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Hijazi MM, Siepmann T, El-Battrawy I, Schröttner P, Podlesek D, Schackert G, Juratli TA, Eyüpoglu IY, Filis A. The importance of the bacterial spectrum in the clinical diagnostics and management of patients with spontaneous pyogenic spondylodiscitis and isolated spinal epidural empyema: a 20-year cohort study at a single spine center. BMC Infect Dis 2024; 24:39. [PMID: 38166791 PMCID: PMC10762996 DOI: 10.1186/s12879-023-08946-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 12/22/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Personalized clinical management of spondylodiscitis (SD) and isolated spinal epidural empyema (ISEE) is challenging due to limited evidence of microbiologic findings and their clinical impact during the clinical course of the disease. We aimed to characterize clinico-microbiological and imaging phenotypes of SD and ISEE to provide useful insights that could improve outcomes and potentially modify guidelines. METHODS We performed chart review and collected data on the following parameters: bacterial antibiogram-resistogram, type of primary spinal infection, location of spinal infection, source of infection, method of detection, clinical complications (sepsis, septic embolism, and endocarditis), length of hospital and intensive care unit (ICU) stay, relapse rate, and disease-related mortality in patients with proven pyogenic SD and ISEE treated surgically in a university hospital in Germany between 2002 and 2022. RESULTS We included data from 187 patients (125 SD, 66.8% and 62 ISEE, 33.2%). Gram-positive bacteria (GPB) were overall more frequently detected than gram-negative bacteria (GNB) (GPB: 162, 86.6% vs. GNB: 25, 13.4%, p < 0.001). Infective endocarditis was caused only by GPB (GPB: 23, 16.5% vs. GNB: 0, 0.0%, p = 0.046). Methicillin-susceptible Staphylococcus aureus was the most frequently isolated strain (MSSA: n = 100, 53.5%), occurred more frequently in the cervical spine compared to other bacteria (OB) (MSSA: 41, 41.0% vs. OB: 18, 20.7%, p = 0.004) and was most frequently detected in patients with skin infection as the primary source of infection (MSSA: 26, 40.6% vs. OB: 11, 16.7%, p = 0.002). Streptococcus spp. and Enterococcus spp. (SE: n = 31, 16.6%) were more often regarded as the cause of endocarditis (SE: 8, 27.6% vs. OB: 15, 11.4%, p = 0.037) and were less frequently detected in intraoperative specimens (SE: 19, 61.3% vs. OB: 138, 88.5%, p < 0.001). Enterobacterales (E: n = 20, 10.7%) were identified more frequently in urinary tract infections (E: 9, 50.0% vs. OB: 4, 3.6%, p < 0.001). Coagulase-negative Staphylococci (CoNS: n = 20, 10.7%) were characterized by a lower prevalence of sepsis (CoNS: 4, 20.0% vs. OB: 90, 53.9%, p = 0.004) and were more frequently detected in intraoperative specimens (CoNS: 20, 100. 0% vs. OB: 137, 82.0%, p = 0.048). Moreover, CoNS-associated cases showed a shorter length of ICU stay (CoNS: 2 [1-18] days vs. OB: 6 [1-53] days, median [interquartile range], p = 0.037), and occurred more frequently due to foreign body-associated infections (CoNS: 8, 61.5% vs. OB: 15, 12.8%, p = 0.008). The presence of methicillin-resistant Staphylococcus aureus (MRSA) prolonged hospital stay by 56 [24-58] days and ICU stay by 16 [1-44] days, whereas patients with Pseudomonas aeruginosa spent only 20 [18-29] days in the hospital and no day in the ICU 0 [0-5] days. CONCLUSIONS Our retrospective cohort study identified distinct bacterial-specific manifestations in pyogenic SD and ISEE regarding clinical course, neuroanatomic targets, method of pathogen detection, and sources of infection. The clinico-microbiological patterns varied depending on the specific pathogens.
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Affiliation(s)
- Mido Max Hijazi
- Department of Neurosurgery, Division of Spine Surgery, Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307, Dresden, Germany.
| | - Timo Siepmann
- Department of Neurology, Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Ibrahim El-Battrawy
- Department of Cardiology, Bergmannsheil University Hospital, Ruhr University Bochum, Bürkle de la Camp-Platz 1, 44789, Bochum, Germany
| | - Percy Schröttner
- Institute for Clinical Chemistry and Laboratory Medicine, Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307, Dresden, Germany
- Institute for Microbiology and Virology, Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Dino Podlesek
- Department of Neurosurgery, Division of Spine Surgery, Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Gabriele Schackert
- Department of Neurosurgery, Division of Spine Surgery, Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Tareq A Juratli
- Department of Neurosurgery, Division of Spine Surgery, Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Ilker Y Eyüpoglu
- Department of Neurosurgery, Division of Spine Surgery, Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Andreas Filis
- Department of Neurosurgery, Division of Spine Surgery, Technische Universität Dresden, Faculty of Medicine, and University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307, Dresden, Germany
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Pomponio MK, Khan IS, Evans LT, Simmons NE, Ball PA, Ryken TC, Hong J. Association between interhospital transfer and increased in-hospital mortality in patients with spinal epidural abscesses. Spine J 2022; 22:921-926. [PMID: 35017053 DOI: 10.1016/j.spinee.2022.01.007] [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] [Received: 06/28/2021] [Revised: 11/30/2021] [Accepted: 01/03/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spinal epidural abscess (SEA) is an uncommon yet serious infection, associated with significant morbidity and mortality. Patients diagnosed with SEA often require surgical interventions or critical care services that are not available at community hospitals and are therefore transferred to tertiary care centers. Little is known about the effects of interhospital transfer on acute outcomes for patients with SEA. PURPOSE To study the effects of interhospital transfer on acute outcomes for patients with SEA. STUDY DESIGN Cross sectional analysis using the 2009 to 2017 National Inpatient Sample (NIS). PATIENT SAMPLE Using the 2009 to 2017 NIS, we identified cases of SEA using ICD, Ninth, or Tenth Revision diagnosis codes 324.1 & G06.1. OUTCOME MEASURES Our primary endpoint was in hospital mortality. METHODS The association between interhospital transfer and inpatient mortality was assessed using multivariable logistic regression to adjust for potential covariates. Patient and hospital factors associated with interhospital transfer were assessed in a secondary analysis. RESULTS A total of 21.5% of patient with SEA were treated after transfer from another hospital. After adjusting for covariates, those who presented after transfer had higher odds of death during hospitalization (OR: 1.51, 95% CI 1.27-1.78, p<.001). Transferred patients were significantly more likely to live in rural communities (11.4 % vs. 5.3 % for nontransferred patients). CONCLUSIONS Interhospital transfer, which occurred more frequently in patients from rural hospitals, was associated with death even after controlling for disease severity. Addressing healthcare delivery disparities across the US, including across the rural-urban spectrum, will require better understanding of the observed increased mortality of interhospital transfer as a preventable source of in-hospital mortality for SEA.
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Affiliation(s)
- Maria K Pomponio
- Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road Hanover, NH 03755, USA
| | - Imad S Khan
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Linton T Evans
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Nathan E Simmons
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Perry A Ball
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Timothy C Ryken
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Jennifer Hong
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA.
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Gliedt JA, Dawson AZ, Daniels CJ, Spector AL, Cupler ZA, King J, Egede LE. Manual therapy interventions in the management of adults with prior cervical spine surgery for degenerative conditions: a scoping review. Chiropr Man Therap 2022; 30:13. [PMID: 35255934 PMCID: PMC8900329 DOI: 10.1186/s12998-022-00422-8] [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: 07/14/2021] [Accepted: 02/24/2022] [Indexed: 11/10/2022] Open
Abstract
Objective Cervical spine surgeries for degenerative conditions are rapidly increasing. Cervical post-surgery syndrome consisting of chronic pain, adjacent segment disease, recurrent disc herniation, facet joint pain, and/or epidural scarring is common. Repeat surgery is regularly recommended, though patients are often unable to undergo or decline further surgery. Manual therapy is included in clinical practice guidelines for neck pain and related disorders, however clinical guidance for utilization of manual therapy in adults with prior cervical spine surgery is lacking. This study aimed to synthesize available literature and characterize outcomes and adverse events for manual therapy interventions in adults with prior cervical spine surgery due to degenerative conditions. Methods Preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews was followed. PubMed, Cumulative Index of Nursing and Allied Health Literature, physiotherapy evidence database, and Index to Chiropractic Literature were searched from inception through October 2021. English-language literature comprised of randomized clinical trials (RCT), case–control, cohort, and case report designs were included. Adults undergoing manual therapy, with or without combination of other interventions, with prior cervical spine surgery due to degenerative conditions were included. Results Twelve articles were identified, including 10 case reports, 1 low-quality RCT, and 1 acceptable-quality RCT. Eight case reports described 9 patients with history of fusion surgery. Two case reports described 2 patients with history of discectomy. One case report described one patient with separate operations of a discectomy at one level and a fusion at another level. One case report described 2 patients with history of cervical disc replacement surgery. The two RCTs included 63 and 86 participants, respectively. Use of manual joint mobilization/manipulation, table/instrument assisted mobilization/manipulation, and multimodal interventions were described in eligible studies. Favorable clinical outcomes were reported in 10 studies. Six case reports/series involving 8 patients described use of unclassified forms of manual therapy. Eight studies described the use of multimodal interventions along with manual therapy. One study described high patient satisfaction. Two studies, accounting for 3 patients, reported serious adverse events. Conclusions There is a lack of literature informing evidence related to clinical outcomes, patient satisfaction, and adverse events associated with manual therapy for patients with prior cervical spine surgery due to degenerative conditions. High-quality studies of higher-level hierarchical study design are needed to understand the clinical utility and safety profile of manual therapy for this population. Supplementary Information The online version contains supplementary material available at 10.1186/s12998-022-00422-8.
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Affiliation(s)
- Jordan A Gliedt
- Center for Advancing Population Science, Medical College of Wisconsin, WI, Milwaukee, USA.,Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Aprill Z Dawson
- Center for Advancing Population Science, Medical College of Wisconsin, WI, Milwaukee, USA.,Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Antoinette L Spector
- Center for Advancing Population Science, Medical College of Wisconsin, WI, Milwaukee, USA.,Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Zachary A Cupler
- Butler VA Health Care System, Butler, PA, USA.,Institute for Clinical Research Education, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jeff King
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Leonard E Egede
- Center for Advancing Population Science, Medical College of Wisconsin, WI, Milwaukee, USA. .,Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
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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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Liu H, Wang X, Wang W, Sun Y, Guo L, Zhang F, Li J, Zhang P, Zhang W. WITHDRAWN: Spinal epidural abscess with emphasis on early diagnosis and surgical treatment: Report of twenty-five cases and review of literature. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Guzner A, Goese D, Yuen L. Using Probability Estimates to Evaluate a Patient With Weakness. Cureus 2022; 14:e21775. [PMID: 35251845 PMCID: PMC8890611 DOI: 10.7759/cureus.21775] [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: 01/24/2022] [Indexed: 11/05/2022] Open
Abstract
In this case report, we review how probabilistic reasoning can be implemented in retrospect to refine the diagnostic process. A 67-year-old female with a history of polymyalgia rheumatica (PMR) and a recent dental procedure presented with weakness, falls, and chills ongoing for two weeks. She reported pain in her shoulders and lower back. On presentation, she was febrile, and labs were notable for leukocytosis with neutrophilic predominance and an elevated erythrocyte sedimentation rate (ESR). Chest radiograph revealed a left lower lung opacity, which was not seen on a repeat film. She was treated with antibiotics for community-acquired pneumonia and steroids for an exacerbation of PMR. After eight days of hospitalization, she was transferred to a subacute rehabilitation facility. A month later, she was readmitted with worsening lower back pain and right lower extremity weakness. Imaging revealed discitis and osteomyelitis at L1-L2. A spinal epidural abscess was present, leading to severe compression of the cauda equina nerve roots. Aspirate was positive for group B streptococcus. With antibiotic treatment alone, she recovered with resolution of her weakness. In reviewing the literature, it becomes evident where improvements could have been made in the diagnostic process. Fever, leukocytosis, and neurological weakness are not commonly associated with PMR exacerbations. Lack of cough or shortness of breath, a persistently elevated erythrocyte sedimentation rate and C-reactive protein despite antibiotic treatment, and a repeat chest radiograph without an opacity suggest an alternative diagnosis to pneumonia. Persistent back pain with an insidious onset is a feature of untreated spinal epidural abscess. Steroid use and dental procedures are possible risk factors for spinal epidural abscess. By shedding light on how probabilities should be estimated, we hope to encourage probabilistic thinking to improve diagnostic accuracy. As with the best political forecasters, making precise probability estimates and frequently updating them may improve diagnostic accuracy for clinicians.
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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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Ortiz AO, Levitt A, Shah LM, Parsons MS, Agarwal V, Baldwin K, Bhattacharyya S, Boulter DJ, Burns J, Fink KR, Hunt CH, Hutchins TA, Kao LS, Khan MA, Lo BM, Moritani T, Reitman C, Repplinger MD, Shah VN, Singh S, Timpone VM, Corey AS. ACR Appropriateness Criteria® Suspected Spine Infection. J Am Coll Radiol 2021; 18:S488-S501. [PMID: 34794603 DOI: 10.1016/j.jacr.2021.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 09/01/2021] [Indexed: 10/19/2022]
Abstract
Spine infection is both a clinical and diagnostic imaging challenge due to its relatively indolent and nonspecific clinical presentation. The diagnosis of spine infection is based upon a combination of clinical suspicion, imaging evaluation and, when possible, microbiologic confirmation performed from blood cultures or image-guided percutaneous or open spine biopsy. With respect to the imaging evaluation of suspected spine infection, MRI without and with contrast of the affected spine segment is the initial diagnostic test of choice. As noncontrast MRI of the spine is often used in the evaluation of back or neck pain not responding to conservative medical management, it may show findings that are suggestive of infection, hence this procedure may also be considered in the evaluation of suspected spine infection. Nuclear medicine studies, including skeletal scintigraphy, gallium scan, and FDG-PET/CT, may be helpful in equivocal or select cases. Similarly, radiography and CT may be appropriate for assessing overall spinal stability, spine alignment, osseous integrity and, when present, the status of spine instrumentation or spine implants. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- A Orlando Ortiz
- Chairman, Department of Radiology, Jacobi Medical Center, Bronx, New York.
| | - Alex Levitt
- Research Author, Jacobi Medical Center, Bronx, New York
| | - Lubdha M Shah
- Panel Chair, University of Utah, Salt Lake City, Utah
| | - Matthew S Parsons
- Panel Vice-Chair, Mallinckrodt Institute of Radiology, Saint Louis, Missouri
| | - Vikas Agarwal
- Vice-Chair of Education, Chief, Neuroradiology, and Director, Spine Intervention, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Keith Baldwin
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, American Academy of Orthopaedic Surgeons
| | - Shamik Bhattacharyya
- Brigham & Women's Hospital & Harvard Medical School, Boston, Massachusetts, American Academy of Neurology
| | - Daniel J Boulter
- Clinical Director, MRI, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Judah Burns
- Program Director, Diagnostic Radiology Residency Program, Montefiore Medical Center, Bronx, New York
| | | | | | - Troy A Hutchins
- Chief Value Officer, Department of Radiology, University of Utah Health, Salt Lake City, Utah
| | - Lillian S Kao
- Chief, Division of Acute Care Surgery, The University of Texas Health Science Center at Houston, Houston, Texas; and American Association for the Surgery of Trauma
| | - Majid A Khan
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Bruce M Lo
- Sentara Norfolk General/Eastern Virginia Medical School, Norfolk, Virginia; Board Member, American Academy of Emergency Medicine; and American College of Emergency Physicians
| | | | - Charles Reitman
- Medical University of South Carolina, Charleston, South Carolina; and Board of Directors, North American Spine Society
| | - Michael D Repplinger
- University of Wisconsin, Madison, Wisconsin; President, Dane County Medical Society; Councillor, American College of Emergency Physicians; and Society for Academic Emergency Medicine
| | - Vinil N Shah
- University of California San Francisco, San Francisco, California; and Executive Committee, American Society of Spine Radiology
| | - Simranjit Singh
- Indiana University School of Medicine, Indianapolis, Indiana; Secretary, SHM, Indiana Chapter; Secretary, SGIM, Midwest Region; and American College of Physicians
| | - Vincent M Timpone
- Co-Director, Neuroradiology Spine Intervention Service, Department of Radiology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Amanda S Corey
- Specialty Chair, Atlanta VA Health Care System and Emory University, Atlanta, Georgia
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Miller AC, Koeneman SH, Arakkal AT, Cavanaugh JE, Polgreen PM. Incidence, Duration, and Risk Factors Associated With Missed Opportunities to Diagnose Herpes Simplex Encephalitis: A Population-Based Longitudinal Study. Open Forum Infect Dis 2021; 8:ofab400. [PMID: 34514018 PMCID: PMC8415533 DOI: 10.1093/ofid/ofab400] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 07/25/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Delays in diagnosing herpes simplex encephalitis (HSE) are associated with increased morbidity and mortality. The purpose of this paper is to determine the frequency and duration of diagnostic delays for HSE and risk factors for diagnostic delays. METHODS Using data from the IBM Marketscan Databases, 2001-2017, we performed a retrospective cohort study of patients with HSE. We estimated the number of visits with HSE-related symptoms before diagnosis that would be expected to occur in the absence of delays and compared this estimate to the observed pattern of visits. Next, we used a simulation-based approach to compute the number of visits representing a delay, the number of missed diagnostic opportunities per case patient, and the duration of delays. We also investigated potential risk factors for delays. RESULTS We identified 2667 patients diagnosed with HSE. We estimated 45.9% (95% confidence interval [CI], 43.6%-48.1%) of patients experienced at least 1 missed opportunity; 21.9% (95% CI, 17.3%-26.3%) of these patients had delays lasting >7 days. Risk factors for delays included being seen only in the emergency department, age <65, or a history of sinusitis or schizophrenia. CONCLUSIONS Many patients with HSE experience multiple missed diagnostic opportunities before diagnosis.
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Affiliation(s)
- Aaron C Miller
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Scott H Koeneman
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Alan T Arakkal
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Joseph E Cavanaugh
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Philip M Polgreen
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa, USA
- Division of Infectious Diseases, Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
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Shroyer SR, Davis WT, April MD, Long B, Boys G, Mehta SG, Mercaldo SF. A Clinical Prediction Tool for MRI in Emergency Department Patients with Spinal Infection. West J Emerg Med 2021; 22:1156-1166. [PMID: 34546893 PMCID: PMC8463051 DOI: 10.5811/westjem.2021.5.52007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/15/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction Patients with pyogenic spinal Infection (PSI) are often not diagnosed at their initial presentation, and diagnostic delay is associated with increased morbidity and medical-legal risk. We derived a decision tool to estimate the risk of spinal infection and inform magnetic resonance imaging (MRI) decisions. Methods We conducted a two-part prospective observational cohort study that collected variables from spine pain patients over a six-year derivation phase. We fit a multivariable regression model with logistic coefficients rounded to the nearest integer and used them for variable weighting in the final risk score. This score, SIRCH (spine infection risk calculation heuristic), uses four clinical variables to predict PSI. We calculated the statistical performance, MRI utilization, and model fit in the derivation phase. In the second phase we used the same protocol but enrolled only confirmed cases of spinal infection to assess the sensitivity of our prediction tool. Results In the derivation phase, we evaluated 134 non-PSI and 40 PSI patients; median age in years was 55.5 (interquartile range [IQR] 38–70 and 51.5 (42–59), respectively. We identified four predictors for our risk score: historical risk factors; fever; progressive neurological deficit; and C-reactive protein (CRP) ≥ 50 milligrams per liter (mg/L). At a threshold SIRCH score of ≥ 3, the predictive model’s sensitivity, specificity, and positive predictive value were, respectively, as follows: 100% (95% confidence interval [CI], 100–100%); 56% (95% CI, 48–64%), and 40% (95% CI, 36–46%). The area under the receiver operator curve was 0.877 (95% CI, 0.829–0.925). The SIRCH score at a threshold of ≥ 3 would prompt significantly fewer MRIs compared to using an elevated CRP (only 99/174 MRIs compared to 144/174 MRIs, P <0.001). In the second phase (49 patient disease-only cohort), the sensitivities of the SIRCH score and CRP use (laboratory standard cut-off 3.5 mg/L) were 92% (95% CI, 84–98%), and 98% (95% CI, 94–100%), respectively. Conclusion The SIRCH score provides a sensitive estimate of spinal infection risk and prompts fewer MRIs than elevated CRP (cut-off 3.5 mg/L) or clinician suspicion.
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Affiliation(s)
- Steven R Shroyer
- Methodist Hospital System, Greater San Antonio Emergency Physicians, San Antonio, Texas
| | - William T Davis
- Uniformed Services University of the Health Sciences, Department of Military and Emergency Medicine, Bethesda, Maryland
| | - Michael D April
- Uniformed Services University of the Health Sciences, Department of Military and Emergency Medicine, Bethesda, Maryland.,Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts
| | - Brit Long
- Uniformed Services University of the Health Sciences, Department of Military and Emergency Medicine, Bethesda, Maryland
| | - Greg Boys
- Methodist Hospital System, Department of Radiology, San Antonio, Texas
| | - Sumeru G Mehta
- Methodist Hospital System, Greater San Antonio Emergency Physicians, San Antonio, Texas
| | - Sarah F Mercaldo
- Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts
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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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Hagedorn JM, Misercola B, Comer A, Tari-Blake J, Hoffmann CM, Mehta P, Deer TR. The Team Approach to Spinal Cord and Dorsal Root Ganglion Stimulation: A Guide for the Advanced Practice Provider. Mayo Clin Proc Innov Qual Outcomes 2021; 5:663-669. [PMID: 34195557 PMCID: PMC8240163 DOI: 10.1016/j.mayocpiqo.2021.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Jonathan M Hagedorn
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | | | - Ashley Comer
- The Spine and Nerve Center of the Virginias, Charleston, WV
| | | | - Chelsey M Hoffmann
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | | | - Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV
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13
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Vig KS, Amarante M, Hutchinson I, Lawrence JP. Pediatric Group A streptococcal spinal epidural abscess presenting with recurrent symptoms of viral illness: An operative case report. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2021; 6:100067. [PMID: 35141632 PMCID: PMC8820052 DOI: 10.1016/j.xnsj.2021.100067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/29/2021] [Accepted: 04/30/2021] [Indexed: 11/06/2022]
Abstract
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.
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14
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Kang X, Zhu Y, Lin K, Xie L, Wen H, Geng W, Zhu S. The Incidence of and Risk Factors for Localized Pain at the Epidural Insertion Site After Epidural Anesthesia: A Prospective Survey of More Than 5000 Cases in Nonobstetric Surgery. Risk Manag Healthc Policy 2021; 14:2171-2180. [PMID: 34079404 PMCID: PMC8164713 DOI: 10.2147/rmhp.s290763] [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: 11/06/2020] [Accepted: 03/29/2021] [Indexed: 11/23/2022] Open
Abstract
Background This prospective research aimed to determine the incidence of and risk factors for localized pain at the epidural insertion site following nonobstetric surgery performed with epidural anesthesia. Methods A total of 5083 surgical inpatients at the teaching hospital undergoing epidural anesthesia were included in the study. The characteristics of the patients, preoperative basic diseases, details of the epidural techniques, surgical procedures and complications were recorded pre-anesthesia until the complications resolved. Multivariate logistic regression analysis was performed to identify predictors of localized pain at the epidural insertion site. Results In our analysis, target complications were reported in 532 (10.5%) patients; localized pain at the epidural insertion site occurred in 460 (9.05%) patients, while other major complications occurred in 72 (1.45%) patients. A total of 334 patients had mild pain, and 126 patients had moderate pain. The incidence of localized pain at the epidural insertion site was highest among all complications, and the identified risk factors in the multivariate analysis were as follows: lumbar insertion (odds ratio, 1.77; 95% CI 1.33–2.35), age less than 50 years old (odds ratio, 1.56; 95% CI 1.29–1.89), multiple block attempts (odds ratio, 3.39; 95% CI 2.68–4.31), and postoperative patient-controlled epidural analgesia (odds ratio, 0.46; 95% CI 0.33–0.63). Conclusion Localized pain at the epidural insertion site is the most common complaint after epidural anesthesia and requires adequate clinical attention. Improving the proficiency of anesthesiologists to avoid repeated punctures is the best way to reduce injuries.
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Affiliation(s)
- Xianhui Kang
- Department of Anesthesiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Yeke Zhu
- Department of Anesthesiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Kun Lin
- Department of Anesthesiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Liwei Xie
- Department of Anesthesiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Heng Wen
- Department of Anesthesiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Wujun Geng
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People's Republic of China
| | - Shengmei Zhu
- Department of Anesthesiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
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Koyama K, Aoki Y, Inoue M, Kubota G, Watanabe A, Nakajima T, Sato Y, Nakajima A, Sonobe M, Takahashi H, Saito J, Norimoto M, Ohtori S, Nakagawa K. Skip decompression surgeries in the treatment of holospinal epidural abscess: a case report. Spinal Cord Ser Cases 2021; 7:38. [PMID: 33986247 DOI: 10.1038/s41394-021-00401-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 04/09/2021] [Accepted: 04/09/2021] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Holospinal epidural abscess (HEA) extending from the cervical to the lumbosacral spine is an extremely rare condition. Surgical treatment of HEA, which involves extensive decompression of the spinal lesion is difficult in emergency settings. However, the authors successfully treated a case of HEA in critical condition with severe neurological deficits through a combination of skip decompression surgeries and catheter irrigation. CASE PRESENTATION A 73-year-old man complained of neck and back pain and developed muscle weakness in the upper and lower extremities (C5 AIS D tetraplegia). When he was transferred to our hospital, a marked increase in leukocytes (13330/μL) and C-reactive protein levels (32.11 mg/dL) was observed. Magnetic resonance imaging (MRI) revealed a HEA extending from C1 to S2 levels. Therefore, an emergency posterior decompression on C4-5 and T4-7 was performed, followed by catheter irrigation using a venous catheter. Blood and intraoperative isolated microorganisms were identified as Streptococcus intermedius, which is a rare cause of spinal infection. He experienced marked improvement in pain after surgery. Two months after surgery, the epidural abscess completely disappeared. Motor weakness gradually improved, and he was able to walk without support and showed no pain recurrence during the final follow-up (20 months after surgery). DISCUSSION Early diagnosis is important for the treatment of HEAs. Therefore, a whole spine MRI is recommended when an extensive spinal epidural abscess is suspected. Decompression surgery at limited spine levels followed by catheter irrigation should be considered in patients with HEA.
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Affiliation(s)
- Keita Koyama
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Japan.,Department of Orthopaedic Surgery, Toho University Sakura Medical Center, Sakura, Japan
| | - Yasuchika Aoki
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Japan. .,Department of General Medical Science, Graduate School of Medicine, Chiba University, Chiba, Japan.
| | - Masahiro Inoue
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Japan.,Department of General Medical Science, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Go Kubota
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Japan.,Department of Orthopaedic Surgery, Sawara Prefectural Hospital, Katori, Japan
| | - Atsuya Watanabe
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Japan.,Department of General Medical Science, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takayuki Nakajima
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Japan.,Department of General Medical Science, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yusuke Sato
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Japan.,Department of General Medical Science, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Arata Nakajima
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, Sakura, Japan
| | - Masato Sonobe
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, Sakura, Japan
| | - Hiroshi Takahashi
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Junya Saito
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, Sakura, Japan
| | - Masaki Norimoto
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, Sakura, Japan
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Koichi Nakagawa
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, Sakura, Japan
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16
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Dai G, Li S, Yin C, Sun Y, Xu D, Wang Z, Luan L, Hou J, Wang T. Studies on 11 Cases of Spinal Epidural Abscess and Literature Review. Infect Drug Resist 2020; 13:3325-3334. [PMID: 33061480 PMCID: PMC7532908 DOI: 10.2147/idr.s257398] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 09/04/2020] [Indexed: 01/23/2023] Open
Abstract
Objective In the present study, we aimed to describe the clinical features, diagnosis, treatment, and prognosis of spinal epidural abscess (SEA). Methods The complete clinical data of 11 SEA patients who were treated in our hospital system from January 2015 to June 2018 were retrospectively analyzed. Moreover, the clinical features, diagnosis, treatment, and prognosis of 642 SEA cases collected from the foreign literature from 2010 to 2019 were also investigated. Results Among our 11 SEA patients, nine cases had purulent inflammation, two cases had tuberculosis, two cases had infection caused by Staphylococcus aureus, one case had infection caused by Streptococcus constellatus, one case had infection caused by Klebsiella pneumoniae, five cases showed negative bacterial culture, and two cases had Mycobacterium tuberculosis. All 11 cases showed focal spinal pain, eight cases exhibited neurological deficits, and six cases experienced fever. Nine of the 11 cases involved the lumbosacral spine, one case involved the thoracic spine, and one case involved the cervical spine. Eight patients had a longer course of disease (>2 weeks), all 11 patients had vertebral osteomyelitis, and nine patients had intervertebral discitis. One patient had motor dysfunction of arms and legs, one patient had lower limb motor dysfunction, one patient had limb numbness, one patient experienced relapse after the conservative treatment, and one patient experienced relapse after the surgical treatment. The follow-up time was 15–24 months. Conclusion The classic diagnosis of triads (focal spine pain, neurological deficit, and fever) was less specific for SEA. MRI examination, blood culture, tissue culture, and biopsy could be used for the diagnosis for SEA. Suppuritis was a common cause of SEA. Early detection, early diagnosis and early treatment, as well as the selection of the most suitable treatment regimen based on comprehensive evaluation, played crucial roles in a better prognosis of SEA. There was no statistically significant difference in terms of the general condition, diagnosis, treatment and prognosis between the patients with negative and positive culture results (P>0.05). For SEA patient with negative culture, antibiotic treatment should be used empirically.
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Affiliation(s)
- Guohua Dai
- Affiliated Hospital of Qingdao University, Qingdao 266003, People's Republic of China
| | - Shuzhong Li
- Affiliated Hospital of Qingdao University, Qingdao 266003, People's Republic of China
| | - Chuqiang Yin
- Affiliated Hospital of Qingdao University, Qingdao 266003, People's Republic of China
| | - Yuanliang Sun
- Affiliated Hospital of Qingdao University, Qingdao 266003, People's Republic of China
| | - Derong Xu
- Affiliated Hospital of Qingdao University, Qingdao 266003, People's Republic of China
| | - Zhongying Wang
- Affiliated Hospital of Qingdao University, Qingdao 266003, People's Republic of China
| | - Liangrui Luan
- Affiliated Hospital of Qingdao University, Qingdao 266003, People's Republic of China
| | - Jianwen Hou
- Affiliated Hospital of Qingdao University, Qingdao 266003, People's Republic of China
| | - Ting Wang
- Affiliated Hospital of Qingdao University, Qingdao 266003, People's Republic of China
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17
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Keys to diagnosis and management of spinal epidural abscesses: 9 years of institutional experience. Clin Neurol Neurosurg 2020; 197:106185. [PMID: 32877765 DOI: 10.1016/j.clineuro.2020.106185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 08/17/2020] [Accepted: 08/23/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Spinal epidural abscesses (SEA's) are a challenge to diagnose, particularly if there are non-contiguous (skip) lesions. There is also limited data to predict which patients can be treated with antibiotics alone and which require surgery. We sought to assess which demographics, clinical and laboratory findings can guide both diagnosis and management of SEA's. METHODS All patients with SEA (ICD9 324.1, ICD10 G06.1) between April 2011-May 2019 at a single tertiary center were included. A retrospective EMR review was completed. Patient and disease characteristics were compared using appropriate statistical tests. RESULTS 108 patients underwent initial surgical treatment versus 105 that were treated medically initially; 22 (21 %) of those failed medical management. Patients who failed medical management had significantly higher CRP, longer symptom duration, and had higher rates of concurrent non-spinal infections. 9% of patients had skip lesions. Patients with skip lesions had significantly higher WBC, ESR, as well as higher rates of bacteremia and concurrent non-spinal infections. Demographic characteristics and proportion with IVDU, smoking, malignancy, and immunosuppression were similar among the three treatment groups. CONCLUSIONS 21 % of SEA patients failed initial medical management; they had significantly greater CRP, longer symptom duration, more commonly had neurologic deficits, and concurrent non-spinal infections. 9% of patients had skip lesions; they had significantly higher WBC, ESR, rates of bacteremia and infections outside the spine. These variables may guide diagnostic imaging, and identify those at risk of failing of medical management, and therefore require more involved clinical evaluation, and consideration for surgical intervention.
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18
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Sharfman ZT, Gelfand Y, Shah P, Holtzman AJ, Mendelis JR, Kinon MD, Krystal JD, Brook A, Yassari R, Kramer DC. Spinal Epidural Abscess: A Review of Presentation, Management, and Medicolegal Implications. Asian Spine J 2020; 14:742-759. [PMID: 32718133 PMCID: PMC7595828 DOI: 10.31616/asj.2019.0369] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 04/17/2020] [Indexed: 12/18/2022] Open
Abstract
Spinal epidural abscess (SEA) is a rare condition associated with significant morbidity and mortality. Despite advances in diagnostic medicine, early recognition of SEAs remains elusive. The vague presentation of the disease, coupled with its numerous risk factors, the diagnostic requirement for obtaining advanced imaging, and the necessity of specialized care constitute extraordinary challenges to both diagnosis and treatment of SEA. Once diagnosed, SEAs require urgent or emergent medical and/or surgical management. As SEAs are a relatively rare pathology, high-quality data are limited and there is no consensus on their optimal management. This paper focuses on presenting the treatment modalities that have been successful in the management of SEAs and providing a critical assessment of how specific SEA characteristics may render one infection more amenable to primary surgical or medical interventions. This paper reviews the relevant history, epidemiology, clinical presentation, radiology, microbiology, and treatment of SEAs and concludes by addressing the medicolegal implications of delayed treatment of the disease.
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Affiliation(s)
- Zachary Tuvya Sharfman
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Yaroslav Gelfand
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Pryiam Shah
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ari Jacob Holtzman
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Joseph Roy Mendelis
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Merritt Drew Kinon
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jonathan David Krystal
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Allan Brook
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Reza Yassari
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - David Claude Kramer
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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19
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Abstract
PURPOSE OF REVIEW Spinal epidural abscess (SEA) is still a rare but potentially very morbid infection of the spine. In recent years, the incidence has risen sharply but the condition remains a medical conundrum wrought with unacceptably long diagnostic delays. The outcome depends on timely diagnosis and missed opportunities can be associated with catastrophic consequences. Management and outcomes have improved over the past decade. This review focuses on risk factors and markers that can aid in establishing the diagnosis, the radiological characteristics of SEA on MRI and their clinical implications, as well as the importance of establishing clear indications for surgical decompression. RECENT FINDINGS This once exclusively surgically managed entity is increasingly treated conservatively with antimicrobial therapy. Patients diagnosed in a timely fashion, prior to cord involvement and the onset of neurologic deficits can safely be managed without decompressive surgery with targeted antimicrobial therapy. Patients with acute cord compression and gross neurologic deficits promptly undergo decompression. The greatest therapeutic dilemma remains the group with mild neurological deficits. As failure rates of delayed surgery approach 40%, recent research is focused on predictive models for failure of conservative SEA management. In addition, protocols are being implemented with some success, to shorten the diagnostic delay of SEA on initial presentation. SUMMARY SEA is a potentially devastating condition that is frequently missed. Protocols are put in place to facilitate early evaluation of back pain in patients with red flags with appropriate cross-sectional imaging, namely contrast-enhanced MRI. Efforts for establishing clear-cut indications for surgical decompression of SEA are underway.
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20
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C Ginestal-López R, Gómez-Iglesias P, García-Yepes M, Yus-Fuertes M, Fernández García C. Subacute spinal injury: the importance of previous trauma. Cir Esp 2020; 99:387-389. [PMID: 32593466 DOI: 10.1016/j.ciresp.2020.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 05/16/2020] [Accepted: 05/26/2020] [Indexed: 11/26/2022]
Affiliation(s)
| | | | | | - Miguel Yus-Fuertes
- Sección de Neurorradiología, Hospital Clínico San Carlos, Madrid, España
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21
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Sensitivity of C-reactive protein cut-off values for pyogenic spinal infection in the emergency department. CAN J EMERG MED 2020; 22:836-843. [PMID: 32538336 DOI: 10.1017/cem.2020.402] [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] [Indexed: 01/18/2023]
Abstract
OBJECTIVES The aim of this study was to describe the sensitivity of various C-reactive protein (CRP) cut-off values to identify patients requiring magnetic resonance imaging evaluation for pyogenic spinal infection among emergency department (ED) adults presenting with neck or back pain. METHODS We prospectively enrolled a convenience series of adults presenting to a community ED with neck or back pain in whom ED providers had concern for pyogenic spinal infection in a derivation cohort from 2004 to 2010 and a validation cohort from 2010 to 2018. The validation cohort included only patients with pyogenic spinal infection. We analysed diagnostic test characteristics of various CRP cut-off values. RESULTS We enrolled 232 patients and analysed 201 patients. The median age was 55 years, 43.8% were male, 4.0% had history of intravenous drug use, and 20.9% had recent spinal surgery. In the derivation cohort, 38 (23.9%) of 159 patients had pyogenic spinal infection. Derivation sensitivity and specificity of CRP cut-off values were > 3.5 mg/L (100%, 24.8%), > 10 mg/L (100%, 41.3%), > 30 mg/L (100%, 61.2%), and > 50 mg/L (89.5%, 69.4%). Validation sensitivities of CRP cut-off values were > 3.5 mg/L (97.6%), > 10 mg/L (97.6%), > 30 mg/L (90.4%), and > 50 mg/L (85.7%). CONCLUSIONS CRP cut-offs beyond the upper limit of normal had high sensitivity for pyogenic spinal infection in this adult ED population. Elevated CRP cut-off values of 10 mg/L and 30 mg/L require validation in other settings.
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22
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Smith DE, Siket MS. High-Risk Chief Complaints III: Neurologic Emergencies. Emerg Med Clin North Am 2020; 38:523-537. [PMID: 32336338 DOI: 10.1016/j.emc.2020.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A careful history and thorough physical examination are necessary in patients presenting with acute neurologic dysfunction. Patients presenting with headache should be screened for red-flag criteria that suggest a dangerous secondary cause warranting imaging and further diagnostic workup. Dizziness is a vague complaint; focusing on timing, triggers, and examination findings can help reduce diagnostic error. Most patients presenting with back pain do not require emergent imaging, but those with new neurologic deficits or signs/symptoms concerning for acute infection or cord compression warrant MRI. Delay to diagnosis and treatment of acute ischemic stroke is a frequent reason for medical malpractice claims.
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Affiliation(s)
- Danielle E Smith
- Robert Larner College of Medicine of the University of Vermont, 89 Beaumont Avenue, Burlington, VT 05405, USA
| | - Matthew S Siket
- Surgery, Larner College of Medicine at the University of Vermont, 111 Colchester Avenue, EC 2, Burlington, VT 05401, USA.
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23
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Lee CC, Chang WK. Response to: A rare case of holocord spinal epidural abscess. QJM 2020; 113:304. [PMID: 31693142 DOI: 10.1093/qjmed/hcz292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- C-C Lee
- Division of Cardiology, No. 325, Chengong Road, Section 2, Neihu, Taipei 114, Taiwan
| | - W-K Chang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, No. 325, Chengong Road, Section 2, Neihu, Taipei 114, Taiwan
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24
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Yentis SM, Lucas DN, Brigante L, Collis R, Cowley P, Denning S, Fawcett WJ, Gibson A. Safety guideline: neurological monitoring associated with obstetric neuraxial block 2020. Anaesthesia 2020; 75:913-919. [DOI: 10.1111/anae.14993] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2019] [Indexed: 11/28/2022]
Affiliation(s)
- S. M. Yentis
- Department of Anaesthesia Chelsea and Westminster Hospital London UK
- Imperial College Working Party co‐Chair and Association of Anaesthetists London UK
| | - D. N. Lucas
- Department of Anaesthesia Northwick Park Hospital Working Party co‐Chair and Obstetric Anaesthetists’ Association London UK
| | - L. Brigante
- Quality and Standards Advisor Royal College of Midwives London UK
| | - R. Collis
- Department of Anaesthesia University Hospital of Wales Obstetric Anaesthetists’ Association Cardiff UK
| | - P. Cowley
- Department of Radiology National Hospital for Neurology and Neurosurgery London UK
| | - S. Denning
- East Midlands School of Anaesthesia Association of Anaesthetists Training Committee UK
| | - W. J. Fawcett
- Royal Surrey County Hospital Association of Anaesthetists Guildford Surrey UK
| | - A. Gibson
- Department of Surgery Royal National Orthopaedic Hospital British Association of Spinal Surgeons Stanmore Middlesex UK
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Davis WT, April MD, Mehta S, Long B, Shroyer S. High risk clinical characteristics for pyogenic spinal infection in acute neck or back pain: Prospective cohort study. Am J Emerg Med 2020; 38:491-496. [DOI: 10.1016/j.ajem.2019.05.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 05/08/2019] [Accepted: 05/13/2019] [Indexed: 11/15/2022] Open
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Corwell BN, Davis NL. The Emergent Evaluation and Treatment of Neck and Back Pain. Emerg Med Clin North Am 2019; 38:167-191. [PMID: 31757249 DOI: 10.1016/j.emc.2019.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Neck and back pain are among the most common symptom-related complaints for visits to the emergency department (ED). They contribute to high levels of lost work days, disability, and health care use. The goal of ED assessment of patients with neck and back pain is to evaluate for potentially dangerous causes that could result in significant morbidity and mortality. This article discusses the efficient and effective evaluation, management, and treatment of patients with neck and back pain in the ED. Emphasis is placed on vertebral osteomyelitis, epidural abscess, acute transverse myelitis, epidural compression syndrome, spinal malignancy, and spinal stenosis.
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Affiliation(s)
- Brian N Corwell
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S. Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA; Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Natalie L Davis
- Department of Pediatrics, University of Maryland School of Medicine, 110 S. Paca Street, 8th Floor, Baltimore, MD 21201, 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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Freeman CW, Lazor JW, Loevner LA, Nabavizadeh SA. Variations of the CNS Venous System Mimicking Pathology: Spectrum of Imaging Findings. J Neuroimaging 2019; 29:673-688. [DOI: 10.1111/jon.12664] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/05/2019] [Accepted: 09/06/2019] [Indexed: 12/18/2022] Open
Affiliation(s)
- Colbey W. Freeman
- Department of RadiologyHospital of the University of Pennsylvania Philadelphia PA
| | - Jillian W. Lazor
- Division of Neuroradiology, Department of RadiologyHospital of the University of Pennsylvania Philadelphia PA
| | - Laurie A. Loevner
- Division of Neuroradiology, Department of RadiologyHospital of the University of Pennsylvania Philadelphia PA
| | - Seyed Ali Nabavizadeh
- Division of Neuroradiology, Department of RadiologyHospital of the University of Pennsylvania Philadelphia PA
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Abstract
PURPOSE OF REVIEW Brain abscesses and spinal epidural abscesses are serious, potentially life-threatening infections of the central nervous system. This article outlines the clinical presentation, evaluation, and management of brain abscesses and spinal epidural abscesses, with a specific focus on bacterial infections. RECENT FINDINGS The overall incidence of brain abscesses has declined, in part because of fewer brain abscesses associated with otogenic infections. However, emerging patient populations at high risk for brain abscess include those with a history of penetrating head trauma, neurosurgery, or immunodeficiency. Improved mortality rates for brain abscess are attributable to modern diagnostic imaging, stereotactic-guided aspiration, and newer antimicrobials that readily penetrate into the central nervous system and abscesses. Brain MRI is more sensitive than CT for brain abscess, particularly in the early stages, but CT remains more widely available and can adequately identify potential abscesses and confirm response to treatment. With the advent of minimally invasive neurosurgical techniques, surgical excision is often employed only for posterior fossa, multiloculated, or superficial well-circumscribed abscesses. In select clinical scenarios, conservative medical management may be a safe alternative to a combined surgical and medical approach. Unlike brain abscess, the incidence of spinal epidural abscess is on the rise and has been attributed to higher prevalence of predisposing factors, including spinal procedures and instrumentation. SUMMARY Successful diagnosis and management of brain abscess and spinal epidural abscess requires a collaborative approach among neurologists, neurosurgeons, radiologists, and infectious disease physicians. The foundation of management of brain abscess includes surgical intervention for diagnostic purposes if a pathogen has not been identified or for decompression of larger abscesses or those with mass effect and significant surrounding edema; appropriate dosing and adequate duration of an antimicrobial regimen tailored to the presumptive source of infection and available culture data, and eradication of the primary source of infection. For spinal epidural abscesses, neurologic status at the time of presentation is directly related to outcomes, underscoring the importance of prompt recognition and intervention.
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Yang X, Guo R, Lv X, Lai Q, Xie B, Jiang X, Dai M, Zhang B. Challenges in diagnosis of spinal epidural abscess: A case report. Medicine (Baltimore) 2019; 98:e14196. [PMID: 30702572 PMCID: PMC6380696 DOI: 10.1097/md.0000000000014196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 12/14/2018] [Accepted: 12/24/2018] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Spinal epidural abscess (SEA) is a rare condition that shows a high prevalence in immunocompromised patients. The clinical presentation of SEA includes the "classic triad" of pain, fever, and neurological dysfunction. However, these nonspecific features can lead to a high rate of misdiagnosis. SEA may lead to paralysis or even death; thus, prognosis of these patients remains unfavorable. PATIENT CONCERNS We report a case of a multilevel (T6-T12) SEA in a 22-year-old woman. DIAGNOSIS The patient was initially diagnosed with spinal tuberculosis at a local hospital based on a history of tuberculosis exposure, as well as radiography and computed tomography. Histopathological examination of the tissue resected during laminectomy confirmed the diagnosis of SEA in this patient. INTERVENTIONS The patient underwent multilevel laminectomy combined with long-term antibiotic therapy. OUTCOMES Physical examination performed 16 months postoperatively revealed that superficial and deep sensation was restored to normal levels in the lower extremities with improvement in the patient's motor function (muscle strength 2/5). LESSONS This case report indicates that whole spine magnetic resonance imaging is warranted in patients with SEA and that prompt surgical intervention is important at symptom onset. Long-term antibiotic therapy is also essential postoperatively.
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Affiliation(s)
| | | | - Xin Lv
- Department of Orthopedics
| | - Qi Lai
- Department of Orthopedics
| | | | - Xiaozhen Jiang
- Department of pathology, The First Affiliated Hospital of Nanchang University, No. 17 Yong Wai Zheng Street, Nanchang, Jiangxi, China
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Fotaki A, Anatoliotaki M, Tritou I, Tzagaraki A, Kampitaki M, Vlachaki G. Review and case report demonstrate that spontaneous spinal epidural abscesses are rare but dangerous in childhood. Acta Paediatr 2019; 108:28-36. [PMID: 30222897 DOI: 10.1111/apa.14579] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 07/03/2018] [Accepted: 09/12/2018] [Indexed: 01/27/2023]
Abstract
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.
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Affiliation(s)
| | | | - Ioanna Tritou
- Radiology Department Venizeleio General Hospital Crete Greece
| | | | - Maria Kampitaki
- Pediatric Department University Hospital of Crete Crete Greece
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Long B, Koyfman A. The Emergency Department Diagnosis and Management of Urinary Tract Infection. Emerg Med Clin North Am 2018; 36:685-710. [PMID: 30296999 DOI: 10.1016/j.emc.2018.06.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Urinary tract infection (UTI) is a common infection seen in the emergency department. The spectrum of UTI includes simple versus complicated infection and lower versus upper UTI. No one history or examination finding is definitive for diagnosis. Testing often includes urinalysis and/or urine dipstick, and several pitfalls may occur in interpretation. Urine cultures should be obtained in complicated or upper UTIs but not simple and lower tract UTIs, unless a patient is pregnant. Imaging often is not required. Most patients with simple cystitis and pyelonephritis are treated as outpatients. A variety of potentially dangerous conditions may mimic UTI and pyelonephritis.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, 3841 Roger Brooke Drive, Fort Sam Houston, TX 78234, USA.
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
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Spiegel Strauss TN, Pachtman SL, Rochelson B. Bacterial Spinal Epidural and Psoas Abscess in Pregnancy Associated with Intravenous Drug Use. Case Rep Obstet Gynecol 2018; 2018:1797421. [PMID: 29992066 PMCID: PMC6016220 DOI: 10.1155/2018/1797421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 05/16/2018] [Indexed: 11/17/2022] Open
Abstract
Spontaneous spinal epidural abscess (SEA) is a rare infection of the central nervous system. We report a case of a 25-year-old G3 P0020 at 36 weeks of gestational age with history of intravenous drug abuse presenting with acute-onset and severe back pain. Despite antibiotic therapy, pain worsened and she developed lower extremity weakness. Magnetic resonance imaging (MRI) revealed an SEA, and cesarean delivery was performed secondary to increasing weakness, followed by laminectomy (T9-12) and decompression of epidural abscess. Postoperative course was complicated by a psoas muscle abscess and persistent SEA refractory to antibiotic therapy, requiring surgical reexploration and extended treatment with antibiotics. She was discharged home in stable condition and neonate did well with no resulting sequelae. Spinal epidural and psoas abscesses are rare and diagnosis is often delayed. Prompt recognition and treatment are necessary to prevent catastrophic neurologic consequences, and the diagnosis should be considered in pregnant patients presenting with back pain, especially in those with risk factors.
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Affiliation(s)
- Tirtza N. Spiegel Strauss
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, NY, USA
| | - Sarah L. Pachtman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, NY, USA
| | - Burton Rochelson
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, NY, USA
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Muck AE, Balhara K, Olson AS. Finding the needle in the haystack. Intern Emerg Med 2018; 13:219-221. [PMID: 29230629 DOI: 10.1007/s11739-017-1772-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Accepted: 11/24/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Andrew Evan Muck
- University of Texas Health at San Antonio, San Antonio, Texas, USA.
| | - Kamna Balhara
- University of Texas Health at San Antonio, San Antonio, Texas, USA
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