature. Cases with evidence of spinal cord compression and consequent neurological deficit are typically managed with prompt surgical drainage and broad-spectrum antibiotics. Surgical intervention is often challenging because this condition is inherently associated with poor prognosis and serious complications, including death. During the surgical evacuation of the abscess, catheter-based irrigation must be adequately performed. In the majority of reported cases, the extent of the advancement of the epidural catheter is blindly assessed by the operating surgeon, increasing the risk of residual collections and subsequent persistent infection. Herein, we report a rare case of HEA that was successfully treated with surgical evacuation and skip laminectomies. We also describe a catheter-based technique that facilitates adequate irrigation, thereby ensuring the complete drainage of HEA in obscured perispinal areas, as well as the decompression of the spinal cord. Postoperative neurological examination exhibited marked improvement in motor function (compared with a baseline of complete quadriparesis), indicating the successful decompression of the spinal cord and neurological improvement.
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McCarter SJ, Johnson-Tesch BA. Pneumorrhachis From Esophageal Perforation Due to Cervical Osteophyte. JAMA Neurol 2022; 79:819-820. [PMID: 35604653 DOI: 10.1001/jamaneurol.2022.1159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Kharbat AF, Cox CT, Purcell A, MacKay BJ. Methicillin-Resistant Staphylococcus aureus Spinal Epidural Abscess: Local and Systemic Case Management. Cureus 2022; 14:e22831. [PMID: 35399478 PMCID: PMC8980237 DOI: 10.7759/cureus.22831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2022] [Indexed: 12/02/2022] Open
Abstract
Spinal epidural abscess (SEA) is a rare condition with complex pathophysiology and highly variable clinical presentation. While it is known to cause focal peripheral nerve symptoms such as muscle weakness, paresthesia, or pain, these are typically accompanied by complaints of back or spine pain and systemic symptoms indicative of infection. In our case, a 53-year-old male initially presented with unilateral pain and swelling in his right hand, with no fever at presentation and no complaints of back pain. Blood culture confirmed methicillin-resistant Staphylococcus aureus (MRSA)for which he was given vancomycin. The patient later endorsed back pain and diagnostic imaging revealed a spinal epidural abscess spanning the T5-T9 vertebrae. The abscess was drained, and vancomycin was placed in the subfascial and epifascial compartments. The hand was debrided in the same operation and showed no gross purulence. Two days after the procedure, intraoperative cultures remained negative, and the patient was subsequently managed with daptomycin.
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Long B, Carlson J, Montrief T, Koyfman A. High risk and low prevalence diseases: Spinal epidural abscess. Am J Emerg Med 2022; 53:168-172. [DOI: 10.1016/j.ajem.2022.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 12/31/2021] [Accepted: 01/04/2022] [Indexed: 02/07/2023] Open
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Roberti F. Tailored minimally invasive tubular laminectomies for the urgent treatment of rare holocord spinal epidural abscess: case report and review of technique. JOURNAL OF SPINE SURGERY 2020; 6:729-735. [PMID: 33447675 DOI: 10.21037/jss-20-603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Spinal abscesses that involve the full length of the spine, from the cervical to the sacral regions, are rare and account for approximately 1% of spinal epidural infections. Urgent surgical decompression combined with antibiotics treatment is usually recommended in these patients and selection of the most suitable surgical approach is tailored on the extent and location of the fluid collection. We present a rare case of holocord spinal epidural abscess treated with cervico-thoracic-lumbar tandem tubular decompressive laminectomies with alternating incisions, which were tailored on the preoperative sagittal and axial extension of the abscess. This minimally invasive procedure allowed for the successful drainage and decompression of the epidural space in an adult patient presenting with acute worsening tetraparesis. After the surgery the patient's neurological examination improved and follow up radiological studies confirmed the successful decompression of the epidural space. Tailoring not only the level but also the laterality of the tandem tubular approach, may be beneficial in minimizing soft tissues trauma, blood loss, operative time and need for more extensive surgical exposure, while successfully treating rare holospinal epidural infections. Minimally invasive tailored decompression of holocord spinal epidural abscesses should be considered as a surgical option in selected patients presenting with acute neurological symptoms.
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Affiliation(s)
- Fabio Roberti
- Section of Neurosurgery, Cleveland Clinic Indian River Hospital, Vero Beach, FL, USA.,Department of Neurological Surgery, The George Washington University, Washington DC, USA
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Yao YC, Lin HH, Chou PH, Wang ST, Liu CL, Chang MC. Risk factors for residual neurologic deficits after surgical treatment for epidural abscess in the thoracic or lumbar spine. Spine J 2020; 20:1638-1645. [PMID: 32417501 DOI: 10.1016/j.spinee.2020.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 05/03/2020] [Accepted: 05/07/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spinal epidural abscess (SEA) can cause neurologic deficits and needs urgent surgical intervention. Many clinical factors had been proposed to predict surgical outcomes in patients with SEA, but the predictive radiographic risk factors for residual neurologic deficits were not addressed sufficiently. PURPOSE To analyze the clinical and radiographic risk factors for residual neurologic deficit in patients with SEA after surgical intervention of the thoracic or lumbar spine. STUDY DESIGN/SETTING A retrospective consecutive case series. PATIENT SAMPLE From January 2005 through December 2014, 53 patients with primary SEA, confirmed by culture or histopathology, in the thoracic or lumbar spine who underwent posterior-only approach surgery at our hospital. OUTCOME MEASURES Neurologic status was assessed using the Frankel grading system preoperatively, postoperatively, and at final follow-up. METHODS The patients were allocated into two groups based on the presence of postoperative residual neurologic deficits. Patients' demographic, clinical, and factors based on magnetic resonance imaging (MRI) were analyzed for their influence on residual neurologic deficits. Clinical factors included age, sex, diabetes, comorbidities, pathogens, affected spinal levels, the interval between onset of symptoms to surgery, preoperative neurologic status, presence of cauda equina syndrome, and surgical procedures. MRI factors included the distribution of abscesses within the spinal canal, presence of ring enhancement, presence of paravertebral abscess or psoas abscess, canal compromise anteroposterior (AP) ratio and cross-sectional area ratio, abscess length, and abscess thickness. RESULTS Thirty-five of the 53 patients (66%) had preoperative neurologic deficits, and 21 of 53 patients (40%) had postoperative residual neurologic deficits. Patients' neurologic status improved significantly after the surgery (p<.001). Risk factors including age, diabetes, cauda equina syndrome, presence of anterior with posterior (A+P) dural abscess, canal compromise AP ratio, cross-sectional area ratio, abscess length, and abscess thickness were significantly correlated with postoperative residual neurologic deficits. In multivariate logistic regression analysis, age ≥70 years, preoperative cauda equina syndrome, abscess length ≥5.5 cm and abscess thickness ≥0.8 cm were the four most significant factors related to residual neurologic deficits. CONCLUSIONS In patients with SEA of the thoracic and lumbar spine, age ≥70 years, preoperative cauda equina syndrome, abscess length ≥5.5 cm and abscess thickness ≥0.8 cm were the most significant preoperative risk factors for residual neurologic deficits after surgery.
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Affiliation(s)
- Yu-Cheng Yao
- Department of Orthopedic Surgery, School of Medicine, National Yang-Ming University, No.155, Sec. 2, Linong Street, Taipei, Taiwan; Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsi-Hsien Lin
- Department of Orthopedic Surgery, School of Medicine, National Yang-Ming University, No.155, Sec. 2, Linong Street, Taipei, Taiwan; Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Po-Hsin Chou
- Department of Orthopedic Surgery, School of Medicine, National Yang-Ming University, No.155, Sec. 2, Linong Street, Taipei, Taiwan; Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shih-Tien Wang
- Department of Orthopedic Surgery, School of Medicine, National Yang-Ming University, No.155, Sec. 2, Linong Street, Taipei, Taiwan; Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.
| | - Chien-Lin Liu
- Department of Orthopedic Surgery, School of Medicine, National Yang-Ming University, No.155, Sec. 2, Linong Street, Taipei, Taiwan; Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ming-Chau Chang
- Department of Orthopedic Surgery, School of Medicine, National Yang-Ming University, No.155, Sec. 2, Linong Street, Taipei, Taiwan; Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan
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Sharfman ZT, Gelfand Y, Shah P, Holtzman AJ, Mendelis JR, Kinon MD, Krystal JD, Brook A, Yassari R, Kramer DC. Spinal Epidural Abscess: A Review of Presentation, Management, and Medicolegal Implications. Asian Spine J 2020; 14:742-759. [PMID: 32718133 PMCID: PMC7595828 DOI: 10.31616/asj.2019.0369] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 04/17/2020] [Indexed: 12/18/2022] Open
Abstract
Spinal epidural abscess (SEA) is a rare condition associated with significant morbidity and mortality. Despite advances in diagnostic medicine, early recognition of SEAs remains elusive. The vague presentation of the disease, coupled with its numerous risk factors, the diagnostic requirement for obtaining advanced imaging, and the necessity of specialized care constitute extraordinary challenges to both diagnosis and treatment of SEA. Once diagnosed, SEAs require urgent or emergent medical and/or surgical management. As SEAs are a relatively rare pathology, high-quality data are limited and there is no consensus on their optimal management. This paper focuses on presenting the treatment modalities that have been successful in the management of SEAs and providing a critical assessment of how specific SEA characteristics may render one infection more amenable to primary surgical or medical interventions. This paper reviews the relevant history, epidemiology, clinical presentation, radiology, microbiology, and treatment of SEAs and concludes by addressing the medicolegal implications of delayed treatment of the disease.
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Affiliation(s)
- Zachary Tuvya Sharfman
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Yaroslav Gelfand
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Pryiam Shah
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ari Jacob Holtzman
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Joseph Roy Mendelis
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Merritt Drew Kinon
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jonathan David Krystal
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Allan Brook
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Reza Yassari
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - David Claude Kramer
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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Longo M, Pennington Z, Gelfand Y, De la Garza Ramos R, Echt M, Ahmed AK, Yanamadala V, Sciubba DM, Yassari R. Readmission after spinal epidural abscess management in urban populations: a bi-institutional study. J Neurosurg Spine 2019; 32:465-472. [PMID: 31756697 DOI: 10.3171/2019.8.spine19790] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 08/28/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The incidence of spinal epidural abscess (SEA) is rising, yet there are few reports discussing readmission rates or predisposing factors for readmission after treatment. The aims of the present study were to determine the rate of 90-day readmission following medical or surgical treatment of SEA in an urban population, identify patients at increased risk for readmission, and delineate the principal causes of readmission. METHODS Neurosurgery records from two large urban institutions were reviewed to identify patients who were treated for SEA. Patients who died during admission or were discharged to hospice were excluded. Univariate analysis was performed using chi-square and Student t-tests to identify potential predictors of readmission. A multivariate logistic regression model, controlled for age, body mass index, sex, and institution, was used to determine significant predictors of readmission. RESULTS Of 103 patients with identified SEA, 97 met the inclusion criteria. Their mean age was 57.1 years, and 56 patients (57.7%) were male. The all-cause 90-day readmission rate was 37.1%. Infection (sepsis, osteomyelitis, persistent abscess, bacteremia) was the most common cause of readmission, accounting for 36.1% of all readmissions. Neither pretreatment neurological deficit (p = 0.16) nor use of surgical versus medical management (p = 0.33) was significantly associated with readmission. Multivariate analysis identified immunocompromised status (p = 0.036; OR 3.5, 95% CI 1.1-11.5) and hepatic disease (chronic hepatitis or alcohol abuse) (p = 0.033; OR 2.9, 95% CI 1.1-7.7) as positive predictors of 90-day readmission. CONCLUSIONS The most common indication for readmission was persistent infection. Readmission was unrelated to baseline neurological status or management strategy. However, both hepatic disease and baseline immunosuppression significantly increased the odds of 90-day readmission after SEA treatment. Patients with these conditions may require closer follow-up upon discharge to reduce overall morbidity and hospital costs associated with SEA.
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Affiliation(s)
- Michael Longo
- 1Spine Research Group and
- 2Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; and
| | - Zach Pennington
- 3Department of Neurological Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yaroslav Gelfand
- 1Spine Research Group and
- 2Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; and
| | - Rafael De la Garza Ramos
- 1Spine Research Group and
- 2Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; and
| | - Murray Echt
- 1Spine Research Group and
- 2Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; and
| | - A Karim Ahmed
- 3Department of Neurological Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Vijay Yanamadala
- 1Spine Research Group and
- 2Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; and
| | - Daniel M Sciubba
- 3Department of Neurological Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Reza Yassari
- 1Spine Research Group and
- 2Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; and
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Ahuja K, Das L, Jain A, Meena PK, Arora SS, Kandwal P. Spinal holocord epidural abscess evacuated with double thoracic interval laminectomy: a rare case report with literature review. Spinal Cord Ser Cases 2019; 5:62. [PMID: 31632720 PMCID: PMC6786417 DOI: 10.1038/s41394-019-0206-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 06/06/2019] [Accepted: 06/08/2019] [Indexed: 12/21/2022] Open
Abstract
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.
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Affiliation(s)
- Kaustubh Ahuja
- Department of Orthopaedic Surgery, All India Institute of Medical Sciences, Rishikesh, 249203 Uttarakhand India
| | - Lakshmana Das
- Department of Orthopaedic Surgery, All India Institute of Medical Sciences, Rishikesh, 249203 Uttarakhand India
| | - Aakriti Jain
- Department of Orthopaedic Surgery, All India Institute of Medical Sciences, Rishikesh, 249203 Uttarakhand India
| | - Pradeep Kumar Meena
- Department of Orthopaedic Surgery, All India Institute of Medical Sciences, Rishikesh, 249203 Uttarakhand India
| | - Shobha S. Arora
- Department of Orthopaedic Surgery, All India Institute of Medical Sciences, Rishikesh, 249203 Uttarakhand India
| | - Pankaj Kandwal
- Department of Orthopaedic Surgery, All India Institute of Medical Sciences, Rishikesh, 249203 Uttarakhand India
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Bridges KJ, Than KD. Holospinal epidural abscesses – Institutional experience. J Clin Neurosci 2018; 48:18-27. [DOI: 10.1016/j.jocn.2017.10.057] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 10/22/2017] [Indexed: 10/18/2022]
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12
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Abstract
Microorganisms can affect the entire neuraxis, producing a variety of neurologic complications that frequently entail prolonged hospitalizations and complicated treatment regimens. The spread of pathogens to new regions and the reemergence of opportunistic organisms in immunocompromised patients pose increasing challenges to health care professionals. Because rapid diagnosis and treatment may prevent long-term neurologic sequelae, providers should approach these diseases with a structured, neuroanatomic framework, incorporating a thorough history, examination, laboratory analysis, and neuroimaging in their clinical reasoning and decision-making.
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13
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Zheng SH, Li Y, Zhang SQ. Acute quadriplegia following a minimal injury in the posterior pharyngeal wall by a fishbone. CNS Neurosci Ther 2017; 23:637-639. [PMID: 28544487 DOI: 10.1111/cns.12704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 04/11/2017] [Accepted: 04/12/2017] [Indexed: 12/20/2022] Open
Affiliation(s)
- Shui-Hong Zheng
- Department of Neurology, Jinhua Hospital of Traditional Chinese Medicine, Jin Hua City, Zhejiang, China
| | - Yang Li
- Department of Neurology, The Fourth People's Hospital, Zibo City, Shandong, China
| | - She-Qing Zhang
- Department of Neurology, Changhai Hospital, Shanghai, China
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14
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Lemaignen A, Ghout I, Dinh A, Gras G, Fantin B, Zarrouk V, Carlier R, Loret JE, Denes E, Greder A, Lescure FX, Boutoille D, Tattevin P, Issartel B, Cottier JP, Bernard L. Characteristics of and risk factors for severe neurological deficit in patients with pyogenic vertebral osteomyelitis: A case-control study. Medicine (Baltimore) 2017; 96:e6387. [PMID: 28538361 PMCID: PMC5457841 DOI: 10.1097/md.0000000000006387] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Severe neurological deficit (SND) is a rare but major complication of pyogenic vertebral osteomyelitis (PVO). We aimed to determine the risk factors and the variables associated with clinical improvement for SND during PVO.This case-control study included patients without PVO-associated SND enrolled in a prospective randomized antibiotic duration study, and patients with PVO-associated SND managed in 8 French referral centers. Risk factors for SND were determined by logistic regression.Ninety-seven patients with PVO-associated SND cases, and 297 controls were included. Risk factors for SND were epidural abscess [adjusted odds ratio, aOR 8.9 (3.8-21)], cervical [aOR 8.2 (2.8-24)], and/or thoracic involvement [aOR 14.8 (5.6-39)], Staphylococcus aureus PVO [aOR 2.5 (1.1-5.3)], and C-reactive protein (CRP) >150 mg/L [aOR 4.1 (1.9-9)]. Among the 81 patients with PVO-associated SND who were evaluated at 3 months, 62% had a favorable outcome, defined as a modified Rankin score ≤ 3. No factor was found significantly associated with good outcome, whereas high Charlson index [adjusted Hazard Ratio (aHR) 0.3 (0.1-0.9)], low American Spinal Injury Association (ASIA) impairment scale at diagnosis [aHR 0.4 (0.2-0.9)], and thoracic spinal cord compression [aHR 0.2 (0.08-0.5)] were associated with poor outcome. Duration of antibiotic treatment was not associated with functional outcome.SND is more common in cervical, thoracic, and S. aureus PVO, in the presence of epidural abscess, and when CRP >150 mg/L. Although neurological deterioration occurs in 30% of patients in early follow-up, the functional outcome is quite favorable in most cases after 3 months. The precise impact of optimal surgery and/or corticosteroids therapy must be specified by further studies.
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Affiliation(s)
- Adrien Lemaignen
- Department of Infectious Diseases, University Hospital of Tours, Francois Rabelais University, Tours
| | - Idir Ghout
- Clinical Research Unit, University Hospital A. Paré, APHP, Boulogne
| | - Aurélien Dinh
- Infectious Diseases Unit, University Hospital R. Poincaré, APHP, Versailles Saint Quentin University, Garches
| | - Guillaume Gras
- Department of Infectious Diseases, University Hospital of Tours, Francois Rabelais University, Tours
| | - Bruno Fantin
- Department of Internal Medicine, University Hospital Beaujon, APHP, Clichy
| | - Virginie Zarrouk
- Department of Internal Medicine, University Hospital Beaujon, APHP, Clichy
| | - Robert Carlier
- Radiology Department, Neuro-musculoskeletal Pole, University Hospital R Poincaré, APHP, Versailles University, Paris-Saclay UMR 1179, Garches
| | | | - Eric Denes
- Department of Infectious Diseases, University Hospital of Limoges, Limoges
| | - Alix Greder
- Department of Infectious Diseases, Mignot Hospital, Versailles
| | | | - David Boutoille
- Department of Infectious Diseases, Hotel-Dieu University Hospital, Nantes
| | - Pierre Tattevin
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes
| | | | - Jean-Philippe Cottier
- Department of Neuroradiology, University Hospital of Tours, Francois Rabelais University, Tours, France
| | - Louis Bernard
- Department of Infectious Diseases, University Hospital of Tours, Francois Rabelais University, Tours
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15
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Spinal Epidural Abscess: A Review with Special Emphasis on Earlier Diagnosis. BIOMED RESEARCH INTERNATIONAL 2016; 2016:1614328. [PMID: 28044125 PMCID: PMC5156786 DOI: 10.1155/2016/1614328] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 10/24/2016] [Indexed: 12/20/2022]
Abstract
Spinal epidural abscess (SEA) is an uncommon but serious condition with significant morbidity and mortality. The prognosis of SEA is highly dependent on the timeliness of its diagnosis before neurological deficits develop. Unfortunately, often due to its nonspecific presentation, such as back pain, the diagnosis of SEA may be delayed in up to 75% of cases. Although many risk factors for SEA can be found in the published literature, their utility is limited by their frequent lack of objective evidence, numerousness, and absence in a significant proportion of cases. In this review, we call for a more discriminate evidence-based use of the term "risk factor" when discussing SEA and explore several approaches to its earlier diagnosis, including a simple algorithm based on its pathophysiology and serum C-reactive protein or erythrocyte sedimentation rate.
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Goulart CR, Mattei TA, Fiore ME, Thoman WJ, Mendel E. Retropharyngeal abscess with secondary osteomyelitis and epidural abscess: proposed pathophysiological mechanism of an underrecognized complication of unstable craniocervical injuries: case report. J Neurosurg Spine 2015; 24:197-205. [PMID: 26407087 DOI: 10.3171/2015.4.spine14952] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Because of the proximity of the oropharynx (a naturally contaminated region) to the spinal structures of the craniocervical junction, it is possible that small mucosal lacerations in the oropharynx caused by unstable traumatic craniocervical injuries may become contaminated and lead to secondary infection and osteomyelitis. In this report, the authors describe the case of a previously healthy and immunocompetent patient who developed a large retropharyngeal abscess with spinal osteomyelitis after a high-energy craniocervical injury. This unusual report of osteomyelitis with a delayed presentation after a high-energy traumatic injury of the craniocervical junction highlights the possibility of direct injury to a specific area in the oropharyngeal mucosa adjacent to the osteoligamentous structures of the craniocervical junction, an overall underrecognized complication of unstable craniocervical injuries.
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Affiliation(s)
- Carlos R Goulart
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center and The James Cancer Hospital, Columbus, Ohio; and
| | - Tobias A Mattei
- Department of Neurosurgery, InvisionHealth Brain & Spine Center, Buffalo, New York
| | - Mariano E Fiore
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center and The James Cancer Hospital, Columbus, Ohio; and
| | - William J Thoman
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center and The James Cancer Hospital, Columbus, Ohio; and
| | - Ehud Mendel
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center and The James Cancer Hospital, Columbus, Ohio; and
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Tuchman A, Pham M, Hsieh PC. The indications and timing for operative management of spinal epidural abscess: literature review and treatment algorithm. Neurosurg Focus 2015; 37:E8. [PMID: 25081968 DOI: 10.3171/2014.6.focus14261] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Delayed or inappropriate treatment of spinal epidural abscess (SEA) can lead to serious morbidity or death. It is a rare event with significant variation in its causes, anatomical locations, and rate of progression. Traditionally the treatment of choice has involved emergency surgical evacuation and a prolonged course of antibiotics tailored to the offending pathogen. Recent publications have advocated antibiotic treatment without surgical decompression in select patient populations. Clearly defining those patients who can be safely treated in this manner remains in evolution. The authors review the current literature concerning the treatment and outcome of SEA to make recommendations concerning what population can be safely triaged to nonoperative management and the optimal timing of surgery. METHODS A PubMed database search was performed using a combination of search terms and Medical Subject Headings, to identify clinical studies reporting on the treatment and outcome of SEA. RESULTS The literature review revealed 28 original case series containing at least 30 patients and reporting on treatment and outcome. All cohorts were deemed Class III evidence, and in all but two the data were obtained retrospectively. Based on the conclusions of these studies along with selected smaller studies and review articles, the authors present an evidence-based algorithm for selecting patients who may be safe candidates for nonoperative management. CONCLUSIONS Patients who are unable to undergo an operation, have a complete spinal cord injury more than 48 hours with low clinical or radiographic concern for an ascending lesion, or who are neurologically stable and lack risk factors for failure of medical management may be initially treated with antibiotics alone and close clinical monitoring. If initial medical management is to be undertaken the patient should be made aware that delayed neurological deterioration may not fully resolve even after prompt surgical treatment. Patients deemed good surgical candidates should receive their operation as soon as possible because the rate of clinical deterioration with SEA is notoriously unpredictable. Although patients tend to recover from neurological deficits after treatment of SEA, the time point when a neurological injury becomes irreversible is unknown, supporting emergency surgery in those patients with acute findings.
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Affiliation(s)
- Alexander Tuchman
- Department of Neurosurgery, Keck School of Medicine, Los Angeles County-University of Southern California Medical Center, Los Angeles, California
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Smith GA, Kochar AS, Manjila S, Onwuzulike K, Geertman RT, Anderson JS, Steinmetz MP. Holospinal epidural abscess of the spinal axis: two illustrative cases with review of treatment strategies and surgical techniques. Neurosurg Focus 2015; 37:E11. [PMID: 25081960 DOI: 10.3171/2014.5.focus14136] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Gabriel A. Smith
- 1Department of Neurological Surgery, University Hospitals, Case Medical Center
- 2Case Western Reserve University School of Medicine; and
| | | | - Sunil Manjila
- 1Department of Neurological Surgery, University Hospitals, Case Medical Center
- 2Case Western Reserve University School of Medicine; and
| | - Kaine Onwuzulike
- 1Department of Neurological Surgery, University Hospitals, Case Medical Center
- 2Case Western Reserve University School of Medicine; and
| | - Robert T. Geertman
- 2Case Western Reserve University School of Medicine; and
- 3Department of Neurological Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - James S. Anderson
- 2Case Western Reserve University School of Medicine; and
- 3Department of Neurological Surgery, MetroHealth Medical Center, Cleveland, Ohio
| | - Michael P. Steinmetz
- 2Case Western Reserve University School of Medicine; and
- 3Department of Neurological Surgery, MetroHealth Medical Center, Cleveland, Ohio
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