Spinal epidural abscess

Epidural abscess related to Streptococcus mitis in a 57-year-old immunocompetent patient

A 57-year-old immunocompetent male patient presented himself to our emergency department with lumbar pain for 10 days, after a lumbar torsion. He was neurologically intact, but showed signs of systemic inflammatory syndrome. A lumbar MRI found a spinal epidural abscess from L3-L4 to L5-S1 levels. The patient was operated early before occurrence of neurological deficit. The abscess cultures found a Streptococcus mitis infection. The patient made a good recovery after surgical decompression, washout with samples taken for cultures and targeted antibiotic therapy for 6 weeks.

Spondylodiscitis in end-stage renal disease: a systematic review

OBJECTIVE

Discitis and osteomyelitis are seen in end-stage renal disease (ESRD) patients due to repeated vascular access for hemodialysis and urinary tract infections leading to recurrent bacteremia. Discitis and osteomyelitis are underdiagnosed due to the nonspecific initial presentation of back pain. In this article, we review the literature for better understanding of the problem and the importance of early diagnosis by primary care physicians and nephrologists. In addition, we discuss the decision-making, follow-up, management, and neurological outcomes.

METHODS

A detailed PubMed search was performed using the following terms: "end stage renal disease (ESRD)" and "chronic renal failure (CRF)," combined with "spine infections," "spondylodiscitis," "discitis," and "osteomyelitis." Search results were limited to articles written in English, case reports, and case series from 1973 to 2012. Editorials, reviews, and commentaries were excluded. Only studies involving human patients were included. The authors also included 4 patients from their own patient population.

RESULTS

A total of 30 articles met the inclusion criteria. Including the 4 patients from the authors' patient population, 212 patients with spine infections and maintenance dialysis were identified. The patients' ages ranged from 38 to 78 years. The duration of dialysis ranged from a few days to 16 years. The time from onset of back pain to diagnosis ranged from 3 days to 6 months. The most common causative organism was Staphylococcus aureus, followed by Staphylococcus epidermidis and gram-negative bacteria. Most of the patients were treated with antibiotics alone (76.8%), although surgery was indicated when patients presented with neurological deficits (p < 0.011). Approximately one-quarter of the patients developed neurological deficits, with devastating consequences. Fever and neurological deficits at presentation, culture positive for methicillin-resistant S. aureus, and age > 65 years were highly correlated with mortality in our analysis.

CONCLUSIONS

Several risk factors lead to failure of antibiotics and progression of disease in patients with ESRD. Challenges to diagnosis include vague presenting symptoms, co-existing destructive spondyloarthropathy, poor immune response, chronic elevations of inflammatory markers, and recurrent bacteremia. Infectious processes are more likely to cause permanent neurological deficits than transient deficits. The authors recommend close observation and serial imaging of these patients for early signs of neurological deficits. Any signs of disease progression will require aggressive surgical debridement.

Serious chronic disease of the cervical spine and trauma in a young female from the middle ages (Czech Republic)

The skeletal remains of the young female (20-24 years) from Grave JP/106, discovered in the Southern Suburb of the Břeclav - Pohansko Stronghold (Early Middle Ages, 9th century-beginning of the 10^th century, present day Czech Republic) display several noteworthy pathologies. The first is deformation of the mandible, which was most probably caused by a fracture of the ramus in combination with a subcondylar fracture. The spine of this young woman also exhibits a probable traumatic injury of the cervical spine in combination with a slowly growing structure situated inside the spinal canal, which caused deformation centered upon C7. The cervical and thoracic spine together with internal surfaces of several ribs exhibit infectious changes of advanced stage, in all likelihood of tuberculous origin, but osteomyelitis cannot be excluded. Histological analysis of the new bone formation in the ribs confirmed infectious origin, as does Micro CT of C5 and C6. Analyses conducted by two different departments with different methods (PCR amplification of 123 bp long section from IS6110 and Next Generation shotgun sequencing) failed to identify DNA of Mycobacterium tuberculosis from the first rib.

Upper Cervical Epidural Abscess in a Patient With Parkinson Disease: A Case Report and Review

To our knowledge, there are no reports in the literature of patients with Parkinson disease (PD) developing upper cervical spine infections. Our objective is to present a case of upper cervical epidural abscess in a patient with PD and to review upper cervical spine infection. We present the patient's presentation, physical examination, imaging findings, and management as well a review of the literature. A 66-year-old male with PD presented to the emergency department (ED) following referral by a neurologist for a presumed C2 fracture. The preceding history was 1 week of severe neck pain requiring a magnetic resonance imaging (MRI), which was initially interpreted as a C2 fracture. On admission from the ED, further review of the MRI appeared to show anterior prevertebral abscess and an epidural abscess. The patient's neurological examination was at baseline. In the span of 2 days, the patient developed significant motor weakness. A repeat MRI demonstrated expansion of the epidural collection and spinal cord compression. Surgical management consisting of C1 and C2 laminectomy, irrigation, and debridement from anterior and posterior approaches was performed. Postoperatively, the patient did not recover any motor strength and elected to withdraw care and died. Spinal epidural abscess requires a high index of suspicion and needs prompt recognition to prevent neurological impairment. Upper cervical spine infections are rare but can lead to lethal consequences.

Diagnosis and Management of Spinal Epidural Abscess

Twenty-five patients with spinal epidural abscess were treated at the University of Western Ontario hospitals between July 1980 and July 1990. There were eighteen males (72%) and seven females (28%), with a median age of 60 years. Concurrent illness resulting in immunocompromise was present in 60%. Eleven presented with complete myelopathy, thirteen had limb weakness, and one had no neurological deficit. In twenty cases the abscess consisted of frankly purulent material, while in five the epidural collection consisted of chronic granulation tissue. Staphylococcus aureus was isolated in 64% of the abscesses. Twenty-seven surgical procedures were performed on 21 patients. Ten cases occurred in the cervical spine (40%), seven in the thoracic spine (28%), three in both the cervical and thoracic spine (12%) and five in the lumbosacral spine (20%). Fourteen patients (56%) retained or recovered ambulation and there were five deaths (20%). The progression from back and radicular pain to weakness and eventual paralysis continues to be characteristic of spinal epidural infection. Morbidity and mortality remain unacceptably high because of delay in diagnosis and treatment. Magnetic resonance imaging is the radiological investigation of choice for the diagnosis of spinal epidural abscess. Prompt intervention, before the development of severe neurological deficits, can improve outcome. Immediate surgical drainage combined with antibiotics remains the treatment of choice.

Spinal epidural abscess and paralytic mechanisms

PURPOSE OF REVIEW

The incidence of spinal epidural abscess is increasing, and the understanding of the pathophysiology is evolving. Better understanding of the pathophysiology, specifically the role of ischemia, warrants a change in therapy.

RECENT FINDINGS

Paralysis in spinal epidural abscess may be the result of spinal cord compression, spinal cord arterial and/or venous ischemia and thrombophlebitis or a combination of these.

SUMMARY

Recent evidence indicates the following areas of investigation and management can improve outcome in spinal epidural abscess: minimally invasive surgery early versus medical management when there are no significant neurological deficits, neuroradiologic arterial evaluation with therapies directed at vascular ischemia and thrombosis, and aggressive rehabilitation.

Sacral epidural abscess complicating closed sacral fracture: a case report

OBJECTIVE

To describe the clinical course of the development of an epidural abscess with a rare localization.

SUMMARY OF BACKGROUND DATA

Epidural abscess usually presents with severe back pain and neurologic deterioration. Spinal fracture may lead to the development of epidural abscess. To the author's knowledge, this is the first reported case of epidural abscess following sacral fracture.

MATERIALS AND METHODS

The patient was observed closely in the hospital after a sacral fracture with bilateral S2, S3 dermotome numbness. Fever, bacteremia, and urinary tract infection developed. Fever responded partially with antibiotics.

RESULTS

Sacral laminectomy for decompression was performed. Unexpectedly, sacral epidural abscess was found during the operation. Sacral roots were decompressed. Epidural abscess was drained.

CONCLUSION

A rare case of sacral epidural abscess following sacral fracture was reported.

Spinal epidural abscess in a neonate

A case of purulent spinal epidural abscess in a 20-day-old girl is presented. The patient had symptoms of fever, localized back pain and swelling over the interscapular area. The diagnosis was made by magnetic resonance imaging. Purulent material grew Staphylococcus aureus from the lesion. Because of severe cord compression surgical laminotomy and drainage were performed, and antibiotics were administered. One year later she was doing well without neurologic sequelae.

Complications associated with regional anesthesia in the obstetric patient

The majority of obstetric patients are concerned about labor pains but also have fears regarding regional anesthesia and its potential effects on themselves and their babies. Anesthesiologists and obstetricians alike must be familiar with potential complications of obstetric regional anesthesia and analgesia, and also be able to provide the information and reassurance each patient needs. If a problem occurs during labor and delivery, it must be dealt with expertly and immediately. This article discusses the diagnostic clues, laboratory tests, and management of neurologic complications related to obstetric delivery and regional anesthesia, as well as the topics of infections, obstetric- and anesthetic-related neurologic deficits, and special tips on neurologic examination. The most common neurologic complication of spinal and epidural anesthesia, postdural puncture headache, will not be discussed in detail here.

Spinal epidural abscess in a young child

This is a case report of a spinal epidural abscess, caused by Staphylococcus aureus, in a 3-year-old girl. The child presented with fever and hip pain, but without any neurologic deficit. After normal plain films and a normal bone scan were obtained, the diagnosis was made via magnetic resonance imaging (MRI). The neurosurgery and pediatric infectious disease teams evaluated the patient, and the decision was made to forego surgical drainage and to treat medically with appropriate intravenous and then oral antibiotics. Several months later, the child was doing well without any signs of neurologic sequelae. Because of the rarity of this disease in children, the treatment guidelines are controversial. Many suggest that a spinal epidural abscess must be drained surgically. Our experience adds to the literature a case of a child successfully treated with antibiotics alone. We believe that this success is related to the fact that the child was diagnosed by MRI early in the course of the disease and that she never displayed any neurologic deficits.

Meningitis complicating spinal surgery

STUDY DESIGN

A retrospective review of all cases of bacterial meningitis after spinal surgery.

OBJECTIVES

To identify the usual clinical and laboratory features, and to determine the frequency of this complication.

SUMMARY OF BACKGROUND DATA

Meningitis has been recognized as a rare complication of spinal surgery, but no series of cases has been reported previously, and there are no published estimates of its frequency.

METHODS

A retrospective review of the medical records of all cases of bacterial meningitis after spinal surgery in Auckland over a 3-year period was done.

RESULTS

Four cases were identified after 2180 operations, an incidence of 0.18%. All four patients survived.

CONCLUSIONS

This is a rare complication from which a good outcome is possible with early diagnosis and prompt management.

[Spinal epidural abscess-an interdisciplinary emergency.]

Introduction Spinal epidural abscess is a rare cause of neurological disability, which is frequently, preceded by local spinal pain. There are only a few case series in the literature and the prognosis for this disease has not improved significantly over the past 50 years. Patients and methods Seven patients were treated neurosurgically with laminectomy and abscess drainage for spinal epidural abscesses from 1991 to 1994. Results All but one patient had several weeks of local spinal pain (mainly after minor trauma), immunosuppression, and all exhibited excessively high blood sedimentation rates. On admission they presented either with hemiparesis or with signs of complete spinal cord transection. Since preoperative neuronal damage persisted too long, only 3 patients showed slight improvement of their neurological functions postoperatively. Conclusion A spinal epidural abscess is a rare, but devastating interdisciplinary emergency, which poses no operative technical problem to the neurosurgeon. Poor results can be avoided by carefully taken individual histories, which are dominated by long-standing and significant local spinal pain in most cases. The pre-operative neurological status is crucial for the long-term outcome. Elevated blood sedimentation rates in conjunction with local pain of the vertebral column should direct attention to the possibility of an epidural abscess. Magnetic resonance imaging is the radiological technique of choice for establishment of the diagnosis. Conventional X-rays are of no value for early diagnosis because neurological signs and symptoms precede bony changes of the vertebrae.

Spinal epidural abscesses in children

Spinal epidural abscess (SEA) is rare, especially in children, in which fewer than 90 cases have been reported. We present three case examples illustrating the complex course before diagnosis and treatment. All patients had back pain, but two had pain of the abdomen or extremity dominating the clinical picture. Magnetic resonance imaging (MRI) was found to be the best diagnostic test. All had surgery with full recovery. A literature review of 58 cases since 1945 was done and showed that 76% of children had neurological compromise before surgery, and the overall mortality rate in children was 12%.

Diagnosis and results of different treatment regimens in patients with spinal abscesses

Bacterial abscesses involving the spinal canal are associated with a high morbidity and mortality. Most frequently, these lesions are found in the epidural, rarely in the subdural space. In this report, our clinical material consists of a series of 16 patients treated during the last seven years. The clinical presentation included local neurological signs (back pain, para-/tetraparesis, bladder dysfunction), disturbances of consciousness (ranging from drowsiness to deep coma) and general inflammatory signs (meningism, fever). All patients presented with risk factors (septic foci, chronic diseases, and iatrogenic causes). Laboratory investigations revealed typically pathological blood sedimentation rate, leucocytosis and CSF-pleocytosis. Radiologically, the diagnosis was confirmed by myelography, CT and preferably MRI. The abscesses were located epidurally in 14 and subdurally in 2 cases. The surgical treatment included laminectomy, or multiple flavectomies in extensive lesions. Drainage systems (either simple silicon outflow drains or suction-/irrigation systems) were installed in all cases, as well as antibiotic treatment. Results of treatment: Following an observation period of 0.5-6 years, we found complete recovery in six (38%) cases, six (38%) others were mildly disabled and four (25%) patients died. Focussing on the results of the two different drainage systems, we found a statistically significant superiority of the inflow-/outflow system. Complications included mandatory re-exploration, post-inflammatory hydrocephalus, syringomyelia, spinal instability, surgical treatment of peripheral septic foci and therapy resistant septicaemia. In conclusion, we propose that spinal epi- or subdural abscesses require surgical evacuation, using a suction-/irrigation drainage system, as well as antibiotic and intensive care treatment.

Epidural abscess associated with intravenous drug abuse in a pregnant patient

The association between intravenous drug abuse and epidural abscess is well known; however, this association has not previously been reported in a pregnant patient. The classic manifestation of epidural abscess is a febrile patient with back pain that progresses rapidly to radicular pain, spinal cord dysfunction, weakness, and then complete paralysis. Although this condition is rare during pregnancy, these serious complications necessitate prompt diagnosis and intervention. If spinal infection is suspected, magnetic resonance imaging should be performed immediately. After epidural abscess is diagnosed, emergent decompressive laminectomy and appropriate antibiotic coverage are necessary. Herein we describe a 27-year-old pregnant patient with epidural abscess probably related to use of contaminated needles for intravenous administration of drugs and subsequent hematologic spread of staphylococci to the epidural space. The differential diagnosis of epidural abscess can be difficult, and management options must consider the well-being of both the mother and the fetus.

Epidural spinal abscesses

Fifteen cases of peridural empyemas are reported. 12 patients reported with motor dysfunction of the lower extremities and pain radiating from the spine. In one case, localized pain of the spine was discovered and in two cases there were no signs of spinal or radiating pain. Treatment in all cases was laminectomy and systemic antibiotic administration. Microbiological analysis showed staphylococcus aureus in 11 cases. 9 patients recovered with no neurological defects, two had major improvement of the paresis, and one died. Three patients with paraplegia recovered from the primary infection.

Anterior cervical epidural abscess with pneumococcus in an infant

Spinal epidural abscess is a rare infection in childhood. We report the first documented case of pneumococcal epidural abscess in an infant and review the literature regarding this entity. In children, the signs and symptoms of spinal epidural abscess may not be as helpful as those in older patients. Furthermore, the offending organism may not be the usual Staphylococcus seen in adults. Infants may recover neurologic function even after prolonged cord compression; however, a high index of suspicion is needed to make the diagnosis in a timely fashion.

Anterior cervical epidural abscess: the use of intraoperative spinal sonography

A case of acute cervical epidural abscess is presented. The use of intraoperative spinal sonography is discussed as a valuable adjunct in the evaluation and treatment of these uncommon lesions.

Spinal epidural abscess

Spinal epidural abscess is an uncommon and serious infection resulting from direct extension of a local process or hematogenous spread from an antecedent or ongoing distant focus of infection. The findings of spinal ache, tenderness, and fever should suggest the diagnosis, and the appearance of weakness and loss of sensation below the area of pain should be considered as the strongest possible clinical confirmation. In cases in which this constellation of findings occurs, rapid evaluation and immediate surgical decompression and drainage offer the patient a possible successful functional recovery. Even in recent series, permanent paralysis and death occur with unfortunate frequency, and these have usually been related to delay in diagnosis and definitive surgical therapy.

Epidural abscess complicating Swenson procedure: a case report and a review of the literature

A case is reported in which an anastomotic leak following the Swenson procedure for Hirschsprung's disease was complicated by the development of a pelvic abscess that communicated freely with the epidural space. The child presented with signs and symptoms of an epidural abscess, but his myelogram was normal. The diagnosis was made by urografin enema. The child was treated by defunctioning colostomy and drainage of the pelvic abscess by enlarging the defect at the anastomosis site digitally. The epidural space drained freely to the pelvis and therefore laminectomy was not required. The possible etiology of such a communication is discussed.

Acute spinal epidural abscess--a cause of meningism

Spinal epidural abscess is a rare condition requiring prompt diagnosis and neurosurgical intervention if permanent neurological sequelae are be avoided. A patient is described who presented with meningism due to an acute spinal epidural abscess extending from the cervical to the lumbar region and which was managed non-operatively.

[Spinal epidural abscesses: report of 5 cases]

Five cases of acute spinal epidural abscess, all in male, two of them in children (6 and 7 years old) and the others in patients older than fifty years are reported. In four cases the pathology was related to skin infection and the staphylococcus was the main agent. All the patients had a severe infectious clinical picture, pain on the spine, radicular or spinal cord involvement or both. There was a delay in diagnosis showing that this pathology is still rather unknown. The cases were treated surgically. Two patients died, two had a complete recovery and the last one recovered with neurological deficit. The patients who died had impairment of the cervical cord and were operated on in very bad general and neurological conditions. Revision of literature was performed and the authors discussed the various aspects of this disease.

Acute spinal epidural abscess. Observations from fourteen cases

Fourteen cases of acute spinal epidural abscess are analysed. Postoperatively 6 recovered completely, 4 patients recovered enough to allow unaided walking, 2 died and 2 who were paraplegic pre-operatively remained so. The purpose of this paper is to remind readers of the existence of this condition and to plead for early diagnosis and prompt surgical treatment.

Acute spinal epidural abscess

A case of acute spinal epidural abscess is reported demonstrating many of the important features in the natural history of the disorder. The pathological changes in the cord at the level of the lesion are described. A series of 12 patients is reviewed. The average interval between the initial consultation and the onset of complete paralysis is 5 days and it is essential that the diagnosis is made during this period. Two indicators of prognosis are discussed--the duration of complete paralysis and the extent of sensory disturbance.

Spinal epidural abscess in patients on maintenance haemodialysis (a presentation of two cases)

Two cases of spinal epidural abscess in patients on maintenance haemodialysis, one of them secondary to infection in an arteriovenous fistula, are described. Both cases presented the typical symptoms known from the literature, but were diagnosed too late to prevent neurological sequelae. The condition is rare, but dialysis patients are to be considered a risk group because of their reduced immunocapacity and increased hazard of infection, especially fistula and shunt infections. Awareness of this, and knowledge of its early symptoms are required for timely neurosurgical intervention and thus prevention of irreversible spinal cord damage.

Spinal epidural infection

Thirty cases of spinal epidural abscess are reviewed with particular emphasis on mode of presentation and results of treatment. In spite of repeated exhortations in the literature for earlier diagnosis, the results remain unsatisfactory because many patients have progressed to severe or complete paralysis before the correct diagnosis is made and surgical treatment carried out.

Epidural abscess: a hazard of spinal epidural anaesthesia

Two cases of spinal epidural abscess following prolonged epidural anaesthesia are presented. The clinical features included fever, malaise, and signs of nerve root compression; backache was not marked. Prompt surgical drainage and appropriate antibiotics are required to avoid the costly sequelae of bladder and leg paralysis from spinal cord compression. Both infections were caused by bacterial contamination of catheter, and although this complication is uncommon, it emphasizes that strict asepsis is essential during continuous epidural anaesthesia.

Anaerobic spinal epidural abscess. Case report

An acute spinal epidural abscess is reported from which a pure growth of the anaerobe Fusobacterium necrophorum was isolated. The mode of infection and pathogen makes it unique. The literature concerning the bacteriology of epidural abscess and the implications of anaerobic epidural infection are discussed.

Spinal epidural abscess in pregnancy

A case of spontaneous epidural abscess occuring in a pregnant woman is reported. Some delay in diagnosis occurred. Decompression resulted in prompt recovery and improvement of a mild neurological deficit.

Spinal epidural abscess

Thirty-nine patients with spinal epidural abscess were evaluated at the Massachusetts General Hospital between 1947 and 1974. Twenty had acute symptoms, and purulent epidural collections were present; 19 had prolonged courses, and epidural granulation tissue was observed at operation. Staphylococcus aureus was the most common etiologic agent (57 per cent), followed by streptococci (18 per cent) and gram-negative bacilli (13 per cent). The source of infection was osteomyelitis in 38 per cent of cases and bacteremia in 26 per cent. In 16 per cent epidural abscess was due to postoperative infection. The progression from spinal ache to root pain to weakness followed by paralysis continues to be characteristic of spinal epidural abscess. Although the disease is uncommon, the complications are so serious that prompt diagnosis and treatment are of paramount importance. The combination of back pain with fewer and local tenderness is an indication for cerebrospinal-fluid examination and, depending on the results, immediate performance of myelography.

Epidural empyema following thoracic extradural block. Case report

✓ An unusual case of epidural sepsis with subsequent paraparesis following the placement of a thoracic epidural catheter for the maintenance of a postoperative analgesic block is reported. The hazards of this technique are reviewed.

Spinal subdural empyema complicating pregnancy. Case report

✓ The authors report the successful treatment of a patient with empyema of the spinal subdural space during the eighth month of pregnancy. The characteristics that distinguish this uncommon lesion from spinal epidural empyema are discussed.

Kyphoscoliosis following lumbar subarachnoid shunts

✓ In a follow-up of 80 lumbar subarachnoid shunts for hydrocephalus, scoliosis with limitation of back flexion was found to have developed in approximately 50% of the surviving children, some of whom showed a disparity in the length and size of their legs. There was no correlation between the direction of the convexity of the scoliosis and the side of the shortened leg, or between the number of shunt revisions and the ultimate development of kyphoscoliosis, or between removal of laminae and the subsequent development of scoliosis. Three case histories are presented to illustrate the still unproven but possible relationship between arachnoiditis due to polyethylene tubes and the ensuing scoliosis. Removal of the lumbar shunts, decompression, and laminectomy seemed to have no beneficial effect in the reversal of the scoliosis in any of the cases reviewed.