Epidural empyema following thoracic extradural block. Case report

Conservative treatment of an epidural abscess after thoracic epidural catheterization

We describe a case of a thoracic epidural abscess after epidural catheter insertion in a patient undergoing lobar segmentectomy. The patient described a "pulsatile" back pain the sixth day after surgery, and purulent material at the entry site of the catheter was observed. The image of the nuclear magnetic resonance confirmed an epidural abscess that was treated conservatively with antibiotics after a consensus decision among neurosurgery, infectious diseases an anesthesia services. The abscess was reabsorbed completely with no sequelae.

Tunneled Epidural Catheters for Prolonged Analgesia in Pediatric Patients

We conducted this retrospective study to document the efficacy and safety, and demonstrate the spectrum of indications for subcutaneously tunneled epidural catheters in the management of prolonged pain in pediatric patients. The charts of 25 patients with prolonged pain that was unresponsive to conventional opioid therapy (10: end stage malignancy, 8: extensive abdominal surgery, 7: trauma, etc.) and who received thoracic, lumbar, or caudal tunneled epidural catheters between 1995 and 1999 were reviewed for efficacy and catheter-related complications (infection or bleeding at the insertion site, toxicity related to local anesthetics, tachyphylaxis and respiratory depression). Tunneled epidural catheters were effective in providing extended analgesia in all subjects. In 14 patients with chronic pain, cumulative 48-h enteral and parenteral opioid requirements were reduced or eliminated after catheter insertion. Catheters remained in place for a median of 11 days (range, 4--240 days) until there was no further need for parenteral analgesia (n = 15), death because of the underlying disease (n = 6), accidental removal (n = 2), or possible infection (n = 2). No serious local or systemic complications (meningitis, epidural abscess, systemic infection, epidural hematoma, or spinal cord injury; seizures, local anesthetic toxicity) occurred related to this technique. Five patients were discharged from the hospital with the catheter for home analgesic therapy. The use of a percutaneously inserted, subcutaneously tunneled epidural catheter is safe, effective, and provides pain relief in situations in which conventional analgesic therapy either fails or is impractical. The technique is one that may be of great value to children suffering from pain.

IMPLICATIONS

Children and adolescents with pain may safely have a spinal catheter placed for a period of time without undo risk of infection or other complications. Spinal catheters provide excellent pain relief, often eliminating the need for riskier medications for painful events such as wound cleansing and dressing changes.

Hematogenous pyogenic spinal infections and their surgical management

STUDY DESIGN

Mainly a retrospective study of 101 cases of pyogenic spinal infection, excluding postoperative infections. Data were obtained through medical record review, imaging examination, and patient follow-up evaluation.

SUMMARY OF BACKGROUND DATA

Hematogenous pyogenic spinal infection has been described variously as spondylodiscitis, discitis, vertebral osteomyelitis, and epidural abscess. Recommended treatment options have included conservative methods (antibiotics and bracing) and surgical intervention. However, a comprehensive classification that would aid in diagnosis, treatment planning, and prognosis has not yet been devised.

OBJECTIVES

To analyze the bacteriology, pathologic entities, complications, and results of treatment options for pyogenic spinal infection.

METHOD

All patients received plain radiographs, gadolinium-enhanced magnetic resonance imaging scans, and bone/gallium radionuclide studies. All patients had tissue biopsies. Bacteriology, hematology, and predisposing factors were analyzed. All patients received intravenous and oral antibiotics. A total of 58 patients underwent surgery. Patient outcomes were correlated with clinical status, with treatment method and, where applicable, with location and nature of epidural compression. Statistical analyses were performed.

RESULTS

Spondylodiscitis occurred most commonly with primary epidural abscess, spondylitis, discitis, and pyogenic facet arthropathy, all occurring rarely. Staphylococcus aureus was the main organism. Infection elsewhere was the most common predisposing factor. Leukocyte counts were elevated in 42.6% of spondylodiscitis cases. The erythrocyte sedimentation rate was elevated in all cases of epidural abscess. There were 35 cases of epidural abscess (frank abscess, 29; granulation tissue, 6). Epidural abscess complicating spondylodiscitis occurred most often in the cervical spine, followed by thoracic and lumbar areas. The rate of paraplegia or paraparesis also was highest in cervical and thoracic regions. There were no cases of quadriplegia. All patients with either epidural granulation tissue or paraparesis recovered completely after surgical decompression. Only 18% of patients with frank epidural abscess and 23% of patients with paralysis recovered completely after surgical decompression. Patients with spondylodiscitis who were treated nonsurgically reported residual back pain more often (64%) than patients treated surgically (26.3%).

CONCLUSIONS

Pyogenic spinal infection can be thought of as a spectrum of disease comprising spondylitis, discitis, spondylodiscitis, pyogenic facet arthropathy, and epidural abscess. Spondylodiscitis is more prone to develop epidural abscesses in the cervical spine (90%) than the thoracic (33.3%) or lumbar (23.6%) areas. Thecal sac neurocompression has a greater chance of causing neurologic deficit in the thoracic spine (81.8%). Treatment of neurologic deficit caused by epidural abscess is prompt surgical decompression, with or without fusion. Patients with frank abscess had less favorable outcomes than those with granulation tissue, and paraplegia responded to treatment more poorly than paraparesis. Surgery was preferable to nonsurgical treatment for improving back pain.

Lumbar osteomyelitis and epidural abscess complicating recurrent pilonidal cyst: report of a case

PURPOSE

This study was conducted to report the rare presentation of lumbar osteomyelitis and epidural abscess as a complication of a pilonidal cyst.

METHODS

A case report is presented.

RESULTS

We describe the rare case of a male patient with diabetes with a recurring pilonidal cyst who developed a lumbar osteomyelitis and epidural abscess three weeks after pilonidal cyst excision with epidural anesthesia, with a fatal outcome despite emergency treatment.

CONCLUSIONS

Life-threatening complications should be kept in mind in high-risk patients with repetitive surgery and neurologic involvement.

Iatrogenic Mycobacterium infection after an epidural injection

STUDY DESIGN

Case report.

OBJECTIVES

Successful excision of the mass and identification of the causative agent by histologic and microbiologic studies.

SUMMARY OF BACKGROUND DATA

Spinal pain, caused by an infective mass, developed in a 39-year-old man 3 months after an epidural injection for low back pain.

METHODS

Exploratory surgery was performed to remove the mass, and histologic and microbiologic studies were conducted.

RESULTS

The inflammatory mass was excised successfully, and several specimens were examined for bacteriologic presence. Histologic examination of the excised specimen showed chronic granulomatous inflammation, and subsequent microbiologic studies cultured an acid- and alcohol-fast bacillus that was later identified as Mycobacterium fortuitum.

CONCLUSION

A review of the literature shows that this is a particularly uncommon micro-organism.

Spinal epidural abscess associated with epidural catheterization: report of a case and a review of the literature

We describe a 53-year-old man who developed a catheter-related epidural abscess 8 days after left upper lobectomy for lung cancer. Methicillin-resistant Staphylococcus aureus (MRSA) was detected in a culture of the epidural pus. Magnetic resonance imaging was essential for the diagnosis of epidural abscess and for determining the extent of spread. The patient was treated by laminectomy and administration of appropriate antibiotics, with almost complete recovery, except for urinary retention. A literature search yielded 29 additional cases of catheter-related epidural abscess. The median duration of catheterization was 4 days and the median time to onset of the clinical symptoms after catheter placement was 8 days. Eleven of the 30 patients had some underlying disorders, including malignancy or herpes zoster, or were receiving steroids. Nine of the 10 patients with thoracic epidural abscess had persistent neurological deficits, whereas 12 of the 15 patients with lumbar epidural abscess showed a full recovery after treatment. Surgical decompression was not required in six patients without significant neurological deficits, who recovered following antibiotic treatment (four patients) or percutaneous drainage (two patients). Thoracic catheters are associated with a disproportionately high incidence of epidural abscess and persistent neurological sequelae following treatment.

Epidural abscess complicating epidural anesthesia and analgesia. An analysis of the literature

BACKGROUND

Epidural abscess is a serious complication of epidural block. Because of its low incidence, the risk factors and the symptoms and cause of epidural abscess related to epidural anesthesia and analgesia are not well known by anesthesiologists.

METHODS

A computer-assisted search of the literature on epidural catheter-related abscess was performed to describe the clinical course and bacteriology of this complication, to determine possible risk factors, and to assess the index of suspicion among physicians.

RESULTS

Forty-two patients with a catheter-related epidural abscess were identified. Only in 15 patients was the correct diagnosis considered initially. The time from insertion of the epidural catheter to symptoms varied between 1 and 60 d. Initial symptoms included back pain, fever, and leukocytosis. The time from symptoms to treatment was a few hours to 108 d. Interval from first symptoms to treatment was significantly longer in patients with persistent neurologic deficits compared with patients who completely recovered. Staphylococcus aureus was the most common etiologic agent. Outcome was reported in 39 patients, but only 19 made a full recovery.

CONCLUSION

The index of suspicion among anesthesiologists, other physicians and nurses taking care of patients with epidural catheters must be increased for this complication; this should shorten the interval from symptoms to treatment and lower the incidence of neurological sequelae.

Spinal epidural abscess associated with the use of temporary epidural catheters: report of two cases and review

Spinal epidural abscess has rarely been associated with the use of epidural catheters. We describe two patients with epidural abscesses that occurred in relation to the use of temporary epidural catheters; a literature review yielded 20 additional well-described cases. The mean age of these 22 patients was 49.9 years, the median duration of epidural catheter use was 3 days, and the median time to onset of clinical symptoms after catheter placement was 5 days. The majority of patients (63.6%) had major neurological deficits, and 22.7% also had concomitant meningitis. Staphylococcus aureus was the predominant pathogen. Despite antibiotic therapy and drainage procedures, 38% of the patients continued to have neurological deficits. These unusual but serious complications of temporary epidural catheter use require efficient and accurate diagnostic evaluation, as they can be substantial.

Introducing epidural fentanyl for on-ward pain relief after major surgery

BACKGROUND

Epidural opioids have been recommended for analgesia after major surgery. In this report we describe how we introduced a low-cost, on-ward, nurse-based acute pain service using epidural fentanyl after major surgery in the University Hospitals of Oulu and Kuopio.

METHODS

In order to evaluate the feasibility of epidural fentanyl infusion administered by ward nurses, we prospectively assessed pain and side effects during fentanyl infusion (median duration 41 h) after major surgery in 305 consecutive patients in Kuopio.

RESULTS

92% of the patients on the ward who had received epidural fentanyl infusion at 31-54 micrograms h-1 reported at most three episodes of severe pain (/Numerical Rating Scale > 3/ 10) during the initial postoperative days, but there were some patients (8%) who reported several episodes (> 3) of more severe pain (Numerical Rating Scale > 3). Three patients (0.9%) showed a diminished respiratory rate (< 10/min), but only one of them (0.3%) was somnolent. One other patient (0.3%) was not arousable until the cessation of infusion. Nausea and pruritus were minor problems in our patients, but a majority needed a urinary catheter.

CONCLUSION

With well-trained nurses, careful monitoring and appropriate protocols, epidural fentanyl infusion proved to be a feasible method for pain relief after major surgery on a surgical ward.

Epidural spinal abscesses

Fifteen cases of peridural empyemas are reported. 12 patients reported with motor dysfunction of the lower extremities and pain radiating from the spine. In one case, localized pain of the spine was discovered and in two cases there were no signs of spinal or radiating pain. Treatment in all cases was laminectomy and systemic antibiotic administration. Microbiological analysis showed staphylococcus aureus in 11 cases. 9 patients recovered with no neurological defects, two had major improvement of the paresis, and one died. Three patients with paraplegia recovered from the primary infection.

Spinal epidural abscess

We present three cases of spinal epidural abscess. Initial presentation of localized spinal pain and tenderness along with fever should lead one to suspect the diagnosis. An emergency myelography and prompt treatment with appropriate antibiotics is necessary to prevent catastrophic neurologic deficit.

Decreased morbidity from acute bacterial spinal epidural abscesses using computed tomography and nonsurgical treatment in selected patients

We describe 5 patients with spinal epidural abscesses in whom computed tomographic scanning confirmed diagnosis without the use of myelography. One patient required urgent surgery because of rapidly deteriorating neurological status, but the other 4 were treated nonsurgically. The medical treatment of these patients and 9 others described in the literature consisted of antibiotics administered parenterally for a minimum of 8 weeks, followed by oral antibiotic therapy. Early diagnosis with computed tomographic scanning and a benign neurological state at the onset of treatment were associated with good results.

Spinal epidural abscess

Spinal epidural abscess is an uncommon and serious infection resulting from direct extension of a local process or hematogenous spread from an antecedent or ongoing distant focus of infection. The findings of spinal ache, tenderness, and fever should suggest the diagnosis, and the appearance of weakness and loss of sensation below the area of pain should be considered as the strongest possible clinical confirmation. In cases in which this constellation of findings occurs, rapid evaluation and immediate surgical decompression and drainage offer the patient a possible successful functional recovery. Even in recent series, permanent paralysis and death occur with unfortunate frequency, and these have usually been related to delay in diagnosis and definitive surgical therapy.