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Deer TR, Russo MA, Sayed D, Pope JE, Grider JS, Hagedorn JM, Falowski SM, Al-Kaisy A, Slavin KV, Li S, Poree LR, Eldabe S, Meier K, Lamer TJ, Pilitsis JG, De Andrés J, Perruchoud C, Carayannopoulos AG, Moeschler SM, Hadanny A, Lee E, Varshney VP, Desai MJ, Pahapill P, Osborn J, Bojanic S, Antony A, Piedimonte F, Hayek SM, Levy RM. The Neurostimulation Appropriateness Consensus Committee (NACC)®: Recommendations for the Mitigation of Complications of Neurostimulation. Neuromodulation 2024; 27:977-1007. [PMID: 38878054 DOI: 10.1016/j.neurom.2024.04.004] [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] [Received: 01/30/2024] [Revised: 03/27/2024] [Accepted: 04/08/2024] [Indexed: 08/09/2024]
Abstract
INTRODUCTION The International Neuromodulation Society convened a multispecialty group of physicians based on expertise and international representation to establish evidence-based guidance on the mitigation of neuromodulation complications. This Neurostimulation Appropriateness Consensus Committee (NACC)® project intends to update evidence-based guidance and offer expert opinion that will improve efficacy and safety. MATERIALS AND METHODS Authors were chosen on the basis of their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from 2017 (when NACC last published guidelines) to October 2023. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on the strength of evidence or consensus when evidence was scant. RESULTS The NACC examined the published literature and established evidence- and consensus-based recommendations to guide best practices. Additional guidance will occur as new evidence is developed in future iterations of this process. CONCLUSIONS The NACC recommends best practices regarding the mitigation of complications associated with neurostimulation to improve safety and efficacy. The evidence- and consensus-based recommendations should be used as a guide to assist decision-making when clinically appropriate.
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Affiliation(s)
- Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA.
| | | | - Dawood Sayed
- The University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Jay S Grider
- UKHealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Adnan Al-Kaisy
- Guy's and St. Thomas National Health Service (NHS) Foundation Trust, The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA; Neurology Section, Jesse Brown Veterans Administration Medical Center, Chicago, IL, USA
| | - Sean Li
- National Spine & Pain Centers, Shrewsbury, NJ, USA
| | - Lawrence R Poree
- Department of Anesthesia and Perioperative Care, University of California at San Francisco, San Francisco, CA, USA
| | - Sam Eldabe
- The James Cook University Hospital, Middlesbrough, UK
| | - Kaare Meier
- Department of Anesthesiology (OPINord), Aarhus University Hospital, Aarhus, Arhus, Denmark; Department of Neurosurgery (Afd. NK), Aarhus University Hospital, Aarhus, Arhus, Denmark
| | | | | | - Jose De Andrés
- Valencia School of Medicine, Anesthesia Critical Care and Pain Management Department, General University Hospital, Valencia, Spain
| | | | - Alexios G Carayannopoulos
- Department of Physical Medicine and Rehabilitation and Comprehensive Spine Center, Rhode Island Hospital, Providence, RI, USA; Brown University Warren Alpert Medical School (Neurosurgery), Providence, RI, USA
| | - Susan M Moeschler
- Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Amir Hadanny
- Department of Neurosurgery, Albany Medical College, Albany, NY, USA
| | - Eric Lee
- Mililani Pain Center, Mililani, HI, USA
| | - Vishal P Varshney
- Anesthesiology and Pain Medicine, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Mehul J Desai
- International Spine, Pain & Performance Center, Virginia Hospital Center, Monument Research Institute, George Washington University School of Medicine, Arlington, VA, USA
| | - Peter Pahapill
- Functional Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - J Osborn
- St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Stana Bojanic
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ajay Antony
- The Orthopaedic Institute, Gainesville, FL, USA
| | - Fabian Piedimonte
- School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Salim M Hayek
- Case Western Reserve University, University Hospitals of Cleveland, Cleveland, OH, USA
| | - Robert M Levy
- Neurosurgical Services, Clinical Research, Anesthesia Pain Care Consultants, Tamarac, FL, USA
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Dadar M, Al-Khaza'leh J, Fakhri Y, Akar K, Ali S, Shahali Y. Human brucellosis and associated risk factors in the Middle East region: A comprehensive systematic review, meta-analysis, and meta-regression. Heliyon 2024; 10:e34324. [PMID: 39100474 PMCID: PMC11296032 DOI: 10.1016/j.heliyon.2024.e34324] [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: 04/22/2024] [Revised: 07/05/2024] [Accepted: 07/08/2024] [Indexed: 08/06/2024] Open
Abstract
Introduction Human brucellosis, caused by the bacteria Brucella, is a significant infectious disease globally, also known as Mediterranean fever or Malta fever. Methods This meta-analysis and systematic review focuses on the prevalence rate, risk factors, and diagnostic methods of human brucellosis in Middle Eastern countries, where the disease remains a significant public health issue. The analysis included 92 studies conducted between 1993 and 2024, following specified inclusion and exclusion criteria among symptomatic patients across these countries. The prevalence rate was calculated by dividing positive samples by total samples. The I2 index and Chi-squared test assessed study heterogeneity. Significant heterogeneity occurred when I2 exceeded 50 %. Results The highest prevalence rate was observed in Oman, Lebanon, and Kuwait countries, emphasizing a notable burden of Brucella infection in these regions. Risk factors associated with human brucellosis were identified, with unpasteurized dairy consumption and close animal contact being predominant. Various professions such as farmers, dairy factory workers, and agriculture workers showed higher prevalence rate. Gender analysis indicated a prevalence rate of 18.02 % (95 % CI: 11.55-25.51 %) in males and 13.61 % (95 % CI: 10.8-16.68 %) in females, with no significant difference in hospitalization rates. The prevalence rate of Brucella spp. was varied across detection methods, with immunocapture agglutination assay (Brucellacapt) showing the highest estimated prevalence rate of (44.04 %, 95 % CI: 27.71-61.04), followed by PCR (39.84 %, 95 % CI: 20.14-61.39) and culture (29.22 %, 95 % CI: 17.89-42.03). Among Brucella species, Brucella melitensis (B. melitensis) and Brucella abortus (B. abortus) were the highest prevalence rate. Although statistically insignificant, the meta-analysis also revealed an upward trend in prevalence rate from 1993 to 2024, (P value = 0.277). Discussion This comprehensive review emphasizes the need for tailored strategies to control brucellosis in the Middle East, highlighting the importance of timely diagnosis, public awareness, and effective treatment protocols. These findings provide valuable insights for policymakers and healthcare professionals working to mitigate the impact of this disease in the region.
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Affiliation(s)
- Maryam Dadar
- Razi Vaccine and Serum Research Institute (RVSRI), Agricultural Research, Education and Extension Organization (AREEO), Karaj, Iran
| | - Ja'far Al-Khaza'leh
- Faculty of Agricultural Technology, Al-Balqa Applied University, P.O. Box 19117, Al-Salt, Jordan
| | - Yadolah Fakhri
- Food Health Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Kadir Akar
- Department of Microbiology, Faculty of Veterinary Medicine, Yuzuncu Yil University, 65080, Zeve Campus, Tusba, Van, Turkiye
| | - Shahzad Ali
- Department of Wildlife & Ecology, University of Veterinary & Animal Sciences, Lahore, Pakistan
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Liu D, Lu W, Huang W, Zhai W, Ling Q. Extensive spinal epidural abscess due to Streptococcus intermedius: a case report treated conservatively and literature review. Front Neurol 2023; 14:1237007. [PMID: 37701856 PMCID: PMC10494933 DOI: 10.3389/fneur.2023.1237007] [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: 06/08/2023] [Accepted: 07/24/2023] [Indexed: 09/14/2023] Open
Abstract
Purpose To describe the clinical significance of prompt, adequate, and targeted intravenous antibiotic (IV antibiotic) therapy in the successful management of spinal epidural abscess (SEA) associated with Streptococcus intermedius (S. intermedius) infection. Case description SEA is a rare, but catastrophic infection that may result in a high risk of permanent neurological disability. A 52-year-old Chinese female patient was presented to the emergency department due to 2 years of low back pain and 3 days of decreased muscle strength in the extremities. The blood culture confirmed the presence of S. intermedius infection, and gadolinium-enhanced magnetic resonance imaging (MRI) demonstrated widespread epidural abscesses in the cervical, thoracic, and lumbar spine canal. Empirical IV antibiotic therapy with vancomycin was promptly initiated, with meropenem and moxifloxacin added subsequently based on blood culture results. After 5 days of IV antibiotic treatment, the patient's blood culture became negative. 6 weeks later, a follow-up MRI showed a decrease in the size of the abscess. The patient's muscle strength was mostly restored after 2 months of IV antibiotic treatment. Conclusion Repeat examinations or gadolinium-enhanced MRI should be considered when initial MRI findings are not diagnostic of SEA. For extensive SEA caused by Streptococcus intermedius infection, surgery may be non-essential, and the judicious antibiotic selection and adequate treatment duration are pivotal for successful conservative management. Furthermore, for patients who are not amenable to surgery, a comprehensive evaluation of their condition and meticulous implementation of a precise pharmacological regimen holds noteworthy clinical significance.
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Affiliation(s)
| | | | | | | | - Qinjie Ling
- Department of Orthopedic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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Sircar K, Jung N, Kernich N, Zarghooni K, Eysel P, Yagdiran A, Herren C. Risk Factors for Neurologic Deficits in Patients With Spinal Epidural Abscess: An Analysis of One-Hundred-Forty Cases. Global Spine J 2023:21925682231194467. [PMID: 37548223 DOI: 10.1177/21925682231194467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Abstract
STUDY DESIGN retrospective study. OBJECTIVES In addition to surgical treatment of spinal epidural abscesses (SEA), a conservative, medical treatment for patients without acute neurologic deficits has been proposed. However, the risk factors for neurologic deficits are unclear. This study aims to identify factors predisposing patients with SEA to neurological impairment. METHODS All patients treated for SEA between 2008 and 2021 were identified from a prospective vertebral-osteomyelitis registry of a tertiary referral centre. Patient demographics, comorbidities, pathogens, degree of osseous destruction, location of SEA and preoperative neurologic status were retrospectively collected. Differences between patients with (Group 1) and without (Group 2) pretreatment neurologic deficits were assessed by univariate and logistic regression analysis. RESULTS A total of 140 patients with SEA were included. Forty-three patients (31%) had a neurologic deficit and 97 patients (69%) had no neurologic deficit prior to therapy. The prevalence of diabetes mellitus (35% vs 19%, P = .03), median visual analogue scale leg pain (8 vs 5, P = .01), median American Society of Anesthesiologists (ASA) Score (3 vs 2.6, P = .003) and mean Body-Mass-Index (29 vs 26, P = .02) differed between Group 1 and 2 in univariate analysis. In multivariable analysis, diabetes mellitus (odds ratio = 2.7), female sex (odds ratio = 2.5) and ASA-Score (odds ratio = 2.4) were significant contributors for neurologic deficits. CONCLUSIONS In patients with a SEA without neurologic deficits, the ASA score and diabetes mellitus should be considered, especially in female patients. These patients may be at a higher risk for developing a neurologic deficit and may benefit from an early surgical treatment.
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Affiliation(s)
- Krishnan Sircar
- Department of Orthopaedics and Trauma Surgery, Faculty of Medicine, University Clinics, University of Cologne, Cologne, Germany
| | - Norma Jung
- Department I of Internal Medicine, Faculty of Medicine, University Clinics, University of Cologne, Cologne, Germany
| | - Nikolaus Kernich
- Department of Orthopaedics and Trauma Surgery, Faculty of Medicine, University Clinics, University of Cologne, Cologne, Germany
| | - Kourosh Zarghooni
- Department of Orthopaedics and Trauma Surgery, Helios Klinikum Hildesheim, Hildesheim, Germany
| | - Peer Eysel
- Department of Orthopaedics and Trauma Surgery, Faculty of Medicine, University Clinics, University of Cologne, Cologne, Germany
| | - Ayla Yagdiran
- Department of Orthopaedics and Trauma Surgery, Faculty of Medicine, University Clinics, University of Cologne, Cologne, Germany
| | - Christian Herren
- Department of Orthopedics, Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Aachen, Germany
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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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Blanco C, Moral M, Minguez JJ, Lorenzo V. Clinical Presentation, MRI Characteristics, and Outcome of Conservative or Surgical Management of Spinal Epidural Empyema in 30 Dogs. Animals (Basel) 2022; 12:ani12243573. [PMID: 36552493 PMCID: PMC9774607 DOI: 10.3390/ani12243573] [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: 11/02/2022] [Revised: 12/06/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Spinal epidural empyema (SEE) represents a neurological emergency in veterinary medicine, but information on this condition is limited to date. This retrospective case series study describes the clinical and magnetic resonance imaging (MRI) features, and the outcome of conservative or surgical management of SEE in 30 dogs diagnosed with SEE from September 2015 to March 2020 at one referral neurology centre. The most frequent clinical sign was pain 28/30 (93%), and 22/30 (73%) showed neurological signs with ambulatory paraparesis/tetraparesis 15/30 (50%), monoparesis 1/30 (3.3%), non-ambulatory paraparesis 3/30 (10%), or paraplegia 3/30 (10%). MRI was valuable for the diagnosis and in the follow-up. In this group of dogs, 24/30 (80%) were conservatively treated and 6/30 (20%) were surgically treated. The outcome was considered favourable in all dogs: 20/30 (66.6%) achieved full recovery (3 surgically treated and 17 medically treated) and 10/30 (33.3%) dogs had an improvement in the neurological signs with residual ambulatory paresis (3 surgically treated and 7 medically treated). Surgical treatment showed better short-term (7 days) outcomes than medical treatment in non-ambulatory paraparetic or paraplegic dogs (33%). Nevertheless, this study suggests that a good recovery may be achieved with conservative treatment even for non-ambulatory or paraplegic dogs. Further prospective studies, with a standardised protocol of diagnostic tests and a homogeneous distribution of conservatively and surgically treated dogs, are needed to establish treatment guidelines.
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Affiliation(s)
- Carlos Blanco
- Neurología Veterinaria, Calle Diseño n 26, 28906 Getafe, Spain
- Correspondence:
| | - Meritxell Moral
- Neurología Veterinaria, Calle Diseño n 26, 28906 Getafe, Spain
| | - Juan José Minguez
- Scarsdale Vets-Pride Veterinary Centre, Riverside Road, Derby DE24 8HX, UK
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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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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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Bazán PL, Adaro JCS, Ciccioli NM, Adaro AOG, Gonzalez RAA. MORPHOLOGICAL ASPECT OF PYOGENIC SPINAL EPIDURAL ABSCESSES. PART I. COLUNA/COLUMNA 2022. [DOI: 10.1590/s1808-185120222101260738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT Background: Pyogenic Spinal Epidural Abscess (PSEA) is difficult to diagnose and can have devastating consequences. Magnetic Resonance Imaging (MRI) has high sensitivity and specificity, which are further increased with the use of contrast. There are several classifications of vertebral infectious processes, with emphasis on spondylodiscitis. Objective: To analyze the morphological parameters and their reproducibility; and to analyze different resonance imaging sequences. Methods: Using an image database, a morphological classification of PSEA was planned, with five parameters: Region (R), indicating the upper and lower limits of the abscess; Location (U), indicating whether the abscess is anterior or posterior within the canal; Compromise (C), meningeal or content of the structures; Association (A), discitis, osteomyelitis or both; and Perivertebral (P), anterior, lateral or posterior extravertebral abscess. The first three parameters give an idea of the volume of the PSEA, while the last two give the related infectious foci. Thirty-five cases were analyzed using Kappa’s coefficient. Results: The global intra- and interobserver reproducibility was Kappa 0.81. The results for each parameter were as follows: R=0.95, U=0.92, C=0.66, A=0.70 and P=0.80. The first three give a notion of volume and the last two relate to the presence of vertebral infectious foci outside the canal. T2 weighted MRI with contrast was found to be the most effective imaging sequence. Conclusion: The morphological classification is simple to use, with excellent reproducibility. The parameters with the highest reproducibility were region and location, with values >0.92. The addition of gadolinium contrast increased the sensitivity of the diagnosis; the use of sagittal and axial images in T2-MRI was the most sensitive imaging sequence. Evidence Level III; Original.
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Affiliation(s)
- Pedro Luis Bazán
- HIGA San Martín de La Plata, Argentina; Hospital Italiano de La Plata, Argentina; Instituto de Diagnóstico La Plata, Argentina
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Usuda D, Taki Y, Izumida T, Sangen R, Higashikawa T, Hatano E, Yokoyama M, Kasamaki Y. Disseminated Spinal Epidural Abscess in an Immunocompetent Individual: A Case Report and Review of the Literature. J Med Cases 2021; 11:417-425. [PMID: 34434354 PMCID: PMC8383548 DOI: 10.14740/jmc3603] [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: 10/05/2020] [Accepted: 10/12/2020] [Indexed: 11/11/2022] Open
Abstract
Spinal epidural abscess (SEA) is an uncommon pyogenic infection, localized between the dura mater and vertebral periosteum, leading to significant morbidity and mortality. SEA development is connected with medical comorbidities and risk factors facilitating bacterial dissemination; multiple factors are believed to play a role, including aging, increased alcohol abuse, use of intravenous drugs, a greater prevalence of medical comorbidities, and increased rates of spinal surgery that furthers iatrogenic spinal infection. Here, we have reported the first known case of disseminated SEA in an immunocompetent individual. A 33-year-old Japanese woman visited our hospital due to 1 week of continuous fever, low back pain, and numbness of the entire left lower limb. She was diagnosed with disseminated SEA by complete spine magnetic resonance imaging scan, of unknown origin. She was treated for 13 days with piperacillin-tazobactam, then for 16 days with levofloxacin tablets; ultimately, she recovered without treatment complications. This case highlights the complicated pathology, diagnosis, and treatment of SEA. In addition, this case suggests the need for a careful and detailed examination when encountering patients presenting with fever, low back pain even in an immunocompetent individual; we should thoroughly investigate, including further image investigations, bacteriological and pathologic examination.
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Affiliation(s)
- Daisuke Usuda
- Department of General Medicine, Kanazawa Medical University Himi Municipal Hospital, 1130 Kurakawa, Himi-shi, Toyama-ken 935-8531, Japan.,Department of Infectious Diseases, Kanazawa Medical University, 1-1 Daigaku, Uchinada-machi, Ishikawa-ken 920-0293, Japan
| | - Yasuhiko Taki
- Department of Orthopedics, Kanazawa Medical University Himi Municipal Hospital, 1130 Kurakawa, Himi-shi, Toyama-ken 935-8531, Japan
| | - Toshihide Izumida
- Department of General Medicine, Kanazawa Medical University Himi Municipal Hospital, 1130 Kurakawa, Himi-shi, Toyama-ken 935-8531, Japan
| | - Ryusho Sangen
- Department of General Medicine, Kanazawa Medical University Himi Municipal Hospital, 1130 Kurakawa, Himi-shi, Toyama-ken 935-8531, Japan
| | - Toshihiro Higashikawa
- Department of Geriatric Medicine, Kanazawa Medical University Himi Municipal Hospital, 1130 Kurakawa, Himi-shi, Toyama-ken 935-8531, Japan
| | - Eiju Hatano
- Department of Orthopedics, Kanazawa Medical University Himi Municipal Hospital, 1130 Kurakawa, Himi-shi, Toyama-ken 935-8531, Japan
| | - Mitsuteru Yokoyama
- Department of Orthopedics, Kanazawa Medical University Himi Municipal Hospital, 1130 Kurakawa, Himi-shi, Toyama-ken 935-8531, Japan
| | - Yuji Kasamaki
- Department of General Medicine, Kanazawa Medical University Himi Municipal Hospital, 1130 Kurakawa, Himi-shi, Toyama-ken 935-8531, Japan
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Lara-Reyna J, Yaeger KA, Margetis K. Transpedicular Approach for Ventral Epidural Abscess Evacuation in the Cervical Spine. World Neurosurg 2020; 145:127-133. [PMID: 32950752 DOI: 10.1016/j.wneu.2020.09.062] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 09/11/2020] [Accepted: 09/12/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Spinal epidural abscess may require prompt surgical intervention. Ventral cervical abscesses pose a particular challenge regarding the approach for surgical evacuation. The aim of this article was to describe the technical nuances of a posterior transpedicular cervical approach for evacuation of a ventral epidural abscess. METHODS After a standard laminectomy, a foraminotomy was performed to identify the exiting nerve root. Then the medial aspect of the pedicle below the nerve was drilled. This allowed the insertion of a dissector to reach the ventral epidural space and drain the contents in conjunction with suction and irrigation. The posterolateral aspect of the superior endplate of the respective vertebra could be further drilled at this point, allowing access to the disc space with minimal retraction of the exiting nerve root. RESULTS Two patients underwent emergent evacuation of a ventral epidural abscess in the cervical spine using this technique. Radiographic and clinical improvement was evident after evacuation of the abscesses in both cases. CONCLUSIONS Access to the ventral epidural space is feasible using a transpedicular approach in the cervical spine for evacuation of an epidural abscess.
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Affiliation(s)
- Jacques Lara-Reyna
- Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Kurt A Yaeger
- Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Konstantinos Margetis
- Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Tetsuka S, Suzuki T, Ogawa T, Hashimoto R, Kato H. Spinal Epidural Abscess: A Review Highlighting Early Diagnosis and Management. JMA J 2019; 3:29-40. [PMID: 33324773 PMCID: PMC7733760 DOI: 10.31662/jmaj.2019-0038] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 08/26/2019] [Indexed: 01/08/2023] Open
Abstract
Spinal epidural abscess (SEA) is still an uncommon but devastating infection of the spine. In recent years, a number of reported cases have risen. The most important prognostic factor for a favorable outcome is early diagnosis and appropriate treatment. However, a diagnosis of SEA is often delayed, particularly in the early stages of the disease before patients present with neurological symptoms. With enough knowledge of risk factors, clinical features, and appropriate diagnostic procedures, it may be possible to reduce diagnostic delay in the early stages of the disease. This review focuses on early diagnosis of SEA based on risk factors, presenting symptoms, and characteristic findings on magnetic resonance imaging (MRI), and also discusses the timing of surgical interventions. Traditionally, the symptoms of SEA are characterized by fever, back pain, and neurological symptoms, which are described as a classical triad of symptoms for this type of infection; but this collection of symptoms is seen in only about 10% of cases. However, most patients complain of severe localized lower back pain. Gadolinium-enhanced MRI is the most sensitive, specific, and beneficial imaging modality for establishing a diagnosis of SEA. Patients diagnosed prior to neurological deficits with a known causative microbial organism can be safely treated with antimicrobial therapy alone. However, about 30%–40% of the patients fail in conservative management without surgery. The best management and timing for surgical decompression in patients with or without mild neurological deficits should be established in the near future. Early diagnosis and management, before the occurrence of serious neurological symptoms, are the most important prognostic factors for good outcomes in patients with SEA. We proposed a simple algorithm for early diagnosis of SEA by selecting patients with severe back pain, leading to emergent MRI.
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Affiliation(s)
- Syuichi Tetsuka
- Department of Neurology, International University of Health and Welfare Hospital, Nasushiobara, Japan
| | - Tomohiro Suzuki
- Department of Neurology, International University of Health and Welfare Hospital, Nasushiobara, Japan
| | - Tomoko Ogawa
- Department of Neurology, International University of Health and Welfare Hospital, Nasushiobara, Japan
| | - Ritsuo Hashimoto
- Department of Neurology, International University of Health and Welfare Hospital, Nasushiobara, Japan
| | - Hiroyuki Kato
- Department of Neurology, International University of Health and Welfare Hospital, Nasushiobara, Japan
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Recent Increase in the Rate of Spinal Infections May be Related to Growing Substance-use Disorder in the State of Washington: Wide Population-based Analysis of the Comprehensive Hospital Abstract Reporting System (CHARS) Database. Spine (Phila Pa 1976) 2019; 44:291-297. [PMID: 30059485 DOI: 10.1097/brs.0000000000002819] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Epidemiological study. OBJECTIVE The aim of this study was to evaluate trends in the incidence of spinal infections (SI) and the possible role of substance use disorder (SUD) as a key associated factor. SUMMARY OF BACKGROUND DATA SI pose major diagnostic and therapeutic challenge in developed countries, resulting in substantial morbidity and mortality. With an estimated incidence of up to 1:20,000, recent clinical experiences suggest that this rate may be rising. METHODS To evaluate a possible change in trend in the proportion of SI, we searched the Washington state Comprehensive Hospital Abstract Reporting System (CHARS) data during a period of 15 years. We retrieved ICD-9 and 10 codes, searching for all conditions that are regarded as SI (discitis, osteomyelitis, and intraspinal abscess), as well as major known SI-related risk factors. RESULTS We found that the proportion of SI among discharged patients had increased by around 40% during the past 6 years, starting at 2012 and increasing steadily thereafter. Analysis of SI-related risk factors within the group of SI revealed that proportion of SUD and malnutrition had undergone the most substantial change, with the former increasing >3-fold during the same period. CONCLUSION Growing rates of drug abuse, drug dependence, and malnutrition throughout the State of Washington may trigger a substantial increase in the incidence of spinal infections in discharged patients. These findings may provide important insights in planning prevention strategies on a broader level. LEVEL OF EVIDENCE 4.
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Neurological Outcomes After Surgical or Conservative Management of Spontaneous Spinal Epidural Abscesses: A Systematic Review and Meta-Analysis of Data From 1980 Through 2016. Clin Spine Surg 2019; 32:18-29. [PMID: 30589647 DOI: 10.1097/bsd.0000000000000762] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
STUDY DESIGN This is a meta-analysis. OBJECTIVE Perform a systematic review and quantitative meta-analysis of neurological outcomes from all available spinal epidural abscess (SEA) literature published between 1980 and 2016. SUMMARY OF BACKGROUND DATA Current literature on SEAs lacks large-scale data characterizing prognostic factors and surgical indications. MATERIALS AND METHODS PubMed was queried for studies reporting neurological outcomes from patients undergoing conservative or surgical management for spontaneous SEA. Inclusion criteria included outcomes data measured ≥6 months after presentation, ≥10 human subjects, and diagnosis by magnetic resonance imaging or Computed tomography-myelogram. Where available, demographic data, abscess location, comorbidities, pretreatment neurological deficits, treatment methods, bacterial speciation, and complications were extracted from each study. Potential outcome predictors represented by continuous variables were compared using student t test and categorical variables were compared using the Pearson χ test. Variables identified as potentially associated with outcome (P≤0.05) were subjected to meta-analysis using Cochran-Mantel-Haenszel testing to calculate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS In total, 808 patients were analyzed from 20 studies that met inclusion criteria. 456 (56.3%) patients were treated with surgery and antibiotics, and 353 (43.7%) patients were managed with antibiotics alone. Neither surgical intervention (OR=1.01, 95% CI=0.40-2.59), lumbosacral location (OR=1.51, 95% CI=0.23-9.79), nor neurological deficit on presentation (OR=0.88, 95% CI=0.40-1.92) were significantly associated with good (stable or improved) or bad (worsened) neurological outcome, whereas delayed surgery was significantly associated with bad outcome (OR=0.01, 95% CI=0.02-0.62) and cervicothoracic location approached significance for predicting bad outcome (OR=0.41, 95% CI=0.15-1.09). CONCLUSIONS Current literature does not definitively support or oppose surgical intervention in all SEA cases. Therefore, until better evidence exists, the decision to operate must be made on an individual case-by-case basis with the goals of preventing neurological decline, obtaining source control after failed conservative treatment, or restoring spinal stability.
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