Holocord spinal epidural abscess

Successful Treatment of Pediatric Holo-Spinal Epidural Abscess With Percutaneous Drainage

Spinal epidural abscess (SEA) is a rare and potentially devastating neurologic disease that is commonly treated with neurosurgical decompression and evacuation. We describe the case of an 11-month-old immunocompetent infant who presented with a large multiloculated methicillin-resistant Staphylococcus aureus abscess in the left lung apex with likely mediastinal involvement, extending into the epidural space from C7 down to L2 causing cord compression which was successfully treated with percutaneous placement of an epidural drainage catheter and antibiotic therapy. Although there are rare reports of percutaneous drainage of SEAs, to our knowledge, there are no reports of successful use of percutaneous indwelling catheters resulting in the complete resolution of an SEA. Holo-spinal epidural abscess in an infant is an extremely rare disease with limited literature available regarding the best practice for its treatment. Multiple considerations must be taken into account when weighing the different treatment options ranging from surgical decompression to conservative management with antibiotic therapy. We present a unique case of successful treatment with percutaneous epidural drain placement. This provides a reasonable alternative for management in children for whom surgical decompression carries multiple risks for complications both acutely and delayed.

Tailored minimally invasive tubular laminectomies for the urgent treatment of rare holocord spinal epidural abscess: case report and review of technique

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.

Spinal Epidural Abscess in an Infant Presenting as Fever and Respiratory Distress

A 9-month-old healthy female presented during winter to the emergency department with a chief complaint of fever and prominent respiratory symptoms. She was discharged on oseltamivir with a presumptive diagnosis of influenza. She returned to the emergency department 2 days later with continued fever and more upper respiratory symptoms. She was admitted for intravenous hydration to the observation unit with a diagnosis of viral illness (with viral testing that returned positive for adenovirus) and dehydration. When her high fevers continued, bloodwork that was concerning for leukocytosis, elevated inflammatory markers, and elevated alkaline phosphatase was obtained. During her workup for fever, a full body magnetic resonance imaging was performed, which revealed the diagnosis of a C3 to L5 spinal epidural abscess. This case demonstrates the difficulty of making this important diagnosis in a preverbal child presenting with a concurrent virus during winter viral season.

Pediatric Holocord Epidural Abscess Treated with Apical Laminotomies with Catheter-directed Irrigation and Drainage

Spinal epidural abscesses (SEA), while fortunately rare, carry significant risk to affected patients. Optimal treatment of these infections is poorly defined due to the heterogeneity of clinical and radiographic presentations. Urgent surgical evacuation of the infection is critical in cases with spinal cord compression or neurological compromise, though challenges may arise from competing surgical objectives, including the need for successful debridement of the infection, desire to minimize operative intervention, and risk of delayed iatrogenic instability. This is particularly concerning in young children with large multiregional collections. We present the first report case of pediatric holocord abscess treated with apical laminotomies and epidural catheterization for irrigation and drainage. This technique allowed successful treatment while avoiding extensive laminectomies and associated morbidities.

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.

Pediatric cervical epidural abscess in a 4-year-old patient: a case-based update

PURPOSE

The purpose of this study was to review a case comprised of a cervical spinal epidural abscess, cervical and thoracic paraspinous edema, and widening of the right thoracic neural foramen secondary to a phlegmon.

METHODS

We reviewed the case of a spinal epidural abscess managed medically in a 4-year-old male and performed a review of the literature with 15 other cases that have previously been reported.

RESULTS

The current mainstay of treatment is largely variant but generally falls into a laminectomy-based surgical approach or longstanding antibiotics. Our review of the literature concluded that there are currently no clear guidelines established to recommend treatment, and current practice is largely based on the discretion of the pediatric neurosurgeon.

CONCLUSIONS

Based on the literature review, and our personal case illustration, we conclude that an antibiotic-based treatment is a valid approach for therapy if initiated promptly in a pediatric patient with no neurological deficit.

Spinal Epidural Abscess in Children: Case Report and Review of the Literature

BACKGROUND

Spinal epidural abscess (SEA) is a rare but serious infection in the epidural space along the spinal cord. SEA should be considered in patients with backache, fever, neurological deficits and/or spinal tenderness. Early diagnosis is imperative to prevent permanent neurological sequelae.

CASE DESCRIPTION

We report a case of lumbar SEA in a 13-year-old girl who was immunocompetent and presented with spinal tenderness, back pain and 4 days of fever. A lumbar magnetic resonance imaging demonstrated an epidural abscess from L3-S1. She had emergent surgical intervention. Cultures grew methicillin-susceptible Staphylococcus aureus. She was also given long-term systemic antibiotics and she made a complete recovery within 2 months.

CONCLUSIONS

SEA in an immunocompetent pediatric without risk factors is an extremely rare condition. In the English-language literature, there are only 30 reported cases in the past 19 years; our case brings the total to 31. Non-surgical treatment has been successful in both adult and pediatric patients under certain conditions. Still, there exists a risk of deterioration with non-surgical management, even in patients for whom treatment is begun in the absence of neurologic deficits. Tracking neurological deficits in children can be challenging, particularly in young children who are non-verbal and not yet ambulating, and a reliable neurologic examination is a critical component of non-surgical care. In consideration of these facts and the accelerated time frame of deterioration, once neurologic deficits are present, surgery plus systemic antibiotics remains the standard of care for pediatric SEA patients, with each individual case meriting review of the full clinical picture.

Holocord spinal epidural abscess: Case report and literature review

Holocord spinal epidural abscess (SEA) is a rare condition. To our knowledge, five cases of SEA have been reported so far, and no consensus has been made on the treatment yet. In this article, we report a case of holocord SEA and review literature to further understanding of SEA. The advent of antibiotic treatment and the recognition of surgical debridement have been important in searching for alternatives to recovery, so the patient was treated surgically together with systemic antibiotics. The patient remained neurologically stable and continued to be clinically in good condition without any low back pain after 1 year. Surgical drainage, together with systemic antibiotics, is the main treatment choice for extensive SEAs. Although treatment should be considered that highlights the importance of examining the factors related to the health and condition of the patients and the anatomy and extent of the abscess, early surgical treatment associated with prolonged antibiotic treatment is necessary.

A 34-Day-Old With Fever, Cerebrospinal Fluid Pleocytosis, and Staphylococcus aureus Bacteremia

A 34-day-old previously healthy boy born full term presented to the emergency department with fever at home (38.1°C), fussiness, and decreased oral intake for 1 day. He was difficult to console at home. He had decreased oral intake without emesis, diarrhea, or a change in urine output. He did not have rhinorrhea, cough, or increased work of breathing noted by parents. He lived at home with his parents and 13-year-old brother, did not attend day care, and had no sick contacts. On examination, he was fussy but consolable. He was febrile to 39.3°C, tachycardic (180 beats per minute), and tachypneic (64 breaths per minute), with mottling and a capillary refill of 3 seconds. The remainder of his examination was normal, without an infectious focus for his fever. A complete blood cell count with differential revealed leukocytosis. A basic metabolic panel was normal. A catheter urinalysis was normal. Cerebrospinal fluid examination yielded pleocytosis, low glucose, and elevated protein. Blood cultures were persistently positive with methicillin-sensitive Staphylococcus aureus, but cerebrospinal fluid cultures remained negative. We present his case, management, and ultimate diagnosis.

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.

Pyogenic and non-pyogenic spinal infections: emphasis on diffusion-weighted imaging for the detection of abscesses and pus collections

The incidence of spinal infections has increased in the past two decades, owing to the increasing number of elderly patients, immunocompromised conditions, spinal surgery and instrumentation, vascular access and intravenous drug use. Conventional MRI is the gold standard for diagnostic imaging; however, there are still a significant number of misdiagnosed cases. Diffusion-weighted imaging (DWI) with a b-value of 1000 and apparent diffusion coefficient (ADC) maps provide early and accurate detection of abscess and pus collection. Pyogenic infections are classified into four types of extension based on MRI and DWI findings: (1) epidural/paraspinal abscess with spondylodiscitis, (2) epidural/paraspinal abscess with facet joint infection, (3) epidural/paraspinal abscess without concomitant spondylodiscitis or facet joint infection and (4) intradural abscess (subdural abscess, purulent meningitis and spinal cord abscess). DWI easily detects abscesses and demonstrates the extension, multiplicity and remote disseminated infection. DWI is often a key image in the differential diagnosis. Important differential diagnoses include epidural, subdural or subarachnoid haemorrhage, cerebrospinal fluid leak, disc herniation, synovial cyst, granulation tissue, intra- or extradural tumour and post-surgical fluid collections. DWI and the ADC values are affected by susceptibility artefacts, incomplete fat suppression and volume-averaging artefacts. Recognition of artefacts is essential when interpreting DWI of spinal and paraspinal infections. DWI is not only useful for the diagnosis but also for the treatment planning of pyogenic and non-pyogenic spinal infections.

Epidural abscess in a neonate

We report the case of a 16-day-old neonate who presented with fever and irritability. Blood and cerebrospinal fluid (CSF) samples collected on his admission grew methicillin sensitive Staphylococcus aureus on culture, prompting an urgent search for parameningeal collections or an occult sinus involving the central nervous system. Magnetic resonance imaging revealed a pyogenic collection within the epidural space extending from the upper cervical to lumbosacral level and multiple other deep tissue collections that required repeated surgical drainage. Central nervous system infections due to S. aureus are uncommon, particularly in the absence of an anatomical defect or prior neurosurgical instrumentation. This case demonstrates the importance of a timely and thorough search for parameningeal foci when CSF cultures are positive for unusual organisms such as S. aureus.

Spinal epidural abscess with myelitis and meningitis caused by Streptococcus pneumoniae in a young child

BACKGROUND

Spinal epidural abscess (SEA) in children is a rare infectious emergency warranting prompt intervention. Predisposing factors include immunosuppression, spinal procedures, and local site infections such as vertebral osteomyelitis and paraspinal abscess. Staphylococcus aureus is the most common isolate.

DESIGN

Case report and literature review.

FINDINGS

A 2.5-year-old boy with tetraparesis was found to have an SEA in the posterior lumbar epidural space with evidence of meningitis and myelitis on MRI spine in the absence of any local or systemic predisposing factors or spinal procedures. Streptococcus pneumoniae was isolated from the evacuated pus.

CONCLUSIONS

Definitive treatment of SEA is a combination of surgical decompression and iv antibiotics. Timely management limits the extent of neurological deficit.

Spontaneous abscess of the lumbar spine presenting as subacute back pain

A 52-year-old lady was admitted with back pain, fever and reduced sensation in her left leg. Soon after admission she developed acute urinary retention. She underwent urgent MRI of the spine which showed an epidural abscess compressing the thecal sac which was treated with neurosurgical decompression and intravenous/oral antibiotics. Cultures from theatre grew Staphylococcus aureus sensitive to flucloxacillin. After 12 weeks of intravenous/oral antibiotics, she was discharged without any neurological disability.