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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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Xiong GX, Nguyen A, Hering K, Schoenfeld AJ. Long-term quality of life and functional outcomes after management of spinal epidural abscess. Spine J 2024; 24:759-767. [PMID: 38072087 DOI: 10.1016/j.spinee.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/06/2023] [Accepted: 11/27/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND/CONTEXT In recent years, the incidence of spinal epidural abscesses (SEA) has tripled in number and nonoperative management has risen in popularity. While there has been a shift towards reserving surgical intervention for patients with focal neurologic deficits, a third of patients will still fail medical management and require surgical intervention. Failure to understand long-term quality of life and functional outcomes hinders effective decision making and prognostication. PURPOSE To describe patterns and associated factors impacting long-term quality of life following treatment of spinal epidural abscess. STUDY DESIGN/SETTING Multicenter cohort study at two urban academic tertiary referral centers and two community centers. PATIENT SAMPLE Adult patients treated for a spinal epidural abscess. OUTCOME MEASURES EuroQoL 5-Dimension 5L (EQ5D), Neuro-Quality of Life Lower Extremity - Mobility (Short Form; NeuroQoL-LE), Patient-Reported Outcomes Measurement Information System Physical Function (short form 4a; PROMIS PF), and PROMIS Global Mental Health score (PROMIS Mental). METHODS Eligible patients were enrolled and administered questionnaires. Multivariable analysis assessed the influence of ambulatory status on HRQL, adjusting for covariates including age, biologic sex, Charlson comorbidity index, intravenous drug use, management approach, and ASIA grade on presentation. RESULTS Sixty-one patients were enrolled (mean age 60.5 years, 46% male). Thirty-four patients (58%) underwent operative management. Mean standard deviation (SD) results for HRQL measures were: EQ5D 0.51 (0.37), EQ5D visual analogue scale 60.34 (25.11), NeuroQoL Lower extremity 41.47 (10.64), PROMIS physical function 39.49 (10.07), and PROMIS Global Mental Health 44.23 (10.36). Adjusted analysis demonstrated ambulatory status at presentation, and at 1 year, to be important drivers of HRQL, irrespective of other factors including IVDU and ASIA grade. Patients with independent ambulatory function at 1 year had mean EQ5D utility of 0.65 (95% CI 0.55, 0.75), whereas those requiring assistive devices saw a 49% decrease with mean EQ5D utility of 0.32 (0.14, 0.51). Ambulatory status was associated with global and physical function but did not impact overall health self-assessment or mental health scores. CONCLUSIONS We found that ambulatory status was the most important factor associated with long-term HRQL regardless of other factors such as ASIA grade or IVDU. Given prior literature demonstrating the protective effect of operative intervention on ambulatory function, this highlights ambulatory dysfunction as a potential indication for surgery and a marker of poor long-term prognosis, even in the absence of focal neurologic deficits. Our work also highlights the importance of optimized long-term rehabilitation strategies aimed to preserve ambulatory function in this high-risk population. LEVEL OF EVIDENCE Level III, cohort study.
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Affiliation(s)
- Grace X Xiong
- Harvard Combined Orthopaedic Residency Program, 55 Fruit St, Boston, MA 02114, USA
| | - Andrew Nguyen
- Harvard Medical School, 25 Shattuck St, Boston MA 02115, USA
| | - Kalei Hering
- Harvard Medical School, 25 Shattuck St, Boston MA 02115, USA
| | - Andrew J Schoenfeld
- Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston MA 02115, USA.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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.
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Crawford AM, Striano BM, Amakiri IC, Williams DL, Lindsey MH, Gong J, Simpson AK, Schoenfeld AJ. The utility of vertebral Hounsfield units as a prognostic indicator of adverse events following treatment of spinal epidural abscess. N Am Spine Soc J 2024; 17:100308. [PMID: 38264152 PMCID: PMC10803939 DOI: 10.1016/j.xnsj.2024.100308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/03/2024] [Accepted: 01/04/2024] [Indexed: 01/25/2024]
Abstract
Background Spinal epidural abscesses (SEAs) are a devastating condition with high levels of associated morbidity and mortality. Hounsfield units (HUs), a marker of radiodensity on CT scans, have previously been correlated with adverse events following spinal interventions. We evaluated whether HUs might also be associated with all-cause complications and/or mortality in this high-risk population. Methods This retrospective cohort study was carried out within an academic health system in the United States. Adults diagnosed with a SEA between 2006 and 2021 and who also had a CT scan characterizing their SEA within 6 months of diagnosis were considered. HUs were abstracted from the 4 vertebral bodies nearest to, but not including, the infected levels. Our primary outcome was the presence of composite 90-day complications and HUs represented the primary predictor. A multivariable logistic regression analysis was conducted adjusting for demographic and disease-specific confounders. In sensitivity testing, separate logistic regression analyses were conducted (1) in patients aged 65 and older and (2) with mortality as the primary outcome. Results Our cohort consisted of 399 patients. The overall incidence of 90-day complications was 61.2% (n=244), with a 7.8% (n=31) 90-day mortality rate. Those experiencing complications were more likely to have undergone surgery to treat their SEA (58.6% vs. 46.5%; p=.018) but otherwise the cohorts were similar. HUs were not associated with composite 90-day complications (Odds ratio [OR] 1.00 [95% CI 1.00-1.00]; p=.842). Similar findings were noted in sensitivity testing. Conclusions While HUs have previously been correlated with adverse events in certain clinical contexts, we found no evidence to suggest that HUs are associated with all-cause complications or mortality in patients with SEAs. Future research hoping to leverage 3-dimensional imaging as a prognostic measure in this patient population should focus on alternative targets. Level of Evidence Level III; Observational Cohort study.
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Affiliation(s)
- Alexander M. Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA 02115,United States
| | - Brendan M. Striano
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA 02115,United States
| | - Ikechukwu C. Amakiri
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA 02115,United States
| | | | - Matthew H. Lindsey
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA 02115,United States
| | - Jonathan Gong
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115,United States
| | - Andrew K. Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115,United States
| | - Andrew J. Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115,United States
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Greenwald P, Chan AK. Spinal Epidural Abscess and Strep Pharyngitis. World Neurosurg 2023; 180:77-78. [PMID: 37741329 DOI: 10.1016/j.wneu.2023.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 09/07/2023] [Accepted: 09/08/2023] [Indexed: 09/25/2023]
Abstract
Spinal epidural abscesses (SEA) require prompt diagnosis to avoid devastating consequences. Here, we discuss the case of a healthy 20-year-old college student-with a recent diagnosis of strep pharyngitis-who presented with neck pain, fever, and a neurologic deficit-the most common symptoms of SEA. Magnetic resonance imaging revealed a T1-postcontrast, peripherally enhancing epidural collection from C3-T5 with associated cord compression and T3 osteomyelitis. The patient was treated with emergent skip hemilaminectomies for abscess evacuation. Surgical cultures grew Fusobacterium necrophorum, a highly unusual pathogen in SEA. It is an oral anaerobe that translocated through the mucosa in the setting of strep pharyngitis. We treated the patient with ceftriaxone for 6 weeks. The patient had a full neurologic recovery and remains without recurrence of infection 11 months postoperatively. Healthy patients without obvious risk factors may present with SEA, highlighting the need for atypical cases such as these to be brought to clinicians' attention.
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Affiliation(s)
- Phoebe Greenwald
- Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA.
| | - Andrew K Chan
- Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
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6
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Song YW, Yang PS, Cheng IC, Hung CH. Cervical spinal epidural abscess secondary to acupuncture: a case report and literature review. Acta Neurol Belg 2023; 123:2419-2421. [PMID: 36952104 DOI: 10.1007/s13760-023-02244-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 03/13/2023] [Indexed: 03/24/2023]
Affiliation(s)
- Yun-Wen Song
- Department of Neurology, Kaohsiung Medical University Hospital, No.100, Shih-Chuan 1st Road, Sanmin Dist., Kaohsiung, 80708, Taiwan
| | - Po-Sung Yang
- Department of Neurology, Kaohsiung Medical University Hospital, No.100, Shih-Chuan 1st Road, Sanmin Dist., Kaohsiung, 80708, Taiwan
| | - I-Chin Cheng
- Department of Neurology, Kaohsiung Medical University Hospital, No.100, Shih-Chuan 1st Road, Sanmin Dist., Kaohsiung, 80708, Taiwan
| | - Chih-Hsien Hung
- Department of Neurology, Kaohsiung Medical University Hospital, No.100, Shih-Chuan 1st Road, Sanmin Dist., Kaohsiung, 80708, Taiwan.
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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Nakamura Y, Namba T, Sakurai M, Yasui M. Silent spinal epidural abscess due to facet joint arthritis. IDCases 2023; 33:e01887. [PMID: 37680212 PMCID: PMC10480523 DOI: 10.1016/j.idcr.2023.e01887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 08/24/2023] [Accepted: 08/27/2023] [Indexed: 09/09/2023] Open
Abstract
Spinal epidural abscess (SEA) is an abscess that forms between the dura mater and vertebrae. SEA is characterized by back pain and neuropathy associated with fever, of which early diagnosis and treatment are necessary to avoid irreversible neurological sequelae. However, its diagnosis is often difficult because specific symptoms are rarely present in the early stages of the disease. A 25-month-old boy, healthy by nature and free of risk factors, was referred and admitted for fever symptoms only, without back pain or neurological symptoms. We focused on the residual activation of the coagulation-fibrinolytic system, which was contrary to the response to therapy, and were able to establish a diagnosis of SEA. After the initiation of antibiotics, the patient responded well to treatment and made a mild recovery without the need for surgical intervention. To date, there are no reported cases of SEA with only febrile symptoms without localized spinal cord tenderness. SEA is easily overlooked and should be considered in the differential diagnosis of pediatric fever of unknown origin. Although imaging studies have drawbacks, such as radiation exposure and sedation, they should be immediately performed if SEA is suspected.
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Affiliation(s)
- Yuta Nakamura
- Department of Pediatrics, Fukuyama City Hospital, Fukuyama, Japan
| | - Takahiro Namba
- Correspondence to: Department of Pediatrics, Fukuyama City Hospital, 5-23-1, Zaocho, Fukuyama, Hiroshima 721-8511, Japan.
| | - Momoko Sakurai
- Department of Pediatrics, Fukuyama City Hospital, Fukuyama, Japan
| | - Masato Yasui
- Department of Pediatrics, Fukuyama City Hospital, Fukuyama, Japan
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Leavitt NJ, Al-Nasseri AM, Brady AC. Epidural abscess secondary to Streptococcus pneumoniae. A case report and review of the literature. IDCases 2023; 33:e01853. [PMID: 37554430 PMCID: PMC10404723 DOI: 10.1016/j.idcr.2023.e01853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 07/19/2023] [Indexed: 08/10/2023] Open
Abstract
While spinal epidural abscess is a well described disease process, this condition is rarely caused by Streptococcus pneumoniae. This case describes a case of spinal epidural abscess secondary to S. pneumoniae in an otherwise healthy, immunocompetent 61-year-old female without a history of spinal procedures, obvious source of hematogenous seeding, or clear risk factors for invasive pneumococcal infection. She was treated with IV and oral antibiotic therapy and made a full recovery.
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Affiliation(s)
- Nathaniel J. Leavitt
- Internal Medicine Resident at HCA Citrus Memorial Hospital, 502 W Highland Blvd, Inverness, FL 34452, USA
| | - Abraheim M. Al-Nasseri
- Internal Medicine Resident at HCA Citrus Memorial Hospital, 502 W Highland Blvd, Inverness, FL 34452, USA
| | - Adam C. Brady
- Medical Director of Department of Infectious Diseases at Samaritan Health Services, 3600 NW Samaritan Dr, Corvallis, OR 97330, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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Jiang JY, Li H, Cai FJ, Jin GY. [Two cases of spinal epidural abscess caused by acupuncture]. Zhongguo Gu Shang 2023; 36:402-5. [PMID: 37211929 DOI: 10.12200/j.issn.1003-0034.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Affiliation(s)
- Jia-Yao Jiang
- Department of Orthopaedics, the 904th Hospital of Joint Logistics Support Force of Chinese PLA, Wuxi 214000, Jiangsu, China
| | - Hong Li
- Department of Orthopaedics, the 904th Hospital of Joint Logistics Support Force of Chinese PLA, Wuxi 214000, Jiangsu, China
| | - Fu-Jin Cai
- Department of Orthopaedics, the 904th Hospital of Joint Logistics Support Force of Chinese PLA, Wuxi 214000, Jiangsu, China
| | - Gen-Yang Jin
- Department of Orthopaedics, the 904th Hospital of Joint Logistics Support Force of Chinese PLA, Wuxi 214000, Jiangsu, China
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Veljanoski D, Tonna I, Barlas R, Abdel-Fattah AR, Almoosawy SA, Bhatt P. Spinal infections in the north-east of Scotland: a retrospective analysis. Ann R Coll Surg Engl 2023; 105:428-433. [PMID: 35904356 PMCID: PMC10149230 DOI: 10.1308/rcsann.2022.0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Spinal infection (SI) is uncommon and patients present with varied clinical features. In this review, the presentation, investigation, treatment and outcome of patients with SI in the north-east of Scotland were assessed. METHODS Electronic medical records of adult patients with SI hospitalised at a health board in the north-east of Scotland between 2014 and 2018 were analysed retrospectively. Collected variables included demographics, presenting clinical features, risk factors, comorbidities, admission blood results, microbiological investigations, imaging, treatment and outcomes. RESULTS Seventy-two patients were included. Mean age (±sd) was 63.3 years (±14.5). The lumbar spine was the most commonly involved region (51.4%). Back pain (84.7%), altered mobility (33.3%) and fever (29.2%) were the most frequent presenting features. Thoracic spine involvement (p = 0.041), urinary symptoms (p = 0.033), cauda equina syndrome (CES) (p = 0.027) and limb weakness (p = 0.026) were associated with poorer outcome. A better outcome was associated with back pain at presentation (p = 0.03) and underlying malignancy (p = 0.045). Diabetes (15.3%), recent falls (15.3%) and immunosuppression (12.5%) were common. A likely causative organism was found in 54 patients (75.0%) and Staphylococcus aureus was isolated in 41.7% of patients. Penicillins were used in 56.3% of patients and 20.8% underwent surgery. Outcomes were full recovery (38.2%), residual symptoms or neurological deficits (50.0%), paraplegia (4.4%) and death (7.4%). CONCLUSIONS Poorer outcomes occurred in patients with thoracic disease, limb weakness, urinary symptoms or CES, whereas better outcomes were associated with the presence of back pain on presentation and malignancy. This analysis highlights the diagnostic and therapeutic challenges of SI, alerting clinicians to key factors associated with prognosis.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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13
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Li S, Mei S, Huang L, Liu J, Chen Y, Huang B, Zhao F. Emergency surgery for a patient with a thoracic spinal epidural abscess: a case report and literature review. J Int Med Res 2023; 51:3000605231168757. [PMID: 37078091 PMCID: PMC10131533 DOI: 10.1177/03000605231168757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023] Open
Abstract
A man in his early 40s visited the Emergency Department because of no motor function in his lower limbs for 10 hours. Magnetic resonance imaging of his thoracic spine showed that the thoracic spinal canal (T2-T6) was occupied, and the thoracic spinal cord was compressed. In view of the severe symptoms, we quickly completed preoperative preparations and performed a thoracic laminectomy within 24 hours of paralysis of both lower limbs. Postoperatively, the patient underwent rehabilitation exercise. Four weeks later, the patient's lower limbs had full 5/5 strength. We reviewed the related literature to summarize the clinical guidelines with spinal surgeons. Timely diagnosis of thoracic spinal epidural abscess, early surgical treatment, and anti-infection management and rehabilitation exercise are essential for the full recovery of lower limb muscle strength.
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Affiliation(s)
- Sanbiao Li
- Department of Orthopedics, Jiande Hospital of Integrated Traditional Chinese and Western Medicine, Hangzhou, China
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shengqian Mei
- Department of Orthopedics, Jiande Hospital of Integrated Traditional Chinese and Western Medicine, Hangzhou, China
| | - Libin Huang
- Department of Orthopedics, Jiande Hospital of Integrated Traditional Chinese and Western Medicine, Hangzhou, China
| | - Junhui Liu
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, Hangzhou, China
| | - Yilei Chen
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, Hangzhou, China
| | - Bao Huang
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, Hangzhou, China
| | - Fengdong Zhao
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Musculoskeletal System Degeneration and Regeneration Translational Research of Zhejiang Province, Hangzhou, China
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14
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Shah AA, Karhade AV, Groot OQ, Olson TE, Schoenfeld AJ, Bono CM, Harris MB, Ferrone ML, Nelson SB, Park DY, Schwab JH. External validation of a predictive algorithm for in-hospital and ninety-day mortality after spinal epidural abscess. Spine J 2023; 23:760-765. [PMID: 36736740 DOI: 10.1016/j.spinee.2023.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 01/05/2023] [Accepted: 01/21/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND CONTEXT Mortality in patients with spinal epidural abscess (SEA) remains high. Accurate prediction of patient-specific prognosis in SEA can improve patient counseling as well as guide management decisions. There are no externally validated studies predicting short-term mortality in patients with SEA. PURPOSE The purpose of this study was to externally validate the Skeletal Oncology Research Group (SORG) stochastic gradient boosting algorithm for prediction of in-hospital and 90-day postdischarge mortality in SEA. STUDY DESIGN/SETTING Retrospective, case-control study at a tertiary care academic medical center from 2003 to 2021. PATIENT SAMPLE Adult patients admitted for radiologically confirmed diagnosis of SEA who did not initiate treatment at an outside institution. OUTCOME MEASURES In-hospital and 90-day postdischarge mortality. METHODS We tested the SORG stochastic gradient boosting algorithm on an independent validation cohort. We assessed its performance with discrimination, calibration, decision curve analysis, and overall performance. RESULTS A total of 212 patients met inclusion criteria, with a short-term mortality rate of 10.4%. The area under the receiver operating characteristic curve (AUROC) of the SORG algorithm when tested on the full validation cohort was 0.82, the calibration intercept was -0.08, the calibration slope was 0.96, and the Brier score was 0.09. CONCLUSIONS With a contemporaneous and geographically distinct independent cohort, we report successful external validation of a machine learning algorithm for prediction of in-hospital and 90-day postdischarge mortality in SEA.
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Affiliation(s)
- Akash A Shah
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA.
| | - Aditya V Karhade
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Olivier Q Groot
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Thomas E Olson
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Christopher M Bono
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Marco L Ferrone
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Sandra B Nelson
- Division of Infectious Diseases, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Don Y Park
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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15
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Fox-Lewis A, Luan K, Hopkins C. Neisseria gonorrhoeae cervical spine epidural abscess requiring spinal decompression and instrumented fusion. J Infect Chemother 2023; 29:527-529. [PMID: 36731777 DOI: 10.1016/j.jiac.2023.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/12/2023] [Accepted: 01/29/2023] [Indexed: 02/01/2023]
Abstract
Disseminated gonococcal infection (DGI) is an uncommon complication of Neisseria gonorrhoeae infection, and typically presents with either a triad of tenosynovitis, dermatitis and polyarthralgia, or with extra-axial large joint septic arthritis. Spinal epidural abscess is a rare manifestation of DGI, with only a few previously reported cases, none of which required placement of metalware into the infected space. Here we report a severe case of isolated N. gonorrhoeae cervical spine epidural abscess necessitating surgical source control (C7/T1 laminectomy and debridement) and metalware placement (C6-T2 posterior instrumented fusion). The case was successfully managed by a combination of surgical intervention followed by six weeks of predominantly oral, targeted antimicrobial therapy.
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Affiliation(s)
- Andrew Fox-Lewis
- Microbiology Department, Middlemore Hospital, Auckland, New Zealand.
| | - Kai Luan
- Infectious Diseases Department, Middlemore Hospital, Auckland, New Zealand
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16
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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17
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Kamalapathy PN, Karhade AV, Groot OQ, Lin KYE, Shah AA, Nelson SB, Schwab JH. Predictors of reoperation after surgery for spinal epidural abscess. Spine J 2022; 22:1830-1836. [PMID: 35738500 DOI: 10.1016/j.spinee.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 05/08/2022] [Accepted: 06/13/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spinal epidural abscess is a rare but severe condition with high rates of postoperative adverse events. PURPOSE The objective of the study was to identify independent prognostic factors for reoperation using two datasets: an institutional and national database. STUDY DESIGN/SETTING Retrospective Review. PATIENT SAMPLE Database 1: Review of five medical centers from 1993 to 2016. Database 2: The National Surgical Quality Improvement Program (NSQIP) was queried between 2012 and 2016. OUTCOME MEASURES Thirty-day and ninety-day reoperation rate. METHODS Two independent datasets were reviewed to identify patients with spinal epidural abscesses undergoing spinal surgery. Multivariate analyses were used to determine independent prognostic factors for reoperation while including factors identified in bivariate analyses. RESULTS Overall, 642 patients underwent surgery for a spinal epidural abscess in the institutional cohort, with a 90-day unplanned reoperation rate of 19.9%. In the NSQIP database, 951 patients were identified with a 30-day unplanned reoperation rate of 12.3%. On multivariate analysis in the NSQIP database, cervical spine abscess was the only factor that reached significance for 30-day reoperation (OR=1.71, 95% CI=1.11-2.63, p=.02, Area under the curve (AUC)=0.61). On multivariate analysis in the institutional cohort, independent prognostic factors for 30-day reoperation were: preoperative urinary incontinence, ventral location of abscess relative to thecal sac, cervical abscess, preoperative wound infection, and leukocytosis (AUC=0.65). Ninety-day reoperation rate also found hypoalbuminemia as a significant predictor (AUC=0.66). CONCLUSION Six novel independent prognostic factors were identified for 90-day reoperation after surgery for a spinal epidural abscess. The multivariable analysis fairly predicts reoperation, indicating that there may be additional factors that need to be uncovered in future studies. The risk factors delineated in this study through the use of two large cohorts of spinal epidural abscess patients can be used to improve preoperative risk stratification and patient management.
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Affiliation(s)
- Pramod N Kamalapathy
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA.
| | - Aditya V Karhade
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA; Harvard Combined Orthopaedic Residency Program, 55 Fruit Street, Boston, MA, USA, 02114
| | - Olivier Q Groot
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA
| | - Kuan-Yu Evan Lin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA
| | - Akash A Shah
- Department of Orthopaedic Surgery, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA, USA, 90095
| | - Sandra B Nelson
- Department of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, USA, 02114
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA.
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18
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Ambulgekar RK, Iqbal Z, Masne P. A Rare Case of Thoracolumbar Epidural Abscess with Tuberculous Etiology in an Adolescent Male with Neurological Deficit. J Orthop Case Rep 2022; 12:98-101. [PMID: 36873335 PMCID: PMC9983397 DOI: 10.13107/jocr.2022.v12.i09.3336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/02/2022] [Indexed: 01/07/2023] Open
Abstract
Introduction Spinal epidural abscess (SEA) refers to collection of infection of the epidural space due to various etiologies. Tuberculosis (TB) of the spine is one of the important causes of SEA. Patient with SEA usually presents with history of fever, back pain, difficulty in walking, and neurological weakness. Magnetic resonance imaging (MRI) is the initial modality for diagnosis and it can be confirmed by examination of abscess for microorganism growth. It can be treated by laminectomy and decompression which helps to drain out the pus and relive the compression on the cord. Case Report A 16-year-old male, student by profession, presented with a history of low back pain and progressive difficulty in walking for the past 12 days and lower limb weakness for the past 8 days associated with fever, generalized weakness, and malaise. Computed tomography brain and whole spine showed no significant changes MRI left facetal joint of L3 L4 vertebrae infective arthritis with abnormal soft-tissue collection in the posterior epidural region extending from D11-L5 vertebrae causing compression on the thecal sac, cauda equine nerve roots, and represents infective abscess with abnormal soft-tissue collection in the posterior paraspinal region and left psoas muscles representing infective abscess. Patient was taken for emergency decompression with clearance of abscess through posterior approach. Laminectomy was done extending from D11 TO L5 vertebrae and thick pus was drained through multiple pockets. Samples pus and soft tissue were sent for investigation. Pus culture ZN and Gram's stain did not show growth of any organism, but GeneXpert was positive for growth of Mycobacterium tuberculosis. Patient was registered under RNTCP program and anti TB drugs were started as per the weight scale. Sutures were removed on post-operative day 12 and neurological evaluation was done for any signs of improvement. Patient showed improvement of power in both lower limb; power 5/5 on the right lower limb whereas 4/5 in the left lower limb. Patient also had improvements in other symptoms and has no complaints of back ache and malaise at discharge. Conclusion Tuberculous thoracolumbar epidural abscess is a rare disease with potential to cause lifelong vegetative state if diagnosis and treatment is not done promptly. Surgical decompression by unilateral laminectomy and evacuation of collection is both diagnostic and therapeutic.
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Affiliation(s)
- Rajesh K Ambulgekar
- Department of Orthopaedics, Dr. Shankarrao Chavan Government Medical College, Nanded, Maharashtra, India
| | - Zafar Iqbal
- Department of Orthopaedics, Dr. Shankarrao Chavan Government Medical College, Nanded, Maharashtra, India
| | - Pratik Masne
- Department of Orthopaedics, Dr. Shankarrao Chavan Government Medical College, Nanded, Maharashtra, India
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Fujita M, Ueno T, Horiuchi M, Mitsuhashi T, Yamamoto S, Arai A, Tomiyama M. Campylobacter coli infection causes spinal epidural abscess with Guillain-Barré syndrome: a case report. BMC Neurol 2022; 22:9. [PMID: 34979984 PMCID: PMC8722166 DOI: 10.1186/s12883-021-02537-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 12/26/2021] [Indexed: 11/17/2022] Open
Abstract
Background Guillain–Barré syndrome (GBS) and spinal epidural abscess (SEA) are known as mimics of each other because they present with flaccid paralysis following an infection; however, they differ in the main causative bacteria. Nevertheless, the two diseases can occur simultaneously if there is a preceding Campylobacter infection. Here, we report the first case of SEA with GBS following Campylobacter coli infection. Case presentation A 71-year-old Japanese man presented with progressive back pain and paralysis of the lower limbs following enteritis. Magnetic resonance imaging showed a lumbar epidural abscess that required surgical decompression; therefore, surgical drainage was performed. Blood cultures revealed the presence of C. coli. Despite surgery, the paralysis progressed to the extremities. Nerve conduction studies led to the diagnosis of GBS. Anti-ganglioside antibodies in the patient suggested that GBS was preceded by Campylobacter infection. Intravascular immunoglobulin therapy attenuated the progression of the paralysis. Conclusions We report a case of SEA and GBS following Campylobacter infection. A combination of the two diseases is rare; however, it could occur if the preceding infection is caused by Campylobacter spp. If a cause is known but the patient does not respond to the corresponding treatment, it is important to reconsider the diagnosis based on the medical history. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-021-02537-6.
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Affiliation(s)
- Masako Fujita
- Department of Neurology, Aomori Prefectural Central Hospital, 2-1-1 Higashi-Tsukurimichi, Aomori, 030-8551, Japan.
| | - Tatsuya Ueno
- Department of Neurology, Aomori Prefectural Central Hospital, 2-1-1 Higashi-Tsukurimichi, Aomori, 030-8551, Japan
| | - Michiru Horiuchi
- Department of Neurology, Aomori Prefectural Central Hospital, 2-1-1 Higashi-Tsukurimichi, Aomori, 030-8551, Japan
| | - Tatsuro Mitsuhashi
- Department of Infection Control Office, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Shouji Yamamoto
- Department of Bacteriology I, National Institute of Infectious Diseases, Tokyo, Japan
| | - Akira Arai
- Department of Neurology, Aomori Prefectural Central Hospital, 2-1-1 Higashi-Tsukurimichi, Aomori, 030-8551, Japan
| | - Masahiko Tomiyama
- Department of Neurology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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20
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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Abstract
Purpose of Review This article provides an update of recent practice trends in neuraxial labor analgesia. It reviews available evidence regarding management of labor pain in obstetric patients with COVID-19, serious adverse events in obstetric anesthesia to help inform risk/benefit decisions, and increasingly popular neuraxial labor analgesia techniques and adjuvants. State-of-the-art modes of epidural drug delivery are also discussed. Recent Findings There has recently been a focus on several considerations specific to obstetric anesthesia, such as anesthetic management of obstetric patients with COVID-19, platelet thresholds for the safe performance of neuraxial analgesia in obstetric patients with thrombocytopenia, and drug delivery modes for initiation and maintenance of neuraxial labor analgesia. Summary Neuraxial labor analgesia (via standard epidural, dural puncture epidural, and combined spinal epidural techniques) is the most effective therapy to alleviate the pain of childbirth. SARS-CoV-2 infection is not, in and of itself, a contraindication to neuraxial labor analgesia or cesarean delivery anesthesia. Early initiation of neuraxial labor analgesia in patients with COVID-19 is recommended if not otherwise contraindicated, as it may reduce the need for general anesthesia should emergency cesarean delivery become necessary. Consensus regarding platelet thresholds for safe initiation of neuraxial procedures has historically been lacking. Recent studies have concluded that the risk of spinal epidural hematoma formation after neuraxial procedures is likely low at or above an imprecise range of platelet count of 70–75,000 × 106/L. Thrombocytopenia has been reported in obstetric patients with COVID-19, but severe thrombocytopenia precluding initiation of neuraxial anesthesia is extremely rare. High neuraxial blockade has emerged as one of the most common serious complications of neuraxial analgesia and anesthesia in obstetric patients. Growing awareness of factors that contribute to failed conversion of epidural labor analgesia to cesarean delivery anesthesia may help avoid the risks associated with performance of repeat neuraxial techniques and induction of general anesthesia after failed epidural blockade. Dural puncture techniques to alleviate the pain of childbirth continue to become more popular, as do adjuvant drugs to enhance or prolong neuraxial analgesia. Novel techniques for epidural drug delivery have become more widely disseminated.
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Affiliation(s)
- Roulhac D. Toledano
- NYU Langone Health, Department of Anesthesiology, Perioperative Care & Pain Medicine, NYU Langone Hospital, Brooklyn, USA
| | - Lisa Leffert
- Department of Anesthesia, Critical Care & Pain Medicine, Harvard Medical School, Boston, USA
- Obstetric Anesthesia Division, Massachusetts General Hospital, Boston, MA USA
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22
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Dominguez JF, Shah S, Ampie L, Chen X, Li B, Ng C, Feldstein E, Wainwright JV, Schmidt M, Cole C, Koo DC, Chadha B, Lee J, Yarrabothula A, Rao N, Adkoli A, Miller I, Gandhi CD, Al-Mufti F, Santarelli J, Bowers C. Spinal Epidural Abscess Patients Have Higher Modified Frailty Indexes Than Back Pain Patients on Emergency Room Presentation: A Single-Center Retrospective Case-Control Study. World Neurosurg 2021; 152:e610-e616. [PMID: 34129981 DOI: 10.1016/j.wneu.2021.06.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Spinal epidural abscess (SEA) patients have increased medical comorbidities and risk factors for infection compared with those without SEA. However, the association between frailty and SEA patients has not been documented. METHODS A total of 46 SEA patients were randomly paired and matched by age and sex with a control group of patients with back pain who had presented to our emergency department from 2012 to 2017. Statistical analysis identified the risk factors associated with SEA and frailty using the modified frailty index (mFI), and the patients were stratified into robust, prefrail, and frail groups. We examined the value of the mFI as a prognostic predictor and evaluated the classic risk factors (CRFs). RESULTS The SEA patients had higher mFIs and CRFs (P = 0.023 and P < 0.001, respectively) and a longer length of stay (22.89 days vs. 1.72 days; P < 0.001). Of the mFI variables, only diabetes had a significant association with SEA (odds ratio [OR], 3.60; P = 0.012). Among the stratified mFI subgroups, a frail ranking (mFI >2) was the strongest risk factor for SEA (OR, 5.18; P = 0.003). A robust ranking (mFI, 0-1) was a weak negative predictor for SEA (OR, 0.41; P = 0.058). The robust patients were also more likely to be discharged to home (OR, 7.58; P = 0.002). Of the CRF variables, only intravenous drug use had a statistically significant association with SEA (OR, 10.72; P = 0.015). CONCLUSIONS Patients with SEA were more frail compared with the control back pain patients. Frailty was determined to be an independent risk factor for SEA, outside of the CRFs. The use of the mFI could be potentially useful in predicting the diagnosis, prognosticating, and guiding SEA treatment.
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Affiliation(s)
- Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA.
| | - Smit Shah
- Department of Neurology, University of South Carolina, Columbia, South Carolina, USA
| | - Leonel Ampie
- Department of Neurosurgery, School of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Xintong Chen
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Boyi Li
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Christina Ng
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Eric Feldstein
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - John V Wainwright
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Meic Schmidt
- Department of Neurosurgery, School of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Chad Cole
- Department of Neurosurgery, School of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Donna C Koo
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Bhawneet Chadha
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Joo Lee
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | | | - Naina Rao
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Anusha Adkoli
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Ivan Miller
- Department of Emergency Medicine, Westchester Medical Center, Valhalla, New York, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Justin Santarelli
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Christian Bowers
- Department of Neurosurgery, School of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
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23
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Schwade MJ, Waller JL, Mohammed A, Young L, Kheda M, Nahman NS, Baer SL, Bollag WB. Morbidity and Mortality of Spinal Epidural Abscess in End-Stage Renal Disease Patients: A Case-Control Study. Am J Med Sci 2021; 361:485-490. [PMID: 33637307 DOI: 10.1016/j.amjms.2020.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/25/2020] [Accepted: 10/22/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Spinal epidural abscess (SEA) is an uncommon and highly morbid infection of the epidural space. End-stage renal disease (ESRD) patients are known to be at increased risk of developing SEA; however, there are no studies that have described the risk factors and outcomes of SEA in ESRD patients utilizing the United States Renal Data System (USRDS). METHODS To determine risk factors, morbidity, and mortality associated with SEA in ESRD patients, a retrospective case-control study was conducted using the USRDS. ESRD patients diagnosed with SEA between 2005 and 2010 were identified, and logistic regression was performed to examine correlates of SEA, as well as risk factors associated with mortality in SEA-ESRD patients. RESULTS The prevalence of SEA amongst ESRD patients was 0.39% (n = 1,697). Patients with SEA were more likely to be male [adjusted Odds Ratio (OR) = 1.22], black (OR = 1.19), diabetic (OR = 1.26), with catheter access (OR = 1.29), and less likely to be ≥65 years old (OR = 0.64). Osteomyelitis, bacteremia/septicemia, MRSA, and endocarditis were all significantly associated with increased risk of SEA (OR = 1.54-5.14). Age ≥65 years (HR = 1.45), urinary tract infections (HR = 1.26), decubitus ulcers (HR=1.37), and post-SEA paraplegia (HR = 1.25) were significantly associated with mortality among those with SEA. CONCLUSIONS As described in previous literature, risk factors for SEA included infections, diabetes, and indwelling catheters. Additionally, clinicians should be aware of the risk factors for mortality in SEA-ESRD patients. As the largest study of SEA to date, our report identifies important risk factors for SEA in ESRD patients, and novel data regarding their mortality-associated risk factors.
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Affiliation(s)
- Mark J Schwade
- Department of Medicine, Medical College of Georgia at Augusta University, Augusta, GA
| | - Jennifer L Waller
- Department of Population Health Sciences, Medical College of Georgia at Augusta University, Augusta, GA
| | - Azeem Mohammed
- Department of Medicine, Medical College of Georgia at Augusta University, Augusta, GA
| | - Lufei Young
- Department of Physiological and Technological Nursing, Augusta University, Augusta, GA
| | | | - N Stanley Nahman
- Department of Medicine, Medical College of Georgia at Augusta University, Augusta, GA
| | - Stephanie L Baer
- Department of Medicine, Medical College of Georgia at Augusta University, Augusta, GA; Charlie Norwood VA Medical Center, Augusta, GA
| | - Wendy B Bollag
- Department of Medicine, Medical College of Georgia at Augusta University, Augusta, GA; Department of Physiology, Medical College of Georgia at Augusta University, Augusta, GA; Charlie Norwood VA Medical Center, Augusta, GA.
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24
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Yao YC, Lin HH, Chou PH, Wang ST, Liu CL, Chang MC. Risk factors for residual neurologic deficits after surgical treatment for epidural abscess in the thoracic or lumbar spine. Spine J 2020; 20:1638-1645. [PMID: 32417501 DOI: 10.1016/j.spinee.2020.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 05/03/2020] [Accepted: 05/07/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spinal epidural abscess (SEA) can cause neurologic deficits and needs urgent surgical intervention. Many clinical factors had been proposed to predict surgical outcomes in patients with SEA, but the predictive radiographic risk factors for residual neurologic deficits were not addressed sufficiently. PURPOSE To analyze the clinical and radiographic risk factors for residual neurologic deficit in patients with SEA after surgical intervention of the thoracic or lumbar spine. STUDY DESIGN/SETTING A retrospective consecutive case series. PATIENT SAMPLE From January 2005 through December 2014, 53 patients with primary SEA, confirmed by culture or histopathology, in the thoracic or lumbar spine who underwent posterior-only approach surgery at our hospital. OUTCOME MEASURES Neurologic status was assessed using the Frankel grading system preoperatively, postoperatively, and at final follow-up. METHODS The patients were allocated into two groups based on the presence of postoperative residual neurologic deficits. Patients' demographic, clinical, and factors based on magnetic resonance imaging (MRI) were analyzed for their influence on residual neurologic deficits. Clinical factors included age, sex, diabetes, comorbidities, pathogens, affected spinal levels, the interval between onset of symptoms to surgery, preoperative neurologic status, presence of cauda equina syndrome, and surgical procedures. MRI factors included the distribution of abscesses within the spinal canal, presence of ring enhancement, presence of paravertebral abscess or psoas abscess, canal compromise anteroposterior (AP) ratio and cross-sectional area ratio, abscess length, and abscess thickness. RESULTS Thirty-five of the 53 patients (66%) had preoperative neurologic deficits, and 21 of 53 patients (40%) had postoperative residual neurologic deficits. Patients' neurologic status improved significantly after the surgery (p<.001). Risk factors including age, diabetes, cauda equina syndrome, presence of anterior with posterior (A+P) dural abscess, canal compromise AP ratio, cross-sectional area ratio, abscess length, and abscess thickness were significantly correlated with postoperative residual neurologic deficits. In multivariate logistic regression analysis, age ≥70 years, preoperative cauda equina syndrome, abscess length ≥5.5 cm and abscess thickness ≥0.8 cm were the four most significant factors related to residual neurologic deficits. CONCLUSIONS In patients with SEA of the thoracic and lumbar spine, age ≥70 years, preoperative cauda equina syndrome, abscess length ≥5.5 cm and abscess thickness ≥0.8 cm were the most significant preoperative risk factors for residual neurologic deficits after surgery.
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Affiliation(s)
- Yu-Cheng Yao
- Department of Orthopedic Surgery, School of Medicine, National Yang-Ming University, No.155, Sec. 2, Linong Street, Taipei, Taiwan; Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsi-Hsien Lin
- Department of Orthopedic Surgery, School of Medicine, National Yang-Ming University, No.155, Sec. 2, Linong Street, Taipei, Taiwan; Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Po-Hsin Chou
- Department of Orthopedic Surgery, School of Medicine, National Yang-Ming University, No.155, Sec. 2, Linong Street, Taipei, Taiwan; Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shih-Tien Wang
- Department of Orthopedic Surgery, School of Medicine, National Yang-Ming University, No.155, Sec. 2, Linong Street, Taipei, Taiwan; Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.
| | - Chien-Lin Liu
- Department of Orthopedic Surgery, School of Medicine, National Yang-Ming University, No.155, Sec. 2, Linong Street, Taipei, Taiwan; Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ming-Chau Chang
- Department of Orthopedic Surgery, School of Medicine, National Yang-Ming University, No.155, Sec. 2, Linong Street, Taipei, Taiwan; Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan
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25
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Lara-Reyna J, Yaeger KA, Margetis K. Transpedicular Approach for Ventral Epidural Abscess Evacuation in the Cervical Spine. World Neurosurg 2020; 145:127-133. [PMID: 32950752 DOI: 10.1016/j.wneu.2020.09.062] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 09/11/2020] [Accepted: 09/12/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Spinal epidural abscess may require prompt surgical intervention. Ventral cervical abscesses pose a particular challenge regarding the approach for surgical evacuation. The aim of this article was to describe the technical nuances of a posterior transpedicular cervical approach for evacuation of a ventral epidural abscess. METHODS After a standard laminectomy, a foraminotomy was performed to identify the exiting nerve root. Then the medial aspect of the pedicle below the nerve was drilled. This allowed the insertion of a dissector to reach the ventral epidural space and drain the contents in conjunction with suction and irrigation. The posterolateral aspect of the superior endplate of the respective vertebra could be further drilled at this point, allowing access to the disc space with minimal retraction of the exiting nerve root. RESULTS Two patients underwent emergent evacuation of a ventral epidural abscess in the cervical spine using this technique. Radiographic and clinical improvement was evident after evacuation of the abscesses in both cases. CONCLUSIONS Access to the ventral epidural space is feasible using a transpedicular approach in the cervical spine for evacuation of an epidural abscess.
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Affiliation(s)
- Jacques Lara-Reyna
- Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Kurt A Yaeger
- Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Konstantinos Margetis
- Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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26
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Talamonti G, Colistra D, Crisà F, Cenzato M, Giorgi P, D'Aliberti G. Spinal epidural abscess in COVID-19 patients. J Neurol 2020; 268:2320-2326. [PMID: 32910251 PMCID: PMC7482053 DOI: 10.1007/s00415-020-10211-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 08/29/2020] [Accepted: 09/02/2020] [Indexed: 12/17/2022]
Abstract
Objective To report the peculiarity of spinal epidural abscess in COVID-19 patients, as we have observed an unusually high number of these patients following the outbreak of SARS-Corona Virus-2. Methods We reviewed the clinical documentation of six consecutive COVID-19 patients with primary spinal epidural abscess that we surgically managed over a 2-month period. These cases were analyzed for what concerns both the viral infection and the spinal abscess. Results The abscesses were primary in all cases indicating that no evident infective source was found. A primary abscess represents the rarest form of spinal epidural abscess, which is usually secondary to invasive procedures or spread from adjacent infective sites, such as spondylodiscitis, generally occurring in patients with diabetes, obesity, cancer, or other chronic diseases. In all cases, there was mild lymphopenia but the spinal abscess occurred regardless of the severity of the viral disease, immunologic state, or presence of bacteremia. Obesity was the only risk factor and was reported in two patients. All patients but one were hypertensive. The preferred localizations were cervical and thoracic, whereas classic abscess generally occur at the lumbar level. No patient had a history of pyogenic infection, even though previous asymptomatic bacterial contaminations were reported in three cases. Conclusion We wonder about the concentration of this uncommon disease in such a short period. To our knowledge, cases of spinal epidural abscess in COVID-19 patients have not been reported to date. We hypothesize that, in our patients, the spinal infection could have depended on the coexistence of an initially asymptomatic bacterial contamination. The well-known COVID-19-related endotheliitis might have created the conditions for retrograde bacterial invasion to the correspondent spinal epidural space. Furthermore, spinal epidural abscess carries a significantly high morbidity and mortality. It is difficult to diagnose, especially in compromised COVID-19 patients but should be kept in mind as early diagnosis and treatment are crucial.
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Affiliation(s)
- G Talamonti
- Departments of Neurosurgery, ASST Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.
| | - Davide Colistra
- Departments of Neurosurgery, ASST Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Francesco Crisà
- Departments of Neurosurgery, ASST Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.,Università Di Milano, Milan, Italy
| | - Marco Cenzato
- Departments of Neurosurgery, ASST Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Pietro Giorgi
- Department of Orthopedics, ASST Niguarda, Milan, Italy
| | - Giuseppe D'Aliberti
- Departments of Neurosurgery, ASST Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
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27
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Brunasso L, Basile L, Gerardo Iacopino D, Gulì C, Graziano F, Pino MA, Nicoletti GF, Tumbiolo S, Maugeri R. All that glitters is not gold: A spinal epidural empyema following epidural steroid injection. Surg Neurol Int 2020; 11:240. [PMID: 32874743 PMCID: PMC7451159 DOI: 10.25259/sni_340_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 07/07/2020] [Indexed: 12/02/2022] Open
Abstract
Background: Therapeutic epidural spinal injections (ESIs) of steroids are one of the most common nonsurgical management modalities employed for alleviating pain due to chronic persistent lumbar spinal disease. However, it is well documented that they have significant risks and complications without any long-term efficacy. ESI may result in epidural empyema which may be difficult to diagnose with delays resulting in significant permanent neurological sequelae. Case Description: A 45-year-old female presented with a lumbar spinal epidural empyema after receiving ESI for low back and right leg pain due to a lumbar disc herniation. Laboratory studies showed elevations of multiple inflammatory markers, and the MR documented a significant lumbar epidural empyema contributing to significant thecal sac compression. Clinically, the patient had an acute cauda equina syndrome warranting emergency surgery consisting of a laminectomy for debridement/decompression followed by long-term antibiotic treatment. Conclusion: Epidural empyema is a major potential complication of lumbar ESI. Multiple markedly elevated inflammatory markers (WBC, ESR, CRP, and procalcitonin) and MRI evidence of an epidural empyema necessitates emergent surgical intervention to limit morbidity, neurological sequelae, and mortality.
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Affiliation(s)
- Lara Brunasso
- Department of Biomedicine Neurosciences and Advanced Diagnostic, University of Palermo, School of Medicine, Palermo, Sicily, Italy
| | - Luigi Basile
- Department of Biomedicine Neurosciences and Advanced Diagnostic, University of Palermo, School of Medicine, Palermo, Sicily, Italy
| | - Domenico Gerardo Iacopino
- Department of Biomedicine Neurosciences and Advanced Diagnostic, University of Palermo, School of Medicine, Palermo, Sicily, Italy
| | - Carlo Gulì
- Department of Biomedicine Neurosciences and Advanced Diagnostic, University of Palermo, School of Medicine, Palermo, Sicily, Italy
| | - Francesca Graziano
- Department of Biomedicine Neurosciences and Advanced Diagnostic, University of Palermo, School of Medicine, Palermo, Sicily, Italy
| | - Maria Angela Pino
- Department of Biomedicine Neurosciences and Advanced Diagnostic, University of Palermo, School of Medicine, Palermo, Sicily, Italy
| | | | - Silvana Tumbiolo
- Division of Neurosurgery, Villa Sofia Hospital, Palermo, Sicily, Italy
| | - Rosario Maugeri
- Department of Biomedicine Neurosciences and Advanced Diagnostic, University of Palermo, School of Medicine, Palermo, Sicily, Italy
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28
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Lyons KW, Baltic SP, Pappas MA, Dunchack JA, Werth PM, McGuire KJ, Pearson AM, Abdu WA. Keys to diagnosis and management of spinal epidural abscesses: 9 years of institutional experience. Clin Neurol Neurosurg 2020; 197:106185. [PMID: 32877765 DOI: 10.1016/j.clineuro.2020.106185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 08/17/2020] [Accepted: 08/23/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Spinal epidural abscesses (SEA's) are a challenge to diagnose, particularly if there are non-contiguous (skip) lesions. There is also limited data to predict which patients can be treated with antibiotics alone and which require surgery. We sought to assess which demographics, clinical and laboratory findings can guide both diagnosis and management of SEA's. METHODS All patients with SEA (ICD9 324.1, ICD10 G06.1) between April 2011-May 2019 at a single tertiary center were included. A retrospective EMR review was completed. Patient and disease characteristics were compared using appropriate statistical tests. RESULTS 108 patients underwent initial surgical treatment versus 105 that were treated medically initially; 22 (21 %) of those failed medical management. Patients who failed medical management had significantly higher CRP, longer symptom duration, and had higher rates of concurrent non-spinal infections. 9% of patients had skip lesions. Patients with skip lesions had significantly higher WBC, ESR, as well as higher rates of bacteremia and concurrent non-spinal infections. Demographic characteristics and proportion with IVDU, smoking, malignancy, and immunosuppression were similar among the three treatment groups. CONCLUSIONS 21 % of SEA patients failed initial medical management; they had significantly greater CRP, longer symptom duration, more commonly had neurologic deficits, and concurrent non-spinal infections. 9% of patients had skip lesions; they had significantly higher WBC, ESR, rates of bacteremia and infections outside the spine. These variables may guide diagnostic imaging, and identify those at risk of failing of medical management, and therefore require more involved clinical evaluation, and consideration for surgical intervention.
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29
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Chang KS, Sun LW, Cheng CY, Chang SW, Chen CM. Full Endoscopic Removal of Cervical Spinal Epidural Abscess: Case Report and Technical Note. Neurospine 2020; 17:S160-S165. [PMID: 32746530 PMCID: PMC7410373 DOI: 10.14245/ns.2040218.109] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 05/06/2020] [Indexed: 11/19/2022] Open
Abstract
Spinal epidural abscess is a rare disease that is less likely to occur in the cervical region. When it occurs here, cervical spondylodiscitis can develop. Surgical treatment is recommended because of possible life-threatening septic and neurological complications. We present a case of an 81-year-old man who suffered from right side paralysis and was subsequently diagnosed with a C4 to C7 epidural abscess. We utilized full endoscopic surgery for patient management. The traditional surgical methods for treating cervical epidural abscesses may cause spinal instability. There has only been one previous case report on the endoscopic-assisted method. Minimal invasive surgery by a full endoscopic method can be done with a small incision and is associated with minimal blood loss and muscle damage. This is the first report on cervical epidural abscess drainage utilization a full endoscopic method. We recommend this alternative minimally invasive method to manage cervical epidural abscess.
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Affiliation(s)
- Kai-Sheng Chang
- Division of Neurosurgery, Department of Surgery, Changhua Christian Hospital, Changuhua, Taiwan
| | - Li-Wei Sun
- Division of Neurosurgery, Department of Surgery, Changhua Christian Hospital, Changuhua, Taiwan
| | - Chun-Yuan Cheng
- Division of Neurosurgery, Department of Surgery, Changhua Christian Hospital, Changuhua, Taiwan
| | - Shang-Wen Chang
- Division of Neurosurgery, Department of Surgery, Changhua Christian Hospital, Changuhua, Taiwan
| | - Chien-Min Chen
- Division of Neurosurgery, Department of Surgery, Changhua Christian Hospital, Changuhua, Taiwan.,School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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30
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Sharfman ZT, Gelfand Y, Shah P, Holtzman AJ, Mendelis JR, Kinon MD, Krystal JD, Brook A, Yassari R, Kramer DC. Spinal Epidural Abscess: A Review of Presentation, Management, and Medicolegal Implications. Asian Spine J 2020; 14:742-759. [PMID: 32718133 PMCID: PMC7595828 DOI: 10.31616/asj.2019.0369] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 04/17/2020] [Indexed: 12/18/2022] Open
Abstract
Spinal epidural abscess (SEA) is a rare condition associated with significant morbidity and mortality. Despite advances in diagnostic medicine, early recognition of SEAs remains elusive. The vague presentation of the disease, coupled with its numerous risk factors, the diagnostic requirement for obtaining advanced imaging, and the necessity of specialized care constitute extraordinary challenges to both diagnosis and treatment of SEA. Once diagnosed, SEAs require urgent or emergent medical and/or surgical management. As SEAs are a relatively rare pathology, high-quality data are limited and there is no consensus on their optimal management. This paper focuses on presenting the treatment modalities that have been successful in the management of SEAs and providing a critical assessment of how specific SEA characteristics may render one infection more amenable to primary surgical or medical interventions. This paper reviews the relevant history, epidemiology, clinical presentation, radiology, microbiology, and treatment of SEAs and concludes by addressing the medicolegal implications of delayed treatment of the disease.
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Affiliation(s)
- Zachary Tuvya Sharfman
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Yaroslav Gelfand
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Pryiam Shah
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ari Jacob Holtzman
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Joseph Roy Mendelis
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Merritt Drew Kinon
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jonathan David Krystal
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Allan Brook
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Reza Yassari
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - David Claude Kramer
- Spine Surgery Outcome Group, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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31
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Gardner WT, Rehman H, Frost A. Spinal epidural abscesses - The role for non-operative management: A systematic review. Surgeon 2020; 19:226-237. [PMID: 32684428 DOI: 10.1016/j.surge.2020.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 06/13/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Spinal Epidural Abscesses (SEAs) are traditionally seen as a surgical emergency. However, SEAs can be discovered in entirely asymptomatic patients. This presents a dilemma for the attending clinician as to whether to subject these patients to significant surgery. This systematic review updates the evidence surrounding the efficacy of non-operative SEA management by means of intravenous antibiotics ± radiologically-guided aspiration. AIMS 1. To assess failure rates of medical therapy for SEA. The absolute definition of 'failure' used by the study was recorded, and comparisons made. 2. To review of risk factors for success/failure of medical treatment for SEA. METHODS A database search with the MESH term 'epidural abscess' and keywords ['treatment' OR 'management'] were used. RESULTS 14 studies were included. The number of SEA patients managed non-operatively ranged from 19 to 142. There was significant heterogeneity across the studies. Pooled Failure of Medical Therapy (FMT) (defined as any poor outcome) was 29.40%. When FMT = mortality the pooled rate was 11.49%. Commonly cited risk factors for FMT included acute neurological compromise, diabetes mellitus, increasing age and Staphylococcus aureus. CONCLUSION SEA will always be a condition mostly managed surgically. Despite this, there is growing evidence that non-operative management can be possible in the correct patients. The key is in patient selection - patients with any of the above-mentioned risk factors have the potential to deteriorate further on medical treatment and have a worse outcome than if they had undergone emergency surgery straight away. Ongoing research will hopefully further investigate this crucial step.
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Affiliation(s)
- W T Gardner
- Department of Trauma & Orthopaedics, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, UK.
| | - H Rehman
- Department of Trauma & Orthopaedics, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, UK
| | - A Frost
- Department of Trauma & Orthopaedics, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, UK
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Abstract
Human Brucellosis is a bacterial infection caused by species of Brucella, which can involve multiple organs and tissues. Spinal epidural abscesses are rare and may be complicated by potentially life threatening neurological or vascular compromise. We report a 21-year-old female with spinal brucellosis complicated by lumbar spondylodiscitis, epidural abscess and a large right-sided paraspinal abscess extended from L4 to sacrum. The diagnosis was based on laboratory and magnetic resonance imaging results, symptoms and her occupation. Ultrasound guided needle aspiration and percutaneous abscess drainage was performed, followed by 8 weeks of combination antibiotic therapy. Our therapeutic strategy in this rare case can cause us to reach a greater clearance rate of the infection.
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Affiliation(s)
- Majid Reza Farrokhi
- Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Reza Mousavi
- Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
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Spennato P, Renedo D, Cascone D, Mirone G, Imperato A, Di Martino G, Cinalli G. Spinal epidural abscess in children: a case-based review. Childs Nerv Syst 2020; 36:1385-92. [PMID: 32291492 DOI: 10.1007/s00381-020-04609-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 04/03/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Pediatric spinal epidural abscess is a major suppurative infection of the central nervous system. It is an extremely rare pathology carrying serious risk of permanent neurological sequelae if is not properly treated. METHODS AND RESULTS All the pertinent literature was analyzed, focused on pediatric cases of spinal epidural abscess and its peculiar features. Two illustrative cases are also presented. The first case is that of a 9-year old girl who took medical attention, when she was already paraplegic. Despite prompt surgical evacuation and good neuroradiological outcome and intensive rehabilitation, motor deficits did not recover after surgery. The second case was that of a 14-year old girl who presented with fever, neck pain, and torticollis. Prompt diagnosis, decompressive surgery, and 6 weeks of antibiotics allowed good neurological outcome. CONCLUSIONS The management of spinal epidural abscess includes evacuation of the abscess with decompression of the spinal cord and prolonged antibiotic treatment. The presence of neurological deficit and the delay in the initiation of proper treatment are the two factors that more worsen prognosis.
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Tonetti DA, Eichar B, Ares WJ, Kanter AS, Hamilton DK. Should the Presence of Spondylodiscitis Alter the Surgical Treatment of Patients with Symptomatic Ventral Cervical Epidural Abscesses? An Institutional Analysiss. World Neurosurg 2020; 138:e282-e288. [PMID: 32112938 DOI: 10.1016/j.wneu.2020.02.103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 02/16/2020] [Accepted: 02/17/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Spinal epidural abscess is a rare pathology with an incidence that has tripled in the past 2 decades. Ventral cervical epidural abscesses (vCEA) of the cervical spine pose particular treatment challenges because of the anatomical location. The aim of this report is to identify trends in the surgical management of these patients and to determine whether concomitant spondylodiscitis warrants fusion at the index surgery. METHODS Patients presenting to a quaternary care institution from January 2009 to December 2018 with isolated vCEA were identified. Patients were excluded if they had dorsal or circumferential epidural abscesses. Clinical and radiographic data were collected. Patients with vCEA were stratified by the presence or absence of spondylodiscitis upon presentation. Clinical outcomes analyzed included neurological sequelae and the need for revision surgery. RESULTS During the 10-year study period, 36 patients presented with symptomatic isolated vCEA and constituted the study cohort; 16 (44%) had concurrent spondylodiscitis. All 36 patients underwent surgical decompression; the initial surgical approach was anterior-only for 7 patients (19%), posterior-only for 27 patients (75%), and and a combined approach for 2 patients (6%). Four patients from the total cohort (11%) ultimately required a revision operation; all 4 were from the subset with concurrent spondylodiscitis (25% vs. 0%, P = 0.03). CONCLUSIONS vCEA can be evacuated safely and effectively by a variety of strategies in patients with neurologic deficits. Concomitant spondylodiscitis with cervical epidural abscess may warrant instrumented fusion as part of the initial surgical strategy.
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Affiliation(s)
- Daniel A Tonetti
- The Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
| | - Bradley Eichar
- The Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - William J Ares
- The Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Adam S Kanter
- The Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David Kojo Hamilton
- The Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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King C, Fisher C, Brown PCM, Priest KC, Tanski M, Sullivan P. Time-to-completed-imaging, survival and function in patients with spinal epidural abscess: Description of a series of 34 patients, 2015-2018. BMC Health Serv Res 2020; 20:119. [PMID: 32059715 PMCID: PMC7023770 DOI: 10.1186/s12913-020-4973-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 02/11/2020] [Indexed: 12/16/2022] Open
Abstract
Introduction Spinal epidural abscess (SEA) is a rare and life-threatening infection with increasing incidence over the past two decades. Delays in diagnosis can cause significant morbidity and mortality among patients. Objective The objective of this study was to describe trends in time-to-imaging and intervention, risk factors, and outcomes among patients presenting to the emergency department with SEA at a single academic medical center in Portland, Oregon. Methods This retrospective cohort study analyzed data from patients with new SEA diagnosis at a single hospital from October 1, 2015 to April 1, 2018. We describe averages to time-to-imaging and interventions, and frequencies of risk factors and outcomes among patients presenting to the emergency department with SEA. Results Of the 34 patients included, 7 (20%) died or were discharged with plegia during the study period. Those who died or were discharged with plegia (n = 7) had shorter mean time-to-imaging order (20.8 h versus 29.2 h). Patients with a history of intravenous drug use had a longer mean time-to-imaging order (30.2 h versus 23.7 h) as compared to those without intravenous drug use. Patients who died or acquired plegia had longer times from imaging completed to final imaging read (20.9 h versus 7.1 h), but shorter times from final imaging read to surgical intervention among patients who received surgery (4.9 h versus 46.2 h). Further, only three (42.9%) of the seven patients who died or acquired plegia presented with the three-symptom classic triad of fever, neurologic symptoms, and neck or back pain. Conclusions SEA is a potentially deadly infection that requires prompt identification and treatment. This research provides baseline data for potential quality improvement work at the study site. Future research should evaluate multi-center approaches for identifying and intervening to treat SEA, particularly among patients with intravenous drug use.
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Affiliation(s)
- Caroline King
- School of Medicine, Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA.
| | - Cameron Fisher
- School of Medicine, Oregon Health & Science University, Portland, OR, USA.,School of Public Health, Oregon Health & Science University-Portland State University, Portland, OR, USA
| | - Patrick C M Brown
- School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Kelsey C Priest
- School of Medicine, Oregon Health & Science University, Portland, OR, USA.,School of Public Health, Oregon Health & Science University-Portland State University, Portland, OR, USA
| | - Mary Tanski
- School of Medicine, Oregon Health & Science University, Portland, OR, USA.,Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Peter Sullivan
- School of Medicine, Oregon Health & Science University, Portland, OR, USA.,Department of Internal Medicine, Oregon Health & Science University, Portland, OR, USA
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Van Baarsel ED, Kesbeh Y, Kahf HA, Patel V, Weng B, Sutjita M. Spinal epidural abscess secondary to gram-negative bacteria: case report and literature review. J Community Hosp Intern Med Perspect 2020; 10:60-64. [PMID: 32128061 PMCID: PMC7034427 DOI: 10.1080/20009666.2019.1705009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 10/17/2019] [Indexed: 12/05/2022] Open
Abstract
Bacterial spinal epidural abscess (SEA) is a rare suppurative infection that commonly presents with nonspecific symptoms along with the infrequent triad of fever, back pain, and neurological deficits. Risk factors include diabetes mellitus, intravenous drug use, degenerative disc disease, infection with human immunodeficiency virus, and recent trauma or surgery. Patients with SEA often experience poor outcomes such as permanent neurological deficits, residual motor weakness, and even death. Staphylococcus aureus is the most predominant organism known to cause SEA; however, gram-negative bacteria are isolated in a small percentage of cases. Here we report three cases of SEA caused by gram-negative organisms. Each patient had identifiable risk factors known to increase the risk for SEA, and upon presentation had symptoms of SEA. Upon work up, the patients had positive cultures for gram-negative organisms and MRI imaging confirmed the presence of SEA. One patient made a full recovery while the other two cases resulted in permanent paraplegia. These cases stress the importance of considering SEA even in the presence of gram-negative infections, despite them being a rare cause. Furthermore, these cases emphasize the importance of broad-spectrum antibiotics that cover gram-negative bacteria in patients found to have risk factors along with symptoms of SEA.
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Affiliation(s)
- Eric D. Van Baarsel
- Department of Internal Medicine, Riverside University Health System, Riverside, CA, USA
| | - Yazeed Kesbeh
- Department of Internal Medicine, Riverside University Health System, Riverside, CA, USA
| | - Huthayfa A. Kahf
- Department of Internal Medicine, Riverside University Health System, Riverside, CA, USA
| | - Vandan Patel
- Department of Internal Medicine, Riverside University Health System, Riverside, CA, USA
| | - Bruce Weng
- Department of Internal Medicine, University of California, Riverside, CA, USA
| | - Made Sutjita
- Department of Internal Medicine, University of California, Riverside, CA, USA
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Fujii M, Shirakawa T, Shime N, Kawabata Y. Successful treatment of extensive spinal epidural abscess with fluoroscopy-guided percutaneous drainage: a case report. JA Clin Rep 2020; 6:4. [PMID: 32026104 PMCID: PMC6967264 DOI: 10.1186/s40981-020-0309-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 01/07/2020] [Indexed: 11/10/2022] Open
Abstract
Background Surgical drainage and antimicrobial therapy are the most accepted empirical treatments for spinal epidural abscess. However, surgery may not be indicated when patient’s general health condition is poor. Percutaneous drainage has been reported as a non-surgical treatment for children or patients with no or minor neurological deficits. Here we describe the successful treatment of an extensive spinal epidural abscess with fluoroscopy-guided percutaneous drainage in an elderly man with progressive muscle weakness who could not be operated because of a poor general health condition. Case presentation An 81-year-old man presented with fever, back pain, and progressive muscle weakness in bilateral legs. Magnetic resonance imaging (MRI) showed extensive fluid retention in the spinal epidural space (Th6 to L3). Paraplegia due to an epidural abscess was suspected. We considered an emergency operation; however, the patient’s general condition was poor. Therefore, fluoroscopy-guided percutaneous epidural drainage was performed. After drainage, his back pain and muscle weakness gradually resolved. After 3 weeks, MRI showed that the abscesses had completely disappeared. Discussion Compared with surgical drainage, fluoroscopy-guided percutaneous epidural drainage is a less invasive treatment option for patients with a poor general condition.
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Affiliation(s)
- Masashi Fujii
- Department of Anaesthesia, Nagahama Red Cross Hospital, 14-7 Miyamae-cho, Nagahama, Shiga, 526-8585, Japan.
| | - Tsutomu Shirakawa
- Department of Orthopedic Surgery, Nagahama Red Cross Hospital, Nagahama, Shiga, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yasuyo Kawabata
- Department of Anaesthesia, Nagahama Red Cross Hospital, 14-7 Miyamae-cho, Nagahama, Shiga, 526-8585, Japan
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Supreeth S, Al Ghafri K. Ventral holocord spinal epidural abscess managed surgically in a critical setting. Surg Neurol Int 2019; 10:248. [PMID: 31893149 PMCID: PMC6935947 DOI: 10.25259/sni_306_2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 08/02/2019] [Indexed: 11/04/2022] Open
Abstract
Background Extensive epidural abscess is an uncommon entity which is increasing in the aging population. Its prevalence is also greater among those with diabetes mellitus and in those who are immunocompromised. Here, a 59-year-old female presented with a spinal epidural abscess (SEA) warranting operative intervention. Case Description A 59-year-old female with a history of diabetes and hypertension, presented with the acute onset of a high-grade fever, generalized back pain, and an evolving quadriparesis. Preliminary laboratory studies revealed elevated inflammatory markers. The magnetic resonance scan showed a ventral epidural abscess extending from C1-2 to the L5 level. She underwent urgent surgical decompression using a Nelaton catheter placed through an L4-L5 hemilaminectomy and threaded cephalad (40 cm); this resulted in a complete recovery. Conclusion This case study underscores a unique way of managing an anterior holospinal SEA extending from the C1-2 through the L5 spinal levels.
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Affiliation(s)
- Sam Supreeth
- Department of Orthopaedics, Khoula Hospital, Muscat, Oman
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Karhade AV, Shah AA, Bono CM, Ferrone ML, Nelson SB, Schoenfeld AJ, Harris MB, Schwab JH. Development of machine learning algorithms for prediction of mortality in spinal epidural abscess. Spine J 2019; 19:1950-9. [PMID: 31255788 DOI: 10.1016/j.spinee.2019.06.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 06/23/2019] [Accepted: 06/26/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT In-hospital and short-term mortality in patients with spinal epidural abscess (SEA) remains unacceptably high despite diagnostic and therapeutic advancements. Forecasting this potentially avoidable consequence at the time of admission could improve patient management and counseling. Few studies exist to meet this need, and none have explored methodologies such as machine learning. PURPOSE The purpose of this study was to develop machine learning algorithms for prediction of in-hospital and 90-day postdischarge mortality in SEA. STUDY DESIGN/SETTING Retrospective, case-control study at two academic medical centers and three community hospitals from 1993 to 2016. PATIENTS SAMPLE Adult patients with an inpatient admission for radiologically confirmed diagnosis of SEA. OUTCOME MEASURES In-hospital and 90-day postdischarge mortality. METHODS Five machine learning algorithms (elastic-net penalized logistic regression, random forest, stochastic gradient boosting, neural network, and support vector machine) were developed and assessed by discrimination, calibration, overall performance, and decision curve analysis. RESULTS Overall, 1,053 SEA patients were identified in the study, with 134 (12.7%) experiencing in-hospital or 90-day postdischarge mortality. The stochastic gradient boosting model achieved the best performance across discrimination, c-statistic=0.89, calibration, and decision curve analysis. The variables used for prediction of 90-day mortality, ranked by importance, were age, albumin, platelet count, neutrophil to lymphocyte ratio, hemodialysis, active malignancy, and diabetes. The final algorithm was incorporated into a web application available here: https://sorg-apps.shinyapps.io/seamortality/. CONCLUSIONS Machine learning algorithms show promise on internal validation for prediction of 90-day mortality in SEA. Future studies are needed to externally validate these algorithms in independent populations.
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Vales Montero M, Mateo Sierra O, Romero Martínez J, Fortea Gil F, Fernández Carballal C, Cuello JP. Spinal epidural abscess caused by Streptococcus agalactiae in an immunocompetent patient. Med Clin (Barc) 2019; 153:290-292. [PMID: 31492449 DOI: 10.1016/j.medcli.2019.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 06/06/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Streptococcus agalactiae is an uncommon microorganism that causes spinal epidural abscess (SEA) and usually affects individuals with a predisposing condition or potential source of infection. CASE DESCRIPTION We present the case of an immunocompetent 53-year-old patient with an unremarkable past medical history who developed progressive low extremity weakness, bowel and bladder dysfunction and genital sensory impairment. A neurological exam on admission revealed flaccid proximal paraparesis, T10 sensory level, atonic anal sphincter and normal myotatic reflexes. Urgent neuroimaging showed a large thoracic epidural spinal abscess. Laminectomy and abscess drainage were immediately performed and systemic antibiotic treatment was initiated. Abscess cultures revealed Streptococcus agalactiae. After an exhaustive workup no predisposing factors or local or systemic source for the infection were found. CONCLUSIONS We report a singular case of spinal epidural abscess caused by Streptococcus agalactiae in a healthy patient with no predisposing factors. This case also highlights the importance of an early diagnosis and treatment to obtain a better neurological outcome.
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Affiliation(s)
- Marta Vales Montero
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España.
| | - Olga Mateo Sierra
- Servicio de Neurocirugía, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - Julia Romero Martínez
- Servicio de Radiología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - Fernando Fortea Gil
- Servicio de Radiología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | | | - Juan Pablo Cuello
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
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Shah AA, Karhade AV, Bono CM, Harris MB, Nelson SB, Schwab JH. Development of a machine learning algorithm for prediction of failure of nonoperative management in spinal epidural abscess. Spine J 2019; 19:1657-65. [PMID: 31059819 DOI: 10.1016/j.spinee.2019.04.022] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 04/15/2019] [Accepted: 04/30/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Data regarding risk of failure of nonoperative management in spinal epidural abscess (SEA) are limited. Given the potential for deterioration with treatment failure, a tool that predicts the probability of failure would be of great clinical utility. PURPOSE We primarily aim to build a machine learning model using independent predictors of nonoperative management failure. Secondarily, we aim to develop an open-access web-based application that provides a patient-specific probability of treatment failure. STUDY DESIGN/SETTING Retrospective, case-control study. PATIENT SAMPLE Patients 18 years or older diagnosed with SEA at 2 academic medical centers and 3 community hospitals. OUTCOME MEASURES Failure of nonoperative management. METHODS This is a retrospective cohort study of 367 patients with SEA initially managed nonoperatively between 1993 and 2016. The primary outcome was failure of nonoperative management defined as neurologic deterioration, worsened back and/or radicular pain, or persistent symptoms despite initiation of antibiotic therapy. Five machine learning algorithms were developed and assessed by discrimination, calibration, and overall performance. RESULTS Ninety-nine (27%) patients failed nonoperative management. Factors determined for prediction of nonoperative management were: motor deficit, diabetes, ventral component of abscess relative to thecal sac, history of compression or pathologic vertebral fracture, sensory deficit, active malignancy, and involvement of 3 or more vertebral levels. The elastic-net penalized logistic regression model was chosen as the final model given its superior discrimination, calibration, and overall model performance. This model was incorporated into an open access web application. CONCLUSION By building a discriminative and well-calibrated model in a user-friendly and open-access digital interface, we hope to provide a prognostic tool that can be used to inform clinical decision-making in real-time.
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Ahluwalia R, Scherer A. Pediatric cervical epidural abscess in a 4-year-old patient: a case-based update. Childs Nerv Syst 2019; 35:1109-1115. [PMID: 30980128 DOI: 10.1007/s00381-019-04143-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 03/29/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE The purpose of this study was to review a case comprised of a cervical spinal epidural abscess, cervical and thoracic paraspinous edema, and widening of the right thoracic neural foramen secondary to a phlegmon. METHODS We reviewed the case of a spinal epidural abscess managed medically in a 4-year-old male and performed a review of the literature with 15 other cases that have previously been reported. RESULTS The current mainstay of treatment is largely variant but generally falls into a laminectomy-based surgical approach or longstanding antibiotics. Our review of the literature concluded that there are currently no clear guidelines established to recommend treatment, and current practice is largely based on the discretion of the pediatric neurosurgeon. CONCLUSIONS Based on the literature review, and our personal case illustration, we conclude that an antibiotic-based treatment is a valid approach for therapy if initiated promptly in a pediatric patient with no neurological deficit.
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Affiliation(s)
- R Ahluwalia
- Florida State College of Medicine, 250 E Colonial Dr #200, Orlando, FL, 32801, USA.
| | - A Scherer
- Department of Neurological Surgery, Nemours Children's Hospital, Orlando, FL, USA
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Karhade AV, Shah KC, Shah AA, Ogink PT, Nelson SB, Schwab JH. Neutrophil to lymphocyte ratio and mortality in spinal epidural abscess. Spine J 2019; 19:1180-1185. [PMID: 30763714 DOI: 10.1016/j.spinee.2019.02.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/25/2019] [Accepted: 02/07/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Neutrophil to lymphocyte ratio and platelet to lymphocyte ratio have been previously identified as markers for overall survival in oncology but remain heretofore unexplored in spinal epidural abscess (SEA). PURPOSE The purpose of this study was to determine the impact of these routinely collected assessments on 90-day mortality in SEA. STUDY DESIGN/SETTING Retrospective, case-control study. PATIENT SAMPLE Patients 18 years or older diagnosed with SEA at 2 academic medical centers and 3 community hospitals. OUTCOME MEASURES Ninety-day postdischarge and in-hospital mortality. METHODS Complete blood count with differential obtained on the day immediately preceding or on the day of admission was used to calculate platelet to lymphocyte and neutrophil to lymphocyte ratios. Multivariate analyses were used to determine if these ratios were independent risk factors for 90-day mortality. RESULTS For 1,053 SEA patients included in the study, the rate of 90-day mortality was 134 (12.7%). The rate of 90-day mortality with neutrophil to lymphocyte ratio (≥8) was (20.5%) compared to (8.1%) with neutrophil to lymphocyte ratio <8. Neutrophil to lymphocyte ratio was positively associated with bacteremia, elevated erythrocyte sedimentation rate, and concurrent systemic infections (endocarditis, meningitis) and negatively associated with duration of symptoms prior to presentation. On multivariate analysis, elevated neutrophil to lymphocyte remained an independent risk factor for 90-day mortality (odds ratio=2.62, 95% confidence interval=1.66-4.17, p<.001). Platelet to lymphocyte ratio was not associated with 90-day mortality. CONCLUSIONS Absolute neutrophil to lymphocyte ratio is a routinely collected but overlooked biomarker in patients with spinal epidural abscess that is a novel independent risk factor for 90-day mortality.
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Affiliation(s)
- Aditya V Karhade
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Kush C Shah
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Akash A Shah
- Department of Orthopedic Surgery, University of California, Los Angeles, CA 90095, USA
| | - Paul T Ogink
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Sandra B Nelson
- Department of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Joseph H Schwab
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA.
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Oh K, Inoue T, Saito T, Nishio C, Konishi H. Spinal epidural abscess caused by Pasteurella multocida mimicking aortic dissection: a case report. BMC Infect Dis 2019; 19:448. [PMID: 31113388 DOI: 10.1186/s12879-019-4097-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 05/15/2019] [Indexed: 11/10/2022] Open
Abstract
Background Pasteurella multocida (P. multocida) forms part of the normal flora of many animals. Although it is a common causative agent of skin and soft tissue infection after an animal bite or scratch, in rare cases it can cause spinal infections in humans. Case presentation A 68-year-old immunocompetent woman presented with fever and sudden onset of severe back pain mimicking aortic dissection. No findings related to the pain were revealed on enhanced computed tomography or initial magnetic resonance imaging (MRI) of the spine. The patient was found to be bacteremic with P. multocida, although she had no apparent injury related to animal contact. Repeated evaluation by MRI with gadolinium-contrast established the diagnosis of spinal epidural abscess. The patient was cured by the rapid initiation of antimicrobial therapy without surgery. Conclusions We describe the successful treatment of an individual with a spinal epidural abscess due to P. multocida without surgery. P. multocida infections may occur as sudden presentations. Obtaining the patient history of recent animal contact is essential. Repeated MRI evaluation may be required when spinal infections are suspected. To the best of our knowledge, this is the first report which describes a case of spinal epidural abscess due to this organism.
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Keller LJ, Alentado VJ, Tanenbaum JE, Lee BS, Nowacki AS, Benzel EC, Mroz TE, Steinmetz MP. Assessment of postoperative outcomes in spinal epidural abscess following surgical decompression. Spine J 2019; 19:888-895. [PMID: 30537555 DOI: 10.1016/j.spinee.2018.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 12/04/2018] [Accepted: 12/05/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT A spinal epidural abscess (SEA) is a serious condition that may be managed with antibiotics alone or with decompressive surgery combined with antibiotics. PURPOSE The objectives of this study were to assess the clinical outcomes of SEA after surgical management and to identify the patient-level factors that are associated with outcomes following surgical decompression and removal of SEA. STUDY DESIGN/SETTING Retrospective chart review analysis. PATIENT SAMPLE An analysis of 154 consecutive patients who initially presented to a tertiary-care, academic medical center with SEA, and were subsequently treated with surgery between 2010 and 2015 was performed. OUTCOME MEASURES Postoperative predischarge American Spinal Injury Association Impairment Scale (AIS) scores, 6-month follow-up encounter AIS scores, need for revision surgery, and mortality during SEA surgery were the primary outcomes.Physiological Measures: AIS scores. METHOD Fisher's exact and Wilcoxon rank-sum tests were used to assess the associations between patient-level factors and surgical outcomes. Moreover, an interactive, predictive model for postoperative predischarge AIS score was developed using a proportional odds regression model. There was no funding secured for this study and there is no conflict of interest-associated biases. RESULTS One hundred fifty-four patients (mean age of 58 years) were treated using surgical decompression in addition to antibiotics. The majority of patients were Caucasian (81%) and male (61%). No intraoperative mortality was reported. A second SEA surgery was performed in 8% of patients. A comparison of the preoperative and postoperative predischarge AIS scores showed that 49% of patients maintained a score of E or improved, while 45% remained at their preoperative status and 6% worsened. Among a subset of patients (n=36; 23%) for whom a 6-month follow-up encounter occurred, 75% maintained an AIS score of E or improved, 19% remained at their preoperative status, and 6% worsened. Both the presence and longer duration of preoperative paresis was associated with an increased risk of remaining at the same AIS score or worsening at the predischarge encounter (both p< .001). A predictive model for predischarge AIS scores was developed based on several patient characteristics. CONCLUSIONS Surgical decompression can contribute to improving or maintaining AIS scores in a high percentage of SEA patients. The presence and duration of preoperative paresis are prognostic for poorer outcomes and suggest that rapid surgical intervention before paresis develops may lead to improved postoperative outcomes. Our modeling tool enables an estimation of probabilities of patients' predischarge condition.
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Affiliation(s)
- Leonard J Keller
- Center for Spine Health, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA; Case Western Reserve University School of Medicine, 10900 Euclid Ave, Cleveland, OH 44106, USA.
| | - Vincent J Alentado
- Department of Neurological Surgery, Indiana University School of Medicine, 355W. 16th Stt, Goodman Hall Suite 5100, Indianapolis, IN 46202, USA
| | - Joseph E Tanenbaum
- Center for Spine Health, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA; Case Western Reserve University School of Medicine, 10900 Euclid Ave, Cleveland, OH 44106, USA; Department of Epidemiology and Biostatistics, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106, USA
| | - Bryan S Lee
- Center for Spine Health, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA; Department of Neurosurgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Amy S Nowacki
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA; Department of Quantitative Health Sciences, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Edward C Benzel
- Center for Spine Health, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA; Department of Neurosurgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Thomas E Mroz
- Center for Spine Health, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA; Department of Neurosurgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA; Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Michael P Steinmetz
- Center for Spine Health, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA; Department of Neurosurgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
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Abstract
Atraumatic spinal emergencies often present a diagnostic and management dilemma for health care practitioners. Spinal epidural abscess, cauda equina syndrome, and spinal epidural hematoma are conditions that can insidiously present to outpatient medical offices, urgent care centers, and emergency departments. Unless a high level of clinical suspicion is maintained, these clinical entities may be initially misdiagnosed and mismanaged. Permanent neurologic sequela and even death can result if delays in appropriate treatment occur. A focused, critical review of 34 peer-reviewed articles was performed to identify current data about accurate diagnosis of spinal emergencies. This review highlights the key features of these 3 pathological entities with an emphasis on appropriate diagnostic strategy to intervene efficiently and minimize morbidity.
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Affiliation(s)
- Jacob M Babu
- Division of Spine Surgery, Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI.
| | - Shyam A Patel
- Division of Spine Surgery, Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI
| | - Mark A Palumbo
- Division of Spine Surgery, Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI
| | - Alan H Daniels
- Division of Spine Surgery, Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI
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Yang H, Shah AA, Nelson SB, Schwab JH. Fungal spinal epidural abscess: a case series of nine patients. Spine J 2019; 19:516-22. [PMID: 30121322 DOI: 10.1016/j.spinee.2018.08.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 07/28/2018] [Accepted: 08/03/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND CONTEXT Fungal spinal epidural abscess (FSEA) is a rare entity with high morbidity and mortality. Reports describing the clinical features, diagnosis, treatment, and outcomes of FSEA are scarce in the literature. PURPOSE This study aimed to describe the clinical features, diagnosis, treatment, and outcomes of FSEA. STUDY DESIGN This study is designed as a retrospective clinical case series. PATIENT SAMPLE A continuous series of patients with the diagnosis of FSEA who presented at our institution from 1993 to 2016. METHODS We reviewed the electronic medical records of patients with SEA who were treated within our hospital system from 1993 to 2016. We only included SEA cases that were due to fungi. We also reviewed FSEA cases in the English language literature from 1952 to 2017 to analyze the features of FSEA. RESULTS From a database of 1,053 SEA patients, we identified 9 patients with FSEA. Aspergillus fumigatus was isolated from 2 (22%) patients, and Candida species were isolated from 7 (78%). Focal spine pain, neurologic deficit, and fever were demonstrated in 89%, 50%, and 44% of FSEA cases, respectively. Five of nine cases involved the thoracic spine, and eight were located anterior to the thecal sac. Three cases had fungemia, six had long symptom duration (>2 weeks) prior to presentation, seven had concurrent immunosuppression, and eight had vertebral osteomyelitis. Additionally, one case had residual motor deficit at last follow-up, one had S1 sensory radicular symptoms, two suffered recurrent FSEA, two died within hospitalization, and two died within 90 days after discharge. CONCLUSIONS In summary, the classic diagnostic triad (focal spine pain, neurologic deficit, and fever) is not of great clinical utility for FSEA. Biopsy, intraoperative tissue culture, and blood culture can be used to diagnose FSEA. The most common pathogens of FSEA are Aspergillus and Candida species. Therefore, empiric treatment for FSEA should cover these species while definitive identification is pending. FSEA is found in patients with poor baseline health status, which is the essential reason for its high mortality.
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Houston R, Gagliardo C, Vassallo S, Wynne PJ, Mazzola CA. Spinal Epidural Abscess in Children: Case Report and Review of the Literature. World Neurosurg 2019; 126:453-460. [PMID: 30797918 DOI: 10.1016/j.wneu.2019.01.294] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 01/29/2019] [Accepted: 01/31/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Spinal epidural abscess (SEA) is a rare but serious infection in the epidural space along the spinal cord. SEA should be considered in patients with backache, fever, neurological deficits and/or spinal tenderness. Early diagnosis is imperative to prevent permanent neurological sequelae. CASE DESCRIPTION We report a case of lumbar SEA in a 13-year-old girl who was immunocompetent and presented with spinal tenderness, back pain and 4 days of fever. A lumbar magnetic resonance imaging demonstrated an epidural abscess from L3-S1. She had emergent surgical intervention. Cultures grew methicillin-susceptible Staphylococcus aureus. She was also given long-term systemic antibiotics and she made a complete recovery within 2 months. CONCLUSIONS SEA in an immunocompetent pediatric without risk factors is an extremely rare condition. In the English-language literature, there are only 30 reported cases in the past 19 years; our case brings the total to 31. Non-surgical treatment has been successful in both adult and pediatric patients under certain conditions. Still, there exists a risk of deterioration with non-surgical management, even in patients for whom treatment is begun in the absence of neurologic deficits. Tracking neurological deficits in children can be challenging, particularly in young children who are non-verbal and not yet ambulating, and a reliable neurologic examination is a critical component of non-surgical care. In consideration of these facts and the accelerated time frame of deterioration, once neurologic deficits are present, surgery plus systemic antibiotics remains the standard of care for pediatric SEA patients, with each individual case meriting review of the full clinical picture.
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Affiliation(s)
- Rebecca Houston
- Rowan University School of Medicine (UMDNJ), Stratford, New Jersey, USA.
| | - Christina Gagliardo
- Division of Pediatric Infectious Diseases, Goryeb Children's Hospital, Atlantic Health System, Morristown, New Jersey, USA; Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sheryl Vassallo
- Division of Pediatric Infectious Diseases, Goryeb Children's Hospital, Atlantic Health System, Morristown, New Jersey, USA
| | - Peter J Wynne
- Department of Radiology, Morristown Medical Center, Morristown, New Jersey, USA
| | - Catherine A Mazzola
- Division of Pediatric Infectious Diseases, Goryeb Children's Hospital, Atlantic Health System, Morristown, New Jersey, USA
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Fotaki A, Anatoliotaki M, Tritou I, Tzagaraki A, Kampitaki M, Vlachaki G. Review and case report demonstrate that spontaneous spinal epidural abscesses are rare but dangerous in childhood. Acta Paediatr 2019; 108:28-36. [PMID: 30222897 DOI: 10.1111/apa.14579] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 07/03/2018] [Accepted: 09/12/2018] [Indexed: 01/27/2023]
Abstract
AIM A spinal epidural abscess (SEA) is a rare paediatric bacterial infection, with possible devastating neurological sequelae. We explored localisation in the cervical segment, which is unusual, but more dangerous, than other SEAs. METHODS We describe 22 cases (12 male) of paediatric SEAs without risk factors: 21 from a literature search from 2000 to 2017 and a 30-month-old boy with a spontaneous cervical SEA due to Group A Streptococcus. RESULTS The average age was eight years and the symptoms were mainly fever, back pain and motor deficit, with an aetiological diagnosis in 68%. Methicillin-sensitive Staphylococcus aureus was isolated in six patients, methicillin-resistant Staphylococcus aureus in two, Staphylococcus aureus with unknown susceptibility patterns in three and Group A Streptococcus in four. All patients underwent gadolinium-enhanced magnetic resonance imaging and most abscesses were localised in the thoracic and lumbar areas. More than half (59%) underwent surgery to remove pus and granulation tissue and nine were just treated with antimicrobial therapy for an average of 5.3 weeks. Most patients had good outcomes. CONCLUSION SEAs were underestimated in children due to the rarity and spectrum of differential diagnoses. Timely diagnosis, immediate antibiotics, spinal magnetic resonance imaging and prompt neurosurgical consultations were essential for favourable outcomes.
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Affiliation(s)
| | | | - Ioanna Tritou
- Radiology Department Venizeleio General Hospital Crete Greece
| | | | - Maria Kampitaki
- Pediatric Department University Hospital of Crete Crete Greece
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Karhade AV, Shah AA, Lin KY, Ogink PT, Shah KC, Nelson SB, Schwab JH. Albumin and Spinal Epidural Abscess: Derivation and Validation in Two Independent Data Sets. World Neurosurg 2019; 123:e416-26. [PMID: 30500590 DOI: 10.1016/j.wneu.2018.11.182] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 11/17/2018] [Accepted: 11/19/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND None of the existing prognostic scoring systems for spinal epidural abscess (SEA) include albumin despite albumin's established role in inflammation, nutrition, lipid peroxidation, and regulation of apoptosis. The purpose of the present study was to determine the prognostic value of albumin in SEA. METHODS We performed a retrospective, case-control study of 2 independent data sets: patients with SEA in an institutional population and patients in the National Surgical Quality Improvement Program (NSQIP). Bivariate analyses and multivariate analyses were used to determine whether albumin is an independent prognostic factor for survival in both data sets. RESULTS For the 1053 patients with SEA in the institutional cohort, the 90-day postdischarge mortality was 134 (12.7%). Overall, 633 (60.1%) underwent surgery in the initial admission, with a 30-day postoperative mortality rate of 5.5% (n = 35). For the 1154 patients with SEA in the NSQIP database, the 30-day postoperative mortality rate was 3.6% (n = 42). The rate of 90-day postdischarge mortality in the institutional cohort for patients with albumin <2.3 g/dL was 25.1%. In contrast, the rate for patients with albumin >3.3 g/dL was 4.5%. On multivariate analysis of the NSQIP database, hypoalbuminemia was an independent prognostic factor for 30-day postoperative mortality. On multivariate analysis of the institutional cohort, hypoalbuminemia remained a prognostic factor for 90-day postdischarge mortality. CONCLUSION Albumin was validated as an independent prognostic factor in patients with SEA. The lack of this marker in existing scoring systems underscores the need for updated models to optimize risk stratification and shared decision-making before surgery.
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