A rare case of multiple spinal epidural abscesses and cauda equina syndrome presenting to the emergency department following acupuncture

Preliminary clinical study: percutaneous lumbar discectomy combined with external drainage for treatment of intervertebral disc infections with epidural abscess

INTRODUCTION

Percutaneous lumbar discectomy (PLD) combined with external drainage (ED) is a new technique for the treatment of intervertebral disc infection with epidural abscess.

AIM

To discuss the feasibility, safety and efficacy of PLD and ED for the treatment of intervertebral disc infections with epidural abscess.

MATERIAL AND METHODS

We enrolled 12 patients who underwent intervertebral disc infections with epidural abscess. The clinical efficacy was evaluated by visual analog scale (VAS) and standard Macnab's evaluation. Postoperative computed tomography and magnetic resonance imaging were also used to evaluate the clinical efficacy.

RESULTS

The technical success rate is 100%. Preoperation mean VAS score was 8.18 ±0.98; 5.36 ±1.50 postoperation 1 month; 3.36 ±2.24 postoperation 6 months; 2.77 ±0.31 postoperation 12 months. The comparison of preoperation and postoperation VAS showed a significant difference (p < 0.05). According to standard Macnab's evaluation, of all 12 cases, postoperation 12 months - excellent 4 cases, good 7 cases, poor 1 case. The efficacy rate was 91.6%. No serious complications were recorded.

CONCLUSIONS

Percutaneous lumbar discectomy combined with external drainage may be a safe and efficacy method for the treatment of intervertebral disc infections with epidural abscess.

Spinal Epidural Abscess: A Review of Presentation, Management, and Medicolegal Implications

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.

Update on spinal epidural abscess

PURPOSE OF REVIEW

Spinal epidural abscess (SEA) is still a rare but potentially very morbid infection of the spine. In recent years, the incidence has risen sharply but the condition remains a medical conundrum wrought with unacceptably long diagnostic delays. The outcome depends on timely diagnosis and missed opportunities can be associated with catastrophic consequences. Management and outcomes have improved over the past decade. This review focuses on risk factors and markers that can aid in establishing the diagnosis, the radiological characteristics of SEA on MRI and their clinical implications, as well as the importance of establishing clear indications for surgical decompression.

RECENT FINDINGS

This once exclusively surgically managed entity is increasingly treated conservatively with antimicrobial therapy. Patients diagnosed in a timely fashion, prior to cord involvement and the onset of neurologic deficits can safely be managed without decompressive surgery with targeted antimicrobial therapy. Patients with acute cord compression and gross neurologic deficits promptly undergo decompression. The greatest therapeutic dilemma remains the group with mild neurological deficits. As failure rates of delayed surgery approach 40%, recent research is focused on predictive models for failure of conservative SEA management. In addition, protocols are being implemented with some success, to shorten the diagnostic delay of SEA on initial presentation.

SUMMARY

SEA is a potentially devastating condition that is frequently missed. Protocols are put in place to facilitate early evaluation of back pain in patients with red flags with appropriate cross-sectional imaging, namely contrast-enhanced MRI. Efforts for establishing clear-cut indications for surgical decompression of SEA are underway.

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

BACKGROUND

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

CASE DESCRIPTION

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

CONCLUSIONS

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

Cervical epidural analgesia complicated by epidural abscess: A case report and literature review

RATIONALE

Spinal epidural abscess is an uncommon complication in clinical practice. If the abscess is large enough, the patient will rapidly develop neurologic signs of spinal injury, and urgent neurosurgical intervention may be required.

PATIENT CONCERNS

Rapid and correct diagnosis and treatment is important for spinal epidural abscess complication.

DIAGNOSES

This report describes a cervical epidural abscess (CEA) caused by epidural analgesia, wherein the patient was punctured twice. A CEA was suspected based on the patient's significant neck pain and elevated white blood cell and neutrophil counts. A CEA from C6 to T8 was confirmed by magnetic resonance imaging scan.

INTERVENTIONS

The patient was treated with a combination of intravenous vancomycin and imipenem/cilastatin for more than 4 weeks.

OUTCOMES

After more than 2 weeks of intensive antibiotic treatment, the epidural abscess gradually diminished in size, the white blood cell count, neutrophil count, hyperallergic C-reactive protein (CRP), and general CRP decreased, and the patient's neck and back pain resolved. After more than 4 weeks of anti-inflammation therapy, the epidural abscess was completely absorbed, and there was no relapse during the 3-month follow-up period.

LESSONS

Although an effective combination of intravenous antibiotics can cure an epidural abscess, caution is warranted when performing epidural steroid injections in immunocompromised patients.

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

Objective

The purpose of this case study was to describe the differential diagnosis of a thoracic epidural abscess in a Navy veteran who presented to a chiropractic clinic for evaluation and management with acupuncture within a Veterans Affairs Medical Center.

Clinical Features

An afebrile 59-year-old man with acute thoracic spine pain and chronic low back pain presented to the chiropractic clinic at a Veterans Affairs Medical Center for consideration for acupuncture treatment.

Intervention and Outcome

The veteran elected to trial acupuncture once per week for 4 weeks. A routine thoracic magnetic resonance imaging scan without gadolinium detected a space-occupying lesion after the patient failed to attain 50% reduction of pain within 2 weeks with conservative care. The patient was diagnosed with a multilevel thoracic spondylodiscitis epidural abscess and was treated same day with emergency debridement and laminectomy of T7-8 with a T6-9 fusion. The patient had complete recovery without neurological compromise and completed an antibiotic regimen for 6 weeks.

Conclusion

A Navy veteran with acute thoracic spine and chronic low back pain appeared to respond initially but failed to achieve clinically meaningful outcomes. Follow-up advanced imaging detected a thoracic spondylodiscitis epidural abscess. Early diagnosis and immediate intervention are important to preserving neurological function and limiting morbidity in cases of spondylodiscitis epidural abscess.