Management of an extensive spinal epidural abscess from C-1 to the sacrum. Case report

Skip decompression surgeries in the treatment of holospinal epidural abscess: a case report

INTRODUCTION

Holospinal epidural abscess (HEA) extending from the cervical to the lumbosacral spine is an extremely rare condition. Surgical treatment of HEA, which involves extensive decompression of the spinal lesion is difficult in emergency settings. However, the authors successfully treated a case of HEA in critical condition with severe neurological deficits through a combination of skip decompression surgeries and catheter irrigation.

CASE PRESENTATION

A 73-year-old man complained of neck and back pain and developed muscle weakness in the upper and lower extremities (C5 AIS D tetraplegia). When he was transferred to our hospital, a marked increase in leukocytes (13330/μL) and C-reactive protein levels (32.11 mg/dL) was observed. Magnetic resonance imaging (MRI) revealed a HEA extending from C1 to S2 levels. Therefore, an emergency posterior decompression on C4-5 and T4-7 was performed, followed by catheter irrigation using a venous catheter. Blood and intraoperative isolated microorganisms were identified as Streptococcus intermedius, which is a rare cause of spinal infection. He experienced marked improvement in pain after surgery. Two months after surgery, the epidural abscess completely disappeared. Motor weakness gradually improved, and he was able to walk without support and showed no pain recurrence during the final follow-up (20 months after surgery).

DISCUSSION

Early diagnosis is important for the treatment of HEAs. Therefore, a whole spine MRI is recommended when an extensive spinal epidural abscess is suspected. Decompression surgery at limited spine levels followed by catheter irrigation should be considered in patients with HEA.

Surgical management of an extensive spinal epidural abscess: illustrative cases

BACKGROUND

Extensive spinal epidural abscesses (SEAs) occupying three or more spinal regions are rare. This study aimed to address the key dilemma of surgical treatment for holospinal epidural abscesses, i.e., to determine the required scope of surgery and minimize surgical trauma with adequate purulent drainage.

OBSERVATIONS

Two patients with extensive SEAs were treated at the Neurosurgery Department of the Central Hospital of Ministry of Internal Affairs of Ukraine from 2018 to 2020. Both patients had a neurological deficit and general inflammatory response syndrome. Spinal magnetic resonance examinations were performed, showing that the first and second patients had extensive SEAs at T11/S1 and C2/L1, respectively. Both underwent minimally invasive abscess drainage via intra- and translaminar access at the most caudal point using an epidural silicone catheter in the cranial direction along the entire length of the abscess.

LESSONS

To achieve the key goal of extensive SEA treatment, i.e., to prevent the development of a persistent neurological deficit, immediate effective spinal canal decompression should be performed. Access method and scope should meet the requirements of spinal canal decompression and purulent content aspiration to the greatest possible extent while inducing minimal trauma.

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: 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.

Ventral holocord spinal epidural abscess managed surgically in a critical setting

Background

Extensive epidural abscess is an uncommon entity which is increasing in the aging population. Its prevalence is also greater among those with diabetes mellitus and in those who are immunocompromised. Here, a 59-year-old female presented with a spinal epidural abscess (SEA) warranting operative intervention.

Case Description

A 59-year-old female with a history of diabetes and hypertension, presented with the acute onset of a high-grade fever, generalized back pain, and an evolving quadriparesis. Preliminary laboratory studies revealed elevated inflammatory markers. The magnetic resonance scan showed a ventral epidural abscess extending from C1-2 to the L5 level. She underwent urgent surgical decompression using a Nelaton catheter placed through an L4-L5 hemilaminectomy and threaded cephalad (40 cm); this resulted in a complete recovery.

Conclusion

This case study underscores a unique way of managing an anterior holospinal SEA extending from the C1-2 through the L5 spinal levels.

Extensive Spinal Epidural Abscesses Resolved with Minimally Invasive Surgery: Two Case Reports and Review of the Recent Literature

PURPOSE

An extensive spinal epidural abscess is a rare condition and causes significant morbidity and mortality. Few authors have described this uncommon entity, which requires early diagnosis and optimal treatment to avoid devastating complications. The purpose of this study was to evaluate a minimally invasive technique for treatment of an extensive spinal epidural abscess by describing two cases. Furthermore, we conducted a review of the recent literature on the management of this rare condition.

METHODS

We report two cases of spinal abscesses extending to the whole epidural space, successfully treated by use of a minimally invasive technique consisting of multilevel laminotomy and catheter irrigation to decompress and drain the epidural space.

RESULTS

This technique is able to decompress the spinal cord, isolate the pathogen and evacuate the abscess. No complications, late spine deformity or dura penetration were observed in our patients.

CONCLUSION

Urgent surgical decompression, in combination with long-term antibiotic treatment, is generally considered the treatment of choice for an extensive spinal epidural abscess. A minimally invasive technique can be very useful as a surgical option.

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.

Recent Developments in the Treatment of Spinal Epidural Abscesses

Spinal epidural abscess (SEA) is a serious condition that can be challenging to diagnose due to nonspecific symptomology and delayed presentation. Despite this, it requires prompt recognition and management in order to prevent permanent neurologic sequelae. Several recent studies have improved our understanding of SEA. Herein, we summarize the recent literature from the past 10 years relevant to SEA diagnosis, management and outcome. While surgical care remains the mainstay of treatment, a select subset of SEA patients may be managed without operative intervention. Multidisciplinary management involves internal medicine, infectious disease, critical care, and spine surgeons in order to optimize care.

Neurological deficit secondary to a pre-sacral abscess with epidural extension up to L3: A case report and literature review

Isolated epidural abscesses are uncommon lesions. Surgical treatment may be difficult due to the extension of these lesions. We present a case of a pelvic abscess spreading along the path of the sciatic nerve to the gluteus muscles and the lumbar canal, causing neurological compression; requiring surgical treatment with three simultaneous approaches.

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.

Pan-spinal infection: a case series and review of the literature

BACKGROUND

Panspinal infection usually presents with fever, back pain, neurological deficit, and in advanced cases multi-organ failure and septic shock. The choice of treatment for panspinal infection is challenging because these patients are usually medically unstable with severe neurological compromise. The objective of this study is to review management and long term outcomes for patients with panspinal infection.

METHODS

A retrospective review of patients with panspinal infection treated in our center over a 5-year period [Jan 2010-Dec 2014] and a review of the current published literatures was undertaken.

RESULTS

We identified 4 patients with panspinal infection. One case was managed medically due to high perioperative risk, whilst the other three were managed surgically whilst on antibiotic therapy. All 3 cases managed surgically improved neurologically and infection subsided, whereas the patient managed medically did not change neurologically and infection subsided.

CONCLUSIONS

Patients with panspinal infection should be treated surgically unless the medical risk of surgery or anaesthesia is prohibitive.

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.

Extensive spinal epidural abscess treated with "apical laminectomies" and irrigation of the epidural space: report of 2 cases

Spinal epidural abscess (SEA) is a rare but often devastating infection of the epidural space around the spinal cord. When an SEA is widespread, extensive decompression with laminectomy is often impossible, as it may subject the patient to very long operative times, extensive blood loss, and mechanical instability. A technique called "skip laminectomy" has been described in the literature, in which laminectomies are performed at the rostral and caudal ends of an abscess that spans 3-5 levels and a Fogarty catheter is used to mechanically drain the abscess, much like in an embolectomy. In this report of 2 patients, the authors present a modification of this technique, which they call "apical laminectomies" to allow for irrigation and drainage of an extensive SEA spanning the entire length of the vertebral column (C1-2 to L5-S1). Two patients presented with cervico-thoraco-lumbar SEA. Laminectomies were performed at the natural apices of the spine, namely, at the midcervical, midthoracic, and midlumbar spine levels. Next, a pediatric feeding tube was inserted in the epidural space from the thoracic laminectomies up toward the cervical laminectomy site and down toward the lumbar laminectomy site, and saline antibiotics were used to irrigate the SEA. Both patients underwent this procedure with no adverse effects. Their SEAs resolved both clinically and radiologically. Neither patient suffered from mechanical instability at 1 year after treatment. For patients who present with extensive SEAs, apical laminectomies seem to allow for surgical cure of the infectious burden and do not subject the patient to extended operating room time, an increased risk of blood loss, and the risk of mechanical instability.

Infektionen

In diesem Kapitel werden zunächst die für die Neurointensivmedizin wesentlichen bakteriellen Infektionen (Meningitis, spinale und Hirnabszesse, Spondylodiszitis, septisch-embolische Herdenzephalitis) abgehandelt, die trotz gezielt eingesetzter Antibiotika und neurochirurgischer Therapieoptionen noch mit einer erheblichen Morbidität und Mortalität behaftet sind. Besonderheiten wie neurovaskuläre Komplikationen, die Tuberkulose des Nervensystems, Neuroborreliose, Neurosyphilis und opportunistische Infektionen bei Immunsuppressionszuständen finden hierbei besondere Berücksichtigung. Der zweite Teil dieses Kapitels behandelt akute und chronische Virusinfektionen des ZNS sowie in einem gesonderten Abschnitt die HIVInfektion und HIV-assoziierte Krankheitsbilder sowie Parasitosen und Pilzinfektionen, die in Industrieländern seit Einführung der HAART bei HIV zwar eher seltener, aber mit zunehmender Globalisierung auch in unseren Breiten immer noch anzutreffen sind.

Minimally invasive treatment of multilevel spinal epidural abscess

The use of minimally invasive tubular retractor microsurgery for treatment of multilevel spinal epidural abscess is described. This technique was used in 3 cases, and excellent results were achieved. The authors conclude that multilevel spinal epidural abscesses can be safely and effectively managed using microsurgery via a minimally invasive tubular retractor system.

Infektionen

Trotz Weiterentwicklung moderner Antibiotika in den letzten Jahren sind die Letalitätszahlen der bakteriellen (eitrigen) Meningitis weiterhin hoch; Überlebende haben häufig neurologische Residuen. Die ungünstigen klinischen Verläufe der bakteriellen Meningitis sind meist Folge intrakranieller Komplikationen, wie z. B. eines generalisierten Hirnödems, einer zerebrovaskulären arteriellen oder venösen Beteiligung oder eines Hydrozephalus.