Extended Cervicolumbar Spinal Epidural Abscess Associated With Paraparesis Successfully Decompressed Using a Minimally Invasive Technique (original) (raw)
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Spinal epidural abscess in clinical practice
QJM, 2007
Spinal epidural abscess (SEA) is a rare but severe infection requiring prompt recognition. The major prognostic factor for a favourable outcome is early diagnosis, leading to appropriate treatment. In clinical practice, a diagnosis of SEA is often not considered, particularly in the early stages of the disease when neurological symptoms are not apparent. Knowledge of persons at risk, clinical features and the required diagnostic procedures may decrease the number of initially misdiagnosed cases. Clinical signs, duration of symptoms and the rate of neurological deterioration show a high interindividual variability, and the classic triad (spinal pain, fever and neurological deficit) is often not found, especially not at first presentation to a physician. However, most patients complain of severe localized back pain. Inflammatory parameters in the blood are generally elevated, but not specific. Gadolinium-enhanced magnetic resonance imaging is the most sensitive, specific and accurate imaging method. Although neurosurgical decompression is still the treatment of choice in the majority of cases, less invasive procedures (e.g. computed tomography-guided needle aspiration) or antimicrobial treatment alone can be applied in selected cases. The choice of the most appropriate therapy should be discussed immediately after a confirmed diagnosis in consultation with infectious disease, radiology and spinal surgery specialists. The outcome of SEA is largely influenced by the severity and duration of neurological deficits prior to surgery, stressing the importance of early recognition.
Neurosurgical focus, 2004
Spinal epidural abscess is associated with considerable rates of morbidity and mortality despite its infrequent occurrence. Advances in magnetic resonance (MR) imaging technology have allowed easier diagnosis of this potentially devastating condition. It is also possible to predict the intraoperative appearance of each case of spinal epidural abscess prior to the procedure, based on the MR findings. Surgical treatment of this condition usually involves extensive decompressive laminectomy, which predisposes patients to spinal instability and deformity. Recent advances in surgical approaches to spinal epidural abscess have included the institution of less invasive techniques to manage this condition, including saline washes of the epidural space through catheters introduced via limited laminotomy. The cases reported here illustrate the ability to predict the intraoperative findings in patients with spinal epidural abscess, and to adjust the surgical approach accordingly to minimize th...
Spinal Epidural Abscess: Diagnosis and Treatment
Operative Techniques in Neurosurgery, 2004
Spinal epidural abscess (SEA) is an uncommon entity, with an incidence of 0.2 to 2 per 10,000 hospital admissions. It is associated with potentially devastating neurological consequences. The incidence is increasing with the increase in intravenous drug use and increasing spinal procedures. SEA is classically described as presenting with fever, focal back pain, and progressive neurological symptoms. However, patients rarely fulfill all the characteristics of this pathognomonic triad. The key in diagnosis is a high level of suspicion when patients present with back pain. MRI is highly accurate in the evaluation. Empiric antibiotics for SEA must include coverage for staphylococci (vancomycin pending organism identification and susceptibility testing) and gram-negative bacilli (e.g., ceftazidime, cefepime, or meropenem), and antibiotics should continue for at least 8 weeks. Surgical evacuation remains the standard treatment in patients who present with neurologic signs on physical examination or who have failed medical management. The prognosis depends on the presenting neurologic status. Despite recent efforts, SEA is associated with a high mortality rate, most likely a result of delayed diagnosis and poor neurologic status at presentation. Therefore, high suspicion and early diagnosis remain the most important factors in the management of SEA. Oper Tech Neurosurg 7: [188][189][190][191][192]
Spinal epidural abscess: A report of 40 cases and review
Surgical Neurology, 1992
Despite modern medical advances, the morbidity and mortality rates associated with spinal epidural abscess remain significant, and the diagnosis often is elusive. A retrospective study was undertaken to define better the incidence and clinical features of this infection, and to establish current diagnostic and therapeutic guidelines. Forty cases of spinal epidural abscess were encountered at our institution between July 1979 and March 1991. All medical records and radiological images were reviewed. We report a significant increase in the incidence of epidural abscess after June 1988 (p = 0 .0195). Sixteen patients used drugs intravenously, and six had undergone spinal procedures. Twelve patients were misdiagnosed in various emergency rooms or clinics and discharged. Localized back pain, fever, and neurological deficit remained the typical clinical manifestations. Erythrocyte sedimentation rate was elevated uniformly when measured (21 cases). Magnetic resonance imaging was diagnostic specifically in 23 of 24 instances. The majority of patients underwent surgical drainage, but five selected patients were managed nonoperatively. The highly variable presentation of spinal epidural abscess may confuse the diagnosis and delay indicated surgical intervention. Localized back pain in a febrile patient at significant risk for epidural abscess warrants erythrocyte sedimentation rate measurement. The presence of erythrocyte sedimentation rate elevation or evidence of spinal cord compression on physical examination are indications for immediate magnetic resonance imaging examination with contrast enhancement. Surgical drainage with sustained intravenous antibiotic treatment remains the cornerstone of therapy. Nonoperative management may be considered in selected cases .
Spinal Epidural Abscess: A Review of Presentation, Management, and Medicolegal Implications
Asian Spine Journal
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, rad...
Spinal epidural abscess: an analysis of 24 cases
Surgical neurology, 2005
Background Despite advances in neuroimaging and neurosurgical care, spinal abscess remains a challenging problem with mortality rates ranging from 4.6% to 31% in recent series. Methods Between January 1986 and December 2003, 24 patients with spinal ...
Nonoperative Management of a Multi-Regional Epidural Abscess with Neurological Dysfunction
International Journal of Spine Surgery, 2015
Spinal epidural abscesses are uncommon, but their incidence is increasing. They represent a collection of purulent material in the epidural space and most commonly occur in the lumbar spine, where they remain localised. Abscesses that affect all three spinal levels (holospinal or multiregional abscesses) are extremely rare, with only a few cases published in the literature. Epidural abscesses are particularly high risk infections as progressive neurological dysfunction can occur rapidly; early diagnosis and treatment is therefore essential to avoid long term neurological complications and reduce potential mortality. Given the uncommon nature of this condition, the treatment remains controversial with no definitive guidance on conservative versus surgical management. The literature mostly recommends surgical decompression along with intravenous antibiotics in patients with neurological abnormalities. We describe a case of a 77-year-old patient presenting with a delayed diagnosis of a multi-regional epidural abscess with associated upper motor neurone signs. The patient was successfully treated nonoperatively with a course of antibiotics resulting in complete radiological resolution of the abscess and full neurological recovery.
Spinal epidural abscess: Report on 27 cases
Surgical Neurology International, 2017
Background: Spinal epidural abscess, although an uncommon disease, often correlates with a high morbidity owing to significant delay in diagnosis. Methods: In a prospective 5-year study, the clinical and magnetic resonance (MR) findings, treatment protocols, microbiology, and neurological outcomes were analyzed for 27 patients with spinal epidural abscess. Results: Patients were typically middle-aged with underlying diabetes and presented with lumbar abscesses. Those undergoing surgical intervention >36 h after the onset of symptoms had poor neurological outcomes. Conclusion: Early recognition and timely evacuation of spinal abscesses minimized neurological morbidity and potential mortality.
Spinal epidural abscess: clinical presentation, management, and outcome
Surgical Neurology, 2005
We sought to describe the clinical characteristics of patients with spinal epidural abscess and to relate presentation and treatment to short-term clinical and neurologic outcome. We retrospectively reviewed the records and radiographic images of all patients admitted to our institution with a diagnosis of spinal epidural abscess between January 1995 and March 2001. Thirty males and 18 females were admitted with spinal epidural abscess. Median age was 61 years (range, 31-84). Twenty-three of 48 patients were febrile at presentation and the mean white blood cell (WBC) count was 15.5 (range, 4.0-38.7). Twenty-seven patients presented with motor deficits, 17 with pain alone, 2 with sepsis, 1 with dysphagia, and 1 incidentally on spinal imaging. Intravenous drug abuse was the most common risk factor (13 patients) followed by the presence of nonspinal infection, including endocarditis (10 patients). Blood cultures were positive in 29 patients. Staphylococcus aureus was the most common organism cultured from abscesses. Collections were located in the cervical spine in 11 patients, cervicothoracic in 4, thoracic in 7, thoracolumbar in 4, and lumbosacral in 22. One patient harbored both cervical and lumbar epidural abscesses. Twenty-three patients initially received nonoperative therapy with antibiotics alone; 25 underwent urgent surgery. Eleven patients initially treated with antibiotics eventually deteriorated and required delayed surgery. Patients receiving antibiotics suffered a significantly greater number of unfavorable outcomes (clinical deterioration or death) than those in the early surgical group (P < 0.005). Patients with spinal epidural abscess may be normothermic and have normal WBC counts. Urgent surgery was more likely to be offered to patients presenting with neurologic deficits than with pain alone. Patients treated without early surgery were significantly more likely to deteriorate and suffer poor outcomes.