Acute spinal epidural abscess

Diagnosis and Management of Spinal Epidural Abscess

Twenty-five patients with spinal epidural abscess were treated at the University of Western Ontario hospitals between July 1980 and July 1990. There were eighteen males (72%) and seven females (28%), with a median age of 60 years. Concurrent illness resulting in immunocompromise was present in 60%. Eleven presented with complete myelopathy, thirteen had limb weakness, and one had no neurological deficit. In twenty cases the abscess consisted of frankly purulent material, while in five the epidural collection consisted of chronic granulation tissue. Staphylococcus aureus was isolated in 64% of the abscesses. Twenty-seven surgical procedures were performed on 21 patients. Ten cases occurred in the cervical spine (40%), seven in the thoracic spine (28%), three in both the cervical and thoracic spine (12%) and five in the lumbosacral spine (20%). Fourteen patients (56%) retained or recovered ambulation and there were five deaths (20%). The progression from back and radicular pain to weakness and eventual paralysis continues to be characteristic of spinal epidural infection. Morbidity and mortality remain unacceptably high because of delay in diagnosis and treatment. Magnetic resonance imaging is the radiological investigation of choice for the diagnosis of spinal epidural abscess. Prompt intervention, before the development of severe neurological deficits, can improve outcome. Immediate surgical drainage combined with antibiotics remains the treatment of choice.

The indications and timing for operative management of spinal epidural abscess: literature review and treatment algorithm

OBJECT

Delayed or inappropriate treatment of spinal epidural abscess (SEA) can lead to serious morbidity or death. It is a rare event with significant variation in its causes, anatomical locations, and rate of progression. Traditionally the treatment of choice has involved emergency surgical evacuation and a prolonged course of antibiotics tailored to the offending pathogen. Recent publications have advocated antibiotic treatment without surgical decompression in select patient populations. Clearly defining those patients who can be safely treated in this manner remains in evolution. The authors review the current literature concerning the treatment and outcome of SEA to make recommendations concerning what population can be safely triaged to nonoperative management and the optimal timing of surgery.

METHODS

A PubMed database search was performed using a combination of search terms and Medical Subject Headings, to identify clinical studies reporting on the treatment and outcome of SEA.

RESULTS

The literature review revealed 28 original case series containing at least 30 patients and reporting on treatment and outcome. All cohorts were deemed Class III evidence, and in all but two the data were obtained retrospectively. Based on the conclusions of these studies along with selected smaller studies and review articles, the authors present an evidence-based algorithm for selecting patients who may be safe candidates for nonoperative management.

CONCLUSIONS

Patients who are unable to undergo an operation, have a complete spinal cord injury more than 48 hours with low clinical or radiographic concern for an ascending lesion, or who are neurologically stable and lack risk factors for failure of medical management may be initially treated with antibiotics alone and close clinical monitoring. If initial medical management is to be undertaken the patient should be made aware that delayed neurological deterioration may not fully resolve even after prompt surgical treatment. Patients deemed good surgical candidates should receive their operation as soon as possible because the rate of clinical deterioration with SEA is notoriously unpredictable. Although patients tend to recover from neurological deficits after treatment of SEA, the time point when a neurological injury becomes irreversible is unknown, supporting emergency surgery in those patients with acute findings.

Independent predictors of failure of nonoperative management of spinal epidural abscesses

BACKGROUND CONTEXT

The notion that all patients with spinal epidural abscess (SEA) require surgical decompression has been recently challenged by reports of successful medical management of select patients with SEA.

PURPOSE

The purpose of this study was to identify the independent variables that determine success or failure of medical management of SEA.

STUDY DESIGN/SETTING

This was a retrospective, case-control study.

PATIENT SAMPLE

Patients 18 years or older with diagnosis of SEA admitted to our institution during the study period were included in the sample.

OUTCOME MEASURES

The outcome measure was successful management of SEA by eradication of the infection without worsening of neurologic deficits.

METHODS

All patients admitted to our health-care system with a diagnosis of SEA from 1993 to 2011 were identified and the data were retrospectively collected. Patients 18 years or older diagnosed with SEA were included. Excluded were those with postsurgical SEA or phlegmon without an abscess and those with a complete spinal cord injury from SEA for longer than 48 hours.

RESULTS

A total of 355 patients with average age of 60 years met our inclusion criteria. Of the patients who initially underwent nonoperative treatment, 54 patients failed medical management and 73 patients were successfully treated without surgery. Univariate and multivariate analysis identified incomplete or complete spinal cord deficits as the most significant risk factor for failure of medical management. Age older than 65 years, diabetes, and methicillin-resistant Staphylococcus aureus (MRSA) were also independent risk factors for failure. An algorithm for probability of failed antibiotic management of spinal epidural abscess predicted 99% probability of failure for patients with all four of these risk factors.

CONCLUSIONS

SEA treated with medical management alone has a very high risk for failure if the patient is older than 65 years with diabetes, MRSA infection, or neurologic compromise. In the absence of these risk factors, nonoperative management of spinal epidural abscess may be considered as the initial line of treatment with close monitoring.

Comparison of operative and nonoperative management of spinal epidural abscess: a retrospective review of clinical and laboratory predictors of neurological outcome

Object

Spinal epidural abscess (SEA), once considered a rare occurrence, has showed a rapid increase in incidence over the past 20–30 years. Recent reports have advocated for conservative, nonoperative management of this devastating disorder with appropriate risk stratification. Crucial to a successful management strategy are decisive diagnosis, prompt intervention, and consistent follow-up care. The authors present a review of their institutional experience with operative and nonoperative management of SEA to assess morbidity and mortality and the accuracy of microbiological diagnosis.

Methods

A retrospective analysis of patient charts, microbiology reports, operative records, and radiology reports was performed on all cases involving patients admitted with the diagnosis of SEA between July 1998 and May 2009.

Results

Seventy-seven cases were reviewed (median patient age 51.4 years, range 17–78 years). Axial pain was the most common presenting symptom (67.5% of cases). Presenting signs included focal weakness (55.8%), radiculopathy (28.6%), and myelopathy (5.2%). Abscesses were localized to the lumbar, thoracic, and cervical spine, respectively, in 39 (50.6%), 20 (26.0%), and 18 (23.4%) of the patients. Peripheral blood cultures were negative in 32 (45.1%) of 71 patients. Surgical site or interventional biopsy cultures were diagnostic in 52 cases (78.8%), with concordant blood culture results in 36 (60.0%). Methicillin-resistant Staphylococcus aureus (MRSA) was the most frequent isolate in 24 cases (31.2%). The mean time from admission to surgery was 5.5 days (range 0–42 days; within 72 hours in 66.7% of cases). Outcome data were available in 72 cases. At discharge, patient condition had improved or resolved in 57 cases (79.2%), improved minimally in 6 (8.3%), and showed no improvement or worsening in 9 (12.5%). Patient age and premorbid weakness were the only factors found to be significantly associated with outcome (p = 0.04 and 0.012, respectively).

Conclusions

These results strongly support immediate surgical decompression combined with appropriately tailored antibiotic therapy for the treatment of symptomatic SEA presenting with focal neurological deficit. The nonsuperiority discovered in other patient subsets may be due to allocation biases between surgically treated and nonsurgically treated cohorts. The present data demonstrate the accuracy of peripheral blood culture for the prediction of causative organisms and confirm patient age as a predictor of outcomes.

Spinal epidural abscesses: conservative treatment for selected subgroups of patients

The aim of this study was to emphasize the importance of non-surgical treatment for subgroups of patients with spinal epidural abscesses (SEA). From 1988 to 2000, thirty cases of epidural spinal abscesses were retrospectively included in the study. The records and radiological studies were evaluated. Staphylococcus aureus was the most frequent microorganism causing SEA in 18 patients. In 20 patients SEA was secondary to interventional procedures. Predisposing factors were present in 15 cases. Fifty per cent was located in the lumbar region. A total of 22 patients received MRI, which always gave the diagnosis of SEA. Surgical treatment was performed in 20 patients. Conservative treatment with antibiotics was used in 10 patients. Eight patients did not have neurological deficits. One patient was critically ill and another patient was paralysed with an epidural lesion extending over six spinal segments. In all cases, a microorganism was known at the time of diagnosis of ESA. The eight patients without deficits recovered completely following treatment with antibiotics. C-reactive protein was the most reliable inflammatory marker to monitor the effect of the treatment. MRI enables diagnosis of ESA before deficits occur. These can safely be treated with antibiotics if the causative microorganism is known, and the neurological status and laboratory values are monitored. Decompressive surgery is restricted to cases with progressive deficits, when the deficits have lasted for less than 36 h and when the microorganism is not known.

Acute paraplegia following chiropractic therapy

We report a 44-year-old man suffering complete paraplegia due to paraspinal and epidural abscess, following chiropractic therapy for severe back pain and whose diagnosis was delayed. He received an immediate laminectomy from T3 through T6 to decompress the full extent of the abscess and appropriate antibiotic therapy for 4 weeks postoperatively for the identified microorganism (Staphylococcus aureus). After 3 months of rehabilitation, he had recovered bladder function with moderate left lower extremity paresis. We emphasise the importance of urgent spinal gadolinium-enhanced MRI in those patients with localised back pain and raised inflammatory markers (including erythrocyte sedimentation rate). Furthermore, it is necessary to be aware of the risk of acute paraplegia after forceful massage to the back.

Spinal epidural abscess: clinical presentation, management, and outcome

BACKGROUND

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Spinal infections

Spinal infections can be thought of as a spectrum of disease comprising spondylitis, discitis, spondylodiscitis, pyogenic facet arthropathy, epidural infections, meningitis, polyradiculopathy and myelitis. Radiological evaluations have gained importance in the diagnosis, treatment planning, treatment and treatment monitoring of the spinal infections. Conventional radiographs are usually the initial imaging study. The sensitivity and specificity of the plain radiographs are very low. The sensitivity of CT is higher while it lacks of specificity. Conventional CT has played minor role for the diagnosis of early spondylitis and disc space infection and for follow-up, researches are going on the value of MDCT. MRI is as sensitive, specific and accurate as combined nuclear medicine studies and the method of choice for the spondylitis. Low signal areas of the vertebral body, loss of definition of the end plates and interruption of the cortical continuity, destruction of the cortical margins are typical on T1WI whereas high signal of affected areas of the vertebral body and disc is typical on T2WI. Contrast is mandatory and increases conspicuity, specificity, and observer confidence in the diagnosis and facilitates the treatment planning. Contrast enhancement is the earliest sign and pathognomonic in the acute inflammatory episode and even in the subtle infection then persists to a varying degree for several weeks or months. The outcome of the treatment is influenced by the type of infection and by the degree of neurologic compromise before treatment. There is an increasing move away from surgical intervention towards conservative therapy, percutaneous drainage of abscess or both. It is therefore critical to monitor treatment response, particularly in the immuno-deficient population.

Infectious origins of cauda equina syndrome

Infections in the spine can lead to a wide range of problems for both the patient and physician. There is perhaps no more devastating complication than the neurological consequences of a cauda equina syndrome due to spinal infection. A variety of organisms and origins can make diagnosis and treatment of spinal infection a difficult task. Both pyogenic and nonpyogenic organisms can cause vertebral involvement and can result in an epidural abscess with neurological compromise. Nonetheless, these two types of infections vary greatly in terms of associated patient demographics, clinical course, and treatments. The purpose of this paper was to review these types of infections and summarize treatment recommendations for this difficult condition.

[Acute headache with meningism and xanthochromic cerebrospinal fluid.An unusual manifestation of cervical epidural abscess]

We report on a 70-year-old female with acute onset of headache, meningism, xanthochromic cerebrospinal fluid, and developing laboratory parameters indicating a systemic infection. Initially, a subarachnoidal hemorrhage was assumed. However, magnetic resonance imaging showed upper cervical osteomyelitis and extending spinal epidural abscess. After application of broad systemic antibiotics, secluded abscess formation was achieved and successful neurosurgical debridement performed. The unusual cranial concentration of the complaints is probably due to the involvement of the craniocervical transition. Cervical epidural spinal abscess represents a potentially dangerous bacterial infection of the upper spine. Inadequate treatment can lead to irreversible neurological deficits. Cervical magnetic resonance imaging is an effective tool for diagnosis, since early diagnosis is important for good prognosis.

Adult spinal epidural abscess: clinical features and prognostic factors

Twenty-nine adult patients with spinal epidural abscess (SEA), aged 31-73 years, have been identified over a period of 8 years. The 29 SEA patients included 21 men and eight women with a mean age of 54 years. Initial diagnosis of SEA was made in only 17% of our patients and another 48% of patients were initially suggested of having infection or mass of the spine. Spinal pain and fever were the two most common clinical features shared among our patients. The two most common pathogens were Staphylococcus aureus and Mycobacterium tuberculosis, which were found in 62% of patients. Twenty-seven patients received surgical intervention and antibiotic treatment for SEAs, one of which succumbed to meningitis. Two patients without neurological abnormalities received conservative treatment alone and survived. The number of patients, which showed improvement of symptoms, included all seven patients with neck/back pain without neurologic deficits, all 15 patients with paraparesis, 10 of 13 patients with bladder/bowel dysfunction with or without motor deficits, and none of the five with plegia. Preoperative plegia was identified as a poor prognostic factor, and patients with SEA continue to show high rates of morbidity and mortality. Thus, in order to improve the therapeutic outcome of patients with SEA, early diagnosis and management are mandatory to treat the patients before the deterioration of neurologic deficit occurs.

Technical note. Pyogenic spinal epidural abscess: a minimally invasive technique for multisegmental decompression

Spontaneous spinal epidural abscess is a rare condition that is devastating and often fatal. Traditionally, surgery and antibiotics have been the treatment of choice; however, there has been some debate on the indications for their use. This technical note discusses a method for decompressing an acute multisegmental pyogenic spinal epidural abscess, thereby avoiding multilevel laminectomies.

Neurological complications in obstetric regional anaesthesia

Neurological complications after obstetric central neural blocks are rare events. Although central neural blockade does cause neurological complications, there must be awareness that neurological deficits may either develop spontaneously (e.g. epidural abscess/haematoma) or as a result of the labour and delivery process (maternal obstetric palsies). We have attempted to review as completely as possible the published survey and case reports in the English literature on neurological complications of obstetric regional blockade obtained from Medline spanning the period 1966 to November 1998. We also performed cross-checking of our references to find important missing articles, e.g. papers published in journals not included in Index Medicus at the time of publication, such as the International Journal of Obstetric Anesthesia. We wish to provide some insight to the incidences, pathophysiology, clinical features, investigations, treatment and prognosis of these complications. Maternal obstetric palsies and case reports of spontaneous epidural abscess/haematoma are also discussed. It is often difficult, if not impossible, to determine the exact aetiology, but unfortunately for the anaesthetists, regional blockade is usually incriminated till proven otherwise. Although we cannot eliminate the occurrence of neurological complications completely, preventive measures can still be taken to decrease their incidence (e.g. aseptic technique). There must also be regular monitoring after neural blockade for the development of neurological complications. Early diagnosis and prompt appropriate treatment will usually lead to complete resolution of the neurological deficit even in cases of epidural haematoma/abscess.

Spinal epidural abscess: contemporary trends in etiology, evaluation, and management

BACKGROUND

Despite advances in neuroimaging and neurosurgical treatment, spinal epidural abscess remains a challenging problem; early diagnosis is often difficult and treatment is delayed. Optimal management is unclear, and morbidity and mortality are significant. To define contemporary trends in etiology and management, and establish diagnostic and therapeutic guidelines, we reviewed our 10-year experience with spinal epidural abscess.

METHODS

We examined medical records, laboratory data, radiological (CT and MRI) studies, and operative reports from 75 cases of spinal epidural abscess between 1983 and 1992. Demographic characteristics, frequency, clinical features, pathogens, risk factors, surgical and medical treatment, and outcome were analyzed.

RESULTS

We found a significant increase in the frequency of spinal epidural abscess over the 10-year period (p-value = 0.0195). Intravenous drug abuse was present in 28 patients (33%), diabetes mellitus in 22 patients (27%), and prior spinal surgery in 11 patients (17%). Back pain, progressive neurologic deficit, and low grade fever remained the distinguishing diagnostic features. Erythrocyte sedimentation rate was elevated in 48 of 50 patients (95%); peripheral leukocyte count was elevated in 45 patients (60%). MRI was the most effective technique for diagnosing spinal epidural abscess, revealing or suggesting the diagnosis in all 59 patients (100%) studied. Sites of spinal epidural abscess were equally distributed along the spinal axis. Staphylococcus aureus was the predominant organism (67% of patients, with 15% having a methicillin-resistant strain); 8% of patients had Streptococcal species. Most patients had open surgical drainage followed by prolonged antibiotic treatment; 22 patients were managed with antibiotics alone; 50 patients (66%) had a good clinical outcome after treatment. Multiple medical problems, prior spinal surgery, and methicillin-resistant Staphylococci were correlated with a significantly worse outcome.

CONCLUSIONS

The frequency of diagnosis of spinal epidural abscess is increasing. To prevent serious morbidity and mortality, early diagnosis is essential. Patients with localized back pain who are at risk for developing such abscesses or who have an increased erythrocyte sedimentation rate and/or neurologic deficit should have an immediate MRI scan with contrast enhancement. Surgical drainage and prolonged antibiotic use are the cornerstones of treatment, although selected patients may be treated conservatively.

Spinal epidural abscess: the importance of early diagnosis and treatment

OBJECTIVES

To remind clinicians of the dangers of delayed diagnosis and the importance of early treatment of spinal epidural abscess.

METHODS

A review of the literature on spinal epidural abscess and a comparison of the published literature with local experience.

RESULTS

Imaging with MRI or CT enables early diagnosis of spinal epidural abcess and optimal therapy is surgical evacuation combined with 6-12 weeks (median 8 weeks) of antimicrobial chemotherapy. Clinical features are fever, pain, and focal neurological signs and may be associated with preceding and pre-existing bone or joint disease. The commonest aetiological organism is S aureus.

CONCLUSION

Early diagnosis and appropriate early antimicrobial chemotherapy with surgery is associated with an excellent prognosis.

Major neurological sequelae of lumbar epidural anesthesia. Report of three cases

We here report the major permanent neurological complications that developed in three patients after epidural anesthesia. MR clearly showed that paraplegia, which arose one and nine days after anesthesia, was due to epi-subdural haematoma in the first case and epidural abscess in the second. The sudden left lower limb palsy in the third patient was caused by a paracentral ischemic lesion all along the conus-epiconus following a probable trauma of the cord during the insertion of the needle. Despite the fact that this was reported to have been performed at L1-L2, an erroneous introduction into the upper interspace must be postulated since the spinal cord of this patient terminated at mid-L1. Our report is useful insofar as it may remind anesthesiologists and neurologists to pay attention to the unusual complications of spinal anesthesia that may require urgent intervention.

Paraplegia with sclerotic vertebral lesions

Images

Spinal epidural abscess: A report of 40 cases and review

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.

Magnetic resonance imaging and the nonoperative treatment of spinal epidural abscess

This report describes three patients with spinal epidural abscess diagnosed by magnetic resonance imaging and treated nonoperatively. Prior to treatment, one patient was neurologically intact, one patient demonstrated a moderate neurological deficit, and one patient was severely paraparetic with loss of bladder and bowel control. Following identification of the pathogenic organism, antibiotic therapy was continued until the patients demonstrated clinical improvement and radiological resolution of the abscess. All patients remained stable or improved neurologically. Analysis of 33 previously reported patients treated with antibiotics suggests that nonoperative treatment may be a reasonable alternative therapy under certain clinical conditions. These include (1) identification of the pathogenic organism, (2) a stable neurological condition, (3) access to magnetic resonance imaging or computed tomography for potentially rapid reevaluation, and (4) appropriate neurosurgical consultation and nursing care. Nonoperative treatment may also be considered as a reasonable alternative for patients who have severe concurrent medical illness.

Spinal epidural abscesses in adults: review and report of iatrogenic cases

A retrospective review of the medical records of adults with diagnosed spinal epidural abscess (SEA) admitted to the Departments of Neurosurgery and Infectious Diseases at the University Hospital of Umeå, Sweden, during a 10-year-period (1978-1987) is presented. 10 patients were diagnosed as having SEA during the study period. An iatrogenic origin was suspected in 5. Spondylitis was the most common source of infection. Bacteriological aetiology was confirmed in 8 cases and Staphylococcus aureus was the most common aetiological agent. Trauma and degenerative diseases of the spine, were underlying conditions in 6 cases. Laminectomy was performed in 7 cases. 5/6 patients operated within 48 h after onset of neurological symptoms improved. The remaining case with therapy resistant tuberculous spondylitis died. One patient with surgery after 96 h became paretic. 2/3 conservatively treated patients had a successful outcome while the third patient had a permanent paraparesis due to missed diagnosis. Early diagnosis and early laminectomy are still the most important prognostic factors. Recommended initial antibiotic therapy is the combination of a cephalosporin with extended spectrum and metronidazole.

Nonoperative treatment of spinal epidural infections

Spinal epidural infections were diagnosed before the onset of neurological deficits in six patients and treated nonsurgically. The diagnosis was based on the clinical presentation and on the results of myelography and computerized tomography scanning. Positive cultures were obtained from blood in all six patients, from aspiration of a paraspinous infection in two, and from a skin abscess and a pulmonary empyema in one patient each. Staphylococcus aureus was the causative organism in five cases. All patients were treated with intravenous antibiotics and remained neurologically intact throughout the course of treatment. Five patients have had no recurrence of their symptoms. One patient eventually required surgery for persistent discitis.

Magnetic resonance imaging in the diagnosis of spinal epidural abscess

In 3 patients with epidural abscess, 2 in the cervical spine and 1 in the lumbar spine the definite diagnosis was established by magnetic resonance imaging (MR). In 1 patient computerized tomography was performed but the correct diagnosis was revealed only by MR. The infections were all acute and due to Staphylococcus aureus organisms. One patient developed a tetraparesis on the third day, before the diagnosis was established or antibiotic treatment initiated. The other 2 showed only minor and passing neurologic deficits. None was subjected to laminectomy. In 2 cases the diagnosis was confirmed by puncture. None of the patients had a preceding trauma or a known focus for the staphylococcal infection.

New perspectives in acute spinal epidural abscess. Illustrated by two case reports

The histories of two patients with spinal epidural abscess are reported. Attention is drawn to the route of infection by means of direct inoculation of pathogens in the wake of paravertebral infiltration of local anaesthetics for relieving lower backpain, furthermore we emphasize the rare occurrence of a relapsing acute spinal epidural abscess. Additionally the diagnostic superiority of nuclear magnetic resonance tomography is described in a patient known to be allergic to commonly used contrast material.