1
|
Hunter S, Ou C, Baker JF. Early Reduction in C-Reactive Protein Following Treatment for Spinal Epidural Abscess: A Potential Treatment Guide. Global Spine J 2024; 14:1296-1303. [PMID: 36802919 DOI: 10.1177/21925682221139801] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023] Open
Abstract
STUDY DESIGN Retrospective Cohort Study. OBJECTIVE To assess the predictive value of early C-reactive protein (CRP) trends following diagnosis of spinal epidural abscess (SEA). Non-operative management with intravenous antibiotics has not demonstrated equivalent outcomes with regard to mortality and morbidity. Knowledge of specific patient and disease factors associated with worse outcomes may predict treatment failure. METHODS All patients treated for spontaneous SEA in a tertiary centre in New Zealand over a 10-year period were followed for at least 2 years. CRP at diagnosis and day 4-5 following treatment initiation was analyzed to determine predictors of CRP reduction of at least 50%. Proportional Cox hazards regression investigated mortality over 2 years. RESULTS 94 patients met inclusion criteria and with CRP values available for analysis. Median age was 62 years (+/- 17.7) and 59 (63%) were treated operatively. Kaplan-Meier analysis estimate of 2-year survival was .81 (95% CI .72-.88). CRP reduction by 50% was seen in 34 patients. Patients who did not experience a 50% reduction were more likely to have thoracic infection (27 vs 8, P = .02) or multifocal sepsis (41 vs 13, P = .002). Failure to achieve a 50% reduction by day 4-5 was associated with worse post-treatment Karnofsky scores (70 vs 90, P = .03) and longer hospital stay (25 days vs 17.5 days, P = .04). Cox regression model showed mortality predicted by Charlson Comorbidity Index, thoracic location of infection, pre-treatment Karnofsky score, and failure to achieve a 50% CRP reduction by day 4-5. CONCLUSIONS Patients who fail to reduce CRP values by 50% at day 4-5 following treatment initiation are more likely to experience prolonged hospital stay, have poorer functional outcome and have greater mortality risk at 2 years. This group has severe illness regardless of treatment type. Failure to achieve a biochemical response to treatment should prompt reassessment.
Collapse
Affiliation(s)
- Sarah Hunter
- Department of Orthopaedic Surgery, University of Auckland, Waikato Hospital, Hamilton, New Zealand
| | - Cindy Ou
- Department of Orthopaedic Surgery, University of Auckland, Waikato Hospital, Hamilton, New Zealand
| | - Joseph F Baker
- Department of Orthopaedic Surgery, University of Auckland, Waikato Hospital, Hamilton, New Zealand
- Department of Surgery, University of Auckland, Waikato Hospital, Hamilton, New Zealand
| |
Collapse
|
2
|
Chen M, Baumann AN, Fraiman ET, Cheng CW, Furey CG. Long-term survivability of surgical and nonsurgical management of spinal epidural abscess. Spine J 2024; 24:748-758. [PMID: 38211902 DOI: 10.1016/j.spinee.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 12/05/2023] [Accepted: 12/27/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND CONTEXT Spinal epidural abscess (SEA) is a rare and life-threatening infection within the epidural space with significant functional impairment and morbidity. Active debate remains over whether to operate for SEAs, with limited existing data comparing the long-term survivability after surgical versus nonsurgical management. PURPOSE This study aims to determine the long-term survival of patients who underwent surgical and nonsurgical management for SEA. STUDY DESIGN Retrospective cohort study. PATIENT SAMPLE A total of 250 consecutive SEA patients. OUTCOME MEASURES Survival and mortality rates, complications. METHODS All patients treated at a tertiary medical center for a primary SEA from January 2000 to June 2020 are identified. Data collection is by retrospective chart review. Cox proportional hazards regression models are used for all survival analyses while controlling for potential confounding variables and with multiple testing corrections. RESULTS A total of 35 out of 250 patients died with an overall all-cause mortality of 14%. More than half of all deaths occurred within 90 days after treatment. The 90-day, 3-year, and 5-year survival rates are 92.8%, 89.2%, and 86.4%, respectively. Among surgery patients, the all-cause mortality was 13.07%, compared to 16.22% for medically-managed patients. Surgical treatment (decompression, fusion, debridement) significantly reduced the risk of death by 62.4% compared to medical therapy (p=.03), but surgery patients experienced a significantly longer mean length of stay (p=.01). Risk factors of short-term mortality included hypoalbuminemia (<3.5 g/dL), American Society of Anesthesiologists (ASA) 4+, and cardiac arrest. Risk factors of long-term mortality were immunocompromised state, elevated WBC count >12,000, sepsis, septic shock, ASA 4+, and cardiac arrest (p<.05). In terms of complications, surgically-managed patients experienced a higher proportion of deep vein thrombosis (p<.05). CONCLUSIONS The overall long-term survivability of SEA treatment is relatively high at (86% at 5-year) in this study. The following SEA mortality risk factors were identified: hypoalbuminemia (short-term), immunocompromised state (long-term), leukocytosis (long-term), sepsis and septic shock (long-term), ASA 4+ and cardiac arrest (overall). For primary SEA patients, surgical management may reduce mortality risk compared to nonsurgical management.
Collapse
Affiliation(s)
- Mingda Chen
- School of Medicine, Case Western Reserve University, 9501 Euclid Ave, Cleveland, OH 44106, USA.
| | - Anthony N Baumann
- Northeast Ohio Medical University, 4209 State Route 44. Rootstown, OH 44272, USA
| | - Elad T Fraiman
- School of Medicine, Case Western Reserve University, 9501 Euclid Ave, Cleveland, OH 44106, USA
| | - Christina W Cheng
- School of Medicine, Case Western Reserve University, 9501 Euclid Ave, Cleveland, OH 44106, USA; Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH 44106, USA
| | - Christopher G Furey
- School of Medicine, Case Western Reserve University, 9501 Euclid Ave, Cleveland, OH 44106, USA; Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH 44106, USA
| |
Collapse
|
3
|
Lenga P, Gülec G, Kiening K, Unterberg AW, Ishak B. Surgical management of ventrally located cervical epidural abscess: A comparative analysis between patients aged 18-64 years and ≥65 years. World Neurosurg X 2024; 22:100344. [PMID: 38455241 PMCID: PMC10918261 DOI: 10.1016/j.wnsx.2024.100344] [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: 05/15/2023] [Accepted: 02/21/2024] [Indexed: 03/09/2024] Open
Abstract
Background We aimed to compare the clinical course of patients aged 18-65 years and ≥65years who underwent anterior cervical discectomy and fusion (ACDF) or corpectomy for ventrally located CSEA. Methods Clinical and imaging data were retrospectively collected from the institutional database between September 2005 and December 2021. Results A total of 35 and 26 patients aged 18-64 and ≥ 65 years, respectively who were diagnosed with ventrally located CSEA were included. The overall mean age was 63.9 ± 3.2 years, with a predominance of the male sex (n = 43/61, 70.5%). Patients aged ≥65 years presented with significantly higher rates of comorbidities (10.3 ± 2.8), as indicated by the CCI, than their younger counterparts (18-64 years: 6.2 ± 2.6; p < 0.001). No differences in the surgical approach or characteristics were observed among the groups. Notably, patients aged ≥65 years had a significantly longer intensive care unit as well as overall hospital stay. In-hospital and 90-day mortality were similar across both groups. Following both types of surgery, a significant improvement was observed in the blood infection parameters and neurological status at discharge compared with the baseline measurements. Older age, higher rates of comorbidities, and higher grades of disability were significant predictors for mortality. Conclusions Emergency surgical evacuation should be undertaken for CSEA in the presence of acute neurological deterioration regardless of the age. Factors, such as age, comorbidities, and neurological status on admission appear to be important predictors of disease outcomes. However, the risk profile of younger patients should not be underestimated.
Collapse
Affiliation(s)
- Pavlina Lenga
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Gelo Gülec
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Karl Kiening
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Basem Ishak
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| |
Collapse
|
4
|
Nery B, Filho CB, Nunes L, Quaggio E, Filho FB, Neto JA, Melo LR, Oliveira AC, Rabello R, Durand VR, Silva RR, Costa RE, Segundo JA. Acute Paraplegia Caused by Spinal Epidural Empyema Following Infectious Cellulitis of the Hand: Case Report and Literature Review. J Neurol Surg Rep 2024; 85:e29-e38. [PMID: 38596232 PMCID: PMC11001457 DOI: 10.1055/a-2267-1810] [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: 07/04/2023] [Accepted: 01/14/2024] [Indexed: 04/11/2024] Open
Abstract
Background Spinal epidural abscess is a rare but serious condition that can cause spinal cord compression and neurological deficits. Case Description and Methods The article reports a case of a 31-year-old patient who presented with an infectious cellulitis in the left hand, which progressed to a spinal epidural abscess. The diagnosis was confirmed by clinical examination and magnetic resonance imaging. Treatment involved laminectomy, after which the patient had complete recovery of neurological deficits. This article is a case report with a literature review. Patient data and images were collected by the researchers who participated in the patient's care. The literature was reviewed by one of the researchers based on the search for articles in the PubMed database. For the research, the following keywords were inserted: "Spinal epidural empyema," "Spinal epidural abscess." Conclusion Spinal epidural abscess is often underdiagnosed, which can lead to delays in treatment and serious complications. The relationship between cellulitis and spinal epidural abscess may be related to the spread of infection through the lymphatic or blood system.
Collapse
Affiliation(s)
- Breno Nery
- Department of Neurosurgery, Hospital Beneficiência Portuguesa de Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Cláudio Brandão Filho
- Department of Neurosurgery, Hospital Beneficiência Portuguesa de Ribeirão Preto, Ribeirão Preto, SP, Brazil
- Department of Neurosurgery, Universitary Center Unifacisa, Campina Grande, Paraíba, Brazil
| | - Lucas Nunes
- Department of Neurosurgery, Hospital Beneficiência Portuguesa de Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Eduardo Quaggio
- Department of Neurosurgery, Hospital Beneficiência Portuguesa de Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Fred Bernardes Filho
- Department of Neurosurgery, Hospital Beneficiência Portuguesa de Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Joaquim Alencar Neto
- Department of Neurosurgery, Hospital Beneficiência Portuguesa de Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Layssa Rhossana Melo
- Department of Neurosurgery, Hospital Beneficiência Portuguesa de Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Anna Carolyne Oliveira
- Department of Neurosurgery, Hospital Beneficiência Portuguesa de Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Rafael Rabello
- Department of Neurosurgery, Hospital Beneficiência Portuguesa de Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Victoria Rodrigues Durand
- Department of Neurosurgery, Hospital Beneficiência Portuguesa de Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Rayssa Rocha Silva
- Department of Neurosurgery, Hospital Beneficiência Portuguesa de Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Rafael Emmanuel Costa
- Department of Neurosurgery, Hospital Beneficiência Portuguesa de Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - José Alencar Segundo
- Department of Neurosurgery, Hospital Beneficiência Portuguesa de Ribeirão Preto, Ribeirão Preto, SP, Brazil
| |
Collapse
|
5
|
Lu KY, Tung WE, Chiang CJ, Hsieh YY, Chen CH, Lee MH, Yen MH, Lu PW, Wu LC. Sciatica caused by spinal epidural abscess as the initial clinical presentation of colon cancer: a rare case report and review of literature. BMC Infect Dis 2024; 24:293. [PMID: 38448866 PMCID: PMC10916147 DOI: 10.1186/s12879-024-09159-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 02/20/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Colorectal cancer is one of the most frequently diagnosed forms of cancer, and it is associated with several common symptoms and signs such as rectal bleeding, altered bowel habits, abdominal pain, anemia, and unintentional weight loss. Sciatica, a debilitating condition in which the patient experiences paresthesia and pain in the dermatome of associated lumbosacral nerve roots or sciatic nerve distribution, is not considered one of these. Here we present a case of colorectal cancer manifesting symptoms of sciatica alone. CASE PRESENTATION A 68-year-old male presented with progressive lower back pain radiating to his left thigh and calf over L5/S1 dermatome. Sciatica was suspected and initially underwent conservative treatment with analgesics. However, the symptoms progressed and MRI revealed an epidural abscess surprisingly. Surgical debridement was performed and pus culture isolated Streptococcus gallolyticus. Based on the strong association of S. gallolyticus with colorectal cancer, the presence of this pathogen prompted further tumor evaluation, even in the absence of the typical symptoms and signs. This investigation ultimately leads to the diagnosis of sigmoid adenocarcinoma. CONCLUSIONS Although rare, sciatica caused by S. gallolyticus infection of the spinal epidural space may serve as the initial presentation of colorectal cancer. Physicians should be aware of the strong association between S. gallolyticus and colorectal cancer. Based on what we currently know about the condition; a thorough systematic assessment of occult neoplasia for patients with S. gallolyticus infection is recommended.
Collapse
Affiliation(s)
- Kuan-Yu Lu
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, 23561, Taiwan
| | - Wei-En Tung
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, 23561, Taiwan
| | - Chang-Jung Chiang
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, 23561, Taiwan
- Department of Orthopedic Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, 110, Taiwan
| | - Yueh-Ying Hsieh
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, 23561, Taiwan
- Department of Orthopedic Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, 110, Taiwan
| | - Chia-Hsien Chen
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, 23561, Taiwan
- School of Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei City, Taiwan
| | - Mei-Hui Lee
- Division of Infectious Diseases, Department of Internal Medicine, Shuang-Ho Hospital, Taipei Medical University, New Taipei City, 23561, Taiwan
| | - Min-Hsuan Yen
- Division of Colorectal Surgery, Department of Surgery, Shuang-Ho Hospital, Taipei Medical University, New Taipei City, 23561, Taiwan
| | - Po-Wen Lu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, 23561, Taiwan
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei City, 110, Taiwan
| | - Lien-Chen Wu
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, 23561, Taiwan.
- Department of Orthopedic Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, 110, Taiwan.
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei City, 110, Taiwan.
| |
Collapse
|
6
|
Nguyen N, Chua HC, Drake T, Jo J, Stramel SA, Vuong NN, Gonzales-Luna AJ, Olson K, On Behalf Of The Houston Infectious Diseases Network. Significant Publications on Infectious Diseases Pharmacotherapy in 2021. J Pharm Pract 2024; 37:198-211. [PMID: 36122416 DOI: 10.1177/08971900221128334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To summarize the most noteworthy infectious diseases (ID) pharmacotherapy articles published in peer-reviewed literature in 2021. Summary: Members of the Houston Infectious Diseases Network (HIDN) nominated articles that were deemed to have significant contributions to ID pharmacotherapy in 2021. These nominations included articles pertaining to both general ID, including coronavirus disease 2019 (COVID-19), and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) pharmacotherapy. A total of 35 articles were nominated by HIDN: 30 articles pertaining to general ID pharmacotherapy and 5 articles with HIV/AIDS focus. To select the most influential articles of 2021, a survey was created and distributed to members of the Society of Infectious Diseases Pharmacists (SIDP). Of the 239 SIDP members who responded to the survey, there were 192 recorded votes for the top 10 general ID pharmacotherapy articles and 47 recorded votes for the top HIV/AIDS article, respectively. The top publications are summarized. Conclusion: Antimicrobial stewardship and the optimal management of infectious disease states continues to be a priority in the midst of the ongoing coronavirus disease 2019 (COVID-19) global pandemic. In light of the sheer volume of ID-related articles published in the past year, this review aims to aid clinicians in remaining up-to-date on key practice-changing ID pharmacotherapy publications from 2021.
Collapse
Affiliation(s)
- Nhi Nguyen
- Department of Pharmacy, The University of Texas Medical Branch, Galveston, TX, USA
| | - Hubert C Chua
- Department of Pharmacy, CHI Baylor St Luke's Medical Center, Houston, TX, USA
| | - Ty Drake
- Department of Pharmacy, Houston Methodist Willowbrook Hospital, Houston, TX, USA
| | - Jinhee Jo
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
| | - Stefanie Anne Stramel
- Department of Pharmacy, Memorial Hermann Memorial City Medical Center, Houston, TX, USA
| | - Nancy N Vuong
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anne J Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
| | - Kelsey Olson
- Department of Pharmacy, HCA Houston Healthcare Clear Lake, Webster, TX, USA
| | | |
Collapse
|
7
|
Kumru H, Uzquiano JC, Cabiol J, Escudero MB, Albu S. Holospinal epidural abscess with multiple muscle abscesses and aortic valve endocarditis: case report. Acta Neurol Belg 2024; 124:295-297. [PMID: 37209258 DOI: 10.1007/s13760-023-02290-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 05/15/2023] [Indexed: 05/22/2023]
Affiliation(s)
- Hatice Kumru
- Institut Guttmann, Institut Universitari de Neurorehabilitació adscrit a la UAB, Camí Can Ruti s/n., Badalona, 089M6, Barcelona, Spain.
- Univ Autonoma de Barcelona, 08M93, Bellaterra (Cerdanyola del Vallès), Spain.
- Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Barcelona, Spain.
| | - Juan C Uzquiano
- Institut Guttmann, Institut Universitari de Neurorehabilitació adscrit a la UAB, Camí Can Ruti s/n., Badalona, 089M6, Barcelona, Spain
- Univ Autonoma de Barcelona, 08M93, Bellaterra (Cerdanyola del Vallès), Spain
- Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Josep Cabiol
- Neurosurgery, Hospital General of Catalunya, 08195, Sant Cugat del Vallès, Spain
| | - M Belen Escudero
- Intensive Medicine Unit, Hospital General of Catalunya, 08195, Sant Cugat del Vallès, Spain
| | - Sergiu Albu
- Institut Guttmann, Institut Universitari de Neurorehabilitació adscrit a la UAB, Camí Can Ruti s/n., Badalona, 089M6, Barcelona, Spain
- Univ Autonoma de Barcelona, 08M93, Bellaterra (Cerdanyola del Vallès), Spain
- Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Barcelona, Spain
| |
Collapse
|
8
|
Hijazi MM, Siepmann T, El-Battrawy I, Aweimer A, Engellandt K, Podlesek D, Schackert G, Juratli TA, Eyüpoglu IY, Filis A. Diagnostics, Management, and Outcomes in Patients with Pyogenic Spinal Intra- or Epidural Abscess. J Clin Med 2023; 12:7691. [PMID: 38137760 PMCID: PMC10744009 DOI: 10.3390/jcm12247691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 12/10/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Owing to the lack of evidence on the diagnostics, clinical course, treatment, and outcomes of patients with extremely rare spinal intradural abscess (SIA) and spinal epidural abscess (SEA), we retrospectively analyzed and compared a cohort of patients to determine the phenotyping of both entities. METHODS Over a period of 20 years, we retrospectively analyzed the electronic medical records of 78 patients with SIA and SEA. RESULTS The patients with SIA showed worse motor scores (MS scores) on admission (SIA: 20 ± 26 vs. SEA: 75 ± 34, p < 0.001), more often with an ataxic gait (SIA: 100% vs. SEA: 31.8%, p < 0.001), and more frequent bladder or bowel dysfunction (SIA: 91.7% vs. SEA: 27.3%, p < 0.001) compared to the SEA patients. Intraoperative specimens showed a higher diagnostic sensitivity in the SEA patients than the SIA patients (SIA: 66.7% vs. SEA: 95.2%, p = 0.024), but various pathogens such as Staphylococcus aureus (SIA 33.3% vs. SEA: 69.4%) and Streptococci and Enterococci (SIA 33.3% vs. SEA: 8.1%, p = 0.038) were detected in both entities. The patients with SIA developed sepsis more often (SIA: 75.0% vs. SEA: 18.2%, p < 0.001), septic embolism (SIA: 33.3% vs. SEA: 8.3%, p = 0.043), signs of meningism (SIA: 100% vs. 18.5%, p < 0.001), ventriculitis or cerebral abscesses (SIA: 41.7% vs. SEA: 3.0%, p < 0.001), and pneumonia (SIA: 58.3% vs. SEA: 13.6%, p = 0.002). The mean MS score improved in both patient groups after surgery (SIA: 20 to 35 vs. SEA: 75 to 90); however, the SIA patients showed a poorer MS score at discharge (SIA: 35 ± 44 vs. SEA: 90 ± 20, p < 0.001). C-reactive protein (CrP) (SIA: 159 to 49 vs. SEA: 189 to 27) and leukocyte count (SIA: 15 to 9 vs. SEA: 14 to 7) were reduced at discharge. The SIA patients had higher rates of disease-related mortality (SIA: 33.3% vs. SEA: 1.5%, p = 0.002), had more pleural empyema (SIA: 58.3% vs. SEA: 13.6%, p = 0.002), required more than one surgery (SIA: 33.3% vs. SEA 13.6%, p = 0.009), were treated longer with intravenous antibiotics (7 ± 4 w vs. 3 ± 2 w, p < 0.001) and antibiotics overall (12 ± 10 w vs. 7 ± 3 w, p = 0.022), and spent more time in the hospital (SIA: 58 ± 36 vs. SEA: 26 ± 20, p < 0.001) and in the intensive care unit (SIA: 14 ± 18 vs. SEA: 4 ± 8, p = 0.002). CONCLUSIONS Our study highlighted distinct clinical phenotypes and outcomes between both entities, with SIA patients displaying a markedly less favorable disease course in terms of complications and outcomes.
Collapse
Affiliation(s)
- Mido Max Hijazi
- Department of Neurosurgery, Division of Spine Surgery, Faculty of Medicine, Technische Universität Dresden, University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany; (D.P.); (G.S.); (T.A.J.); (I.Y.E.); (A.F.)
| | - Timo Siepmann
- Department of Neurology, Faculty of Medicine, Technische Universität Dresden, 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; (I.E.-B.); (A.A.)
| | - Assem Aweimer
- Department of Cardiology, Bergmannsheil University Hospital, Ruhr University Bochum, Bürkle De La Camp-Platz 1, 44789 Bochum, Germany; (I.E.-B.); (A.A.)
| | - Kay Engellandt
- Institute of Diagnostic and Interventional Neuroradiology, Faculty of Medicine, Technische Universität Dresden, University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany;
| | - Dino Podlesek
- Department of Neurosurgery, Division of Spine Surgery, Faculty of Medicine, Technische Universität Dresden, University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany; (D.P.); (G.S.); (T.A.J.); (I.Y.E.); (A.F.)
| | - Gabriele Schackert
- Department of Neurosurgery, Division of Spine Surgery, Faculty of Medicine, Technische Universität Dresden, University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany; (D.P.); (G.S.); (T.A.J.); (I.Y.E.); (A.F.)
| | - Tareq A. Juratli
- Department of Neurosurgery, Division of Spine Surgery, Faculty of Medicine, Technische Universität Dresden, University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany; (D.P.); (G.S.); (T.A.J.); (I.Y.E.); (A.F.)
| | - Ilker Y. Eyüpoglu
- Department of Neurosurgery, Division of Spine Surgery, Faculty of Medicine, Technische Universität Dresden, University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany; (D.P.); (G.S.); (T.A.J.); (I.Y.E.); (A.F.)
| | - Andreas Filis
- Department of Neurosurgery, Division of Spine Surgery, Faculty of Medicine, Technische Universität Dresden, University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany; (D.P.); (G.S.); (T.A.J.); (I.Y.E.); (A.F.)
| |
Collapse
|
9
|
Dhodapkar MM, Patel T, Rubio DR. Imaging in spinal infections: Current status and future directions. NORTH AMERICAN SPINE SOCIETY JOURNAL 2023; 16:100275. [PMID: 37822347 PMCID: PMC10562850 DOI: 10.1016/j.xnsj.2023.100275] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/27/2023] [Accepted: 09/02/2023] [Indexed: 10/13/2023]
Abstract
Imaging plays an important role in the diagnosis of spinal infections. Early diagnosis is paramount in the treatment of spinal infections and leads to improved outcomes. This article reviews the imaging and relevant clinical details of infections of the spine: pyogenic spondylodiscitis, tuberculous spondylodiscitis, septic facet arthritis, epidural abscess, and subdural abscess. Though radiographs can reveal subtle changes with infections, advanced imaging modalities have increased sensitivity to aid in early diagnosis. Magnetic resonance imaging (MRI) is emphasized given it is generally the most sensitive and specific advanced imaging modality. However, nuclear medicine imaging and computer tomography (CT) play a role diagnosis in cases where MRI is not available or contra-indicated. Additionally, CT is also important for image-guided biopsy to guide antimicrobial treatment.
Collapse
Affiliation(s)
- Meera M. Dhodapkar
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Tamanna Patel
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Daniel R. Rubio
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| |
Collapse
|
10
|
Reinas R, Alves ÓL, Kitumba D, Baptista AM. Surgical treatment of an all-spine epidural empyema. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2023; 14:438-441. [PMID: 38268691 PMCID: PMC10805168 DOI: 10.4103/jcvjs.jcvjs_109_23] [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: 08/30/2023] [Accepted: 10/01/2023] [Indexed: 01/26/2024] Open
Abstract
Spinal epidural empyema (SEE) is a severe infectious disease of the spine which may cause significant morbidity and mortality. Surgical drainage of the empyema is a key feature. However, approach-related morbidity may be significant in very extensive collections. We present the case of a 55-year-old female with an empyema due to methicillin-susceptible Staphylococcus aureus spawning from C2 to S1. She underwent drainage of the pus through skip-level laminectomies and catheter epidural saline irrigation. The technique described was both safe and effective at treating the SEE, and the patient returned to normal life.
Collapse
Affiliation(s)
- Rui Reinas
- Department of Neurosurgery, Centro Hospitalar De Vila Nova De Gaia, Vila Nova de Gaia, Portugal
| | - Óscar L. Alves
- Department of Neurosurgery, Centro Hospitalar De Vila Nova De Gaia, Vila Nova de Gaia, Portugal
- Department of Neurosurgery, Hospital Lusíadas Porto, Porto, Portugal
| | - Djamel Kitumba
- Department of Neurosurgery, Complexo Hospitalar Cardeal D. Alexandre do Nascimento, Luanda, Angola
| | | |
Collapse
|
11
|
Janssen IK, Ryang YM, Wostrack M, Shiban E, Meyer B. Incidence and outcome of patients suffering from meningitis due to spondylodiscitis. BRAIN & SPINE 2023; 3:101781. [PMID: 38020984 PMCID: PMC10668068 DOI: 10.1016/j.bas.2023.101781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 05/23/2023] [Accepted: 07/10/2023] [Indexed: 12/01/2023]
Abstract
Introduction Meningitis is a rare but severe complication in patients with spondylodiscitis. Data about the incidence and clinical management are rare. Research question Aim of this study was to assess the incidence, clinical course and outcome of patients suffering from meningitis due to spondylodiscitis. Material and methods We performed a retrospective analysis of our prospective clinical database that included all patients suffering from spondylodiscitis between January 2010 and December 2019 were included. We assessed clinical findings, laboratory tests, treatment and outcome comparing patients with and without meningitis. Results Out of 469 patients suffering from spondylodiscitis, 30 patients (14 female) were diagnosed with an associated meningitis (6.4%). The mean CSF cell count was 3375.85 ± 8486.78/μl (range 32-41500/μl). The mean age at presentation was 70.87 ± 8.84 yrs (range 48-88 yrs). Mean C-reactive protein (CRP) and white blood cell (WBC) counts at time of admission were statistically higher in patients with associated meningitis (CRP: 19.81 ± 12.56 mg/dl vs. 11.63 ± 11.08 mg/dl, p = 0.001; WBC: 14.67 ± 7.76 g/l vs. 10.88 ± 05.11 g/l, p = 0.005. Mortality was also higher, as 13.3% and 7.1% of patients with and without concomitant meningitis died, respectively. Conclusion Bacterial meningitis due to spondylodiscitis is a rare but severe condition and is associated with higher morbidity and mortality rates. In patients with spondylodiscitis presenting with an altered state of consciousness an associated meningitis should be ruled out.
Collapse
Affiliation(s)
- Insa K. Janssen
- Department of Neurosurgery, Hôpitaux Universitaires Genève, Rue Gabrielle-Perret Gentil 4, 1205, Geneva, Switzerland
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Yu-Mi Ryang
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Straße 22, 81675, Munich, Germany
- Department of Neurosurgery, Helios Klinikum Berlin-Buch, Schwanebecker Chaussee 50, 13125, Berlin, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Ehab Shiban
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Straße 22, 81675, Munich, Germany
- Department of Neurosurgery, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Straße 22, 81675, Munich, Germany
| |
Collapse
|
12
|
Liu D, Lu W, Huang W, Zhai W, Ling Q. Extensive spinal epidural abscess due to Streptococcus intermedius: a case report treated conservatively and literature review. Front Neurol 2023; 14:1237007. [PMID: 37701856 PMCID: PMC10494933 DOI: 10.3389/fneur.2023.1237007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 07/24/2023] [Indexed: 09/14/2023] Open
Abstract
Purpose To describe the clinical significance of prompt, adequate, and targeted intravenous antibiotic (IV antibiotic) therapy in the successful management of spinal epidural abscess (SEA) associated with Streptococcus intermedius (S. intermedius) infection. Case description SEA is a rare, but catastrophic infection that may result in a high risk of permanent neurological disability. A 52-year-old Chinese female patient was presented to the emergency department due to 2 years of low back pain and 3 days of decreased muscle strength in the extremities. The blood culture confirmed the presence of S. intermedius infection, and gadolinium-enhanced magnetic resonance imaging (MRI) demonstrated widespread epidural abscesses in the cervical, thoracic, and lumbar spine canal. Empirical IV antibiotic therapy with vancomycin was promptly initiated, with meropenem and moxifloxacin added subsequently based on blood culture results. After 5 days of IV antibiotic treatment, the patient's blood culture became negative. 6 weeks later, a follow-up MRI showed a decrease in the size of the abscess. The patient's muscle strength was mostly restored after 2 months of IV antibiotic treatment. Conclusion Repeat examinations or gadolinium-enhanced MRI should be considered when initial MRI findings are not diagnostic of SEA. For extensive SEA caused by Streptococcus intermedius infection, surgery may be non-essential, and the judicious antibiotic selection and adequate treatment duration are pivotal for successful conservative management. Furthermore, for patients who are not amenable to surgery, a comprehensive evaluation of their condition and meticulous implementation of a precise pharmacological regimen holds noteworthy clinical significance.
Collapse
Affiliation(s)
| | | | | | | | - Qinjie Ling
- Department of Orthopedic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| |
Collapse
|
13
|
Sircar K, Jung N, Kernich N, Zarghooni K, Eysel P, Yagdiran A, Herren C. Risk Factors for Neurologic Deficits in Patients With Spinal Epidural Abscess: An Analysis of One-Hundred-Forty Cases. Global Spine J 2023:21925682231194467. [PMID: 37548223 DOI: 10.1177/21925682231194467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Abstract
STUDY DESIGN retrospective study. OBJECTIVES In addition to surgical treatment of spinal epidural abscesses (SEA), a conservative, medical treatment for patients without acute neurologic deficits has been proposed. However, the risk factors for neurologic deficits are unclear. This study aims to identify factors predisposing patients with SEA to neurological impairment. METHODS All patients treated for SEA between 2008 and 2021 were identified from a prospective vertebral-osteomyelitis registry of a tertiary referral centre. Patient demographics, comorbidities, pathogens, degree of osseous destruction, location of SEA and preoperative neurologic status were retrospectively collected. Differences between patients with (Group 1) and without (Group 2) pretreatment neurologic deficits were assessed by univariate and logistic regression analysis. RESULTS A total of 140 patients with SEA were included. Forty-three patients (31%) had a neurologic deficit and 97 patients (69%) had no neurologic deficit prior to therapy. The prevalence of diabetes mellitus (35% vs 19%, P = .03), median visual analogue scale leg pain (8 vs 5, P = .01), median American Society of Anesthesiologists (ASA) Score (3 vs 2.6, P = .003) and mean Body-Mass-Index (29 vs 26, P = .02) differed between Group 1 and 2 in univariate analysis. In multivariable analysis, diabetes mellitus (odds ratio = 2.7), female sex (odds ratio = 2.5) and ASA-Score (odds ratio = 2.4) were significant contributors for neurologic deficits. CONCLUSIONS In patients with a SEA without neurologic deficits, the ASA score and diabetes mellitus should be considered, especially in female patients. These patients may be at a higher risk for developing a neurologic deficit and may benefit from an early surgical treatment.
Collapse
Affiliation(s)
- Krishnan Sircar
- Department of Orthopaedics and Trauma Surgery, Faculty of Medicine, University Clinics, University of Cologne, Cologne, Germany
| | - Norma Jung
- Department I of Internal Medicine, Faculty of Medicine, University Clinics, University of Cologne, Cologne, Germany
| | - Nikolaus Kernich
- Department of Orthopaedics and Trauma Surgery, Faculty of Medicine, University Clinics, University of Cologne, Cologne, Germany
| | - Kourosh Zarghooni
- Department of Orthopaedics and Trauma Surgery, Helios Klinikum Hildesheim, Hildesheim, Germany
| | - Peer Eysel
- Department of Orthopaedics and Trauma Surgery, Faculty of Medicine, University Clinics, University of Cologne, Cologne, Germany
| | - Ayla Yagdiran
- Department of Orthopaedics and Trauma Surgery, Faculty of Medicine, University Clinics, University of Cologne, Cologne, Germany
| | - Christian Herren
- Department of Orthopedics, Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Aachen, Germany
| |
Collapse
|
14
|
Kučinskaite G, Lutz T, Frey S, Wetterkamp M, Schulte TL, Lukas C. Diagnosis behind the mask: A rare case of infected Charcot's spine. Radiol Case Rep 2023; 18:2800-2805. [PMID: 37324554 PMCID: PMC10267433 DOI: 10.1016/j.radcr.2023.05.012] [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: 02/20/2023] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 06/17/2023] Open
Abstract
Charcot's spine is a very uncommon long-term complication of spinal cord injury. Infection of the spine is a common pathology, but infection of a Charcot's spine is rare and is challenging to diagnose, especially in differentiating between the Charcot defect and the osteomyelitis defect. Surgical reconstruction has to be extremely individualized. A 65-year-old man with a history of thoracic spinal cord injury with paraplegia 49 years ago was admitted to our hospital with high fever and aphasia. After a thorough diagnostic process, destructive Charcot's spine and secondary infection were diagnosed. This report additionally reviews the surgical management of secondary infected destructive lumbar Charcot's spine and follows the patient's recovery and postoperative quality of life.
Collapse
Affiliation(s)
- Giedre Kučinskaite
- Department of Diagnostic and Interventional Radiology, St. Josef Hospital, Ruhr University of Bochum, Gudrunstrasse 56, Bochum, 44791, Germany
| | - Theodor Lutz
- Department of Diagnostic and Interventional Radiology, St. Marien Hospital Hamm, Germany
| | - Sönke Frey
- Department of Orthopedics and Trauma Surgery, St. Josef Hospital, Ruhr University of Bochum, Bochum, Germany
| | - Mark Wetterkamp
- Department of Orthopedics and Trauma Surgery, St. Josef Hospital, Ruhr University of Bochum, Bochum, Germany
| | - Tobias L. Schulte
- Department of Orthopedics, Emergency Surgery and Hand Surgery, Florence Nightingale Hospital, Dusseldorf, Germany
| | - Carsten Lukas
- Institute of Neuroradiology, St. Josef Hospital, Ruhr University of Bochum, Bochum, Germany
- Department of Neurology, St. Josef Hospital, Ruhr University of Bochum, Bochum, Germany
| |
Collapse
|
15
|
Gall A, Cowher A, France J, Cui S. Complete Spinal Cord Injury Secondary to Serratia marcescens Spinal Epidural Abscess: A Report of Significant Neurological Improvement After a Delayed Presentation. Cureus 2023; 15:e44451. [PMID: 37791159 PMCID: PMC10544132 DOI: 10.7759/cureus.44451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2023] [Indexed: 10/05/2023] Open
Abstract
The exact time at which neurological deficits secondary to a spinal cord injury (SCI) become permanent is unknown. However, urgent decompression within 24 hours of insult is advocated to maximize the return of function. Despite previous literature showing poor neurological recovery with intervention after 24-72 hours, multiple cases have since shown noteworthy clinical improvement following significant delays in presentation. We report the case of a 55-year-old incarcerated male who presented to our hospital with a four-week history of a complete (American Spinal Injury Association (ASIA) A) SCI after a prison altercation. The patient exhibited profound deficits of over one-month duration, and magnetic resonance imaging (MRI) revealed an epidural abscess at T7-T8 with severe cord compression and another epidural abscess at L4-L5. This prompted immediate IV antibiotic therapy. A full neurological examination at hospital admission showed a complete absence of sensation, motor, rectal tone, and rectal function below T8, indicating a grade ASIA A SCI. Blood cultures grew Serratia marcescens. After thorough deliberation, considering over a month of complete neurological deficits, it was decided that surgical intervention would be unlikely to improve the patient's clinical status. Nonetheless, after only 24 hours of IV antibiotic administration, the patient progressed from an ASIA A to B, with a return of 100% accurate, although dull, sensation below T8. Within one week, his abscesses diminished on follow-up MRI, yet T7-T8 remained under significant pressure with no further clinical improvements. Due to his unexpected improvement to an ASIA B, which then plateaued at this level, surgery was again discussed in an attempt to maximize recovery. The patient wished to proceed, even given low chances of a meaningful recovery. He subsequently underwent evacuation and decompression. Two weeks postoperatively, the patient advanced from an ASIA B to C; he remained so until discharge 46 days after presentation and 30 days after surgical decompression. This case is noteworthy within the literature due to two compelling features. Firstly, it represents a significantly delayed presentation of a complete SCI with unexpected, meaningful, and swift improvement after medication and surgical intervention. Secondly, it is one of the few documented cases of Serratia marcescens spinal epidural abscess (SEA).
Collapse
Affiliation(s)
- Ashley Gall
- Orthopaedic Surgery, West Virginia University School of Medicine, Morgantown, USA
| | - Abigail Cowher
- Orthopaedic Surgery, West Virginia University School of Medicine, Morgantown, USA
| | - John France
- Orthopaedic Surgery, West Virginia University School of Medicine, Morgantown, USA
| | - Shari Cui
- Orthopaedic Surgery, Prisma Health, Columbia, USA
| |
Collapse
|
16
|
Pitaro NL, Tang JE, Arvind V, Cho BH, Geng EA, Amakiri UO, Cho SK, Kim JS. Readmission and Associated Factors in Surgical Versus Non-Surgical Management of Spinal Epidural Abscess: A Nationwide Readmissions Database Analysis. Global Spine J 2023; 13:1533-1540. [PMID: 34866455 PMCID: PMC10448106 DOI: 10.1177/21925682211039185] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES Spinal epidural abscess (SEA) is a rare but potentially life-threatening infection treated with antimicrobials and, in most cases, immediate surgical decompression. Previous studies comparing medical and surgical management of SEA are low powered and limited to a single institution. As such, the present study compares readmission in surgical and non-surgical management using a large national dataset. METHODS We identified all hospital admissions for SEA using the Nationwide Readmissions Database (NRD), which is the largest collection of hospital admissions data. Patients were grouped into surgically and non-surgically managed cohorts using ICD-10 coding and compared using information retrieved from the NRD such as demographics, comorbidities, length of stay and cost of admission. RESULTS We identified 350 surgically managed and 350 non-surgically managed patients. The 90-day readmission rates for surgical and non-surgical management were 26.0% and 35.1%, respectively (P < .05). Expectedly, surgical management was associated with a significantly higher charge and length of stay at index hospital admission. Surgically managed patients had a significantly lower risk of readmission for osteomyelitis (P < .05). Finally, in patients with a low comorbidity burden, we observed a significantly lower 90-day readmission rate for surgically managed patients (surgical: 23.0%, non-surgical: 33.8%, P < .05). CONCLUSION In patients with a low comorbidity burden, we observed a significantly lower readmission rate for surgically managed patients than non-surgically managed patients. The results of this study suggest a lower readmission rate as an advantage to surgical management of SEA and emphasize the importance of SEA as a not-to-miss diagnosis.
Collapse
Affiliation(s)
- Nicholas L. Pitaro
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Justin E. Tang
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Varun Arvind
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brian H. Cho
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eric A. Geng
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Uchechukwu O. Amakiri
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel K. Cho
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jun S. Kim
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
17
|
Blecher R, Frieler S, Qutteineh B, Pierre CA, Yilmaz E, Ishak B, Glinski AV, Oskouian RJ, Kramer M, Drexler M, Chapman JR. Who Needs Surgical Stabilization for Pyogenic Spondylodiscitis? Retrospective Analysis of Non-Surgically Treated Patients. Global Spine J 2023; 13:1550-1557. [PMID: 34530628 PMCID: PMC10448100 DOI: 10.1177/21925682211039498] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective case series analysis. OBJECTIVE To identify relevant clinical and radiographic markers for patients presenting with infectious spondylo-discitis associated with spinal instability directly related to the infectious process. METHODS We evaluated patients presenting with de-novo intervertebral discitis or vertebral osteomyelitis /discitis (VOD) who initiated non-surgical treatment. Patients who failed conservative treatment and required stabilization surgery within 90 days were defined as "failed treatment group" (FTG). Patients who experienced an uneventful course served as controls and were labeled as "nonsurgical group" (NSG). A wide array of baseline clinical and radiographic parameters was retrieved and compared between 2 groups. RESULTS Overall 35 patients had initiated non-surgical treatment for VOD. 25 patients had an uneventful course (NSG), while 10 patients failed conservative treatment ("FTG") within 90 days. Factors found to be associated with poorer outcome were intra-venous drug abuse (IVDA) as well as the presence of fever upon initial presentation. Radiographically, involvement of the same-level facets and the extent of caudal and rostral VB involvement in both MRI and CT were found to be significantly associated with poorer clinical and radiographic outcome. CONCLUSIONS We show that clinical factors such as IVDA status and fever as well as the extent of osseous and posterior element involvement may prove to be helpful in favoring surgical treatment early on in the management of spinal infections.
Collapse
Affiliation(s)
- Ronen Blecher
- Swedish Neuroscience Institute, Seattle, WA, USA
- Assuta University Hospital Ashdod, Ben Gurion University of the Negev, Beersheba, Israel
| | | | | | | | - Emre Yilmaz
- Department of Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Basem Ishak
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
| | | | | | - Moti Kramer
- Assuta University Hospital Ashdod, Ben Gurion University of the Negev, Beersheba, Israel
| | - Michael Drexler
- Assuta University Hospital Ashdod, Ben Gurion University of the Negev, Beersheba, Israel
| | | |
Collapse
|
18
|
Doub JB, Tran J, Smith R, Pease T, Koh E, Ludwig S, Lee A, Chan B. Feasibility of Using Bacteriophage Therapy to Reduce Morbidity and Mortality Associated with Spinal Epidural Abscesses. Infect Chemother 2023; 55:257-263. [PMID: 37407243 DOI: 10.3947/ic.2022.0168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 03/09/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND The aim of this study was to determine the feasibility of using bacteriophage therapeutics in spinal epidural abscess (SEA) by reviewing the causes and outcomes of SEA at a single institution and testing a bacteriophage for activity against preserved SEA clinical isolates. MATERIALS AND METHODS Medical records were reviewed of patients that received incision and drainage for SEA at a single medical center. Causative organisms, incidence of coinciding bacteremia and outcomes were recorded. A subset of SEA patients (N = 11), that had preserved clinical isolates, were assessed to evaluate if a bacteriophage therapeutic had ample activity to those isolates as seen with spot tests and growth inhibition assays. RESULTS Staphylococcus aureus was the predominate bacterial cause (71%) and bacteremia was associated with 96% of S. aureus SEA. Over 50% of the patients either died within three months, had recurrence of their infection, required repeat debridement, or had long term sequalae. A single bacteriophage had positive spot tests for all the S. aureus clinical isolates and inhibited bacterial growth for more than 24 hours for 9 of the 11 (82%) clinical isolates. CONCLUSION SEA is associated with significant mortality and morbidity making this a potential indication for adjuvant bacteriophage therapeutics. Since S. aureus is the predominate cause of SEA and most cases are associated bacteremia this creates a potential screening and treatment platform for Staphylococcal bacteriophages therapeutics, allowing for potential pilot studies to be devised.
Collapse
Affiliation(s)
- James B Doub
- Division of Infectious Disease, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Jeremy Tran
- Walter Reed National Military Medical Center, Baltimore, MD, USA
| | - Ryan Smith
- Department of Orthopedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Tyler Pease
- Department of Orthopedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Eugene Koh
- Department of Orthopedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Stephen Ludwig
- Department of Orthopedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Alina Lee
- Yale Center for Phage Biology & Therapy, Yale University, New Haven, CT, USA
| | - Ben Chan
- Yale Center for Phage Biology & Therapy, Yale University, New Haven, CT, USA
| |
Collapse
|
19
|
Hijazi MM, Siepmann T, El-Battrawy I, Glatte P, Eyüpoglu I, Schackert G, Juratli TA, Podlesek D. Clinical phenotyping of spondylodiscitis and isolated spinal epidural empyema: a 20-year experience and cohort study. Front Surg 2023; 10:1200432. [PMID: 37273827 PMCID: PMC10232866 DOI: 10.3389/fsurg.2023.1200432] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/02/2023] [Indexed: 06/06/2023] Open
Abstract
Background The incidence of spondylodiscitis (SD) and isolated spinal epidural empyema (ISEE) has been increasing in the last decades, but the distinct differences between both entities are poorly understood. We aimed to evaluate the clinical phenotypes and long-term outcomes of SD and ISEE in depth. Methods We performed a chart review and analyzed data from our cohorts of consecutive SD and ISEE patients who were treated and assessed in detail for demographic, clinical, imaging, laboratory, and microbiologic characteristics at a university neurosurgical center in Germany from 2002 to 2021. Between-group comparisons were performed to identify meaningful differences in both entities. Results We included 208 patients (72 females: age 75 [75 32-90] y vs. 136 males: 65 [23-87] y, median [interquartile range], p < 0.001), of which 142 (68.3%) had SD and 66 (31.7%) had ISEE. Patients with SD were older than ISEE (ISEE: 62 y vs. SD: 70 y, p = 0.001). While SD was more common in males than females (males: n = 101, 71.1% vs. females: n = 41, 28.9%, p < 0.001), there was no sex-related difference in ISEE (males: n = 35, 53.0% vs. females: n = 31, 47.0%, p = 0.71). Obesity was more frequent in ISEE than in SD (ISEE: n = 29, 43.9% vs. SD: n = 37, 26.1%, p = 0.016). However, there were no between-group differences in rates of diabetes and immunodeficiency. In the entire study population, a causative pathogen was identified in 192 (92.3%) patients, with methicillin-susceptible staphylococcus aureus being most frequent (n = 100, 52.1%) and being more frequent in ISEE than SD (ISEE: n = 43, 65.2% vs. SD: n = 57, 40.1%, p = 0.003). SD and ISEE occurred most frequently in the lumbar spine, with no between-group differences (ISEE: n = 25, 37.9% vs. SD: n = 65, 45.8%, p = 0.297). Primary infectious sources were identified in 145 patients (69.7%) and among this skin infection was most common in both entities (ISEE: n = 14, 31.8% vs. SD: n = 25, 24.8%, p = 0.418). Furthermore, epidural administration was more frequent the primary cause of infection in ISEE than SD (ISEE: n = 12, 27.3% vs. SD: n = 5, 4.9%, p < 0.001). The most common surgical procedure in SD was instrumentation (n = 87, 61%) and in ISEE abscess evacuation (n = 63, 95%). Patients with ISEE displayed lower in-hospital complication rates compared to SD for sepsis (ISEE: n = 12, 18.2% vs. SD: n = 94, 66.2%, p < 0.001), septic embolism (ISEE: n = 4/48 cases, 8.3% vs. SD: n = 52/117 cases, 44.4%, p < 0.001), endocarditis (ISEE: n = 1/52 cases, 1.9% vs. SD: n = 23/125 cases, 18.4%, p = 0.003), relapse rate (ISEE: n = 4/46, 8.7% vs. SD: n = 27/92, 29.3%, p = 0.004), and disease-related mortality (ISEE: n = 1, 1.5% vs. SD: n = 11, 7.7%, p = 0.108). Patients with SD showed prolonged length of hospital stay (ISEE: 22 [15, 30] d vs. SD: 38 [29, 53] d, p < 0.001) and extended intensive care unit stay (ISEE: 0 [0, 4] d vs. SD: 3 [0, 12] d, p < 0.002). Conclusions Our 20-year experience and cohort analysis on the clinical management of SD and ISEE unveiled distinct clinical phenotypes and outcomes in both entities, with ISEE displaying a more favorable disease course with respect to complications and relapse rates as well as disease-related mortality.
Collapse
Affiliation(s)
- Mido Max Hijazi
- Department of Neurosurgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Timo Siepmann
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Ibrahim El-Battrawy
- Department of Cardiology, Bergmannsheil University Hospitals Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Patrick Glatte
- Department of Neurosurgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Ilker Eyüpoglu
- Department of Neurosurgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Gabriele Schackert
- Department of Neurosurgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Tareq A. Juratli
- Department of Neurosurgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Dino Podlesek
- Department of Neurosurgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| |
Collapse
|
20
|
Fu YK, Huang YF, Chang CT. Early Staphylococcus aureus epidural abscess with successful medical management. J Infect Chemother 2023:S1341-321X(23)00128-9. [PMID: 37207958 DOI: 10.1016/j.jiac.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 04/26/2023] [Accepted: 05/15/2023] [Indexed: 05/21/2023]
Affiliation(s)
- Yi-Kai Fu
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei, 22056, Taiwan
| | - Yi-Fang Huang
- Department of General Dentistry, Chang Gung Memorial Hospital, Linkou, 33305, Taiwan; School of Dentistry, College of Oral Medicine, Taipei Medical University, Taipei, 11031, Taiwan; Graduate Institute of Dental and Craniofacial Science, College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan
| | - Chung-Ta Chang
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei, 22056, Taiwan; School of Dentistry, College of Oral Medicine, Taipei Medical University, Taipei, 11031, Taiwan; Graduate Institute of Medicine, Yuan Ze University, Taoyuan, 32003, Taiwan.
| |
Collapse
|
21
|
Lenga P, Gülec G, Kiening K, Unterberg AW, Ishak B. Mortality, complication risks, and clinical outcomes after surgical treatment of spinal epidural abscess: a comparative analysis of patients aged 18-64 years, 65-79 years, and ≥ 80 years, with a 3-year follow-up. Neurosurg Rev 2023; 46:96. [PMID: 37099226 PMCID: PMC10133033 DOI: 10.1007/s10143-023-02003-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/30/2023] [Accepted: 04/16/2023] [Indexed: 04/27/2023]
Abstract
Spinal epidural abscess (SEA) with pyogenic vertebral osteomyelitis (PVO) is a rare illness with a steadily increasing incidence. However, comparative analyses of young and older patients with SEA are lacking. We aimed to compare the clinical course of patients aged 18-64 years, 65-79 years, and ≥ 80 years undergoing surgery for SEA. Clinical and imaging data were retrospectively collected from the institutional database between September 2005 and December 2021. Ninety-nine patients aged 18-64 years, 45 patients aged 65-79 years, and 32 patients ≥ 80 years were enrolled. Patients ≥ 80 years presented with a poorer baseline history (9.2 ± 2.4), as indicated by the CCI, than their younger counterparts (18-74 years: 4.8 ± 1.6;6.5 ± 2.5; p < 0.001). Patients aged 65-79 years and 80 years had a significantly longer length of stay. In-hospital mortality was significantly higher in those aged ≥ 80 years compared to their younger counterparts (≥ 80 years, n = 3, 9.4% vs. 18-64 years, n = 0, 0.0%; 65-79 years, n = 0, 0.0%; p < 0.001), while no differences in 90-day mortality or 30-day readmission were observed. After surgery, a significant decrease in C-reactive protein levels and leukocytes and amelioration of motor scores were observed in all the groups. Of note, older age (> 65 years), presence of comorbidities, and poor preoperative neurological condition were significant predictors of mortality. Surgical management led to significant improvements in laboratory and clinical parameters in all age groups. However, older patients are prone to multiple risks, requiring meticulous evaluation before surgery. Nevertheless, the risk profile of younger patients should not be underestimated. The study has the limitations of a retrospective design and small sample size. Larger randomized studies are warranted to establish the guidelines for the optimal management of patients from every age group and to identify the patients who can benefit from solely conservative management.
Collapse
Affiliation(s)
- Pavlina Lenga
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
| | - Gelo Gülec
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Karl Kiening
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Andreas W Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Basem Ishak
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| |
Collapse
|
22
|
Walker JK, Cronin JT, Richards BW, Skedros JG. Acute Sternoclavicular Joint Sepsis With Medial Clavicle Osteomyelitis (Staphylococcus aureus) and Cervical-Thoracic Epidural Phlegmon in an Adult Female With No Apparent Risk Factors. Cureus 2023; 15:e35870. [PMID: 37033534 PMCID: PMC10079283 DOI: 10.7759/cureus.35870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2023] [Indexed: 03/09/2023] Open
Abstract
This is a case of a 71-year-old female with a history of only one known medical problem (hypertension) who presented with a right sternoclavicular joint (SCJ) infection in addition to (1) a contiguous lower cervical and upper thoracic epidural phlegmon and (2) cellulitis and a phlegmon in her posterior neck, which was subcutaneous and near the lower cervical and upper thoracic spinous processes. These loci of infection developed several days after she had pricked her fingers when cutting rose bushes and were initially considered to be epidural abscesses. However, after the patient was transferred to our tertiary medical center, a neurosurgeon and radiologist determined that the cervicothoracic infections were phlegmons rather than fully developed abscesses. The phlegmons were treated with only IV antibiotics. The SCJ infection was surgically debrided, and the medial clavicle was excised. Bone and fluid cultures grew methicillin-sensitive Staphylococcus aureus (S. aureus). The patient recovered uneventfully (the final follow-up was four years later). This case is uncommon because of the concurrent SCJ infection with medial clavicle osteomyelitis, cervical-thoracic epidural, and paraspinous phlegmons.
Collapse
|
23
|
Surgical treatment of cervical epidural abscess in the very elderly. Acta Neurochir (Wien) 2023; 165:883-884. [PMID: 36764961 DOI: 10.1007/s00701-023-05523-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 02/02/2023] [Indexed: 02/12/2023]
|
24
|
MacNeille R, Lay J, Razzouk J, Bogue S, Harianja G, Ouro-Rodrigues E, Ting C, Ramos O, Veltman J, Danisa O. Patients Follow-up for Spinal Epidural Abscess as a Critical Treatment Plan Consideration. Cureus 2023; 15:e35058. [PMID: 36938240 PMCID: PMC10023045 DOI: 10.7759/cureus.35058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2023] [Indexed: 02/18/2023] Open
Abstract
INTRODUCTION Spinal epidural abscess (SEA) is a rare process with significant risk for morbidity and mortality. Treatment includes an extended course of antibiotics with or without surgery depending on the clinical presentation. Both non-operative and surgically treated patients require close follow-up to ensure the resolution of the infection without recurrence and/or progression of neurologic deficits. No previous study has looked specifically at follow-up in the SEA population, but the review of the literature does show evidence of varying degrees of difficulty with follow-up for this patient population. METHODS This retrospective review looked at follow-up for 147 patients with SEA at a single institution from 2012 to 2021. Statistical analyses were performed to assess differences between groups of surgical versus non-surgical patients and those with adequate versus inadequate follow-up. RESULTS Sixty-two of 147 (42.2%) patients had inadequate follow-up (less than 90 days) with their surgical team, and 112 of 147 (76.2%) patients had inadequate follow-up (less than 90 days) with infectious disease (ID). The primary statistically significant difference between patients with adequate versus inadequate follow-up was found to be surgical status with those treated surgically more likely to have adequate follow-up than those treated non-operatively. CONCLUSION Improved follow-up in surgical patients should be considered as a factor when deciding on surgical versus non-operative treatment in the SEA patient population. Extra efforts coordinating follow-up care should be made for SEA patients.
Collapse
Affiliation(s)
- Rhett MacNeille
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, USA
| | - Johnson Lay
- Department of Orthopaedics, School of Medicine, California University of Science and Medicine, Colton, USA
| | - Jacob Razzouk
- Department of Orthopaedic Surgery, Loma Linda University School of Medicine, Loma Linda, USA
| | - Shelly Bogue
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, USA
| | - Gideon Harianja
- Department of Orthopaedic Surgery, Loma Linda University School of Medicine, Loma Linda, USA
| | - Evelyn Ouro-Rodrigues
- Department of Orthopaedic Surgery, Loma Linda University School of Medicine, Loma Linda, USA
| | - Caleb Ting
- Department of Orthopaedics, School of Medicine, University of California Riverside School of Medicine, Riverside, USA
| | - Omar Ramos
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, USA
| | - Jennifer Veltman
- Department of Infectious Diseases, Loma Linda University Medical Center, Loma Linda, USA
| | - Olumide Danisa
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, USA
| |
Collapse
|
25
|
ACDF versus corpectomy in octogenarians with cervical epidural abscess: early complications and outcomes with 2 years of follow-up. Acta Neurochir (Wien) 2023; 165:875-882. [PMID: 36629954 PMCID: PMC10068646 DOI: 10.1007/s00701-023-05488-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 01/01/2023] [Indexed: 01/12/2023]
Abstract
PURPOSE Cervical spinal epidural abscess (CSEA) is a rare condition, manifesting as rapid neurological deterioration and leading to early neurological deficits. Its management remains challenging, especially in patients older than 80 years. Therefore, we aimed to compare the clinical course and determine morbidity and mortality rates after anterior cervical discectomy and fusion (ACDF) versus corpectomy in octogenarians with ventrally located CSEA at two levels. METHODS In this single-center retrospective review, we obtained the following from electronic medical records between September 2005 and December 2021: patient demographics, surgical characteristics, complications, hospital clinical course, and 90-day mortality rate. Comorbidities were assessed using the age-adjusted Charlson comorbidity index (CCI). RESULTS Over 16 years, 15 patients underwent ACDF, and 16 patients underwent corpectomy with plate fixation. Between the two groups, patients who underwent corpectomy had a significantly poorer baseline reserve (9.0 ± 2.6 vs. 10.8 ± 2.7; p = 0.004) and had a longer hospitalization period (16.4 ± 13.1 vs. 10.0 ± 5.3 days; p = 0.004) since corpectomy lasted significantly longer (229.6 ± 74.9 min vs. 123.9 ± 47.5 min; p < 0.001). Higher in-hospital and 90-day mortality and readmission rates were observed in the corpectomy group, but the difference was not statistically significant. Both surgeries significantly improved blood infection parameters and neurological status at discharge. Revision surgery due to pseudoarthrosis was required in two patients after corpectomy. CONCLUSIONS We showed that both ACDF and corpectomy for ventrally located CSEA can be considered as safe treatment strategies for patients aged 80 years and above. However, the surgical approach should be carefully weighed and discussed with the patients and their relatives.
Collapse
|
26
|
Pi YW, Gong Y, Jiang JJ, Zhu DJ, Tong YX, Jiang LM, Zhao DX. Extensive spinal epidural abscess caused by Staphylococcus epidermidis: A case report and literature review. Front Surg 2023; 10:1114729. [PMID: 36969757 PMCID: PMC10032522 DOI: 10.3389/fsurg.2023.1114729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/20/2023] [Indexed: 03/29/2023] Open
Abstract
Background Extensive spinal epidural abscess (SEA) is an exceptional and threatening condition that requires prompt recognition and proper management to avoid potentially disastrous complications. We aimed to find key elements of early diagnosis and rational treatments for extensive SEA. Case presentation A 70-year-old man complained of intense pain in the cervical-thoracic-lumbar spine that radiated to the lower extremity. Laboratory test results revealed a marked increase in all indicators of infection. The spinal magnetic resonance imaging (MRI) revealed a ventral SEA extending from C2 to L4. Owing to the patient's critical condition, laminectomy, drainage, and systemic antibiotic therapy were administered. And the multidrug-resistant Staphylococcus epidermidis was detected in the purulent material from this abscess. Results Postoperative MRI revealed diminished epidural abscess, and the clinical symptoms were dramatically and gradually relieved after two rounds of surgery and systemic antibiotic therapy involving the combination of ceftriaxone, linezolid, and rifampicin. Conclusions A comprehensive emergency assessment based on neck or back pain, neurological dysfunctions, signs of systemic infection, and MRI are important for early diagnosis of extensive SEA. Further, the combination of laminectomy, drainage, and systemic antibiotic therapy may be a rational treatment choice for patients with SEA, especially for extensive abscess or progressive neurological dysfunction.
Collapse
|
27
|
Lenga P, Gülec G, Bajwa AA, Issa M, Kiening K, Unterberg AW, Ishak B. Surgical Management of Spinal Epidural Abscess in Elderly Patients: A Comparative Analysis Between Patients 65-79 Years and ≥80 Years with 3-Year Follow-Up. World Neurosurg 2022; 167:e795-e805. [PMID: 36041723 DOI: 10.1016/j.wneu.2022.08.095] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/19/2022] [Accepted: 08/20/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Recently, the incidence of pyogenic vertebral osteomyelitis with spinal epidural abscess (SEA) has increased. However, the most appropriate surgical management remains debatable, especially for older patients. This study aimed to compare the clinical course in older patients aged between 65 and 79 years and those 80 years or older undergoing surgery for SEA. METHODS Data on patient demographics, surgical characteristics, complications, hospital clinical course, and 90-day mortality of patients diagnosed with pyogenic vertebral osteomyelitis and SEA between September 2005 and December 2021 were collected. Comorbidities were assessed using the age-adjusted Charlson comorbidity index. RESULTS We enrolled 45 patients aged 65-79 years and 32 patients ≥80 years. Patients ≥80 years had significantly higher rates of Charlson comorbidity index (9.2 ± 2.4) than younger patients (6.5 ± 2.5; P < 0.001). Arterial hypertension, renal failure, and dementia were significantly more prevalent in octogenarians (P < 0.05). Patients aged ≥80 years had a significantly longer length of hospitalization, while the intensive care unit stay was similar between groups. In-hospital mortality was significantly greater in those ≥80 years (n = 3, 9.4% vs. n = 0, 0.0%; P = 0.029), whereas no differences in 90-day mortality or 30-day readmission were observed. In the second-stage analysis, significant improvements in blood infection parameters and neurologic status were detected in both groups. Of adverse events, pneumonia occurred significantly more frequently in patients aged ≥80 years. CONCLUSIONS Surgical management leads to significant improvements in both laboratory and clinical parameters in older patients. Nevertheless, a personalized medical approach is mandatory in frail patients, especially octogenarians. A clear discussion regarding the potential risk is unambiguously recommended.
Collapse
Affiliation(s)
- Pavlina Lenga
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany.
| | - Gelo Gülec
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Awais Akbar Bajwa
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Mohammed Issa
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Karl Kiening
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Andreas W Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Basem Ishak
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| |
Collapse
|
28
|
Muacevic A, Adler JR. The Surgical Management of Holospinal Epidural Abscess: A Case Report and Review on Catheter-Based Irrigation Techniques. Cureus 2022; 14:e30437. [PMID: 36407233 PMCID: PMC9671263 DOI: 10.7759/cureus.30437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2022] [Indexed: 01/25/2023] Open
Abstract
Holospinal epidural abscess (HEA) is an extremely rare spinal infection involving the entire spine and is infrequently reported in the literature. Cases with evidence of spinal cord compression and consequent neurological deficit are typically managed with prompt surgical drainage and broad-spectrum antibiotics. Surgical intervention is often challenging because this condition is inherently associated with poor prognosis and serious complications, including death. During the surgical evacuation of the abscess, catheter-based irrigation must be adequately performed. In the majority of reported cases, the extent of the advancement of the epidural catheter is blindly assessed by the operating surgeon, increasing the risk of residual collections and subsequent persistent infection. Herein, we report a rare case of HEA that was successfully treated with surgical evacuation and skip laminectomies. We also describe a catheter-based technique that facilitates adequate irrigation, thereby ensuring the complete drainage of HEA in obscured perispinal areas, as well as the decompression of the spinal cord. Postoperative neurological examination exhibited marked improvement in motor function (compared with a baseline of complete quadriparesis), indicating the successful decompression of the spinal cord and neurological improvement.
Collapse
|
29
|
C-reactive Protein-to-albumin Ratio in Spinal Epidural Abscess: Association with Post-treatment Complications. J Am Acad Orthop Surg 2022; 30:851-857. [PMID: 35984080 DOI: 10.5435/jaaos-d-22-00172] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 04/04/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Spinal epidural abscess (SEA) is a complex medical condition with high morbidity and healthcare costs. Clinical presentation and laboratory data may have prognostic value in forecasting morbidity and mortality. C-reactive protein-to-albumin ratio (CAR) demonstrates promise for the prediction of adverse events in multiple orthopaedic and nonorthopaedic surgical conditions. We investigated the relationship between CAR and outcomes after treatment of SEA. METHODS We retrospectively evaluated adult patients treated within a single healthcare system for a diagnosis of SEA (2005 to 2017). Laboratory and clinical data included age at diagnosis, sex, race, body mass index, smoking status, history of intravenous drug use, Charlson Comorbidity Index, and CAR. The primary outcome was the occurrence of any complication; mortality and readmissions were considered secondarily. We used logistic regression to determine the association between baseline CAR and outcomes, adjusting for confounders. RESULTS We included 362 patients with a 90-day mortality rate of 13.3% and a 90-day complication rate of 47.8%. A reduced complication rate was observed in the lowest decile of CAR values compared with the remaining 90% of patients, a threshold value of 2.5 (27.0% versus 50.2%; odds ratio [OR] 2.66, 95% confidence interval [CI] 1.22 to 5.81). CAR values in the highest two deciles experienced significantly increased odds of complications compared with the lowest decile (80th: OR 3.44; 95% CI 1.25 to 9.42; 90th: OR 3.28; 95% CI 1.19 to 9.04). DISCUSSION We found elevated CAR to be associated with an increased likelihood of major morbidity in SEA. We suggest using a CAR value of 2.5 as a threshold for enhanced surveillance and recognizing patients with values above 73.7 as being at exceptional risk of morbidity. LEVEL OF EVIDENCE Level III observational cohort study.
Collapse
|
30
|
Muhlestein WE, Koduri S, Park P. Commentary: Development and Validation of a Predictive Model for Failure of Medical Management in Spinal Epidural Abscesses. Neurosurgery 2022; 91:e81-e82. [PMID: 35876675 DOI: 10.1227/neu.0000000000002066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 05/10/2022] [Indexed: 11/19/2022] Open
|
31
|
Surgical management of spontaneous spinal epidural abscess: Case report and review of the literature. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2021.101465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|
32
|
Bara GA, Thissen J. Cervical epidural abscess due to implantation of a spinal cord stimulation lead. Clin Case Rep 2022; 10:e05931. [PMID: 35662778 PMCID: PMC9163478 DOI: 10.1002/ccr3.5931] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 07/31/2021] [Accepted: 11/10/2021] [Indexed: 11/17/2022] Open
Abstract
Spinal cord stimulation (SCS) for intractable pain syndromes has become a pillar of modern pain management. Common complications include lead migration, implant infection, cerebral spinal fluid leak, and lead fracture. Spinal epidural abscess due to spinal cord stimulator implantation is a very rare occurrence with only two cases reported in the literature so far. We present an illustrative case and discuss the pathophysiology and best clinical management for this very rate entity.
Collapse
|
33
|
Panspinal Epidural Abscess: A Devastating Complication of Group B Streptococcal Bacteremia. Case Rep Infect Dis 2022; 2022:5028335. [PMID: 35646402 PMCID: PMC9142316 DOI: 10.1155/2022/5028335] [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] [Received: 03/10/2022] [Accepted: 04/30/2022] [Indexed: 12/02/2022] Open
Abstract
Background SEAs are infrequent; however, panspinal infections are even rarer, especially when GBS infection is involved. The cornerstone of treatment is based on early diagnosis and use of targeted antimicrobial therapy; in case of cord compression or neurological compromise, urgent surgical intervention should be pursued. Overall, it is an infrequent condition and therefore requires prospective multicenter studies. Case Presentation. We describe a case who presented with diabetic lower extremity wounds; however, soon the patient developed bowel and bladder incontinence in the setting of back pain, secondary to panspinal epidural abscess. The patient's case is unique in two aspects: firstly, it is panspinal, and secondly, its causative agent is GBS. Conclusion Prompt diagnosis of SEA is critical in the preservation of neurological function. Anyone presenting with fevers, back pain, and neurological changes should have urgent MRI evaluation of the spine.
Collapse
|
34
|
Decompression only versus fusion in octogenarians with spinal epidural abscesses: early complications, clinical and radiological outcome with 2-year follow-up. Neurosurg Rev 2022; 45:2877-2885. [PMID: 35536406 PMCID: PMC9349057 DOI: 10.1007/s10143-022-01805-4] [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: 02/24/2022] [Revised: 04/08/2022] [Accepted: 05/01/2022] [Indexed: 11/21/2022]
Abstract
Despite increased life expectancy due to health care quality improvements globally, pyogenic vertebral osteomyelitis (PVO) treatment with a spinal epidural abscess (SEA) remains challenging in patients older than 80 years. We aimed to assess octogenarians for PVO prevalence with SEA and compare after-surgery clinical outcomes of decompression and decompression and instrumentation. A retrospective review of electronic medical records at a single institution was conducted between September 2005 and December 2020. Patient demographics, surgical characteristics, complications, hospital course, and 90-day mortality were collected. Comorbidities were assessed using the age-adjusted Charlson comorbidity index (CCI). Over 16 years, 35 patients aged ≥80 years with PVO and SEA were identified. Eighteen patients underwent surgical decompression (“decompression group”), and 17 underwent surgical decompression with instrumentation (“instrumentation group”). Both groups had a CCI >6 (mean±SD, 8.9±2.1 vs. 9.6±2.7, respectively; p=0.065). Instrumentation group patients had a significantly longer hospital stay but no ICU stay. In-hospital and 90-days mortality rates were similar in both groups. The mean follow-up was 26.6±12.4 months. No further surgeries were performed. Infection levels and neurological status were improved in both groups at discharge. At the second-stage analysis, significant improvements in the blood infection parameters and the neurological status were detected in the decompression group. Octogenarians with PVO and SEA have a high adverse events risk after surgical procedures. Surgical decompression might contribute to earlier clinical recovery in older patients. Thus, the surgical approach should be discussed with patients and their relatives and be carefully weighed.
Collapse
|
35
|
Ammar AA, Hamad MK, Obeidallah MS, Kobets AJ, Lee SK, Abbott IR. Successful Treatment of Pediatric Holo-Spinal Epidural Abscess With Percutaneous Drainage. Cureus 2022; 14:e24735. [PMID: 35673318 PMCID: PMC9165922 DOI: 10.7759/cureus.24735] [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: 05/04/2022] [Indexed: 11/08/2022] Open
Abstract
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.
Collapse
|
36
|
Letter to Editor regarding: “High risk and low prevalence diseases: Spinal epidural abscess”. Am J Emerg Med 2022; 57:160-161. [DOI: 10.1016/j.ajem.2022.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 04/23/2022] [Indexed: 11/24/2022] Open
|
37
|
Hsu TL, Yang CJ, Pao JL. Salmonella spondylodiscitis and epidural abscess successfully treated with unilateral biportal endoscopic discectomy and debridement: a rare case report. J Int Med Res 2022; 50:3000605221085405. [PMID: 35321567 PMCID: PMC8958527 DOI: 10.1177/03000605221085405] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Spinal epidural abscess (SEA) is a rare but severe infection with potentially devastating consequences. Epidural abscesses caused by Salmonella serogroup C2 are even rarer and tend to be more invasive with multidrug resistance. Early diagnosis, effective use of antibiotics and surgical intervention are the mainstay strategies for managing SEA, especially for more virulent and multidrug-resistant Salmonella infections. This case report presents a rare case of an elderly and fragile woman with Salmonella spondylodiscitis and an extensive epidural abscess, which were successfully treated with intravenous antibiotics and unilateral biportal endoscopic (UBE) debridement and drainage through four small surgical incisions. After surgery, her fever subsided, she regained consciousness and her low back pain dramatically improved. Follow-up magnetic resonance imaging showed complete resolution of the epidural abscess. At 6 months after surgery, the patient regained muscle strength, ambulated with a walker and had no recurrence of the infection. The UBE technique can effectively eradicate infection while minimizing surgery-related risks and complications. A multidisciplinary team is required to achieve a good outcome.
Collapse
Affiliation(s)
- Ta-Li Hsu
- Department of Orthopaedic Surgery, Far Eastern Memorial Hospital, New Taipei City
| | - Chia-Jui Yang
- Department of Infectious Disease, Division of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City.,School of Medicine, 34914National Yang Ming Chiao Tung University, National Yang Ming Chiao Tung University, Taipei
| | - Jwo-Luen Pao
- Department of Orthopaedic Surgery, Far Eastern Memorial Hospital, New Taipei City.,General Education Centre, Longhwa University of Science & Technology, Taoyuan
| |
Collapse
|
38
|
Laws EJ, Sánchez L, Beltran E, Domínguez E, Ekiri AB, Brocal J, De Risio L. Multicenter Study of Clinical Presentation, Treatment, and Outcome in 41 Dogs With Spinal Epidural Empyema. Front Vet Sci 2022; 9:813316. [PMID: 35330611 PMCID: PMC8940254 DOI: 10.3389/fvets.2022.813316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/18/2022] [Indexed: 11/25/2022] Open
Abstract
There is limited information on canine spinal epidural empyema (SEE). The aim of this multicenter retrospective study is to describe the clinical presentation and outcome of dogs undergoing spinal surgery or conservative management for SEE. Forty-one dogs met the inclusion criteria; the SEE was treated surgically in 17 dogs and conservatively in 24 dogs. Two dogs underwent spinal surgery after failure of conservative management, meaning that 19 dogs in total had spinal surgery. Long-term (i.e., >6 months) follow-up was available in 35 dogs (19 conservatively treated and 16 surgically treated dogs). Recovery to a functional pet status was achieved in 15/19 (78.9%) conservatively treated and 12/16 (75%) surgically treated dogs. There was no significant difference (p = 1.000) in long-term outcome between conservatively and surgically treated dogs (78.9 and 75%, respectively). However, significantly more surgically treated dogs were non-ambulatory at presentation (9/17 vs. 5/24, p = 0.048) compared with conservatively treated dogs. This study suggests that conservative treatment may be appropriate for dogs with SEE that are ambulatory at presentation and that surgically treated dogs generally have good outcomes. Age may be a negative prognostic indicator as dogs with poor long-term outcomes were significantly older than dogs with a good long-term outcome (p = 0.048). A larger prospective randomized study may provide further insight on treatment and outcome of SEE in dogs.
Collapse
Affiliation(s)
- Emma J. Laws
- Linnaeus Veterinary Limited, Solihull, United Kingdom
- *Correspondence: Emma J. Laws
| | - Lluís Sánchez
- Neurology/Neurosurgery Service, Willows Veterinary Centre and Referral Centre, Linnaeus Veterinary Limited, Solihull, United Kingdom
| | - Elsa Beltran
- Neurology/Neurosurgery Service, Queen Mother Hospital for Animals, Royal Veterinary College, Potters Bar, United Kingdom
| | - Elisabet Domínguez
- Diagnostic Imaging Service, Anicura ARS Hospital Veterinari, Barcelona, Spain
| | - Abel B. Ekiri
- Department of Veterinary Epidemiology and Public Health, School of Veterinary Medicine, University of Surrey, Guildford, United Kingdom
| | - Josep Brocal
- Neurology/Neurosurgery Service, Anderson Moores, Linnaeus Veterinary Limited, Winchester, United Kingdom
| | | |
Collapse
|
39
|
Kharbat AF, Cox CT, Purcell A, MacKay BJ. Methicillin-Resistant Staphylococcus aureus Spinal Epidural Abscess: Local and Systemic Case Management. Cureus 2022; 14:e22831. [PMID: 35399478 PMCID: PMC8980237 DOI: 10.7759/cureus.22831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2022] [Indexed: 12/02/2022] Open
Abstract
Spinal epidural abscess (SEA) is a rare condition with complex pathophysiology and highly variable clinical presentation. While it is known to cause focal peripheral nerve symptoms such as muscle weakness, paresthesia, or pain, these are typically accompanied by complaints of back or spine pain and systemic symptoms indicative of infection. In our case, a 53-year-old male initially presented with unilateral pain and swelling in his right hand, with no fever at presentation and no complaints of back pain. Blood culture confirmed methicillin-resistant Staphylococcus aureus (MRSA)for which he was given vancomycin. The patient later endorsed back pain and diagnostic imaging revealed a spinal epidural abscess spanning the T5-T9 vertebrae. The abscess was drained, and vancomycin was placed in the subfascial and epifascial compartments. The hand was debrided in the same operation and showed no gross purulence. Two days after the procedure, intraoperative cultures remained negative, and the patient was subsequently managed with daptomycin.
Collapse
|
40
|
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
|
41
|
Xiong GX, Crawford AM, Striano B, Lightsey HM, Nelson SB, Schwab JH. The NIMS framework: an approach to the evaluation and management of epidural abscesses. Spine J 2021; 21:1965-1972. [PMID: 34010684 DOI: 10.1016/j.spinee.2021.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 05/06/2021] [Accepted: 05/07/2021] [Indexed: 02/03/2023]
Affiliation(s)
- Grace X Xiong
- Harvard Combined Orthopaedic Residency Program, 55 Fruit St., Boston, MA, 02114
| | | | - Brendan Striano
- Harvard Combined Orthopaedic Residency Program, 55 Fruit St., Boston, MA, 02114
| | - Harry M Lightsey
- Harvard Combined Orthopaedic Residency Program, 55 Fruit St., Boston, MA, 02114
| | - Sandra B Nelson
- Division of Infectious Diseases, Massachusetts General Hospital, Bulfinch 130, 55 Fruit St., Boston, MA, 02114
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Yawkey 3A, 55 Fruit St., Boston, MA 02114.
| |
Collapse
|
42
|
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.
Collapse
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
| |
Collapse
|
43
|
Kitov B, Kitova T, Kehayov I, Angelova P. Letter to the Editor Regarding "Predictors of Failure for Nonoperative Management of Spinal Epidural Abscess" by Hunter et al. Global Spine J 2021; 11:1313-1314. [PMID: 34525869 PMCID: PMC8453683 DOI: 10.1177/21925682211029268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Borislav Kitov
- Department of Neurosurgery, Faculty of Medicine, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Tanya Kitova
- Department of Neurosurgery, Faculty of Medicine, Medical University of Plovdiv, Plovdiv, Bulgaria,Department of Anatomy, Histology and Embryology, Medical Faculty, Medical University of Plovdiv, Plovdiv, Bulgaria,Tanya Kitova, Department of Anatomy, Histology and Embryology, Medical Faculty, Medical University of Plovdiv, 15A “Vasil Aprilov” Blvd., Plovdiv 4002, Bulgaria.
| | - Ivo Kehayov
- Department of Neurosurgery, Faculty of Medicine, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Polina Angelova
- Department of Neurosurgery, Faculty of Medicine, Medical University of Plovdiv, Plovdiv, Bulgaria
| |
Collapse
|
44
|
Bai AD, Findlater A, Irfan N, Singhal N, Loeb M. Cefazolin versus cloxacillin as definitive antibiotic therapy for methicillin-susceptible Staphylococcus aureus spinal epidural abscess: a retrospective cohort study. Int J Antimicrob Agents 2021; 58:106429. [PMID: 34469802 DOI: 10.1016/j.ijantimicag.2021.106429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 08/19/2021] [Accepted: 08/21/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVES We compared the effectiveness of cefazolin and cloxacillin as definitive antibiotic therapy for methicillin-susceptible Staphylococcus aureus (MSSA) spinal epidural abscess (SEA). METHODS This retrospective cohort study included patients with MSSA SEA from two academic hospitals in Hamilton, Ontario, Canada, between 2014 and 2020. Patients treated with cefazolin were compared to those treated with cloxacillin. Co-primary outcomes included 90-day mortality, antibiotic failure, adverse reactions and recurrence. Inverse probability of treatment weighting using propensity scores was used to balance important prognostic factors and to estimate an adjusted risk difference. RESULTS Of 98 patients with MSSA SEA, 50 and 48 patients were treated with cefazolin and cloxacillin, respectively. Mortality at 90 days was 8% and 13% in the cefazolin and cloxacillin groups, respectively (P = 0.52). The antibiotic failure rate was 12% and 19% in the cefazolin and cloxacillin groups, respectively (P = 0.41). The serious adverse reactions rate was 0% and 4% in the cefazolin and cloxacillin groups, respectively (P = 0.24). The recurrence rate was 2% and 8% in the cefazolin and cloxacillin groups, respectively (P = 0.20). The adjusted risk difference for mortality at 90 days was -1% [95% confidence interval (CI) -10% to 8%] favouring cefazolin. The adjusted risk differences for antibiotic failure, adverse reactions and recurrence were 1% (95% CI -12% to 14%), -5% (95% CI -11% to 2%) and -18% (-36% to -1%) respectively. CONCLUSION Cefazolin is likely as effective as an antistaphylococcal penicillin and may be considered as a first-line treatment for MSSA SEA.
Collapse
Affiliation(s)
- Anthony D Bai
- Health Research Methodology Program, McMaster University, Hamilton, Ontario, Canada.
| | - Aidan Findlater
- Division of Infectious Diseases, McMaster University, Hamilton, Ontario, Canada
| | - Neal Irfan
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nishma Singhal
- Division of Infectious Diseases, McMaster University, Hamilton, Ontario, Canada
| | - Mark Loeb
- Division of Infectious Diseases, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
45
|
Kim C, Lee S, Kim J. Spinal epidural abscess due to coinfection of bacteria and tuberculosis: A case report. World J Clin Cases 2021; 9:4072-4080. [PMID: 34141768 PMCID: PMC8180206 DOI: 10.12998/wjcc.v9.i16.4072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 02/23/2021] [Accepted: 03/24/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Spinal epidural abscess (SEA) is a rare condition that mostly results from infection with either bacteria or tuberculosis. However, coinfection with bacteria and tuberculosis is extremely rare, and it results in delays in diagnosis and antimicrobial treatment causing unfavorable outcomes.
CASE SUMMARY A 75-year-old female visited the hospital with low back pain, and magnetic resonance imaging (MRI) revealed an SEA at the lumbosacral segment. Staphylococcus hominis and methicillin-resistant Staphylococcus epidermidis were identified from preoperative blood culture and intraoperative abscess culture, respectively. Thus, the patient underwent treatment with vancomycin medication for 9 wk after surgical drainage of the SEA. However, the low back pain recurred 2 wk after vancomycin treatment. MRI revealed an aggravated SEA in the same area in addition to erosive destruction of vertebral bodies. Second surgery was performed for SEA removal and spinal instrumentation. The microbiological study and pathological examination confirmed Mycobacterium tuberculosis as the pathogen concurrent with the bacterial SEA. The patient improved completely after 12 mo of antitubercular medication.
CONCLUSION We believe that the identification of a certain pathogen in SEAs does not exclude coinfection with other pathogens. Tubercular coinfection should be suspected if an SEA does not improve despite appropriate antibiotics for the identified pathogen.
Collapse
Affiliation(s)
- Choonghyo Kim
- Department of Neurosurgery, Kangwon National University School of Medicine, Chuncheon 24341, Gangwon, South Korea
- Department of Neurosurgery, Kangwon National University Hospital, Chuncheon 24289, Gangwon, South Korea
| | - Seungkoo Lee
- Department of Anatomic Pathology, Kangwon National University School of Medicine, Chuncheon 24341, Gangwon, South Korea
- Department of Anatomic Pathology, Kangwon National University Hospital, Chuncheon 24289, Gangwon, South Korea
| | - Jiha Kim
- Department of Neurosurgery, Kangwon National University School of Medicine, Chuncheon 24341, Gangwon, South Korea
- Department of Neurosurgery, Kangwon National University Hospital, Chuncheon 24289, Gangwon, South Korea
| |
Collapse
|
46
|
Prod'homme M, Grasset D, Chalaron M, Boscherini D. Epidural abscess related to Streptococcus mitis in a 57-year-old immunocompetent patient. BMJ Case Rep 2021; 14:e239295. [PMID: 33837023 PMCID: PMC8043008 DOI: 10.1136/bcr-2020-239295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2021] [Indexed: 11/04/2022] Open
Abstract
A 57-year-old immunocompetent male patient presented himself to our emergency department with lumbar pain for 10 days, after a lumbar torsion. He was neurologically intact, but showed signs of systemic inflammatory syndrome. A lumbar MRI found a spinal epidural abscess from L3-L4 to L5-S1 levels. The patient was operated early before occurrence of neurological deficit. The abscess cultures found a Streptococcus mitis infection. The patient made a good recovery after surgical decompression, washout with samples taken for cultures and targeted antibiotic therapy for 6 weeks.
Collapse
Affiliation(s)
- Marc Prod'homme
- Neuro Orthopedic Center, La Source College of Health, Lausanne, Vaud, Switzerland
| | - Didier Grasset
- Neuro Orthopedic Center, La Source College of Health, Lausanne, Vaud, Switzerland
| | - Marc Chalaron
- Radiology, La Source College of Health, Lausanne, Vaud, Switzerland
| | - Duccio Boscherini
- Neuro Orthopedic Center, La Source College of Health, Lausanne, Vaud, Switzerland
| |
Collapse
|
47
|
Corsini Campioli C, Go JR, Abu Saleh O, Challener D, Yetmar Z, Osmon DR. Antistaphylococcal Penicillin vs Cefazolin for the Treatment of Methicillin-Susceptible Staphylococcus aureus Spinal Epidural Abscesses. Open Forum Infect Dis 2021; 8:ofab071. [PMID: 33738321 PMCID: PMC7953649 DOI: 10.1093/ofid/ofab071] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/08/2021] [Indexed: 12/29/2022] Open
Abstract
Cefazolin is commonly used as an alternative to antistaphylococcal penicillins (ASPs) in treating methicillin-susceptible Staphylococcus aureus (MSSA) infections; however, no study has compared these agents in MSSA spinal epidural abscess (SEA). We describe our experience in managing MSSA SEA and compare the clinical efficacy of cefazolin with ASPs. This retrospective multicenter study reviewed 79 adult patients diagnosed with SEA between January 2006 and July 2020 using data collected from electronic health records and clinical microbiology laboratory databases. Forty-five patients received cefazolin, while 34 received ASPs. The total antibiotic duration was longer in the ASPs group but not statistically significant. There were no significant differences in treatment failure at week 6 vs week 12, 30-day vs overall mortality, or in 90-day recurrence rates between the treatment groups. Cefazolin was equally as effective as ASPs, and our findings suggest that it can be an alternative to ASPs in the treatment of MSSA SEA.
Collapse
Affiliation(s)
| | - John Raymond Go
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Omar Abu Saleh
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Douglas Challener
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Zachary Yetmar
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Douglas R Osmon
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
48
|
Abstract
CLINICAL/METHODOLOGICAL PROBLEM Spondylodiscitis is an inflammation of the intervertebral disc, which in adults is generally associated with spondylitis of the adjacent vertebrae. It often presents clinically with nonspecific symptoms such as back or neck pain. It may be caused by various pathogens, especially bacteria. One or more vertebral segments can be affected. The infection can spread to surrounding compartments and can lead to epidural abscesses. Radiology, in particular magnetic resonance imaging (MRI), plays an important role in the diagnostic work-up and in the follow-up to monitor response to therapy. Treatment consists of conservative (antibiotics) and invasive approaches, including surgery. Interventional puncture and drainage is a promising alternative to surgery, especially in early stages of abscess formation. STANDARD RADIOLOGICAL METHODS Magnetic resonance imaging (MRI), computed tomography (CT), nuclear medical procedures, conventional x‑ray. PERFORMANCE MRI has the highest value. CT and nuclear medical procedures can be used as a supplement to MRI and in patients with contraindications for MRI. PRACTICAL RECOMMENDATIONS With adequate diagnosis and therapy, spondylodiscitis has a good prognosis. In addition to targeted or calculated drug therapy, invasive treatment is the main focus, especially for epidural abscesses. Interventional radiological drainage can represent a less invasive alternative to surgical treatment.
Collapse
|
49
|
Eroshkin A, Romanukha D, Voitsekhovskyi S. Surgical management of an extensive spinal epidural abscess: illustrative cases. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE2050. [PMID: 35854928 PMCID: PMC9241317 DOI: 10.3171/case2050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 10/30/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Extensive spinal epidural abscesses (SEAs) occupying three or more spinal regions are rare. This study aimed to address the key dilemma of surgical treatment for holospinal epidural abscesses, i.e., to determine the required scope of surgery and minimize surgical trauma with adequate purulent drainage. OBSERVATIONS Two patients with extensive SEAs were treated at the Neurosurgery Department of the Central Hospital of Ministry of Internal Affairs of Ukraine from 2018 to 2020. Both patients had a neurological deficit and general inflammatory response syndrome. Spinal magnetic resonance examinations were performed, showing that the first and second patients had extensive SEAs at T11/S1 and C2/L1, respectively. Both underwent minimally invasive abscess drainage via intra- and translaminar access at the most caudal point using an epidural silicone catheter in the cranial direction along the entire length of the abscess. LESSONS To achieve the key goal of extensive SEA treatment, i.e., to prevent the development of a persistent neurological deficit, immediate effective spinal canal decompression should be performed. Access method and scope should meet the requirements of spinal canal decompression and purulent content aspiration to the greatest possible extent while inducing minimal trauma.
Collapse
Affiliation(s)
- Aleksey Eroshkin
- Department of Neurosurgery, Central Hospital of Ministry of Internal Affairs of Ukraine (Central Police Hospital), Kyiv, Ukraine; and
| | - Dmytro Romanukha
- Department of Neurosurgery, Central Hospital of Ministry of Internal Affairs of Ukraine (Central Police Hospital), Kyiv, Ukraine; and
| | | |
Collapse
|
50
|
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES The aim of this study is to identify predictive factors associated with failure of nonoperative management of spinal epidural abscess (SEA). METHODS Between January 2007 and January 2017, there were 97 patients 18 years or older treated for SEA at a tertiary referral center. Of these, 58 were initially managed nonoperatively. Details on presenting complaint, laboratory parameters, radiographic evaluation, demographics, comorbidities, and neurologic status (Frankel grades A-E) were collected. Success of treatment was defined as eradication of infection with no requirement for further antimicrobial therapy. Diagnosis of SEA was made via evaluation of imaging and intraoperative findings. Patients with repeat presentation of SEA, children, and those who were transferred for immediate surgical decompression were excluded. RESULTS Fifty-eight patients initially treated nonoperatively were included. Of these, 21 failed nonoperative management and required surgical intervention. The mean age was 60 years, 66% male, and 19% of Maori ethnicity. Abscess location was predominantly dorsal, and in the lumbar region (53%). Multivariate analysis identified Maori ethnicity, multifocal sepsis, and elevated white cell count as predictors of failure of nonoperative management. With 1 predictor the risk of failure was 44%. In the presence of 2 predictive variables, failure rate increased to 60%, and if all 3 variables were present, patients had a 75% risk of failure. CONCLUSION Thirty-six percent of patients treated nonoperatively failed nonoperative management-the failure rate was significantly increased in patients with multifocal sepsis, in patients with elevated white cell count, and in patients of Maori ethnicity.
Collapse
Affiliation(s)
- Sarah Hunter
- University of Auckland, Auckland, Auckland, New Zealand
- Waikato Hospital, Hamilton, New Zealand
- Sarah Hunter, Waikato Hospital, Pembroke St, Hamilton West, Hamilton 3204, New Zealand.
| | - Robert Cussen
- Waikato Hospital, Hamilton, New Zealand
- University College Cork, Cork, Ireland
| | - Joseph F. Baker
- University of Auckland, Auckland, Auckland, New Zealand
- Waikato Hospital, Hamilton, New Zealand
| |
Collapse
|