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Azad TD, Kalluri AL, Jiang K, Jimenez AE, Liu J, Madhu P, Horowitz MA, Ran K, Ishida W, Medikonda R, Xia Y, Liu A, Jin Y, Lubelski D, Bydon A, Theodore N, Witham TF. External Validation of Predictive Models for Failed Medical Management of Spinal Epidural Abscess. World Neurosurg 2024; 187:e638-e648. [PMID: 38692569 DOI: 10.1016/j.wneu.2024.04.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 04/22/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVE There is limited consensus regarding management of spinal epidural abscesses (SEAs), particularly in patients without neurologic deficits. Several models have been created to predict failure of medical management in patients with SEA. We evaluate the external validity of 5 predictive models in an independent cohort of patients with SEA. METHODS One hundred seventy-six patients with SEA between 2010 and 2019 at our institution were identified, and variables relevant to each predictive model were collected. Published prediction models were used to assign probability of medical management failure to each patient. Predicted probabilities of medical failure and actual patient outcomes were used to create receiver operating characteristic (ROC) curves, with the area under the receiver operating characteristic curve used to quantify a model's discriminative ability. Calibration curves were plotted using predicted probabilities and actual outcomes. The Spiegelhalter z-test was used to determine adequate model calibration. RESULTS One model (Kim et al) demonstrated good discriminative ability and adequate model calibration in our cohort (ROC = 0.831, P value = 0.83). Parameters included in the model were age >65, diabetes, methicillin-resistant Staphylococcus aureus infection, and neurologic impairment. Four additional models did not perform well for discrimination or calibration metrics (Patel et al, ROC = 0.580, P ≤ 0.0001; Shah et al, ROC = 0.653, P ≤ 0.0001; Baum et al, ROC = 0.498, P ≤ 0.0001; Page et al, ROC = 0.534, P ≤ 0.0001). CONCLUSIONS Only 1 published predictive model demonstrated acceptable discrimination and calibration in our cohort, suggesting limited generalizability of the evaluated models. Multi-institutional data may facilitate the development of widely applicable models to predict medical management failure in patients with SEA.
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Affiliation(s)
- Tej D Azad
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA.
| | - Anita L Kalluri
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Kelly Jiang
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Adrian E Jimenez
- Department of Neurosurgery, Columbia University Medical Center, New York, New York, USA
| | - Jiaqi Liu
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Praneethkumar Madhu
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Melanie A Horowitz
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Kathleen Ran
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Wataru Ishida
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Ravi Medikonda
- Stanford University School of Medicine, Stanford, California, USA
| | - Yuanxuan Xia
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Ann Liu
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York, USA
| | - Yike Jin
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Ali Bydon
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Timothy F Witham
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
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Hugues Dokponou YC, Ontsi Obame FL, Mohcine S, Saad ME, Abderrahmane H, Imbunhe N, Mandour C, Gazzaz M. Extensive Spinal Epidural Abscess: A Systematic Review of Risk Factors, Clinical Presentation, and Management with a Case Illustration. World Neurosurg 2024; 189:273-284. [PMID: 38906469 DOI: 10.1016/j.wneu.2024.06.073] [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: 04/15/2024] [Revised: 06/13/2024] [Accepted: 06/14/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND Extensive spinal epidural abscess (ESEA) is a rare clinical entity subject to delayed diagnosis, which can be explained by the extension of the epidural collection, thereby delaying the mass effect responsible for its clinical manifestations. METHODS We report a rare case of an extensive C7-T10 epidural abscess in a 54-year-old man treated with antibiotics, laminectomy, and abscess drainage. In addition, we conducted a systematic literature search according to the "Preferred Reporting Items for Systematic Reviews" guidelines. Relevant studies (1980-2023) reporting patients with ESEA were identified from PubMed databases. RESULTS A total of 48 studies reporting 55 patients were included in this study with a mean age of 55.7 ± 14.6 years with a male predominance of 61.8% (n = 34). The median duration of follow-up was 38 months (21.5-64.3). The mortality rate of ESEA was 1.8% for a 21.8% morbidity rate with 76.4% (n = 42) reported to have been improved after surgery. CONCLUSIONS Both single and multilevel laminectomy with abscess drainage for ESEA leads to patient recovery from this devastating condition. Evaluation of the outcome with data on time-to-Nadir and Nadir-to-surgery is needed to codify ESEA management.
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Affiliation(s)
| | | | - Salami Mohcine
- Department of Neurosurgery, Mohammed V Military Teaching Hospital, Rabat, Morocco
| | - Moussa Elmi Saad
- Department of Neurosurgery, Mohammed V Military Teaching Hospital, Rabat, Morocco
| | - Housni Abderrahmane
- Department of Neurosurgery, Mohammed V Military Teaching Hospital, Rabat, Morocco
| | - Napoleão Imbunhe
- Department of Neurosurgery, Mohammed V Military Teaching Hospital, Rabat, Morocco
| | - Cherkaoui Mandour
- Department of Neurosurgery, Mohammed V Military Teaching Hospital, Rabat, Morocco
| | - Miloud Gazzaz
- Department of Neurosurgery, Mohammed V Military Teaching Hospital, Rabat, Morocco
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Anderson ES, Frazee BW. The Intersection of Substance Use Disorders and Infectious Diseases in the Emergency Department. Emerg Med Clin North Am 2024; 42:391-413. [PMID: 38641396 DOI: 10.1016/j.emc.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
Substance use disorders (SUDs) intersect clinically with many infectious diseases, leading to significant morbidity and mortality if either condition is inadequately treated. In this article, we will describe commonly seen SUDs in the emergency department (ED) as well as their associated infectious diseases, discuss social drivers of patient outcomes, and introduce novel ED-based interventions for co-occurring conditions. Clinicians should come away from this article with prescriptions for both antimicrobial medications and pharmacotherapy for SUDs, as well as an appreciation for social barriers, to care for these patients.
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Affiliation(s)
- Erik S Anderson
- Department of Emergency Medicine, Alameda Health System, Wilma Chan Highland Hospital, 1411 East 31st Street, Oakland, CA 94602, USA; Division of Addiction Medicine, Highland Hospital, Alameda Health System, 1411 East 31st Street, Oakland, CA 94602, USA.
| | - Bradley W Frazee
- Department of Emergency Medicine, Alameda Health System, Wilma Chan Highland Hospital, 1411 East 31st Street, Oakland, CA 94602, USA
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4
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Chen M, Baumann AN, Fraiman ET, Cheng CW, Furey CG. Long-term survivability of surgical and nonsurgical management of spinal epidural abscess. Spine J 2024; 24:748-758. [PMID: 38211902 DOI: 10.1016/j.spinee.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 12/05/2023] [Accepted: 12/27/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND CONTEXT Spinal epidural abscess (SEA) is a rare and life-threatening infection within the epidural space with significant functional impairment and morbidity. Active debate remains over whether to operate for SEAs, with limited existing data comparing the long-term survivability after surgical versus nonsurgical management. PURPOSE This study aims to determine the long-term survival of patients who underwent surgical and nonsurgical management for SEA. STUDY DESIGN Retrospective cohort study. PATIENT SAMPLE A total of 250 consecutive SEA patients. OUTCOME MEASURES Survival and mortality rates, complications. METHODS All patients treated at a tertiary medical center for a primary SEA from January 2000 to June 2020 are identified. Data collection is by retrospective chart review. Cox proportional hazards regression models are used for all survival analyses while controlling for potential confounding variables and with multiple testing corrections. RESULTS A total of 35 out of 250 patients died with an overall all-cause mortality of 14%. More than half of all deaths occurred within 90 days after treatment. The 90-day, 3-year, and 5-year survival rates are 92.8%, 89.2%, and 86.4%, respectively. Among surgery patients, the all-cause mortality was 13.07%, compared to 16.22% for medically-managed patients. Surgical treatment (decompression, fusion, debridement) significantly reduced the risk of death by 62.4% compared to medical therapy (p=.03), but surgery patients experienced a significantly longer mean length of stay (p=.01). Risk factors of short-term mortality included hypoalbuminemia (<3.5 g/dL), American Society of Anesthesiologists (ASA) 4+, and cardiac arrest. Risk factors of long-term mortality were immunocompromised state, elevated WBC count >12,000, sepsis, septic shock, ASA 4+, and cardiac arrest (p<.05). In terms of complications, surgically-managed patients experienced a higher proportion of deep vein thrombosis (p<.05). CONCLUSIONS The overall long-term survivability of SEA treatment is relatively high at (86% at 5-year) in this study. The following SEA mortality risk factors were identified: hypoalbuminemia (short-term), immunocompromised state (long-term), leukocytosis (long-term), sepsis and septic shock (long-term), ASA 4+ and cardiac arrest (overall). For primary SEA patients, surgical management may reduce mortality risk compared to nonsurgical management.
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Affiliation(s)
- Mingda Chen
- School of Medicine, Case Western Reserve University, 9501 Euclid Ave, Cleveland, OH 44106, USA.
| | - Anthony N Baumann
- Northeast Ohio Medical University, 4209 State Route 44. Rootstown, OH 44272, USA
| | - Elad T Fraiman
- School of Medicine, Case Western Reserve University, 9501 Euclid Ave, Cleveland, OH 44106, USA
| | - Christina W Cheng
- School of Medicine, Case Western Reserve University, 9501 Euclid Ave, Cleveland, OH 44106, USA; Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH 44106, USA
| | - Christopher G Furey
- School of Medicine, Case Western Reserve University, 9501 Euclid Ave, Cleveland, OH 44106, USA; Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH 44106, USA
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Xiong GX, Nguyen A, Hering K, Schoenfeld AJ. Long-term quality of life and functional outcomes after management of spinal epidural abscess. Spine J 2024; 24:759-767. [PMID: 38072087 DOI: 10.1016/j.spinee.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/06/2023] [Accepted: 11/27/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND/CONTEXT In recent years, the incidence of spinal epidural abscesses (SEA) has tripled in number and nonoperative management has risen in popularity. While there has been a shift towards reserving surgical intervention for patients with focal neurologic deficits, a third of patients will still fail medical management and require surgical intervention. Failure to understand long-term quality of life and functional outcomes hinders effective decision making and prognostication. PURPOSE To describe patterns and associated factors impacting long-term quality of life following treatment of spinal epidural abscess. STUDY DESIGN/SETTING Multicenter cohort study at two urban academic tertiary referral centers and two community centers. PATIENT SAMPLE Adult patients treated for a spinal epidural abscess. OUTCOME MEASURES EuroQoL 5-Dimension 5L (EQ5D), Neuro-Quality of Life Lower Extremity - Mobility (Short Form; NeuroQoL-LE), Patient-Reported Outcomes Measurement Information System Physical Function (short form 4a; PROMIS PF), and PROMIS Global Mental Health score (PROMIS Mental). METHODS Eligible patients were enrolled and administered questionnaires. Multivariable analysis assessed the influence of ambulatory status on HRQL, adjusting for covariates including age, biologic sex, Charlson comorbidity index, intravenous drug use, management approach, and ASIA grade on presentation. RESULTS Sixty-one patients were enrolled (mean age 60.5 years, 46% male). Thirty-four patients (58%) underwent operative management. Mean standard deviation (SD) results for HRQL measures were: EQ5D 0.51 (0.37), EQ5D visual analogue scale 60.34 (25.11), NeuroQoL Lower extremity 41.47 (10.64), PROMIS physical function 39.49 (10.07), and PROMIS Global Mental Health 44.23 (10.36). Adjusted analysis demonstrated ambulatory status at presentation, and at 1 year, to be important drivers of HRQL, irrespective of other factors including IVDU and ASIA grade. Patients with independent ambulatory function at 1 year had mean EQ5D utility of 0.65 (95% CI 0.55, 0.75), whereas those requiring assistive devices saw a 49% decrease with mean EQ5D utility of 0.32 (0.14, 0.51). Ambulatory status was associated with global and physical function but did not impact overall health self-assessment or mental health scores. CONCLUSIONS We found that ambulatory status was the most important factor associated with long-term HRQL regardless of other factors such as ASIA grade or IVDU. Given prior literature demonstrating the protective effect of operative intervention on ambulatory function, this highlights ambulatory dysfunction as a potential indication for surgery and a marker of poor long-term prognosis, even in the absence of focal neurologic deficits. Our work also highlights the importance of optimized long-term rehabilitation strategies aimed to preserve ambulatory function in this high-risk population. LEVEL OF EVIDENCE Level III, cohort study.
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Affiliation(s)
- Grace X Xiong
- Harvard Combined Orthopaedic Residency Program, 55 Fruit St, Boston, MA 02114, USA
| | - Andrew Nguyen
- Harvard Medical School, 25 Shattuck St, Boston MA 02115, USA
| | - Kalei Hering
- Harvard Medical School, 25 Shattuck St, Boston MA 02115, USA
| | - Andrew J Schoenfeld
- Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston MA 02115, USA.
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Mitani K, Minami M, Takahashi T, Toyoda M, Kanematsu R, Hanakita J. Acute cervical epidural abscess with concurrent calcium pyrophosphate deposition after cervical spinal surgery: A case report. Surg Neurol Int 2024; 15:87. [PMID: 38628534 PMCID: PMC11021091 DOI: 10.25259/sni_740_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 02/17/2024] [Indexed: 04/19/2024] Open
Abstract
Background Spinal epidural abscess (SEA) is a rare condition that may result in catastrophic outcomes. On the other hand, calcium pyrophosphate (CPP) deposition disease (CPPD) causes inflammatory arthritis. Spinal involvement of a crystal-induced inflammation caused by CPPD is also common. Surgery is a common risk factor for both SEA and CPPD; however, the postoperative acute onset of SEA complicated with CPPD is extremely rare. Case Description A man in his 70s presented to our hospital, complaining of right upper limb weakness, loss of dexterity, and gait disturbance. The diagnosis of cervical spondylotic myelopathy was made, and he performed laminectomy at C3, C4, and C5 levels. Four days after the laminectomy, he suffered from acute neck pain, weakness, and hypoesthesia in his arms and legs. Magnetic resonance imaging revealed a mass occupying the dorsal epidural space of C6 and C7, compressing the cervical spinal cord. Considering the acute symptomatology, an acute spinal epidural hematoma after surgery was suspected; therefore, emergency C6 and C7 laminectomy was performed. Surgical findings indicated that the pressure inside the spinal canal was elevated, and the mass was purulent exudate. Pathological examination showed suppurative inflammation with concomitant deposition of CPP. SEA complicated with CPPD was considered; therefore, antibiotics and non-steroidal anti-inflammatory drugs were administered. The motor weakness and hypoesthesia were improved despite a slight residual deficit in his dexterity. Conclusion An acute onset of SEA complicated with CPPD after cervical surgery has rarely been reported. The suppurative inflammation fostered by the crystal-induced inflammation may account for the acute symptomatology.
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Affiliation(s)
- Koki Mitani
- Spinal Disorders Center, Fujieda Heisei Memorial Hospital, Fujieda, Japan
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Lu KY, Tung WE, Chiang CJ, Hsieh YY, Chen CH, Lee MH, Yen MH, Lu PW, Wu LC. Sciatica caused by spinal epidural abscess as the initial clinical presentation of colon cancer: a rare case report and review of literature. BMC Infect Dis 2024; 24:293. [PMID: 38448866 PMCID: PMC10916147 DOI: 10.1186/s12879-024-09159-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 02/20/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Colorectal cancer is one of the most frequently diagnosed forms of cancer, and it is associated with several common symptoms and signs such as rectal bleeding, altered bowel habits, abdominal pain, anemia, and unintentional weight loss. Sciatica, a debilitating condition in which the patient experiences paresthesia and pain in the dermatome of associated lumbosacral nerve roots or sciatic nerve distribution, is not considered one of these. Here we present a case of colorectal cancer manifesting symptoms of sciatica alone. CASE PRESENTATION A 68-year-old male presented with progressive lower back pain radiating to his left thigh and calf over L5/S1 dermatome. Sciatica was suspected and initially underwent conservative treatment with analgesics. However, the symptoms progressed and MRI revealed an epidural abscess surprisingly. Surgical debridement was performed and pus culture isolated Streptococcus gallolyticus. Based on the strong association of S. gallolyticus with colorectal cancer, the presence of this pathogen prompted further tumor evaluation, even in the absence of the typical symptoms and signs. This investigation ultimately leads to the diagnosis of sigmoid adenocarcinoma. CONCLUSIONS Although rare, sciatica caused by S. gallolyticus infection of the spinal epidural space may serve as the initial presentation of colorectal cancer. Physicians should be aware of the strong association between S. gallolyticus and colorectal cancer. Based on what we currently know about the condition; a thorough systematic assessment of occult neoplasia for patients with S. gallolyticus infection is recommended.
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Affiliation(s)
- Kuan-Yu Lu
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, 23561, Taiwan
| | - Wei-En Tung
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, 23561, Taiwan
| | - Chang-Jung Chiang
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, 23561, Taiwan
- Department of Orthopedic Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, 110, Taiwan
| | - Yueh-Ying Hsieh
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, 23561, Taiwan
- Department of Orthopedic Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, 110, Taiwan
| | - Chia-Hsien Chen
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, 23561, Taiwan
- School of Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei City, Taiwan
| | - Mei-Hui Lee
- Division of Infectious Diseases, Department of Internal Medicine, Shuang-Ho Hospital, Taipei Medical University, New Taipei City, 23561, Taiwan
| | - Min-Hsuan Yen
- Division of Colorectal Surgery, Department of Surgery, Shuang-Ho Hospital, Taipei Medical University, New Taipei City, 23561, Taiwan
| | - Po-Wen Lu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, 23561, Taiwan
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei City, 110, Taiwan
| | - Lien-Chen Wu
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, 23561, Taiwan.
- Department of Orthopedic Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, 110, Taiwan.
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei City, 110, Taiwan.
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Hijazi MM, Siepmann T, El-Battrawy I, Aweimer A, Engellandt K, Podlesek D, Schackert G, Juratli TA, Eyüpoglu IY, Filis A. Diagnostics, Management, and Outcomes in Patients with Pyogenic Spinal Intra- or Epidural Abscess. J Clin Med 2023; 12:7691. [PMID: 38137760 PMCID: PMC10744009 DOI: 10.3390/jcm12247691] [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: 11/23/2023] [Revised: 12/10/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Owing to the lack of evidence on the diagnostics, clinical course, treatment, and outcomes of patients with extremely rare spinal intradural abscess (SIA) and spinal epidural abscess (SEA), we retrospectively analyzed and compared a cohort of patients to determine the phenotyping of both entities. METHODS Over a period of 20 years, we retrospectively analyzed the electronic medical records of 78 patients with SIA and SEA. RESULTS The patients with SIA showed worse motor scores (MS scores) on admission (SIA: 20 ± 26 vs. SEA: 75 ± 34, p < 0.001), more often with an ataxic gait (SIA: 100% vs. SEA: 31.8%, p < 0.001), and more frequent bladder or bowel dysfunction (SIA: 91.7% vs. SEA: 27.3%, p < 0.001) compared to the SEA patients. Intraoperative specimens showed a higher diagnostic sensitivity in the SEA patients than the SIA patients (SIA: 66.7% vs. SEA: 95.2%, p = 0.024), but various pathogens such as Staphylococcus aureus (SIA 33.3% vs. SEA: 69.4%) and Streptococci and Enterococci (SIA 33.3% vs. SEA: 8.1%, p = 0.038) were detected in both entities. The patients with SIA developed sepsis more often (SIA: 75.0% vs. SEA: 18.2%, p < 0.001), septic embolism (SIA: 33.3% vs. SEA: 8.3%, p = 0.043), signs of meningism (SIA: 100% vs. 18.5%, p < 0.001), ventriculitis or cerebral abscesses (SIA: 41.7% vs. SEA: 3.0%, p < 0.001), and pneumonia (SIA: 58.3% vs. SEA: 13.6%, p = 0.002). The mean MS score improved in both patient groups after surgery (SIA: 20 to 35 vs. SEA: 75 to 90); however, the SIA patients showed a poorer MS score at discharge (SIA: 35 ± 44 vs. SEA: 90 ± 20, p < 0.001). C-reactive protein (CrP) (SIA: 159 to 49 vs. SEA: 189 to 27) and leukocyte count (SIA: 15 to 9 vs. SEA: 14 to 7) were reduced at discharge. The SIA patients had higher rates of disease-related mortality (SIA: 33.3% vs. SEA: 1.5%, p = 0.002), had more pleural empyema (SIA: 58.3% vs. SEA: 13.6%, p = 0.002), required more than one surgery (SIA: 33.3% vs. SEA 13.6%, p = 0.009), were treated longer with intravenous antibiotics (7 ± 4 w vs. 3 ± 2 w, p < 0.001) and antibiotics overall (12 ± 10 w vs. 7 ± 3 w, p = 0.022), and spent more time in the hospital (SIA: 58 ± 36 vs. SEA: 26 ± 20, p < 0.001) and in the intensive care unit (SIA: 14 ± 18 vs. SEA: 4 ± 8, p = 0.002). CONCLUSIONS Our study highlighted distinct clinical phenotypes and outcomes between both entities, with SIA patients displaying a markedly less favorable disease course in terms of complications and outcomes.
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Affiliation(s)
- Mido Max Hijazi
- Department of Neurosurgery, Division of Spine Surgery, Faculty of Medicine, Technische Universität Dresden, University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany; (D.P.); (G.S.); (T.A.J.); (I.Y.E.); (A.F.)
| | - Timo Siepmann
- Department of Neurology, Faculty of Medicine, Technische Universität Dresden, University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany;
| | - Ibrahim El-Battrawy
- Department of Cardiology, Bergmannsheil University Hospital, Ruhr University Bochum, Bürkle De La Camp-Platz 1, 44789 Bochum, Germany; (I.E.-B.); (A.A.)
| | - Assem Aweimer
- Department of Cardiology, Bergmannsheil University Hospital, Ruhr University Bochum, Bürkle De La Camp-Platz 1, 44789 Bochum, Germany; (I.E.-B.); (A.A.)
| | - Kay Engellandt
- Institute of Diagnostic and Interventional Neuroradiology, Faculty of Medicine, Technische Universität Dresden, University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany;
| | - Dino Podlesek
- Department of Neurosurgery, Division of Spine Surgery, Faculty of Medicine, Technische Universität Dresden, University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany; (D.P.); (G.S.); (T.A.J.); (I.Y.E.); (A.F.)
| | - Gabriele Schackert
- Department of Neurosurgery, Division of Spine Surgery, Faculty of Medicine, Technische Universität Dresden, University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany; (D.P.); (G.S.); (T.A.J.); (I.Y.E.); (A.F.)
| | - Tareq A. Juratli
- Department of Neurosurgery, Division of Spine Surgery, Faculty of Medicine, Technische Universität Dresden, University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany; (D.P.); (G.S.); (T.A.J.); (I.Y.E.); (A.F.)
| | - Ilker Y. Eyüpoglu
- Department of Neurosurgery, Division of Spine Surgery, Faculty of Medicine, Technische Universität Dresden, University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany; (D.P.); (G.S.); (T.A.J.); (I.Y.E.); (A.F.)
| | - Andreas Filis
- Department of Neurosurgery, Division of Spine Surgery, Faculty of Medicine, Technische Universität Dresden, University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany; (D.P.); (G.S.); (T.A.J.); (I.Y.E.); (A.F.)
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Gall A, Cowher A, France J, Cui S. Complete Spinal Cord Injury Secondary to Serratia marcescens Spinal Epidural Abscess: A Report of Significant Neurological Improvement After a Delayed Presentation. Cureus 2023; 15:e44451. [PMID: 37791159 PMCID: PMC10544132 DOI: 10.7759/cureus.44451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2023] [Indexed: 10/05/2023] Open
Abstract
The exact time at which neurological deficits secondary to a spinal cord injury (SCI) become permanent is unknown. However, urgent decompression within 24 hours of insult is advocated to maximize the return of function. Despite previous literature showing poor neurological recovery with intervention after 24-72 hours, multiple cases have since shown noteworthy clinical improvement following significant delays in presentation. We report the case of a 55-year-old incarcerated male who presented to our hospital with a four-week history of a complete (American Spinal Injury Association (ASIA) A) SCI after a prison altercation. The patient exhibited profound deficits of over one-month duration, and magnetic resonance imaging (MRI) revealed an epidural abscess at T7-T8 with severe cord compression and another epidural abscess at L4-L5. This prompted immediate IV antibiotic therapy. A full neurological examination at hospital admission showed a complete absence of sensation, motor, rectal tone, and rectal function below T8, indicating a grade ASIA A SCI. Blood cultures grew Serratia marcescens. After thorough deliberation, considering over a month of complete neurological deficits, it was decided that surgical intervention would be unlikely to improve the patient's clinical status. Nonetheless, after only 24 hours of IV antibiotic administration, the patient progressed from an ASIA A to B, with a return of 100% accurate, although dull, sensation below T8. Within one week, his abscesses diminished on follow-up MRI, yet T7-T8 remained under significant pressure with no further clinical improvements. Due to his unexpected improvement to an ASIA B, which then plateaued at this level, surgery was again discussed in an attempt to maximize recovery. The patient wished to proceed, even given low chances of a meaningful recovery. He subsequently underwent evacuation and decompression. Two weeks postoperatively, the patient advanced from an ASIA B to C; he remained so until discharge 46 days after presentation and 30 days after surgical decompression. This case is noteworthy within the literature due to two compelling features. Firstly, it represents a significantly delayed presentation of a complete SCI with unexpected, meaningful, and swift improvement after medication and surgical intervention. Secondly, it is one of the few documented cases of Serratia marcescens spinal epidural abscess (SEA).
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Affiliation(s)
- Ashley Gall
- Orthopaedic Surgery, West Virginia University School of Medicine, Morgantown, USA
| | - Abigail Cowher
- Orthopaedic Surgery, West Virginia University School of Medicine, Morgantown, USA
| | - John France
- Orthopaedic Surgery, West Virginia University School of Medicine, Morgantown, USA
| | - Shari Cui
- Orthopaedic Surgery, Prisma Health, Columbia, USA
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10
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Leavitt NJ, Al-Nasseri AM, Brady AC. Epidural abscess secondary to Streptococcus pneumoniae. A case report and review of the literature. IDCases 2023; 33:e01853. [PMID: 37554430 PMCID: PMC10404723 DOI: 10.1016/j.idcr.2023.e01853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 07/19/2023] [Indexed: 08/10/2023] Open
Abstract
While spinal epidural abscess is a well described disease process, this condition is rarely caused by Streptococcus pneumoniae. This case describes a case of spinal epidural abscess secondary to S. pneumoniae in an otherwise healthy, immunocompetent 61-year-old female without a history of spinal procedures, obvious source of hematogenous seeding, or clear risk factors for invasive pneumococcal infection. She was treated with IV and oral antibiotic therapy and made a full recovery.
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Affiliation(s)
- Nathaniel J. Leavitt
- Internal Medicine Resident at HCA Citrus Memorial Hospital, 502 W Highland Blvd, Inverness, FL 34452, USA
| | - Abraheim M. Al-Nasseri
- Internal Medicine Resident at HCA Citrus Memorial Hospital, 502 W Highland Blvd, Inverness, FL 34452, USA
| | - Adam C. Brady
- Medical Director of Department of Infectious Diseases at Samaritan Health Services, 3600 NW Samaritan Dr, Corvallis, OR 97330, USA
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11
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Park J, Han S, Jeon Y, Hong JY. Spinal epidural abscess as predicting factor for the necessity of early surgical intervention in patients with pyogenic spondylitis. BMC Musculoskelet Disord 2023; 24:586. [PMID: 37464374 DOI: 10.1186/s12891-023-06703-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 07/06/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Pyogenic spondylitis is a condition with low incidence that can lead to neurological sequelae and even life-threatening conditions. While conservative methods, including antibiotics and bracing, are considered the first-line treatment option for pyogenic spondylitis, it is important to identify patients who require early surgical intervention to prevent progressive neurologic deficits or deterioration of the systemic condition. Surgical treatment should be considered in patients with progressive neurologic deficits or deteriorating systemic condition. However, currently, there is a lack of treatment guidelines, particularly with respect to whether surgical treatment is necessary for pyogenic spondylitis. This study aims to analyze the radiological epidural abscess on MRI and clinical factors to predict the need for early surgical intervention in patients with pyogenic spondylitis and provide comprehensive insight into the necessity of early surgical intervention in these patients. METHODS This study retrospectively reviewed 47 patients with pyogenic spondylitis including spondylodiscitis, vertebral osteomyelitis, epidural abscess, and/or psoas abscess. All patients received plain radiographs, and a gadolinium-enhanced magnetic resonance imaging (MRI) scan. All patients have either tissue biopsies and/or blood cultures for the diagnosis of a pathogen. Demographic data, laboratory tests, and clinical predisposing factors including comorbidities and concurrent other infections were analyzed. RESULTS We analyzed 47 patients, 25 of whom were female, with a mean age of 70,7 years. MRI revealed that 26 of 47 patients had epidural abscesses. The surgical group had a significantly higher incidence of epidural abscess than the non-surgical group (p = 0.001). In addition, both CRP and initial body temperature (BT) were substantially higher in the surgical group compared to the non-surgical group. There was no significant difference between the surgical group and the non-surgical group in terms of age, gender, comorbidities, and concurrent infectious disorders, as well as the number of affected segments and affected spine levels. However, the surgical group had lengthier hospital stays and received more antibiotics. CONCLUSION The presence of an epidural abscess on MRI should be regarded crucial in the decision-making process for early surgical treatment in patients with pyogenic spondylitis in order to improve clinical outcomes.
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Affiliation(s)
- Jiwon Park
- Department of Orthopedics, Korea University Ansan Hospital, Ansan, 123, Jeokgeum-ro, Danwon-gu, 15355, Ansan-si, Gyeonggi-do, Republic of Korea
| | - Sangsoo Han
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, 170 Jomaru- ro, 14584, Bucheon, Gyeonggi-do, Republic of Korea
| | - Yeong Jeon
- Department of Orthopedics, Korea University Ansan Hospital, Ansan, 123, Jeokgeum-ro, Danwon-gu, 15355, Ansan-si, Gyeonggi-do, Republic of Korea
| | - Jae-Young Hong
- Department of Orthopedics, Korea University Ansan Hospital, Ansan, 123, Jeokgeum-ro, Danwon-gu, 15355, Ansan-si, Gyeonggi-do, Republic of Korea.
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Pitaro NL, Tang JE, Arvind V, Cho BH, Geng EA, Amakiri UO, Cho SK, Kim JS. Readmission and Associated Factors in Surgical Versus Non-Surgical Management of Spinal Epidural Abscess: A Nationwide Readmissions Database Analysis. Global Spine J 2023; 13:1533-1540. [PMID: 34866455 PMCID: PMC10448106 DOI: 10.1177/21925682211039185] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES Spinal epidural abscess (SEA) is a rare but potentially life-threatening infection treated with antimicrobials and, in most cases, immediate surgical decompression. Previous studies comparing medical and surgical management of SEA are low powered and limited to a single institution. As such, the present study compares readmission in surgical and non-surgical management using a large national dataset. METHODS We identified all hospital admissions for SEA using the Nationwide Readmissions Database (NRD), which is the largest collection of hospital admissions data. Patients were grouped into surgically and non-surgically managed cohorts using ICD-10 coding and compared using information retrieved from the NRD such as demographics, comorbidities, length of stay and cost of admission. RESULTS We identified 350 surgically managed and 350 non-surgically managed patients. The 90-day readmission rates for surgical and non-surgical management were 26.0% and 35.1%, respectively (P < .05). Expectedly, surgical management was associated with a significantly higher charge and length of stay at index hospital admission. Surgically managed patients had a significantly lower risk of readmission for osteomyelitis (P < .05). Finally, in patients with a low comorbidity burden, we observed a significantly lower 90-day readmission rate for surgically managed patients (surgical: 23.0%, non-surgical: 33.8%, P < .05). CONCLUSION In patients with a low comorbidity burden, we observed a significantly lower readmission rate for surgically managed patients than non-surgically managed patients. The results of this study suggest a lower readmission rate as an advantage to surgical management of SEA and emphasize the importance of SEA as a not-to-miss diagnosis.
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Affiliation(s)
- Nicholas L. Pitaro
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Justin E. Tang
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Varun Arvind
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brian H. Cho
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eric A. Geng
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Uchechukwu O. Amakiri
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel K. Cho
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jun S. Kim
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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13
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Popovici GC, Georgescu CV, Arbune AA, Vasile MC, Olteanu I, Arbune M. Post-COVID-19 Spondylodiscitis: A Case Study and Review of the Literature. Medicina (B Aires) 2023; 59:medicina59030616. [PMID: 36984617 PMCID: PMC10059316 DOI: 10.3390/medicina59030616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/12/2023] [Accepted: 03/16/2023] [Indexed: 03/22/2023] Open
Abstract
COVID-19 is currently a major health problem, leading to respiratory, cardiovascular and neurological complications, with additional morbidity and mortality. Spinal infections are rare, representing around 1% of all bone infections and comprising less than 2 per 10,000 of all hospitalizations in tertiary care centers. Spondylodiscitis is a complex disease, with challenging diagnosis and management. We report the case of a 45-year-old man, non-smoker hospitalized for severe COVID-19 disease with respiratory failure. Post-COVID-19, in the 8th week after discharge, he was diagnosed by magnetic resonance imaging with spondylodiscitis, but etiology was not confirmed by microbiological investigations. Antibiotics were used, considering the identification of MRSA from cultures of pleural fluid and nasal swab, but surgical intervention was not provided. Clinic, biologic and imagistic were improved, but rehabilitation and long term follow up are necessary. We concluded that spondylodiscitis with spinal abscess is a rare but severe complication post-COVID-19 disease, due to dysbalanced immune response related to the respiratory viral infection, endothelial lesions, hypercoagulation and bacterial superinfection.
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Affiliation(s)
- George-Cosmin Popovici
- School for Doctoral Studies in Biomedical Sciences “Dunarea de Jos” University from Galati, 800008 Galati, Romania
- Pneumophtiziology Hospital Galati, 800189 Galati, Romania
| | - Costinela-Valerica Georgescu
- Pharmaceutical Sciences Department “Dunarea de Jos” University from Galati, 800008 Galati, Romania
- Gynecology and Obstetrics Clinic Hospital Galati, 544886 Galati, Romania
- Correspondence: (C.-V.G.); (A.-A.A.)
| | - Anca-Adriana Arbune
- Neurology Department Clinic Institute Fundeni Bucharest, 022328 Bucharest, Romania
- Correspondence: (C.-V.G.); (A.-A.A.)
| | - Mihaela-Camelia Vasile
- School for Doctoral Studies in Biomedical Sciences “Dunarea de Jos” University from Galati, 800008 Galati, Romania
- Clinic Hospital for Infectious Diseases Galati, 800179 Galati, Romania
| | - Ionut Olteanu
- Emergency University Clinic Hospital Bucharest, 050474 Bucharest, Romania
| | - Manuela Arbune
- Clinic Hospital for Infectious Diseases Galati, 800179 Galati, Romania
- Medical Clinic Department “Dunarea de Jos” University from Galati, 800008 Galati, Romania
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14
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Walker JK, Cronin JT, Richards BW, Skedros JG. Acute Sternoclavicular Joint Sepsis With Medial Clavicle Osteomyelitis (Staphylococcus aureus) and Cervical-Thoracic Epidural Phlegmon in an Adult Female With No Apparent Risk Factors. Cureus 2023; 15:e35870. [PMID: 37033534 PMCID: PMC10079283 DOI: 10.7759/cureus.35870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2023] [Indexed: 03/09/2023] Open
Abstract
This is a case of a 71-year-old female with a history of only one known medical problem (hypertension) who presented with a right sternoclavicular joint (SCJ) infection in addition to (1) a contiguous lower cervical and upper thoracic epidural phlegmon and (2) cellulitis and a phlegmon in her posterior neck, which was subcutaneous and near the lower cervical and upper thoracic spinous processes. These loci of infection developed several days after she had pricked her fingers when cutting rose bushes and were initially considered to be epidural abscesses. However, after the patient was transferred to our tertiary medical center, a neurosurgeon and radiologist determined that the cervicothoracic infections were phlegmons rather than fully developed abscesses. The phlegmons were treated with only IV antibiotics. The SCJ infection was surgically debrided, and the medial clavicle was excised. Bone and fluid cultures grew methicillin-sensitive Staphylococcus aureus (S. aureus). The patient recovered uneventfully (the final follow-up was four years later). This case is uncommon because of the concurrent SCJ infection with medial clavicle osteomyelitis, cervical-thoracic epidural, and paraspinous phlegmons.
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15
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Buchori E, Sari PP. Spondylitis with epidural abscess and spinal tuberculoma as a major cause of myeloradiculopathy: a case report. Radiol Case Rep 2023; 18:532-537. [DOI: 10.1016/j.radcr.2022.10.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/15/2022] [Accepted: 10/23/2022] [Indexed: 11/27/2022] Open
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16
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Pi YW, Gong Y, Jiang JJ, Zhu DJ, Tong YX, Jiang LM, Zhao DX. Extensive spinal epidural abscess caused by Staphylococcus epidermidis: A case report and literature review. Front Surg 2023; 10:1114729. [PMID: 36969757 PMCID: PMC10032522 DOI: 10.3389/fsurg.2023.1114729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/20/2023] [Indexed: 03/29/2023] Open
Abstract
Background Extensive spinal epidural abscess (SEA) is an exceptional and threatening condition that requires prompt recognition and proper management to avoid potentially disastrous complications. We aimed to find key elements of early diagnosis and rational treatments for extensive SEA. Case presentation A 70-year-old man complained of intense pain in the cervical-thoracic-lumbar spine that radiated to the lower extremity. Laboratory test results revealed a marked increase in all indicators of infection. The spinal magnetic resonance imaging (MRI) revealed a ventral SEA extending from C2 to L4. Owing to the patient's critical condition, laminectomy, drainage, and systemic antibiotic therapy were administered. And the multidrug-resistant Staphylococcus epidermidis was detected in the purulent material from this abscess. Results Postoperative MRI revealed diminished epidural abscess, and the clinical symptoms were dramatically and gradually relieved after two rounds of surgery and systemic antibiotic therapy involving the combination of ceftriaxone, linezolid, and rifampicin. Conclusions A comprehensive emergency assessment based on neck or back pain, neurological dysfunctions, signs of systemic infection, and MRI are important for early diagnosis of extensive SEA. Further, the combination of laminectomy, drainage, and systemic antibiotic therapy may be a rational treatment choice for patients with SEA, especially for extensive abscess or progressive neurological dysfunction.
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17
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Zian A, Arts MP, van der Gaag NA. Case report: Anterior midline decompression of a cervical epidural abscess: Technical note and case series of seven patients. Front Surg 2022; 9:988565. [PMID: 36632524 PMCID: PMC9826791 DOI: 10.3389/fsurg.2022.988565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 11/17/2022] [Indexed: 12/27/2022] Open
Abstract
Background A spinal epidural abscess (SEA) of the cervical spine is a relatively rare disease and is generally characterized by progressive neurological deterioration due to compression of the spinal cord. Up to 40% of cervical SEAs are located ventrally of the spinal cord. Urgent surgical intervention is warranted to decompress the spinal cord and collect material for cultures to guide antibiotic treatment. However, the optimal timing of the intervention is unclear, and the associated risk of spinal instability in the presence of an extensive infection is a significant clinical dilemma. Methods In this paper, we present a novel surgical technique to treat a cervical SEA by anterior decompression through a linear transvertebral midline approach. This technique has the advantage of effectively draining the ventrally located SEA and obtaining material for bacteria culture while maintaining spinal stability without additional instrumentation. Results This case study presents seven patients with cervical SEAs who were successfully treated with surgical decompression by this transvertebral linear midline technique and antibiotic treatment. Conclusion Anterior decompression through a linear transvertebral midline approach for a ventrally located cervical SEA is a safe and pragmatic surgical procedure to achieve spinal cord decompression and collect bacteria culture without destabilizing the cervical spine.
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Affiliation(s)
- Ahmed Zian
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, Netherlands,Correspondence: Ahmed Zian
| | - Mark P. Arts
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, Netherlands
| | - Niels A. van der Gaag
- Department of Neurosurgery, Leiden University Medical Center (LUMC), Leiden, Netherlands
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18
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McCarthy S, Milne D, O'Connor K, Tse R, Garland J. Cervical Epidural Abscess: A Blind Spot for Postmortem Computed Tomography. Am J Forensic Med Pathol 2022; 43:273-276. [PMID: 34939948 DOI: 10.1097/paf.0000000000000742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Spinal epidural abscess is an uncommon condition, which may have serious complications, including neurological sequelae and death. Classical symptoms include spinal pain, fever, and neurological deficit; however, diagnosis is difficult and requires a high degree of clinical suspicion. Antemortem magnetic resonance imaging (MRI) scanning is the gold-standard diagnostic tool. Computed tomography (CT) is less sensitive and as such, postmortem CT may miss the diagnosis. We report a case of Staphylococcus aureus cervical epidural abscess presenting as neck pain and causing flaccid paralysis and subsequently death. Antemortem MRI showed a small epidural collection, spinal cord edema, and fluid in the adjacent cervical disc and facet joints; however, these findings could not be appreciated on postmortem CT. Postmortem examination, guided by the antemortem imaging, was able to confirm a cervical spinal epidural abscess; however, similar deaths may occur before medical presentation. This case demonstrates a limitation of postmortem imaging in diagnosing spinal epidural abscess and highlights that such cases may be missed.
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Affiliation(s)
| | - David Milne
- Department of Radiology, Auckland District Health Board
| | - Kate O'Connor
- Department of Radiology, Auckland District Health Board
| | | | - Jack Garland
- Forensic and Analytical Science Service, NSW Health Pathology, New South Wales, Australia
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19
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Huang Q, Gu Q, Song J, Yan F, Lin X. The effectiveness of percutaneous endoscopic lumbar discectomy combined with external lumbar drainage in the treatment of intervertebral infections. Front Surg 2022; 9:975681. [PMID: 36017524 PMCID: PMC9395960 DOI: 10.3389/fsurg.2022.975681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 07/26/2022] [Indexed: 11/30/2022] Open
Abstract
Objective To analyze the effect of percutaneous endoscopic lumbar discectomy in treating lumbar intervertebral infections. Methods A total of 13 patients with lumbar intervertebral infections who underwent percutaneous endoscopic lumbar discectomy combined with external drainage between November 2016 and December 2019 were enrolled in the present study. After the operation, sensitive antibiotics were used based on the results of the bacterial culture. If no pathogens were detected in the biopsy culture of the infected tissues, empirical antibiotics were administrated to these patients. The clinical efficacy was evaluated by using a visual analog scale (VAS), Japanese Orthopaedic Association (JOA), Oswestry Disability Index (ODI), and standard Macnab's evaluation. Postoperative computed tomography (CT) and MRI were also used to evaluate clinical efficacy. Results The follow-up time was 10–18 months, and the average time was (13.69 ± 2.63) months. Causative bacteria were isolated in 7 of 13 infected tissue biopsy cultures. Systemic antibiotics and anti-tuberculous chemotherapy were administered according to sensitivity studies for identified. There were no pathogens isolated from the other six patients. Empiric antibiotics were administrated in these patients. One week after the operation, WBC, a fractional fraction of medium granulocytes, ESR and CRP were significantly lower compared to before the operation (all P < 0.05). At the last follow-up visit, the above-mentioned markers were all within normal range, which differed compared to the pre-operative data (P < 0.05). The VAS and ODI of the patients at 1 week and 3 months after operation were significantly lower compared to preoperative data (all P < 0.05). During the last follow-up visit, seven patients were excellent, five were good, and one was poor according to standard Macnab's evaluation. No serious complications were recorded. Conclusions Percutaneous lumbar discectomy combined with external drainage resulted as an effective method for treating lumbar intervertebral infections and was associated with fewer injuries, less pain, low cost, and low recurrence rate.
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Affiliation(s)
| | | | | | - Fei Yan
- Correspondence: Fei Yan XiaoLong Lin
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20
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Choi SW, Lee JC, Lee WS, Hwang JY, Baek MJ, Choi YS, Jang HD, Shin BJ. Clinical differences between delayed and acute onset postoperative spinal infection. Medicine (Baltimore) 2022; 101:e29366. [PMID: 35713438 PMCID: PMC9276148 DOI: 10.1097/md.0000000000029366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 04/11/2022] [Indexed: 11/25/2022] Open
Abstract
Spine surgeons often encounter cases of delayed postoperative spinal infection (PSI). Delayed-onset PSI is a common clinical problem. However, since many studies have investigated acute PSIs, reports of delayed PSI are rare. The purpose of this study was to compare the clinical features, treatment course, and prognosis of delayed PSI with acute PSI.Ninety-six patients diagnosed with postoperative spinal infection were enrolled in this study. Patients were classified into 2 groups: acute onset (AO) within 90 days (n = 73) and delayed onset (DO) after 90 days (n = 23). The baseline data, clinical manifestations, specific treatments, and treatment outcomes were compared between the 2 groups.The history of diabetes mellitus (DM) and metallic instrumentation at index surgery were more DO than the AO group. The causative organisms did not differ between the 2 groups. Redness or heat sensation around the surgical wound was more frequent in the AO group (47.9%) than in the DO group (21.7%) (P = .02). The mean C-reactive protein levels during infection diagnosis was 8.9 mg/dL in the AO and 4.0 mg/dL in the DO group (P = .02). All patients in the DO group had deep-layer infection. In the DO group, revision surgery and additional instrumentation were required, and the duration of parenteral antibiotic use and total antibiotic use was significantly longer than that in the AO group. Screw loosening, disc space collapse, and instability were higher in the DO group (65.2%) than in the AO group (41.1%) (P = .04). However, the length of hospital stay did not differ between the groups.Delayed-onset PSI requires more extensive and longer treatment than acute-onset surgical site infection. Clinicians should try to detect the surgical site infection as early as possible.
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Affiliation(s)
- Sung-Woo Choi
- Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jae Chul Lee
- Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Won Seok Lee
- Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jin Yeong Hwang
- Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Min Jung Baek
- Department of Obstetrics and Gynecology, Bundang CHA Hospital, Seongnam, Korea
| | - Yoon Seo Choi
- Early Childhood Education, Ewha Woman's University, Korea
| | - Hae-Dong Jang
- Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Byung-Joon Shin
- Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Seoul, Korea
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21
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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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22
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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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Xiong GX, Crawford AM, Striano B, Lightsey HM, Nelson SB, Schwab JH. The NIMS framework: an approach to the evaluation and management of epidural abscesses. Spine J 2021; 21:1965-1972. [PMID: 34010684 DOI: 10.1016/j.spinee.2021.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 05/06/2021] [Accepted: 05/07/2021] [Indexed: 02/03/2023]
Affiliation(s)
- Grace X Xiong
- Harvard Combined Orthopaedic Residency Program, 55 Fruit St., Boston, MA, 02114
| | | | - Brendan Striano
- Harvard Combined Orthopaedic Residency Program, 55 Fruit St., Boston, MA, 02114
| | - Harry M Lightsey
- Harvard Combined Orthopaedic Residency Program, 55 Fruit St., Boston, MA, 02114
| | - Sandra B Nelson
- Division of Infectious Diseases, Massachusetts General Hospital, Bulfinch 130, 55 Fruit St., Boston, MA, 02114
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Yawkey 3A, 55 Fruit St., Boston, MA 02114.
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Kitov B, Kitova T, Kehayov I, Angelova P. Letter to the Editor Regarding "Predictors of Failure for Nonoperative Management of Spinal Epidural Abscess" by Hunter et al. Global Spine J 2021; 11:1313-1314. [PMID: 34525869 PMCID: PMC8453683 DOI: 10.1177/21925682211029268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Borislav Kitov
- Department of Neurosurgery, Faculty of Medicine, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Tanya Kitova
- Department of Neurosurgery, Faculty of Medicine, Medical University of Plovdiv, Plovdiv, Bulgaria,Department of Anatomy, Histology and Embryology, Medical Faculty, Medical University of Plovdiv, Plovdiv, Bulgaria,Tanya Kitova, Department of Anatomy, Histology and Embryology, Medical Faculty, Medical University of Plovdiv, 15A “Vasil Aprilov” Blvd., Plovdiv 4002, Bulgaria.
| | - Ivo Kehayov
- Department of Neurosurgery, Faculty of Medicine, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Polina Angelova
- Department of Neurosurgery, Faculty of Medicine, Medical University of Plovdiv, Plovdiv, Bulgaria
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25
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Kim HJ, Ryu JH, Park HY, Kim SI, Chang DG. Rapidly progressive gas-forming infection involving the spine as a life-threatening fatal condition : a case report. BMC Musculoskelet Disord 2021; 22:696. [PMID: 34399703 PMCID: PMC8365979 DOI: 10.1186/s12891-021-04589-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 08/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Gas forming infection of the spine is a consequence of vertebral osteomyelitis, necrotizing fasciitis, or a gas-forming epidural abscess, which is very rare and fatal conditions. This is the rare case of necrotizing fasciitis that rapidly progressed from the lumbar area to upper thoracic area. CASE PRESENTATION A 58-year-old male complained of lower back pain with fever and chills. The patient had a history of uncontrolled diabetes mellitus without diabetic medication over the previous 3 months, and he had received several local injections around the lumbar area. Laboratory data revealed white blood cell count of 19,710 /mm3, erythrocyte sedimentation of 40 mm/h, and C-reactive protein of 30.7 mg/L. Radiological findings revealed a small amount of air bubbles in the paraspinal area and lumbar epidural spaces. The patient refused emergency surgery and was discharged from the hospital. The patient re-visited the emergency department two days after discharge complaining of more severe back pain with persistent fever, and his vital signs had deteriorated, with low blood pressure and tachycardia. K. pneumoniae was isolated in cultures from ultrasound-guided aspirates and peripheral blood. The follow-up radiographs revealed aggressive dissemination of innumerable air bubbles from the lumbar area to the T5 level. The patient underwent emergent decompressive laminectomy and debridement of infected paravertebral fascia and musculature. Despite intensive care for deteriorated vital signs and his back wound, the patient died on postoperative day 3 due to multi-organ failure. CONCLUSIONS Necrotizing fasciitis involving the spine is a very rare disease with life-threatening conditions, rapid progression, and a high mortality rate. Therefore, prompt surgical treatment with a high index of suspicion is imperative to prevent potentially fatal conditions in similar extremely rare cases.
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Affiliation(s)
- Hong Jin Kim
- Spine Center and Department of Orthopedic Surgery, College of Medicine, Inje University Sanggye Paik Hospital, Inje University, 1342, Dongil-Ro, Nowon-Gu, 01757, Seoul, Republic of Korea
| | - Ji-Hyun Ryu
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyung-Youl Park
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang-Il Kim
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong-Gune Chang
- Spine Center and Department of Orthopedic Surgery, College of Medicine, Inje University Sanggye Paik Hospital, Inje University, 1342, Dongil-Ro, Nowon-Gu, 01757, Seoul, Republic of Korea.
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26
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Bari V, Frommelt J, Jain V. Compressive epidural fluid collection secondary to varicella zoster transverse myelitis. J Am Coll Emerg Physicians Open 2021; 2:e12493. [PMID: 34401867 PMCID: PMC8357074 DOI: 10.1002/emp2.12493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 05/21/2021] [Accepted: 06/07/2021] [Indexed: 11/09/2022] Open
Abstract
Transverse myelitis is often clinically indistinguishable from compressive myelopathies that require emergent neurosurgical intervention. Here, we present a case of acute varicella zoster virus transverse myelitis that was associated with a compressive fluid collection on magnetic resonance imaging (MRI) requiring emergent operative intervention. To our knowledge, this is the first reported case of acute transverse myelitis and a compressive cord lesion in the adult population.
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Affiliation(s)
- Vase Bari
- Department of AnesthesiaEmory University School of MedicineAtlantaGAUSA
| | - Jonathan Frommelt
- Department of Emergency MedicineMetrohealth Medical CenterClevelandOhioUSA
- Assistant Professor Emergency MedicineCase Western Reserve University School of MedicineClevelandOhioUSA
| | - Vikas Jain
- Department of RadiologyMetrohealth Medical CenterClevelandOhioUSA
- Associate Professor Emergency MedicineCase Western Reserve University School of MedicineClevelandOhioUSA
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27
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Egídio de Sousa I, Brito Monteiro M, Piteira M, Cuco A, Telles Freitas P. Epidural Abscess: A Cause of Back Pain That Must Not Be Missed. Cureus 2021; 13:e14376. [PMID: 34079646 PMCID: PMC8159304 DOI: 10.7759/cureus.14376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Low back and cervical pain are common emergency department complaints. Most cases represent low-risk pathologies but in rare cases, it can be a symptom of a serious underlying disease and the distinction can be challenging. A case is reported of a 58-year-old male with recurrent cervical pain requiring several emergency department visits. He eventually presented with intense cervical and low back pain, tetraparesis, and dyspnea. His condition deteriorated in less than 24 hours, evolving with fever, shock, and respiratory insufficiency and was admitted to the Intensive Care Unit for aminergic support, invasive mechanical ventilation and started on empiric antibiotics. Investigations revealed raised inflammatory markers and a cervical pre-vertebral purulent collection associated with an epidural collection at the level of C2 to C5 with spinal cord compression. The patient underwent transoral drainage and removal of the posterior C1 arch along with C2-C3-C4-C5 laminectomy. Staphylococcus aureus was isolated in the blood, pus, and bone. Re-intervention was required due to persistent pre-vertebral abscesses with clinical improvement thereafter. Eight weeks of antibiotic treatment were completed in total. The patient was discharged after 72 days of hospitalization with significant improvement in force and autonomy. Epidural abscess is a rare finding that can cause rapid irreversible neurological deterioration. Clinical suspicion must be high for an early diagnosis and treatment, essential for a better prognosis.
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Affiliation(s)
| | | | - Maria Piteira
- Internal Medicine Department, Hospital do Espirito Santo de Évora, Évora, PRT
| | - António Cuco
- Neurosurgery Department, Hospital Egas Moniz, Lisbon, PRT
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28
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Kotheeranurak V, Jitpakdee K, Singhatanadgige W, Limthongkul W, Yingsakmongkol W, Kim JS. Anterior transcorporeal full-endoscopic drainage of a long-span ventral cervical epidural abscess: A novel surgical technique. NORTH AMERICAN SPINE SOCIETY JOURNAL 2021; 5:100052. [PMID: 35141618 PMCID: PMC8820016 DOI: 10.1016/j.xnsj.2021.100052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 01/28/2021] [Accepted: 02/06/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND A long-span ventral cervical epidural abscess is a rare and devastating condition. Typically, extensive procedures are chosen to deal with this condition and usually end up with limited cervical motion. Here, we describe a novel minimally invasive anterior full-endoscopic transcorporeal approach for drainage of large ventral cervical epidural abscess. CASE DESCRIPTION A 33-year-old man presented with seizures and acute weakness in all extremities persistent for 2 hours. His motor power of the upper and lower extremities was rapidly declined from grade III to grade 0 within 12 hours. Magnetic resonance imaging (MRI) showed a long-span ventral epidural abscess extending from C2 to T1, cervical spinal cord, and a retropharyngeal abscess. A typical anterior cervical approach to the prevertebral space was performed to evacuate pus from the retropharyngeal abscess, after which anterior transcorporeal full-endoscopic drainage of the large ventral cervical epidural abscess was successfully performed. OUTCOME The patient's motor power recovered to grade IV within 2 weeks post-operation. He had no neck pain or instability following the operation. Postoperative MRI and computed tomography revealed diminished epidural abscess. CONCLUSIONS For managing cases with a ventral-type cervical epidural abscess, anterior transcorporeal full-endoscopic drainage is an alternative minimally invasive method that yields sufficient debridement and drainage.
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Affiliation(s)
- Vit Kotheeranurak
- Department of Orthopedics, Queen Savang Vadhana Memorial Hospital, Sriracha, Chonburi, Thailand
| | - Khanathip Jitpakdee
- Department of Orthopedics, Queen Savang Vadhana Memorial Hospital, Sriracha, Chonburi, Thailand
| | | | - Worawat Limthongkul
- Department of Orthopaedic, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Wicharn Yingsakmongkol
- Department of Orthopaedic, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Jin-Sung Kim
- Department of Neurosurgery, Seoul St. Mary's Hospital, Spine Center, College of medicine, The Catholic University of Korea, Seoul, South Korea
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