Spontaneous spinal epidural abscess in a neonate. With a review of the literature

Successful Treatment of Pediatric Holo-Spinal Epidural Abscess With Percutaneous Drainage

Spinal epidural abscess (SEA) is a rare and potentially devastating neurologic disease that is commonly treated with neurosurgical decompression and evacuation. We describe the case of an 11-month-old immunocompetent infant who presented with a large multiloculated methicillin-resistant Staphylococcus aureus abscess in the left lung apex with likely mediastinal involvement, extending into the epidural space from C7 down to L2 causing cord compression which was successfully treated with percutaneous placement of an epidural drainage catheter and antibiotic therapy. Although there are rare reports of percutaneous drainage of SEAs, to our knowledge, there are no reports of successful use of percutaneous indwelling catheters resulting in the complete resolution of an SEA. Holo-spinal epidural abscess in an infant is an extremely rare disease with limited literature available regarding the best practice for its treatment. Multiple considerations must be taken into account when weighing the different treatment options ranging from surgical decompression to conservative management with antibiotic therapy. We present a unique case of successful treatment with percutaneous epidural drain placement. This provides a reasonable alternative for management in children for whom surgical decompression carries multiple risks for complications both acutely and delayed.

Pediatric Group A streptococcal spinal epidural abscess presenting with recurrent symptoms of viral illness: An operative case report

Background

Spinal epidural abscess (SEA) in children is a rare condition with dangerous sequelae, and with only 22 other cases reported in the literature, treatment algorithms are poorly understood. Quick identification of the classic tried of sepsis, back pain and neurological deficit is critical. Source identification difficult and often cannot be identified. Reported pathogens include varicella-zoster virus, S. aureus, and S pyogenes.

Case description

We report a case of spontaneous pediatric SEA in a 22-month old female without obvious neurologic deficit, who underwent a T10-11 decompressive laminotomy and evacuation of abscess and subsequent 3-week course of intravenous ceftriaxone for culture positive S. pyogenes

Outcome

The patient showed marked improvement in symptoms after decompression. 5 weeks postoperatively after transitioning from intravenous ceftriaxone to oral ceftin, the patient redeveloped a deep space infection and was taken back for a repeat debridement. The cultures from this procedure were negative and the patient was discharged on oral clindamycin.

Conclusions

Pediatric spontaneous SEA is a rare condition and early diagnosis and surgical intervention if indicated can prevent dangerous sequelae. Further studies into the surgical indications for decompression will aid in algorithmic decision making.

Spinal Epidural Abscess in Children: Case Report and Review of the Literature

BACKGROUND

Spinal epidural abscess (SEA) is a rare but serious infection in the epidural space along the spinal cord. SEA should be considered in patients with backache, fever, neurological deficits and/or spinal tenderness. Early diagnosis is imperative to prevent permanent neurological sequelae.

CASE DESCRIPTION

We report a case of lumbar SEA in a 13-year-old girl who was immunocompetent and presented with spinal tenderness, back pain and 4 days of fever. A lumbar magnetic resonance imaging demonstrated an epidural abscess from L3-S1. She had emergent surgical intervention. Cultures grew methicillin-susceptible Staphylococcus aureus. She was also given long-term systemic antibiotics and she made a complete recovery within 2 months.

CONCLUSIONS

SEA in an immunocompetent pediatric without risk factors is an extremely rare condition. In the English-language literature, there are only 30 reported cases in the past 19 years; our case brings the total to 31. Non-surgical treatment has been successful in both adult and pediatric patients under certain conditions. Still, there exists a risk of deterioration with non-surgical management, even in patients for whom treatment is begun in the absence of neurologic deficits. Tracking neurological deficits in children can be challenging, particularly in young children who are non-verbal and not yet ambulating, and a reliable neurologic examination is a critical component of non-surgical care. In consideration of these facts and the accelerated time frame of deterioration, once neurologic deficits are present, surgery plus systemic antibiotics remains the standard of care for pediatric SEA patients, with each individual case meriting review of the full clinical picture.

Review and case report demonstrate that spontaneous spinal epidural abscesses are rare but dangerous in childhood

AIM

A spinal epidural abscess (SEA) is a rare paediatric bacterial infection, with possible devastating neurological sequelae. We explored localisation in the cervical segment, which is unusual, but more dangerous, than other SEAs.

METHODS

We describe 22 cases (12 male) of paediatric SEAs without risk factors: 21 from a literature search from 2000 to 2017 and a 30-month-old boy with a spontaneous cervical SEA due to Group A Streptococcus.

RESULTS

The average age was eight years and the symptoms were mainly fever, back pain and motor deficit, with an aetiological diagnosis in 68%. Methicillin-sensitive Staphylococcus aureus was isolated in six patients, methicillin-resistant Staphylococcus aureus in two, Staphylococcus aureus with unknown susceptibility patterns in three and Group A Streptococcus in four. All patients underwent gadolinium-enhanced magnetic resonance imaging and most abscesses were localised in the thoracic and lumbar areas. More than half (59%) underwent surgery to remove pus and granulation tissue and nine were just treated with antimicrobial therapy for an average of 5.3 weeks. Most patients had good outcomes.

CONCLUSION

SEAs were underestimated in children due to the rarity and spectrum of differential diagnoses. Timely diagnosis, immediate antibiotics, spinal magnetic resonance imaging and prompt neurosurgical consultations were essential for favourable outcomes.

A 34-Day-Old With Fever, Cerebrospinal Fluid Pleocytosis, and Staphylococcus aureus Bacteremia

A 34-day-old previously healthy boy born full term presented to the emergency department with fever at home (38.1°C), fussiness, and decreased oral intake for 1 day. He was difficult to console at home. He had decreased oral intake without emesis, diarrhea, or a change in urine output. He did not have rhinorrhea, cough, or increased work of breathing noted by parents. He lived at home with his parents and 13-year-old brother, did not attend day care, and had no sick contacts. On examination, he was fussy but consolable. He was febrile to 39.3°C, tachycardic (180 beats per minute), and tachypneic (64 breaths per minute), with mottling and a capillary refill of 3 seconds. The remainder of his examination was normal, without an infectious focus for his fever. A complete blood cell count with differential revealed leukocytosis. A basic metabolic panel was normal. A catheter urinalysis was normal. Cerebrospinal fluid examination yielded pleocytosis, low glucose, and elevated protein. Blood cultures were persistently positive with methicillin-sensitive Staphylococcus aureus, but cerebrospinal fluid cultures remained negative. We present his case, management, and ultimate diagnosis.

Pediatric spinal epidural abscess in an immunocompetent host without risk factors: Case report and review of the literature

Spinal epidural abscesses (SEAs) are unusual bacterial infections, with possible devastating neurologic sequelae. Despite abundance of case series in adults, reports in children are scanty.

We describe a spontaneous SEA due to methicillin susceptible Staphylococcus aureus (MSSA) in a previously healthy 15-year old male, and we perform a literature review regarding management of pediatric SEAs without risk factors, from 2001 to 2014.

We found a total of 12 cases (8 males, average age 9.6 years). Clinical presentation was mainly fever, back pain and elevation of inflammation markers. All cases were initially misdiagnosed. Lumbar puncture was performed in 36% of patients. Etiological diagnosis was obtained in 8 cases. MSSA was isolated in 4 patients, methicillin-resistant S. aureus in 1 patient, and S. aureus with unknown susceptibility patterns in 2 cases. The average of therapy duration was 6 weeks. Patients’ spine was always evaluated by gadolinium-enhanced magnetic resonance imaging; most abscesses were localized at thoracic and lumbar area, without osteomyelitis. In 8 cases, laminectomy and/or abscess drainage were performed in association with medical therapy; 3 cases were successfully treated with antimicrobial therapy only; no data were available in one case. A good outcome was obtained in all patients, except a reported residual headache and paraspinal pain lasting for 3 years.

The rarity and the possible differential diagnosis can lead to underestimate SEA occurrence in children without risk factors. It seems therefore essential to maintain a high attention to pediatric SEAs. A prompt diagnosis and adequate therapy are essential prognostic factors for remission.

Primary pyogenic spinal epidural abscess: How late is too late and how bad is too bad? - A study on surgical outcome after delayed presentation

Spinal epidural abscess is a rare clinical entity with considerable morbidity. Even with prompt diagnosis and treatment, many patients are left with persistent residual neurological deficits. The present study details the outcome in 23 patients of primary pyogenic spinal epidural abscess, addressing the outcome following late presentation at a neurological facility. At presentation only 2 patients had relatively preserved neurological status. Eleven patients were paraplegic. All the patients underwent laminectomy and evacuation of abscess. A good functional outcome was observed in almost half of the patients, and there was a significant reduction in the number of the patients with severe disability. Factors influencing the outcome are described in this study.

A 3-month-old infant with upper extremity weakness

A detailed history should be obtained for all pediatric patients presenting with acute neurological changes. A thorough physical exam can help narrow the possible etiologies. Prompt imaging can lead to a more precise understanding of the level of neuronal involvement. Neurenteric cysts and fistulas are extremely rare in the pediatric population, with most occurring in the lower cervical and upper thoracic region. Most patients will present with symptoms related to cord or brainstem compression; however, associated infections have been reported. Epidural abscesses are also rare, occurring in the mid-thoracic or lower lumbar region. When there is no communication between the gastrointestinal tract and spinal canal, S. aureus accounts for most of these infections. When gram-negative pathogens, such as E.coli and E. cloacae, are isolated, it is imperative to evaluate for the presence of neurenteric fistulas. Because of numerous anomalies associated with neurenteric cysts, the entire spinal canal should be evaluated completely.

Epidural abscess in a neonate

We report the case of a 16-day-old neonate who presented with fever and irritability. Blood and cerebrospinal fluid (CSF) samples collected on his admission grew methicillin sensitive Staphylococcus aureus on culture, prompting an urgent search for parameningeal collections or an occult sinus involving the central nervous system. Magnetic resonance imaging revealed a pyogenic collection within the epidural space extending from the upper cervical to lumbosacral level and multiple other deep tissue collections that required repeated surgical drainage. Central nervous system infections due to S. aureus are uncommon, particularly in the absence of an anatomical defect or prior neurosurgical instrumentation. This case demonstrates the importance of a timely and thorough search for parameningeal foci when CSF cultures are positive for unusual organisms such as S. aureus.

Pro con debate: the use of regional vs systemic analgesia for neonatal surgery

In recent years the inclusion of regional techniques to pediatric anesthesia has transformed practice. Simple procedures such as caudal anesthesia with local anaesthetics can reduce the amounts of general anesthesia required and provide complete analgesia in the postoperative period while avoiding large amounts of opioid analgesia with potential side effects that can impair recovery. However, the application of central blocks (epidural and spinal local anesthesia) via catheters in the younger infant, neonate and even preterm neonate remains more controversial. The potential for such invasive maneuvers themselves to augment risk, can be argued to outweigh the benefits, others would argue that epidural analgesia can reduce the need for postoperative ventilation and that this not only facilitates surgery when intensive care facilities are limited, but also reduces cost in terms of PICU stay and recovery profile. Currently, opinions are divided and strongly held with some major units adopting this approach widely and others maintaining a more conservative stance to anesthesia for major neonatal surgery. In this pro-con debate the evidence base is examined, supplemented with expert opinion to try to provide a balanced overall view.

Spinal epidural abscess in a neonate

Spinal epidural abscess constitutes a neurosurgical emergency in which early diagnosis and prompt decompression are necessary to avoid permanent cord damage. This entity is rare in premature infants and neonates in whom diagnosis can be challenging. The authors present a case of a premature twin neonate who developed an epidural abscess with complete paraparesis after coagulase-negative Staphylococcus epidermidis bacteremia that was treated with a single-level flavotomy and catheter irrigation.

A posterior epidural mass causing paraparesis in a 20-year-old healthy individual

We present a case of a posterior epidural abscess at the thoracic vertebral level causing paraparesia in a young, healthy individual with no otherwise predisposing factors, with normal laboratory findings, as diagnosed using fat-suppressed MR imaging. Spinal epidural abscess is a rare condition, encountered mostly in the midthoracic or lower lumbar vertebral levels of elderly patients, that has a high mortality and morbidity (18-31%) when diagnosis and treatment is delayed. It is rarely spontaneous and is usually accompanied by spinal osteomyelitis. Diagnosis is rather easy in cases of vertebral osteomyelitis or when classical clinical, laboratory and imaging findings are present. However, cases of spontaneous development, with no predisposing factors, and lack of abscess suggesting clinical and laboratory findings may be a diagnostic challenge. In such cases, other posterior epidural masses such as schwannoma, neurofibroma, meningioma and hematoma should be considered in the differential diagnosis. Both the clinician and the radiology physician should have a high suspicion of epidural abscesses, because their early diagnosis and treatment is important. In addition to routine MR images, fat-suppressed MR images prove helpful in the diagnosis of spontaneous epidural abscesses by showing the inflammatory changes in the paraspinal area.

Spontaneous spinal epidural hematoma in an 11-month-old girl

An 11-month-old girl was admitted for a 2-month history of regression of motor milestones and lateralizing neurologic findings. Tests for hypercoagulability were all within normal limits except for a moderately elevated fibrinogen level. Urine and blood cultures were negative for growth. Complete MRI of the spine revealed a well-defined extradural inhomogeneous signal intensity extending from C(4) to T(3) suggestive of a subacute hematoma with evidence of evolving hemorrhagic change. There was no evidence of underlying arterial venous fistula or malformation. She underwent a cervicothoracic laminoplasty and evacuation of the hematoma. The clot was confirmed to be a hematoma on pathologic investigation. She made an uneventful recovery with gradual return of neurologic function. This case represents the longest known duration between initial symptoms and definitive management of spontaneous spinal epidural hematoma.

Epidural abscesses

Until recently epidural abscess was considered a rare, almost theoretical, complication of central nerve block, but anecdotal reports suggest that this is no longer the case. Thus a review of the risk factors, pathogenesis, clinical features and outcome of this condition is appropriate, the primary aim being to make recommendations on best anaesthetic practice to minimize the risk of this serious complication. A search of EMBASE(c), PUBMED(c) and MEDLINE(c) databases from 1966 to September 2004 was performed using several strategies, supplemented by reference list screening. Spontaneous epidural abscess is rare, accounting for 0.2-1.2 cases per 10,000 hospital admissions per year. Estimates of the incidence after central nerve block vary from 1:1,000 to 1:100,000. Risk factors (compromised immunity, spinal column disruption, source of infection) are present in the majority of patients, whether the condition is spontaneous or associated with central nerve block. Presentation is vague, fever and back pain usually preceding neurological deficit. Diagnosis requires a high index of suspicion and modern imaging techniques. Treatment involves early surgical drainage to prevent permanent deficit and high dose parenteral antibiotics chosen with bacteriological advice. Primary prevention depends on proper use of full aseptic precautions. Epidural abscess can be a catastrophic consequence of central nerve block. Early diagnosis will minimize permanent damage, but primary prevention should be the aim. There is a need for a large survey to indicate the true incidence to better inform the risk-benefit ratio for central nerve block.

[Spinal epidural empyema. Analysis of 14 cases]

OBJECTIVE

The goal of this study was to review our series of spinal epidural empyema diagnosed in the last 20 years and review the literature regarding the pathogenesis, diagnosis and treatment of these lesions.

PATIENTS AND METHODS

This is a retrospective study over 14 patients diagnosed of spinal epidural empyema. We review the epidemiological data, clinical symptoms, laboratory and imaging data, the treatment regimen and the results.

RESULTS

Fourteen patients, 7 males and 7 females, with an age range from 8 to 76 years (mean 48.9) were identified. The first symptom was localized back/ neck pain in 12 patients and the mean duration of symptoms was 9.3 days. Erythrocyte sedimentation rate (ESR) was elevated in all patients; peripheral leukocyte count was elevated in 13 cases (92.9%). Site of spinal epidural empyemas was distributed along the axis but in 11 cases the location was thoracic. Thirteen patients had surgery for debridement and spinal decompression and one patient was treated successfully with antibiotics alone.

CONCLUSIONS

Patients with localized back pain and fever who are at risk for developing such empyemas with elevation of white blood cells and increased ESR, should have an immediate magnetic resonance imaging sean. Urgent surgical drainage and antibiotic use are the treatment of choice in order to prevent irreversible neurological deficits. Nonsurgical treatment should be reserved for poor surgical candidates and patients without neurological deficits.

Regional anaesthetic techniques for neonatal surgery: indications and selection of techniques

The goal of neonatal care is to optimise the outcome of term and preterm infants with minimal suffering. Neonates are rare patients for the anaesthetist, therefore personal and even global experiences are limited. This chapter focuses on strategies for dealing with common clinical situations, e.g. heel lancing, obtaining vascular access, circumcision, hernia repair and pyloric stenosis, as well as major neonatal surgery. With the exception of heel lancing, regional techniques are useful in all cases. However, a careful risk-benefit analysis is mandatory, especially when considering more invasive techniques such as epidural catheters.

[MRI appearance of lumbar epidural abscesses: report of three cases]

The authors report three cases of non-tuberculous epidural abscess. Presenting symptoms included lumbar back pain, muscle spasms, soft tIssue swelling, and neurological deficits in all three cases. MR imaging was helpful for diagnosis and showed involvement of perivertebral soft tissues and an epidural abscess of variable size. There was no significant involvement of intervertebral disks or vertebrae. Diagnosis was confirmed by bacteriologic exam. Clinical outcome was favourable with antibiotic treatment.