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Nery B, Filho CB, Nunes L, Quaggio E, Filho FB, Neto JA, Melo LR, Oliveira AC, Rabello R, Durand VR, Silva RR, Costa RE, Segundo JA. Acute Paraplegia Caused by Spinal Epidural Empyema Following Infectious Cellulitis of the Hand: Case Report and Literature Review. J Neurol Surg Rep 2024; 85:e29-e38. [PMID: 38596232 PMCID: PMC11001457 DOI: 10.1055/a-2267-1810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [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: 07/04/2023] [Accepted: 01/14/2024] [Indexed: 04/11/2024] Open
Abstract
Background Spinal epidural abscess is a rare but serious condition that can cause spinal cord compression and neurological deficits. Case Description and Methods The article reports a case of a 31-year-old patient who presented with an infectious cellulitis in the left hand, which progressed to a spinal epidural abscess. The diagnosis was confirmed by clinical examination and magnetic resonance imaging. Treatment involved laminectomy, after which the patient had complete recovery of neurological deficits. This article is a case report with a literature review. Patient data and images were collected by the researchers who participated in the patient's care. The literature was reviewed by one of the researchers based on the search for articles in the PubMed database. For the research, the following keywords were inserted: "Spinal epidural empyema," "Spinal epidural abscess." Conclusion Spinal epidural abscess is often underdiagnosed, which can lead to delays in treatment and serious complications. The relationship between cellulitis and spinal epidural abscess may be related to the spread of infection through the lymphatic or blood system.
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Affiliation(s)
- Breno Nery
- Department of Neurosurgery, Hospital Beneficiência Portuguesa de Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Cláudio Brandão Filho
- Department of Neurosurgery, Hospital Beneficiência Portuguesa de Ribeirão Preto, Ribeirão Preto, SP, Brazil
- Department of Neurosurgery, Universitary Center Unifacisa, Campina Grande, Paraíba, Brazil
| | - Lucas Nunes
- Department of Neurosurgery, Hospital Beneficiência Portuguesa de Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Eduardo Quaggio
- Department of Neurosurgery, Hospital Beneficiência Portuguesa de Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Fred Bernardes Filho
- Department of Neurosurgery, Hospital Beneficiência Portuguesa de Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Joaquim Alencar Neto
- Department of Neurosurgery, Hospital Beneficiência Portuguesa de Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Layssa Rhossana Melo
- Department of Neurosurgery, Hospital Beneficiência Portuguesa de Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Anna Carolyne Oliveira
- Department of Neurosurgery, Hospital Beneficiência Portuguesa de Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Rafael Rabello
- Department of Neurosurgery, Hospital Beneficiência Portuguesa de Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Victoria Rodrigues Durand
- Department of Neurosurgery, Hospital Beneficiência Portuguesa de Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Rayssa Rocha Silva
- Department of Neurosurgery, Hospital Beneficiência Portuguesa de Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Rafael Emmanuel Costa
- Department of Neurosurgery, Hospital Beneficiência Portuguesa de Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - José Alencar Segundo
- Department of Neurosurgery, Hospital Beneficiência Portuguesa de Ribeirão Preto, Ribeirão Preto, SP, Brazil
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Aguilar Mora HM, Soto Barraza JC. Cryptogenic Epidural Cervicothoracic Abscess: A Case Report and Literature Review. Cureus 2024; 16:e52189. [PMID: 38222999 PMCID: PMC10787145 DOI: 10.7759/cureus.52189] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2024] [Indexed: 01/16/2024] Open
Abstract
A spinal epidural abscess (SEA) is a rare infection characterized by pus formation in the spinal epidural space, associated with various degrees of motor, sensory, or combined deficits. It is linked to several risk factors and predominantly impacts middle-aged men. This report discusses an atypical case of a patient without any predisposing factors who developed a cervicothoracic SEA associated with significant transverse myelitis. A targeted literature search was conducted on PubMed, Scopus, and SpringerLink, employing terms such as "spinal epidural abscess, subdural empyema, and transverse myelitis." While there are numerous studies on this topic with a multidisciplinary approach, reports of cryptogenic SEA associated with the extensive involvement of cervical and thoracic spinal segments are rare. SEA is a very uncommon condition. Hence, a comprehensive understanding of its clinical presentation is crucial for adopting an appropriate diagnostic approach and delivering timely treatment.
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Boukebous B, Petrie L, Baker JF. Keeping It Simple: Developing a Prognostic Tool for Spinal Epidural Abscess. Global Spine J 2023:21925682231221497. [PMID: 38105544 DOI: 10.1177/21925682231221497] [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] [Indexed: 12/19/2023] Open
Abstract
STUDY DESIGN A retrospective study. OBJECTIVE To develop a prognostic score for mortality and treatment failure in Spinal epidural abscess (SEA), based on simplicity and multidimensional assessment principles. METHODS One-hundred-fifty patients were reviewed. Variables assessed included comorbidities, functional status, clinical presentation, Frankel classification, and biochemical and radiological parameters. The main outcomes were the 90-day mortality and treatment failure, corresponding to any intensification of the initial treatment plan. Variables were sorted out with a factorial analysis. Logistic regressions were performed, and the new score was derived from the coefficients. ROC curves with Area Under Curve, calibration plots, and cross-validation were performed. RESULTS Forty-three patients (29%) had treatment failure, and 15 died (10%) by 90 days. Factorization created 3 groups: Comorbidities (C), Severity (S), and Function (F). For 90-day mortality, Odds ratios were 1.20 (P = .0002), 1.15, (P = .03), 1.36, (P < 10-4) for C, S, F, respectively. The new score 'CSF' had 1 point per item, ranging from zero to 3. OR increased by 1.2/point for 90-day mortality (P < 10-4), AUC was .86. For failures OR increased by 1.15/point (P = .014), AUC was .58, and increased to .64 for patients who survived after 90 days, probably due to competing risks. CONCLUSIONS Comorbidities, Severity, and Function is a new simplistic tool, easy to use in daily practice; its performances were excellent for 90-day mortality, and acceptable for failures. Simple tools are more likely to be adopted into practice. External validation of this technique is desirable.
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Affiliation(s)
- Baptiste Boukebous
- Department of Orthopaedic Surgery, University of Auckland, Waikato Hospital, Hamilton, New Zealand
- ECAMO team, UMR 1153, CRESS (Centre of Research in Epidemiology and StatisticS), University of Paris Cité, INSERM, Paris, France
| | - Liam Petrie
- Department of Orthopaedic Surgery, University of Auckland, Waikato Hospital, Hamilton, New Zealand
- Department of Surgery, University of Auckland, Waikato Hospital, Hamilton, New Zealand
| | - Joseph F Baker
- Department of Orthopaedic Surgery, University of Auckland, Waikato Hospital, Hamilton, New Zealand
- Department of Surgery, University of Auckland, Waikato Hospital, Hamilton, New Zealand
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Hijazi MM, Siepmann T, El-Battrawy I, Aweimer A, Engellandt K, Podlesek D, Schackert G, Juratli TA, Eyüpoglu IY, Filis A. Diagnostics, Management, and Outcomes in Patients with Pyogenic Spinal Intra- or Epidural Abscess. J Clin Med 2023; 12:7691. [PMID: 38137760 PMCID: PMC10744009 DOI: 10.3390/jcm12247691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 12/10/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Owing to the lack of evidence on the diagnostics, clinical course, treatment, and outcomes of patients with extremely rare spinal intradural abscess (SIA) and spinal epidural abscess (SEA), we retrospectively analyzed and compared a cohort of patients to determine the phenotyping of both entities. METHODS Over a period of 20 years, we retrospectively analyzed the electronic medical records of 78 patients with SIA and SEA. RESULTS The patients with SIA showed worse motor scores (MS scores) on admission (SIA: 20 ± 26 vs. SEA: 75 ± 34, p < 0.001), more often with an ataxic gait (SIA: 100% vs. SEA: 31.8%, p < 0.001), and more frequent bladder or bowel dysfunction (SIA: 91.7% vs. SEA: 27.3%, p < 0.001) compared to the SEA patients. Intraoperative specimens showed a higher diagnostic sensitivity in the SEA patients than the SIA patients (SIA: 66.7% vs. SEA: 95.2%, p = 0.024), but various pathogens such as Staphylococcus aureus (SIA 33.3% vs. SEA: 69.4%) and Streptococci and Enterococci (SIA 33.3% vs. SEA: 8.1%, p = 0.038) were detected in both entities. The patients with SIA developed sepsis more often (SIA: 75.0% vs. SEA: 18.2%, p < 0.001), septic embolism (SIA: 33.3% vs. SEA: 8.3%, p = 0.043), signs of meningism (SIA: 100% vs. 18.5%, p < 0.001), ventriculitis or cerebral abscesses (SIA: 41.7% vs. SEA: 3.0%, p < 0.001), and pneumonia (SIA: 58.3% vs. SEA: 13.6%, p = 0.002). The mean MS score improved in both patient groups after surgery (SIA: 20 to 35 vs. SEA: 75 to 90); however, the SIA patients showed a poorer MS score at discharge (SIA: 35 ± 44 vs. SEA: 90 ± 20, p < 0.001). C-reactive protein (CrP) (SIA: 159 to 49 vs. SEA: 189 to 27) and leukocyte count (SIA: 15 to 9 vs. SEA: 14 to 7) were reduced at discharge. The SIA patients had higher rates of disease-related mortality (SIA: 33.3% vs. SEA: 1.5%, p = 0.002), had more pleural empyema (SIA: 58.3% vs. SEA: 13.6%, p = 0.002), required more than one surgery (SIA: 33.3% vs. SEA 13.6%, p = 0.009), were treated longer with intravenous antibiotics (7 ± 4 w vs. 3 ± 2 w, p < 0.001) and antibiotics overall (12 ± 10 w vs. 7 ± 3 w, p = 0.022), and spent more time in the hospital (SIA: 58 ± 36 vs. SEA: 26 ± 20, p < 0.001) and in the intensive care unit (SIA: 14 ± 18 vs. SEA: 4 ± 8, p = 0.002). CONCLUSIONS Our study highlighted distinct clinical phenotypes and outcomes between both entities, with SIA patients displaying a markedly less favorable disease course in terms of complications and outcomes.
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Affiliation(s)
- Mido Max Hijazi
- Department of Neurosurgery, Division of Spine Surgery, Faculty of Medicine, Technische Universität Dresden, University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany; (D.P.); (G.S.); (T.A.J.); (I.Y.E.); (A.F.)
| | - Timo Siepmann
- Department of Neurology, Faculty of Medicine, Technische Universität Dresden, University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany;
| | - Ibrahim El-Battrawy
- Department of Cardiology, Bergmannsheil University Hospital, Ruhr University Bochum, Bürkle De La Camp-Platz 1, 44789 Bochum, Germany; (I.E.-B.); (A.A.)
| | - Assem Aweimer
- Department of Cardiology, Bergmannsheil University Hospital, Ruhr University Bochum, Bürkle De La Camp-Platz 1, 44789 Bochum, Germany; (I.E.-B.); (A.A.)
| | - Kay Engellandt
- Institute of Diagnostic and Interventional Neuroradiology, Faculty of Medicine, Technische Universität Dresden, University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany;
| | - Dino Podlesek
- Department of Neurosurgery, Division of Spine Surgery, Faculty of Medicine, Technische Universität Dresden, University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany; (D.P.); (G.S.); (T.A.J.); (I.Y.E.); (A.F.)
| | - Gabriele Schackert
- Department of Neurosurgery, Division of Spine Surgery, Faculty of Medicine, Technische Universität Dresden, University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany; (D.P.); (G.S.); (T.A.J.); (I.Y.E.); (A.F.)
| | - Tareq A. Juratli
- Department of Neurosurgery, Division of Spine Surgery, Faculty of Medicine, Technische Universität Dresden, University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany; (D.P.); (G.S.); (T.A.J.); (I.Y.E.); (A.F.)
| | - Ilker Y. Eyüpoglu
- Department of Neurosurgery, Division of Spine Surgery, Faculty of Medicine, Technische Universität Dresden, University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany; (D.P.); (G.S.); (T.A.J.); (I.Y.E.); (A.F.)
| | - Andreas Filis
- Department of Neurosurgery, Division of Spine Surgery, Faculty of Medicine, Technische Universität Dresden, University Hospital Carl Gustav Carus, Fetscherstrasse 74, 01307 Dresden, Germany; (D.P.); (G.S.); (T.A.J.); (I.Y.E.); (A.F.)
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Hagel V, Dymel F, Werle S, Barrera V, Farshad M. Combined endoscopic and microsurgical approach for the drainage of a multisegmental thoracolumbar epidural abscess: illustrative case. J Neurosurg Case Lessons 2023; 6:CASE23230. [PMID: 37931248 PMCID: PMC10631545 DOI: 10.3171/case23230] [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] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 09/21/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Spinal epidural abscess is a rare but serious infectious disease that can rapidly develop into a life-threatening condition. Therefore, the appropriate treatment is indispensable. Although conservative treatment is justifiable in certain cases, surgical treatment needs to be considered as an alternative early on because of complications such as (progressive) neurological deficits or sepsis. However, traditional surgical techniques usually include destructive approaches up to (multilevel) laminectomies. Such excessive approaches do have biomechanical effects potentially affecting the long-term outcomes. Therefore, minimally invasive approaches have been described as alternative strategies, including endoscopic approaches. OBSERVATIONS The authors describe a surgical technique involving a combination of two minimally invasive approaches (endoscopic and microsurgical) to drain a multisegmental (thoracolumbar) abscess using the physical phenomenon of continuous pressure difference to minimize collateral tissue damage. LESSONS The combination of minimally invasive approaches, including the endoscopic technique, may be an alternative in draining selected epidural abscesses while achieving a similar amount of abscess removal and causing less collateral approach damage in comparison with more traditional techniques.
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Affiliation(s)
- Vincent Hagel
- University Spine Center Zürich, Balgrist University Hospital, Zürich, Switzerland; and
- Spine Center, Asklepios Hospital Lindau, Lindau, Germany
| | - Felix Dymel
- Spine Center, Asklepios Hospital Lindau, Lindau, Germany
| | - Stephan Werle
- Spine Center, Asklepios Hospital Lindau, Lindau, Germany
| | - Vera Barrera
- Spine Center, Asklepios Hospital Lindau, Lindau, Germany
| | - Mazda Farshad
- University Spine Center Zürich, Balgrist University Hospital, Zürich, Switzerland; and
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Oliveira F, Fonseca D, Fernandes M, Teles AR, Fonseca S. Infected Spinal Hematoma After Accidental Exteriorization of an Epidural Catheter: A Case Report. Cureus 2023; 15:e47722. [PMID: 38021824 PMCID: PMC10676040 DOI: 10.7759/cureus.47722] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2023] [Indexed: 12/01/2023] Open
Abstract
Optimal treatment and outcome after spinal hematoma remain unclear. Close neurological monitoring is the key to successful treatment. Here, we present a case of an infected spinal hematoma management. We report the case of a 51-year-old male patient, American Society of Anesthesiologists physical status I, admitted to a level I hospital due to right lower limb necrotizing fasciitis. A lumbar epidural catheter was placed for pain control without complications. On the 26th day of hospitalization, three hours after the accidental exteriorization of the epidural catheter, the patient developed severe back pain not relieved by systemic analgesia. Prophylactic low-molecular-weight heparin had been administered less than six hours before. The patient had inflammatory signs and digital pressure pain at the catheter insertion site and a positive Brudzinski sign. Sensory-motor deficits were never felt. An urgent dorsolumbar MRI exhibited a significant hematic collection at the subdural and anterior epidural level, and an infected epidural hematoma was assumed. Empirical antibiotics and hourly monitoring of sensory-motor deficits, meningeal signs, and fever were initiated. The patient remained on absolute bed rest. Low-molecular-weight heparin was stopped. The pain disappeared on the third day after the MRI. Citrobacter koseri was isolated. A re-evaluation CT scan did not show spinal compression. The patient was discharged on the 27th day after an MRI in an asymptomatic condition and was referred to acute pain consultation. Neurological deficits are usually expected at the time of spinal hematoma diagnosis. However, the classic triad of pain, sensory deficits, and motor deficits is only seen in less than half of patients. Our patient only developed severe lumbar pain. In selected cases, diagnostic MRI associated with tight monitoring and conservative management can be applied.
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Affiliation(s)
- Flávia Oliveira
- Department of Anesthesiology, Centro Hospitalar Universitário de São João, Porto, PRT
| | - Diana Fonseca
- Department of Anesthesiology, Centro Hospitalar Universitário de São João, Porto, PRT
| | - Mariana Fernandes
- Department of Anesthesiology, Centro Hospitalar Universitário de São João, Porto, PRT
| | - Ana Rita Teles
- Department of Anesthesiology, Centro Hospitalar Universitário de São João, Porto, PRT
| | - Sara Fonseca
- Department of Anesthesiology, Centro Hospitalar Universitário de São João, Porto, PRT
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Kitov BD, Davarski AN, Kilova KP, Kitova TT. Letter to Editor Regarding "Socioeconomic Disparities in Outcomes Following Conservative Treatment of Spinal Epidural Abscesses". Int J Spine Surg 2023; 17:706-707. [PMID: 37553258 PMCID: PMC10623682 DOI: 10.14444/8526] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023] Open
Affiliation(s)
- Borislav D Kitov
- Clinic of Neurosurgery, Sv. Georgi University Hospital, Plovdiv, Bulgaria
| | - Atanas N Davarski
- Department of Neurosurgery, Faculty of Medicine, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Kristina P Kilova
- Department of Medical Informatics, Biostatistics and e-Learning, Faculty of Public Health, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Tanya T Kitova
- Department of Anatomy, Histology and Embryology, Medical Faculty, Medical University of Plovdiv, Plovdiv, Bulgaria
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Cai AG, Zocchi MS, Carlson JN, Bedolla J, Pines JM. Implementation of an emergency department back pain clinical management tool on the early diagnosis and testing of spinal epidural abscess. Acad Emerg Med 2023; 30:995-1001. [PMID: 37326026 DOI: 10.1111/acem.14765] [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: 01/12/2023] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND Spinal epidural abscess (SEA) is a rare, catastrophic condition for which diagnostic delays are common. Our national group develops evidence-based guidelines, known as clinical management tools (CMT), to reduce high-risk misdiagnoses. We study whether implementation of our back pain CMT improved SEA diagnostic timeliness and testing rates in the emergency department (ED). METHODS We conducted a retrospective observational study before and after implementation of a nontraumatic back pain CMT for SEA in a national group. Outcomes included diagnostic timeliness and test utilization. We used regression analysis to compare differences before (January 2016-June 2017) and after (January 2018-December 2019) with 95% confidence intervals (CIs) clustered by facility. We graphed monthly testing rates. RESULTS In 59 EDs, pre versus post periods included 141,273 (4.8%) versus 192,244 (4.5%) back pain visits and 188 versus 369 SEA visits, respectively. After implementation, SEA visits with prior related visits were unchanged (12.2% vs. 13.3%, difference +1.0%, 95% CI -4.5% to 6.5%). Mean number of days to diagnosis decreased but not significantly (15.2 days vs. 11.9 days, difference -3.3 days, 95% CI -7.1 to 0.6 days). Back pain visits receiving CT (13.7% vs. 21.1%, difference +7.3%, 95% CI 6.1% to 8.6%) and MRI (2.9% vs. 4.4%, difference +1.4%, 95% CI 1.0% to 1.9%) increased. Spine X-rays decreased (22.6% vs. 20.5%, difference 2.1%, 95% CI -4.3% to 0.1%). Back pain visits receiving erythrocyte sedimentation rate or C-reactive protein increased (1.9% vs. 3.5%, difference +1.6%, 95% CI 1.3% to 1.9%). CONCLUSIONS Back pain CMT implementation was associated with an increased rate of recommended imaging and laboratory testing in back pain. There was no associated reduction in the proportion of SEA cases with a related prior visit or time to SEA diagnosis.
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Affiliation(s)
- Angela G Cai
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- US Acute Care Solutions, Canton, Ohio, USA
| | - Mark S Zocchi
- Department of Health Policy, Heller School for Social Policy and Management, Waltham, Massachusetts, USA
| | - Jestin N Carlson
- US Acute Care Solutions, Canton, Ohio, USA
- Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - John Bedolla
- US Acute Care Solutions, Canton, Ohio, USA
- Department of Emergency Medicine, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Jesse M Pines
- US Acute Care Solutions, Canton, Ohio, USA
- Allegheny Health Network, Pittsburgh, Pennsylvania, USA
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Liu D, Lu W, Huang W, Zhai W, Ling Q. Extensive spinal epidural abscess due to Streptococcus intermedius: a case report treated conservatively and literature review. Front Neurol 2023; 14:1237007. [PMID: 37701856 PMCID: PMC10494933 DOI: 10.3389/fneur.2023.1237007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 07/24/2023] [Indexed: 09/14/2023] Open
Abstract
Purpose To describe the clinical significance of prompt, adequate, and targeted intravenous antibiotic (IV antibiotic) therapy in the successful management of spinal epidural abscess (SEA) associated with Streptococcus intermedius (S. intermedius) infection. Case description SEA is a rare, but catastrophic infection that may result in a high risk of permanent neurological disability. A 52-year-old Chinese female patient was presented to the emergency department due to 2 years of low back pain and 3 days of decreased muscle strength in the extremities. The blood culture confirmed the presence of S. intermedius infection, and gadolinium-enhanced magnetic resonance imaging (MRI) demonstrated widespread epidural abscesses in the cervical, thoracic, and lumbar spine canal. Empirical IV antibiotic therapy with vancomycin was promptly initiated, with meropenem and moxifloxacin added subsequently based on blood culture results. After 5 days of IV antibiotic treatment, the patient's blood culture became negative. 6 weeks later, a follow-up MRI showed a decrease in the size of the abscess. The patient's muscle strength was mostly restored after 2 months of IV antibiotic treatment. Conclusion Repeat examinations or gadolinium-enhanced MRI should be considered when initial MRI findings are not diagnostic of SEA. For extensive SEA caused by Streptococcus intermedius infection, surgery may be non-essential, and the judicious antibiotic selection and adequate treatment duration are pivotal for successful conservative management. Furthermore, for patients who are not amenable to surgery, a comprehensive evaluation of their condition and meticulous implementation of a precise pharmacological regimen holds noteworthy clinical significance.
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Affiliation(s)
| | | | | | | | - Qinjie Ling
- Department of Orthopedic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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Sircar K, Jung N, Kernich N, Zarghooni K, Eysel P, Yagdiran A, Herren C. Risk Factors for Neurologic Deficits in Patients With Spinal Epidural Abscess: An Analysis of One-Hundred-Forty Cases. Global Spine J 2023:21925682231194467. [PMID: 37548223 DOI: 10.1177/21925682231194467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Abstract
STUDY DESIGN retrospective study. OBJECTIVES In addition to surgical treatment of spinal epidural abscesses (SEA), a conservative, medical treatment for patients without acute neurologic deficits has been proposed. However, the risk factors for neurologic deficits are unclear. This study aims to identify factors predisposing patients with SEA to neurological impairment. METHODS All patients treated for SEA between 2008 and 2021 were identified from a prospective vertebral-osteomyelitis registry of a tertiary referral centre. Patient demographics, comorbidities, pathogens, degree of osseous destruction, location of SEA and preoperative neurologic status were retrospectively collected. Differences between patients with (Group 1) and without (Group 2) pretreatment neurologic deficits were assessed by univariate and logistic regression analysis. RESULTS A total of 140 patients with SEA were included. Forty-three patients (31%) had a neurologic deficit and 97 patients (69%) had no neurologic deficit prior to therapy. The prevalence of diabetes mellitus (35% vs 19%, P = .03), median visual analogue scale leg pain (8 vs 5, P = .01), median American Society of Anesthesiologists (ASA) Score (3 vs 2.6, P = .003) and mean Body-Mass-Index (29 vs 26, P = .02) differed between Group 1 and 2 in univariate analysis. In multivariable analysis, diabetes mellitus (odds ratio = 2.7), female sex (odds ratio = 2.5) and ASA-Score (odds ratio = 2.4) were significant contributors for neurologic deficits. CONCLUSIONS In patients with a SEA without neurologic deficits, the ASA score and diabetes mellitus should be considered, especially in female patients. These patients may be at a higher risk for developing a neurologic deficit and may benefit from an early surgical treatment.
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Affiliation(s)
- Krishnan Sircar
- Department of Orthopaedics and Trauma Surgery, Faculty of Medicine, University Clinics, University of Cologne, Cologne, Germany
| | - Norma Jung
- Department I of Internal Medicine, Faculty of Medicine, University Clinics, University of Cologne, Cologne, Germany
| | - Nikolaus Kernich
- Department of Orthopaedics and Trauma Surgery, Faculty of Medicine, University Clinics, University of Cologne, Cologne, Germany
| | - Kourosh Zarghooni
- Department of Orthopaedics and Trauma Surgery, Helios Klinikum Hildesheim, Hildesheim, Germany
| | - Peer Eysel
- Department of Orthopaedics and Trauma Surgery, Faculty of Medicine, University Clinics, University of Cologne, Cologne, Germany
| | - Ayla Yagdiran
- Department of Orthopaedics and Trauma Surgery, Faculty of Medicine, University Clinics, University of Cologne, Cologne, Germany
| | - Christian Herren
- Department of Orthopedics, Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Aachen, Germany
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Gall A, Cowher A, France J, Cui S. Complete Spinal Cord Injury Secondary to Serratia marcescens Spinal Epidural Abscess: A Report of Significant Neurological Improvement After a Delayed Presentation. Cureus 2023; 15:e44451. [PMID: 37791159 PMCID: PMC10544132 DOI: 10.7759/cureus.44451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2023] [Indexed: 10/05/2023] Open
Abstract
The exact time at which neurological deficits secondary to a spinal cord injury (SCI) become permanent is unknown. However, urgent decompression within 24 hours of insult is advocated to maximize the return of function. Despite previous literature showing poor neurological recovery with intervention after 24-72 hours, multiple cases have since shown noteworthy clinical improvement following significant delays in presentation. We report the case of a 55-year-old incarcerated male who presented to our hospital with a four-week history of a complete (American Spinal Injury Association (ASIA) A) SCI after a prison altercation. The patient exhibited profound deficits of over one-month duration, and magnetic resonance imaging (MRI) revealed an epidural abscess at T7-T8 with severe cord compression and another epidural abscess at L4-L5. This prompted immediate IV antibiotic therapy. A full neurological examination at hospital admission showed a complete absence of sensation, motor, rectal tone, and rectal function below T8, indicating a grade ASIA A SCI. Blood cultures grew Serratia marcescens. After thorough deliberation, considering over a month of complete neurological deficits, it was decided that surgical intervention would be unlikely to improve the patient's clinical status. Nonetheless, after only 24 hours of IV antibiotic administration, the patient progressed from an ASIA A to B, with a return of 100% accurate, although dull, sensation below T8. Within one week, his abscesses diminished on follow-up MRI, yet T7-T8 remained under significant pressure with no further clinical improvements. Due to his unexpected improvement to an ASIA B, which then plateaued at this level, surgery was again discussed in an attempt to maximize recovery. The patient wished to proceed, even given low chances of a meaningful recovery. He subsequently underwent evacuation and decompression. Two weeks postoperatively, the patient advanced from an ASIA B to C; he remained so until discharge 46 days after presentation and 30 days after surgical decompression. This case is noteworthy within the literature due to two compelling features. Firstly, it represents a significantly delayed presentation of a complete SCI with unexpected, meaningful, and swift improvement after medication and surgical intervention. Secondly, it is one of the few documented cases of Serratia marcescens spinal epidural abscess (SEA).
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Affiliation(s)
- Ashley Gall
- Orthopaedic Surgery, West Virginia University School of Medicine, Morgantown, USA
| | - Abigail Cowher
- Orthopaedic Surgery, West Virginia University School of Medicine, Morgantown, USA
| | - John France
- Orthopaedic Surgery, West Virginia University School of Medicine, Morgantown, USA
| | - Shari Cui
- Orthopaedic Surgery, Prisma Health, Columbia, USA
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12
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Kals KS, Ramayani A, Hariharan R, Lee TT. A Rare Multilevel Spinal Epidural Abscess With Streptococcus agalactiae in an Adult With Uncontrolled Diabetes: A Case Report. Cureus 2023; 15:e42802. [PMID: 37664334 PMCID: PMC10470477 DOI: 10.7759/cureus.42802] [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] [Accepted: 08/01/2023] [Indexed: 09/05/2023] Open
Abstract
Spinal epidural abscess (SEA) is a rare, life-threatening infection that typically presents with fever, back pain, and neurologic deficits. Although most commonly caused by Staphylococcus aureus, this case reviews a rare occurrence of a multilevel SEA caused by Streptococcus agalactiae in a 62-year-old female with uncontrolled type II diabetes mellitus. The patient initially presented with lower back pain and was subsequently diagnosed with a SEA complicated by hyperglycemia. A prompt diagnosis with magnetic resonance imaging (MRI) revealed extensive abscess formation, leading to emergent neurosurgical intervention. Streptococcus agalactiae was identified as the causative organism through culture. The report emphasizes the challenges of early detection of SEA and highlights the importance of considering unusual pathogens in high-risk patients. Timely management is crucial to prevent permanent neurologic deficits and to achieve favorable outcomes.
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Affiliation(s)
- Karanvir S Kals
- Internal Medicine Residency Program, St. John's Riverside Hospital, Yonkers, USA
| | - Aakriti Ramayani
- Internal Medicine Residency Program, St. John's Riverside Hospital, Yonkers, USA
| | | | - Thomas T Lee
- Neurological Surgery, St. John's Riverside Hospital, Yonkers, USA
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13
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Panigrahi S, Acharya A, Otta S, Puppala S. Spinal fungal abscess mimicking as potts spine. Int J Mycobacteriol 2023; 12:364-366. [PMID: 37721246 DOI: 10.4103/ijmy.ijmy_115_23] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
Spinal epidural abscess (SEA) is a rarest form of spinal infections and is characterized by the presence of pus in the space between the dura mater, and the osseoligamentous confines of the vertebral canal. This can cause spinal injury due to direct compression or local ischemia. The major etiology of SEA is bacterial and tuberculous in endemic regions. The incidence of fungal spinal abscess is relatively low and <5% of SEA is attributable to fungi. We, here, report a case of 77-year-old known patient of chronic renal disease on hemodialysis that presented with low-back pain for 15 days and was subsequently diagnosed with SEA by magnetic resonance imaging, and causative organism was identified as Candida by culture. The abscess was surgically drained after laminectomy. The patient improved with surgery and antifungal treatment.
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Affiliation(s)
- Souvagya Panigrahi
- Department of Neurosurgery, IMS and SUM Hospital, Bhubaneswar, Odisha, India
| | - Abhijit Acharya
- Department of Neurosurgery, IMS and SUM Hospital, Bhubaneswar, Odisha, India
| | - Sarita Otta
- Department of Microbiology, IMS and SUM Hospital, Bhubaneswar, Odisha, India
| | - Sumirini Puppala
- Department of Neurology, IMS and SUM Hospital, Bhubaneswar, Odisha, India
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14
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Manoku E, Piedade GS, Gelhardt AL, Cordeiro JG, Terzis JA. Spinal Infection Due to Enterococcus faecalis as the First Manifestation of Colorectal Cancer. Cureus 2023; 15:e39815. [PMID: 37397680 PMCID: PMC10314309 DOI: 10.7759/cureus.39815] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2023] [Indexed: 07/04/2023] Open
Abstract
Spinal epidural abscess is a relatively infrequent surgical indication, but it may be neurologically compromising. The most frequent pathogen is Staphylococcus aureus, present in two-thirds of the cases. Enterococcus faecalis is part of the intestinal flora and is uncommon in this condition. Colorectal cancer is reported to be a cause of hematogenic translocation and distant infection. We present a case of an 82-year-old patient admitted for acute low back pain with increased inflammatory markers and negative blood cultures. An MRI revealed an epidural lumbar abscess with adjacent spondylitis. After surgical treatment, E. faecalis was identified, and antibiotics were adjusted accordingly. A colonoscopy revealed colon cancer. This is the first case in the literature of a spinal epidural abscess by E. faecalis as the first manifestation of a newly diagnosed colorectal cancer. When facing a spinal infection caused by atypical intestinal bacteria and no other clear sources, a colonoscopy should be considered.
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Affiliation(s)
- Eni Manoku
- Department of Neurosurgery, Helios Universitätsklinikum Wuppertal, Wuppertal, DEU
| | - Guilherme S Piedade
- Department of Neurosurgery, Helios Universitätsklinikum Wuppertal, Wuppertal, DEU
| | - Andreas L Gelhardt
- Department of Neurosurgery, Medical School, Federal University of Paraná, Curitiba, BRA
| | - Joacir G Cordeiro
- Department of Neurological Surgery, University of Miami, Coral Gables, USA
| | - Jorge A Terzis
- Department of Neurosurgery, Helios Universitätsklinikum Wuppertal, Wuppertal, DEU
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15
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Callander JK, Clark AJ, Dillon W, Ryan WR. Spondylodiscitis and Spinal Epidural Abscess After Transoral Robotic Surgery Radical Tonsillectomy. OTO Open 2023; 7:e61. [PMID: 37351270 PMCID: PMC10284497 DOI: 10.1002/oto2.61] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/14/2023] [Accepted: 05/27/2023] [Indexed: 06/24/2023] Open
Affiliation(s)
- Jacquelyn K. Callander
- Department of Otolaryngology–Head and Neck SurgeryUniversity of California San FranciscoSan FranciscoCaliforniaUnited States
| | - Aaron J. Clark
- Department of Neurological SurgeryUniversity of California San FranciscoSan FranciscoCaliforniaUnited States
| | - William Dillon
- UCSF Department of RadiologyNeuroradiology Section, University of California San FranciscoSan FranciscoCaliforniaUnited States
| | - William R. Ryan
- Department of Otolaryngology–Head and Neck SurgeryUniversity of California San FranciscoSan FranciscoCaliforniaUnited States
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16
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Gupta VK, Carvalho AS, Shekhawat NS, Gupta E. Button-Hole Disco-Osteotomy Drainage-A Novel Approach for High-Risk Patients with Cervical Abscess. Neurol India 2023; 71:331-333. [PMID: 37148064 DOI: 10.4103/0028-3886.375430] [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: 05/07/2023]
Abstract
Spinal epidural abscess (SEA) is a very serious infection of the central nervous system (CNS). It is of very low incidence with a peak age in the geriatric age group. Immunocompromised patients are more susceptible to SEA. It can present with significant neurological deficits, which can be permanent if not identified and treated promptly. In this case report, a 75-year-old immunocompromised patient presented with progressive spastic quadriparesis and septicemia. He was diagnosed with a case of cervical spinal epidural abscess with underlying cord compression. Anterior retropharyngeal approach and button-hole disco-osteotomy of C5-C6 was performed and the cervical SEA was drained, followed by antibiotic saline irrigation (cranially and caudally) was done, total duration of surgery was 70 min. At the time of discharge (7th postoperative day), the patient improved neurologically and sepsis had resolved.
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Affiliation(s)
- Vijay K Gupta
- Department of Neurosurgery, NIIMS University and Super Specialty Hospital, Jaipur, Rajasthan, India
| | | | | | - Ekata Gupta
- Health Care Clinic, Shree Gopal Nagar, Jaipur, Rajasthan, India
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17
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Cao J, Fang J, Shao X, Shen J, Jiang X. Case Report: A case of cervical spinal epidural abscess combined with cervical paravertebral soft tissue abscess. Front Surg 2022; 9:967806. [PMID: 36277281 PMCID: PMC9581127 DOI: 10.3389/fsurg.2022.967806] [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: 06/13/2022] [Accepted: 08/23/2022] [Indexed: 11/06/2022] Open
Abstract
Background Spinal epidural abscess (SEA) is a rare purulent infection of the central nervous system. Abscesses confined to the spinal canal can compress the spinal cord, causing nerve damage and even death in severe cases (1). Prompt diagnosis and treatment can relieve symptoms and prevent complications. To increase awareness of this rare disease, we report a case of a 58-year-old man with a cervical spinal epidural abscess combined with a soft tissue abscess in the neck and describe its clinical course, imaging feature, pathology, treatment, and patient prognosis. Case description A 58-year-old male Chinese patient was admitted to our hospital because of neck pain for 2 months, which worsened for 4 days. On the third day of admission, the muscle strength of the limbs decreased, and MRI of the spinal cord showed abnormal signal shadows in the spinal canal at the C1-C7 level and in the surrounding soft tissue on the right side of spine, suggesting the possibility of inflammatory lesions with local abscess formation. We immediately performed decompression of the spinal canal on the patient and performed incision and drainage of the cervical abscess. During the operation, we found a large amount of pus in the epidural space of the spinal canal, and there was a fistula between the cervical abscess and the epidural abscess of the spinal canal. The patient underwent continuous drainage and anti-infective treatment with sensitive antibiotics after operation. No recurrence of the abscess was observed and the patient recovered well. Conclusion Early diagnosis is the key to the treatment of SEA, so radiologists and neurosurgeons need to strengthen their understanding of this rare disease to avoid misdiagnosis. For SEA with definite diagnosis, decompression surgery should be performed in a timely manner when symptoms of nerve compression occur, continuous drainage should be performed after surgery, and sensitive antibiotics should be used for anti-infective treatment.
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Affiliation(s)
- Jun Cao
- Correspondence: Xuefei Shao Jun Cao Jincheng Fang
| | | | - Xuefei Shao
- Correspondence: Xuefei Shao Jun Cao Jincheng Fang
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18
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Xu T, Du Y, Guo J, Li J, Shao C, Shi C, Ren X, Xi Y. Extensive Spinal Epidural Abscess Resulting in Complete Paraplegia Treated by Selective Laminectomies and Irrigation. Orthop Surg 2022; 14:2380-2385. [PMID: 35732468 PMCID: PMC9483064 DOI: 10.1111/os.13367] [Citation(s) in RCA: 1] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 04/11/2022] [Accepted: 04/27/2022] [Indexed: 11/30/2022] Open
Abstract
Background Spinal epidural abscess (SEA) is an uncommon clinical entity that is often subject to delayed diagnosis and suboptimal treatment. Untreated disease leads to compression of the spinal cord, resulting in devastating complications. Case Presentation A 56‐year‐old man visited our hospital for progressive lower back and lower extremity pain of several days' duration. Significant pyrexia (39.5°C) and elevated C‐reactive protein (89.2 mg/L) were detected during admission, but no positive neurological examination findings were observed. Magnetic resonance imaging revealed pyogenic discitis at L3–4. Despite the administration of directed antibiotic therapy, the patient's condition rapidly deteriorated, culminating in complete paraplegia secondary to an extensive SEA from L4 to C7. Emergency spinal decompression surgery was canceled due to his poor clinical condition and refusal of informed consent. After further deterioration, he consented to two‐level selective laminectomies and irrigation. Conclusions In contrast with prior case reports, this case illustrates the natural history of an extensive SEA during conservative and late surgical treatment. Early diagnosis and timely surgical decompression are of great importance for extensive SEA.
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Affiliation(s)
- Tongshuai Xu
- Department of Spinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yukun Du
- Department of Spinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Jianwei Guo
- Department of Spinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Jianyi Li
- Department of Spinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Cheng Shao
- Department of Spinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Changfang Shi
- Department of Spinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xianfeng Ren
- Department of Spinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yongming Xi
- Department of Spinal Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
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19
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Göre B, Yenigün EC, Cevher ŞK, Çankaya E, Aydın N, Dede F. IGA nephropathy and spinal epidural abscess after COVID-19 infection: a case report. Future Virol 2022. [PMID: 35783673 PMCID: PMC9246087 DOI: 10.2217/fvl-2021-0314] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 10/30/2021] [Accepted: 06/15/2022] [Indexed: 11/25/2022]
Abstract
A 56-year-old male admitted to the hospital for generalized weakness and fever. He was treated in hospital for 10 days due to COVID-19. He did not receive any immunosuppressive therapy during admission. One day after his discharge he experienced back pain and received analgesic therapy for 10 days. About one month later he experienced severe back pain and gross hematuria. He was admitted to hospital with acute kidney injury and new-onset lower extremity muscle weakness. His renal biopsy revealed IgA nephropathy and thoracic/cervical/lumbar-spine imaging showed an epidural abscess. This is a unique case report of a patient developing an epidural abscess and acute kidney injury together as a serious complication of COVID-19 infection.
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Affiliation(s)
- Burak Göre
- Department of Internal Medicine, Ankara City Hospital, Ankara, 06800, Turkey
| | | | | | - Emre Çankaya
- Department of Nephrology, Ankara City Hospital, Ankara, 06800, Turkey
| | - Numan Aydın
- Department of Internal Medicine, Ankara City Hospital, Ankara, 06800, Turkey
| | - Fatih Dede
- Department of Nephrology, Ankara City Hospital, Ankara, 06800, Turkey
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20
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Bara GA, Thissen J. Cervical epidural abscess due to implantation of a spinal cord stimulation lead. Clin Case Rep 2022; 10:e05931. [PMID: 35662778 PMCID: PMC9163478 DOI: 10.1002/ccr3.5931] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [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: 01/26/2021] [Revised: 07/31/2021] [Accepted: 11/10/2021] [Indexed: 11/17/2022] Open
Abstract
Spinal cord stimulation (SCS) for intractable pain syndromes has become a pillar of modern pain management. Common complications include lead migration, implant infection, cerebral spinal fluid leak, and lead fracture. Spinal epidural abscess due to spinal cord stimulator implantation is a very rare occurrence with only two cases reported in the literature so far. We present an illustrative case and discuss the pathophysiology and best clinical management for this very rate entity.
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21
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Hsu TL, Yang CJ, Pao JL. Salmonella spondylodiscitis and epidural abscess successfully treated with unilateral biportal endoscopic discectomy and debridement: a rare case report. J Int Med Res 2022; 50:3000605221085405. [PMID: 35321567 PMCID: PMC8958527 DOI: 10.1177/03000605221085405] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Spinal epidural abscess (SEA) is a rare but severe infection with potentially devastating consequences. Epidural abscesses caused by Salmonella serogroup C2 are even rarer and tend to be more invasive with multidrug resistance. Early diagnosis, effective use of antibiotics and surgical intervention are the mainstay strategies for managing SEA, especially for more virulent and multidrug-resistant Salmonella infections. This case report presents a rare case of an elderly and fragile woman with Salmonella spondylodiscitis and an extensive epidural abscess, which were successfully treated with intravenous antibiotics and unilateral biportal endoscopic (UBE) debridement and drainage through four small surgical incisions. After surgery, her fever subsided, she regained consciousness and her low back pain dramatically improved. Follow-up magnetic resonance imaging showed complete resolution of the epidural abscess. At 6 months after surgery, the patient regained muscle strength, ambulated with a walker and had no recurrence of the infection. The UBE technique can effectively eradicate infection while minimizing surgery-related risks and complications. A multidisciplinary team is required to achieve a good outcome.
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Affiliation(s)
- Ta-Li Hsu
- Department of Orthopaedic Surgery, Far Eastern Memorial Hospital, New Taipei City
| | - Chia-Jui Yang
- Department of Infectious Disease, Division of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City.,School of Medicine, 34914National Yang Ming Chiao Tung University, National Yang Ming Chiao Tung University, Taipei
| | - Jwo-Luen Pao
- Department of Orthopaedic Surgery, Far Eastern Memorial Hospital, New Taipei City.,General Education Centre, Longhwa University of Science & Technology, Taoyuan
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22
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Baum J, Viljoen SV, Gifford CS, Minnema AJ, Shaikhouni A, Grossbach AJ, Nimjee S, Farhadi HF. Baseline parameters and the prediction of treatment failure in patients with intravenous drug use-associated spinal epidural abscesses. J Neurosurg Spine 2021; 36:660-669. [PMID: 34740181 DOI: 10.3171/2021.7.spine21689] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/01/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite the increasing incidence of spinal epidural abscess (SEA), the baseline parameters potentially predictive of treatment failure remain poorly characterized. In this study, the authors identify the relevant baseline parameters that predict multimodal treatment failure in patients with either intravenous drug use (IVDU)-associated SEA or non-IVDU-associated SEA. METHODS The authors reviewed the electronic medical records of a large institutional series of consecutive patients with diagnosed SEA between January 2011 and December 2017 to characterize epidemiological trends as well as the complement of baseline measures that are predictive of failure after multimodal treatment in patients with and without concomitant IVDU. The independent impact of clinical and imaging factors in detecting treatment failure was assessed by performing stepwise binary logistic regression analysis. RESULTS A total of 324 consecutive patients with diagnosed SEA were identified. Overall, 226 patients (69.8%) had SEA related to other causes and 98 (30.2%) had a history of recent IVDU. While non-IVDU SEA admission rates remained constant, year-over-year admissions of patients with IVDU SEA nearly tripled. At baseline, patients with IVDU SEA were distinct in many respects including younger age, greater unemployment and disability, less frequent diabetes mellitus (DM), and more frequent methicillin-resistant Staphylococcus aureus infection. However, differences in length of stay, loss to follow-up, and treatment failure did not reach statistical significance between the groups. The authors constructed independent multivariate logistic regression models for treatment failure based on identified parameters in the two cohorts. For the non-IVDU cohort, the authors identified four variables as independent factors: DM, hepatitis B/C, osteomyelitis, and compression deformity severity. In contrast, for patients with IVDU, the authors identified three variables: albumin, endocarditis, and endplate destruction. Receiver operating characteristic and area under the curve (AUC) analyses were undertaken for the multivariate models predicting the likelihood of treatment failure in the two cohorts (AUC = 0.88 and 0.89, respectively), demonstrating that the derived models could adequately predict the risk of multimodal treatment failure. Treatment failure risk factor point scales were derived for the identified variables separately for both cohorts. CONCLUSIONS Patients with IVDU SEA represent a unique population with a distinct set of baseline parameters that predict treatment failure. Identification of relevant prognosticating factors will allow for the design of tailored treatment and follow-up regimens.
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23
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Sati WO, Haddad M, Anjum S. A Case of Spinal Epidural Abscess Presenting with Horner Syndrome. Cureus 2021; 13:e14541. [PMID: 34017656 PMCID: PMC8130198 DOI: 10.7759/cureus.14541] [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] [Indexed: 11/06/2022] Open
Abstract
A spinal epidural abscess (SEA) is an uncommon disease, but it is associated with significant morbidity. SEA can be promoted by multiple risk factors. Moreover, the diagnosis of SEA usually requires the presence of a classic triad of back pain, fever, and neurological deficit, hence, the difficulty in making the diagnosis if presented otherwise. Horner syndrome (HS) is an uncommon presentation in association with SEA. Even though nonsurgical versus surgical management of SEA is still controversial, the literature review indicates a preference for surgical decompression as a treatment for SEA presenting with neurological compromise, followed by long-term antimicrobial therapy. The rapidity of making the diagnosis and the initiation of appropriate treatment determine the outcome. We present a case of a 23-year-old male with no past medical history. The patient arrived at the Hamad General Hospital emergency department (ED) with severe upper back pain radiating to his left shoulder, which progressed to numbness and weakness of the left upper limb and spastic paraplegia. A left HS was revealed in a further neurological examination. However, the diagnosis of a spinal epidural abscess (SEA) was made after a left posterolateral epidural abscess extending from C5/6-T2/3 with associated cord compression and edema was revealed on an MRI scan. The patient then underwent a left C7, T1 hemilaminectomy and received antibiotics followed by admission to the rehabilitation unit. Staph. aureus was reported in culture microbiology results. Unfortunately, motor power recovery after the surgery was not significant. Although it is difficult to diagnose SEA, it is crucial to suspect it in the presence of a neurological deficit regardless of the presence or absence of predisposing factors. Nevertheless, HS is not a relatively common finding in association with SEA. In this case report, we have a young patient with SEA who presented with left HS, upper back pain, and progressive neurological deficit in the absence of identifiable risk factors.
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Affiliation(s)
- Wala O Sati
- Emergency Medicine, Hamad General Hospital, Doha, QAT
| | - Mahmoud Haddad
- Emergency Medicine, Hamad Medical Corporation, Doha, QAT
| | - Shahzad Anjum
- Emergency Medicine, Hamad Medical Corporation, Doha, QAT
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24
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Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES The aim of this study is to identify predictive factors associated with failure of nonoperative management of spinal epidural abscess (SEA). METHODS Between January 2007 and January 2017, there were 97 patients 18 years or older treated for SEA at a tertiary referral center. Of these, 58 were initially managed nonoperatively. Details on presenting complaint, laboratory parameters, radiographic evaluation, demographics, comorbidities, and neurologic status (Frankel grades A-E) were collected. Success of treatment was defined as eradication of infection with no requirement for further antimicrobial therapy. Diagnosis of SEA was made via evaluation of imaging and intraoperative findings. Patients with repeat presentation of SEA, children, and those who were transferred for immediate surgical decompression were excluded. RESULTS Fifty-eight patients initially treated nonoperatively were included. Of these, 21 failed nonoperative management and required surgical intervention. The mean age was 60 years, 66% male, and 19% of Maori ethnicity. Abscess location was predominantly dorsal, and in the lumbar region (53%). Multivariate analysis identified Maori ethnicity, multifocal sepsis, and elevated white cell count as predictors of failure of nonoperative management. With 1 predictor the risk of failure was 44%. In the presence of 2 predictive variables, failure rate increased to 60%, and if all 3 variables were present, patients had a 75% risk of failure. CONCLUSION Thirty-six percent of patients treated nonoperatively failed nonoperative management-the failure rate was significantly increased in patients with multifocal sepsis, in patients with elevated white cell count, and in patients of Maori ethnicity.
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Affiliation(s)
- Sarah Hunter
- University of Auckland, Auckland, Auckland, New Zealand
- Waikato Hospital, Hamilton, New Zealand
- Sarah Hunter, Waikato Hospital, Pembroke St, Hamilton West, Hamilton 3204, New Zealand.
| | - Robert Cussen
- Waikato Hospital, Hamilton, New Zealand
- University College Cork, Cork, Ireland
| | - Joseph F. Baker
- University of Auckland, Auckland, Auckland, New Zealand
- Waikato Hospital, Hamilton, New Zealand
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25
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Makito K, Mouri H, Matsui H, Michihata N, Fushimi K, Yasunaga H. Spinal epidural hematoma and abscess after neuraxial anesthesia: a historical cohort study using the Japanese Diagnosis Procedure Combination database. Can J Anaesth 2020; 68:42-52. [PMID: 33037571 DOI: 10.1007/s12630-020-01827-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 01/23/2020] [Revised: 07/12/2020] [Accepted: 07/13/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Spinal epidural hematoma and abscess are rare complications of neuraxial anesthesia but can cause severe neurologic deficits. The incidence of these complications vary widely in existing studies and the risk factors remain uncertain. We estimated the incidence of these complications and explored associations using a national inpatient database in Japan. METHODS Using Japanese Diagnosis Procedure Combination data on surgical inpatients who underwent neuraxial anesthesia from July 2010 to March 2017, we identified patients with spinal epidural hematoma and/or abscess. We investigated age, sex, Charlson comorbidity index, antithrombotic therapy, type of surgery, admission, and hospital for association with these complications. The incidences of spinal epidural hematoma and abscess were estimated separately, and a nested case-control study was performed to examine factors associated with these complications. RESULTS We identified 139 patients with spinal epidural hematoma and/or abscess among 3,833,620 surgical patients undergoing neuraxial anesthesia. The incidences of spinal epidural hematoma and abscess were 27 (95% confidence interval [CI], 22 to 32) and 10 (7 to 13) per one million patients, respectively. Spinal anesthesia was associated with significantly fewer complications compared with epidural or combined spinal epidural anesthesia (odds ratio, 0.15; 95% CI, 0.08 to 0.32). Antiplatelet agent (odds ratio, 0.49; 95% CI, 0.06 to 3.91) and anticoagulants (odds ratio, 1.65; 95% CI, 0.95 to 2.85) were not significantly associated with these complications. CONCLUSIONS This analysis identified the incidences of spinal epidural hematoma and/or abscess after neuraxial anesthesia. Additional large-scale studies are warranted to examine the incidences and factors associated with these complications.
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Affiliation(s)
- Kanako Makito
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan.
| | - Hideyuki Mouri
- Department of Anesthesiology and Intensive Care Medicine, Kanazawa University, Kanazawa, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Nobuaki Michihata
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Graduate School of Medicine, Tokyo, Medical and Dental University, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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Kitov B, Kehayov I, Davarski A, Stoyanova R. Outcome of Surgical Treatment of Spontaneous Spinal Epidural Abscesses for a 10-year Period. Folia Med (Plovdiv) 2020; 62:482-489. [PMID: 33009757 DOI: 10.3897/folmed.62.e49902] [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: 01/06/2020] [Accepted: 04/15/2020] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Spinal epidural abscess is uncommon but potentially debilitating infection. Delay in early diagnosis may be associated with increased morbidity and mortality despite recent advances in medicine. AIM To present the clinical course and outcome of treatment of spontaneous spinal epidural abscesses. MATERIALS AND METHODS Thirty-four patients (20 men and 14 women) with clinical, neuroimaging and/or histological data for spinal epidural abscess were treated at the Clinic of Neurosurgery at St George University Hospital, Plovdiv, Bulgaria, for the period 2009-2018. RESULTS The average age of patients was 62 years (21-76 years) and the ratio of men to women was 1.4:1. All patients (100%) presented with vertebralgia, 13 patients (38.2%) had additional radiculalgia, and 10 patients (29.4%) presented with sensory or motor deficit. The duration of complaints varied from 4 to 180 days. At hospital admission, only 9 patients (26.4%) had intact neurological status. The most common localization of the spinal epidural abscess was in the lumbar and lumbosacral area (52.9%), concomitant spondylodiscitis was present in 31 patients (91.2%). Twenty-four patients (70.6%) underwent emergency surgery within 24 hours, and the rest had planned surgery. Decompressive interlaminotomy or hemilaminectomy was performed in 9 patients (26.5%). The remaining 25 patients (73.5%) underwent laminectomy, in 15 patients (44.1%) it was combined with posterior pedicle screw fixation. After the treatment, 23 patients (67.6%) had a good outcome, the remaining 11 (32.4%) had a poor outcome, and 3 patients died (8.8%). CONCLUSION In patients with spinal epidural abscess, emergency surgery is the treatment method of choice. It allows decompression of neural structures, correction of the spinal deformity, segmental stabilization and rapid mobilization of patients.
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Affiliation(s)
| | - Ivo Kehayov
- Medical University of Plovdiv, Plovdiv, Bulgaria
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Manassero A, Bossolasco M, Carrega M, Coletta G. Postoperative Thoracic Epidural Analgesia: Adverse Events from a Single-Center Series of 3126 Patients. Local Reg Anesth 2020; 13:111-119. [PMID: 32982397 PMCID: PMC7490049 DOI: 10.2147/lra.s272410] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [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: 07/23/2020] [Accepted: 08/27/2020] [Indexed: 11/25/2022] Open
Abstract
Purpose Thoracic epidural analgesia (TEA) has been shown to reduce postsurgical morbidity and mortality; nevertheless, major and minor complications can occur. We report our 10-year experience with TEA and incidence of complications. Patients and Methods Patients received continuous infusion TEA (0.2% ropivacaine and 2 µg ml−1 fentanyl) to control postoperative pain. Every 8 hours, the acute pain service recorded the analgesia regimen and occurrence of side effects. The initial infusion rate was tapered daily in response to improvement in pain symptoms or occurrence of side effects. Results A total of 3126 patients received TEA. The median age was 65 years (range, 18–94) and the duration of catheter placement was 3.5 days (range, 2–8). Three major complications were identified (1:1042): two subarachnoid blocks and one epidural abscess which led to permanent sequela (1:3126). Minor complications were hypotension (4.8%), pruritus (4.4%), accidental catheter removal (3.7%), insertion site inflammation (2.5%), motor weakness (2.0%), postoperative nausea and vomiting (1.8%), catheter disconnection (1.9%), catheter occlusion (0.3%), post-dural puncture headache (0.5%), and catheter fragment retention (0.06%), which were the reasons for a 7.4% rate of early discontinuation of epidural analgesia. No occurrence of epidural hematoma, local anesthetic systemic toxicity, and cardiovascular/respiratory depression was recorded. Conclusion Postoperative TEA is an advanced technique that poses certain difficulties that can subvert its great potential. While serious complications were rare, minor complications occurred more often and affected the postoperative course negatively. A risk/benefit evaluation of each patient should be done before employing the technique.
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Affiliation(s)
- Alberto Manassero
- Department of Emergency and Critical Care, Division of Operating Room Management, S. Croce e Carle Hospital, Cuneo, Italy
| | - Matteo Bossolasco
- Department of Emergency and Critical Care, Division of Operating Room Management, S. Croce e Carle Hospital, Cuneo, Italy
| | - Mattia Carrega
- Department of Emergency and Critical Care, Division of Operating Room Management, S. Croce e Carle Hospital, Cuneo, Italy
| | - Giuseppe Coletta
- Department of Emergency and Critical Care, Division of Operating Room Management, S. Croce e Carle Hospital, Cuneo, Italy
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Mallik J, Motiani V, Pai MG. Spinal Epidural Abscess Post Spinal Anesthesia: An Uncommon Complication of a Common Procedure. Asian J Neurosurg 2020; 15:730-732. [PMID: 33145241 PMCID: PMC7591180 DOI: 10.4103/ajns.ajns_154_20] [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: 04/11/2020] [Revised: 04/19/2020] [Accepted: 07/03/2020] [Indexed: 11/11/2022] Open
Abstract
Spinal epidural abscess (SEA) is a severe pyogenic infection of the epidural space. Bacteria gain access to the epidural space either by hematogenous spread, contiguous spread from a neighboring infected structure, or through iatrogenic inoculation. The diagnosis of SEA is a challenge, largely because of its rarity. We present here a case of SEA of iatrogenic origin (post spinal anesthesia), which we treated at Tata Main Hospital, Jamshedpur.
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Affiliation(s)
- Jeevesh Mallik
- Department of Neurosurgery, Tata Main Hospital, Jamshedpur, Jharkhand, India
| | - Vanita Motiani
- Department of Internal Medicine, Ziauddin Medical University, Karachi, Pakistan
| | - Manish Ganesh Pai
- Department of Neurosurgery, Denver Children's Hospital, Anschutz Medical Campus, University of Colorado, Aurora, Colorado, USA
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Khan MM, Babu RA, Iqbal J, Batas SN, Raza A. Cervical Epidural Abscess due to Brucella Treated with Decompression and Instrumentation: A Case Report and Review of Literature. Asian J Neurosurg 2020; 15:440-444. [PMID: 32656150 PMCID: PMC7335118 DOI: 10.4103/ajns.ajns_358_19] [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: 12/11/2019] [Revised: 02/05/2020] [Accepted: 03/17/2020] [Indexed: 01/18/2023] Open
Abstract
Brucella is caused by a Gram-negative bacillus and is a common disease in endemic areas where people are in close contact with animals and dairy products, but brucellar cervical epidural abscess is rare. We describe a rare case of a C5–6 brucellar epidural abscess in a veterinary doctor who was treated with decompression and instrumentation. We also review the cases of cervical brucellar epidural abscess treated with instrumentation in the literature.
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Affiliation(s)
| | - R Arun Babu
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | - Javeed Iqbal
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | | | - Ali Raza
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
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Magrassi L, Mussa M, Montalbetti A, Colaneri M, di Matteo A, Malfitano A, Simoncelli AM, Egitto MG, Bernucci C, Brunetti E. Primary Spinal Epidural Abscesses Not Associated With Pyogenic Infectious Spondylodiscitis: A New Pathogenetic Hypothesis. Front Surg 2020; 7:20. [PMID: 32426366 PMCID: PMC7203469 DOI: 10.3389/fsurg.2020.00020] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 03/24/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Spinal epidural abscess (SEA) incidence is rising. However, most series do not differentiate between SEAs associated with pyogenic infectious spondylodiscitis (PS) and SEAs limited to the epidural space. Methods: We retrospectively reviewed the records and radiological images of all patients admitted to our institutions with a diagnosis of SEA not associated with PS between January 2013 and December 2018. Results: We found three males and four females; five of the seven were intravenous drug users. All patients presented with pain: in six, it was associated with acute motor and sensory deficits, while one had only pain and paresthesias. Staphylococcus aureus was cultured from abscesses and/or from multiple blood cultures in four patients. Abscesses were localized to the cervical spine in one patient, thoracic in three, lumbar in one, and in two, the SEAs involved multiple segments. All patients but one underwent urgent open surgery. This patient had a multisegmental abscess and was successfully treated by percutaneous aspiration when pain became intractable. After abscess evacuation, the neurological deficits improved in all patients except one. The patients that were treated without spine instrumentation did not develop delayed kyphosis or instability at follow-up. Conclusion: Patients with SEAs not associated with PS are likely to present with pain and motor deficits, appear to benefit from urgent abscess evacuation, and seem to be less dependent on spine instrumentation to avoid delayed spinal deformities compared to SEA associated with PS. Finally, the lack of initial involvement of bone and intervertebral disks may suggest that at least some of the SEAs without PS originate from infection of epidural lymphatic vessels that are not present inside those structures.
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Affiliation(s)
- Lorenzo Magrassi
- Neurosurgery, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Marco Mussa
- Unit of Infectious and Tropical Diseases, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, IRCCS San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Andrea Montalbetti
- Neurosurgery, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, IRCCS San Matteo Hospital Foundation, Pavia, Italy.,Neurosurgery Pope John XXIII Hospital, Bergamo, Italy
| | - Marta Colaneri
- Unit of Infectious and Tropical Diseases, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, IRCCS San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Angela di Matteo
- Unit of Infectious and Tropical Diseases, IRCCS Policlinico San Matteo Hospital Foundation, Pavia, Italy
| | - Antonello Malfitano
- Unit of Infectious and Tropical Diseases, IRCCS Policlinico San Matteo Hospital Foundation, Pavia, Italy
| | - Anna Maria Simoncelli
- Diagnostic Radiology, Interventional Radiology and Neuroradiology Unit, IRCCS Policlinico San Matteo Hospital Foundation, Pavia, Italy
| | | | | | - Enrico Brunetti
- Unit of Infectious and Tropical Diseases, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, IRCCS San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
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Abstract
Surgical decompression and antibiotic therapy are the treatments of choice for patients with spinal epidural abscess (SEA). Surgical treatment included decompression, evacuation of abscess, and debridement. Recently, minimal invasive surgery has been introduced more widely, and biportal endoscopic spinal surgery have shown satisfactory clinical outcomes compared with traditional open surgery. The purpose of this study was to evaluate the efficacy of biportal endoscopic spinal surgery for the treatment of SEA .From January 2016 to June 2017, 13 patients who underwent biportal endoscopic spinal surgery under the diagnosis of SEA were retrospectively enrolled in this study. The surgical indications of the enrolled patients included SEA with or without early stage spondylodiscitis who had neurological symptoms. Periopertaive data and clinical outcomes were assessed by regular serologic testing, imaging studies, physical examination, visual analog scale, Oswestry Disability Index and modified Macnab criteria.Offending pathogens were identified in seven (54%) of 13 biopsy specimens. Appropriate intravenous antibiotics for the identified pathogens isolated from infected tissue biopsy cultures were administrated to patients for at least 30 days. All patients reported satisfactory relief of pain and neurological symptoms after surgery. No surgery-related complications and recurrences were found after 2 years follow up.Biportal endoscopic spinal surgery may be an effective alternative to traditional open surgical decompression for the treatment of SEA.
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32
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Longo M, Pennington Z, Gelfand Y, De la Garza Ramos R, Echt M, Ahmed AK, Yanamadala V, Sciubba DM, Yassari R. Readmission after spinal epidural abscess management in urban populations: a bi-institutional study. J Neurosurg Spine 2019; 32:1-8. [PMID: 31756697 DOI: 10.3171/2019.8.spine19790] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 08/28/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The incidence of spinal epidural abscess (SEA) is rising, yet there are few reports discussing readmission rates or predisposing factors for readmission after treatment. The aims of the present study were to determine the rate of 90-day readmission following medical or surgical treatment of SEA in an urban population, identify patients at increased risk for readmission, and delineate the principal causes of readmission. METHODS Neurosurgery records from two large urban institutions were reviewed to identify patients who were treated for SEA. Patients who died during admission or were discharged to hospice were excluded. Univariate analysis was performed using chi-square and Student t-tests to identify potential predictors of readmission. A multivariate logistic regression model, controlled for age, body mass index, sex, and institution, was used to determine significant predictors of readmission. RESULTS Of 103 patients with identified SEA, 97 met the inclusion criteria. Their mean age was 57.1 years, and 56 patients (57.7%) were male. The all-cause 90-day readmission rate was 37.1%. Infection (sepsis, osteomyelitis, persistent abscess, bacteremia) was the most common cause of readmission, accounting for 36.1% of all readmissions. Neither pretreatment neurological deficit (p = 0.16) nor use of surgical versus medical management (p = 0.33) was significantly associated with readmission. Multivariate analysis identified immunocompromised status (p = 0.036; OR 3.5, 95% CI 1.1-11.5) and hepatic disease (chronic hepatitis or alcohol abuse) (p = 0.033; OR 2.9, 95% CI 1.1-7.7) as positive predictors of 90-day readmission. CONCLUSIONS The most common indication for readmission was persistent infection. Readmission was unrelated to baseline neurological status or management strategy. However, both hepatic disease and baseline immunosuppression significantly increased the odds of 90-day readmission after SEA treatment. Patients with these conditions may require closer follow-up upon discharge to reduce overall morbidity and hospital costs associated with SEA.
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Affiliation(s)
- Michael Longo
- 1Spine Research Group and
- 2Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; and
| | - Zach Pennington
- 3Department of Neurological Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yaroslav Gelfand
- 1Spine Research Group and
- 2Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; and
| | - Rafael De la Garza Ramos
- 1Spine Research Group and
- 2Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; and
| | - Murray Echt
- 1Spine Research Group and
- 2Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; and
| | - A Karim Ahmed
- 3Department of Neurological Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Vijay Yanamadala
- 1Spine Research Group and
- 2Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; and
| | - Daniel M Sciubba
- 3Department of Neurological Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Reza Yassari
- 1Spine Research Group and
- 2Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; and
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Tetsuka S, Suzuki T, Ogawa T, Hashimoto R, Kato H. Spinal Epidural Abscess: A Review Highlighting Early Diagnosis and Management. JMA J 2019; 3:29-40. [PMID: 33324773 PMCID: PMC7733760 DOI: 10.31662/jmaj.2019-0038] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [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: 05/22/2019] [Accepted: 08/26/2019] [Indexed: 01/08/2023] Open
Abstract
Spinal epidural abscess (SEA) is still an uncommon but devastating infection of the spine. In recent years, a number of reported cases have risen. The most important prognostic factor for a favorable outcome is early diagnosis and appropriate treatment. However, a diagnosis of SEA is often delayed, particularly in the early stages of the disease before patients present with neurological symptoms. With enough knowledge of risk factors, clinical features, and appropriate diagnostic procedures, it may be possible to reduce diagnostic delay in the early stages of the disease. This review focuses on early diagnosis of SEA based on risk factors, presenting symptoms, and characteristic findings on magnetic resonance imaging (MRI), and also discusses the timing of surgical interventions. Traditionally, the symptoms of SEA are characterized by fever, back pain, and neurological symptoms, which are described as a classical triad of symptoms for this type of infection; but this collection of symptoms is seen in only about 10% of cases. However, most patients complain of severe localized lower back pain. Gadolinium-enhanced MRI is the most sensitive, specific, and beneficial imaging modality for establishing a diagnosis of SEA. Patients diagnosed prior to neurological deficits with a known causative microbial organism can be safely treated with antimicrobial therapy alone. However, about 30%–40% of the patients fail in conservative management without surgery. The best management and timing for surgical decompression in patients with or without mild neurological deficits should be established in the near future. Early diagnosis and management, before the occurrence of serious neurological symptoms, are the most important prognostic factors for good outcomes in patients with SEA. We proposed a simple algorithm for early diagnosis of SEA by selecting patients with severe back pain, leading to emergent MRI.
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Affiliation(s)
- Syuichi Tetsuka
- Department of Neurology, International University of Health and Welfare Hospital, Nasushiobara, Japan
| | - Tomohiro Suzuki
- Department of Neurology, International University of Health and Welfare Hospital, Nasushiobara, Japan
| | - Tomoko Ogawa
- Department of Neurology, International University of Health and Welfare Hospital, Nasushiobara, Japan
| | - Ritsuo Hashimoto
- Department of Neurology, International University of Health and Welfare Hospital, Nasushiobara, Japan
| | - Hiroyuki Kato
- Department of Neurology, International University of Health and Welfare Hospital, Nasushiobara, Japan
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Abstract
Spinal epidural abscesses (SEA), while fortunately rare, carry significant risk to affected patients. Optimal treatment of these infections is poorly defined due to the heterogeneity of clinical and radiographic presentations. Urgent surgical evacuation of the infection is critical in cases with spinal cord compression or neurological compromise, though challenges may arise from competing surgical objectives, including the need for successful debridement of the infection, desire to minimize operative intervention, and risk of delayed iatrogenic instability. This is particularly concerning in young children with large multiregional collections. We present the first report case of pediatric holocord abscess treated with apical laminotomies and epidural catheterization for irrigation and drainage. This technique allowed successful treatment while avoiding extensive laminectomies and associated morbidities.
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Affiliation(s)
- Elena Kurudza
- Department of Neurological Surgery, University of Wisconsin, Madison School of Medicine and Public Health, Madison, USA
| | - James A Stadler
- Department of Neurological Surgery, University of Wisconsin, Madison School of Medicine and Public Health, Madison, USA
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35
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Barner KL, Yuquimpo KM, McMillan DA, Shaw EM. A Unique Presentation of a Large, Seven-segment, Spinal Epidural Abscess in a Patient with a Pleural Empyema. Cureus 2019; 11:e4084. [PMID: 31019862 PMCID: PMC6467428 DOI: 10.7759/cureus.4084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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] [Indexed: 11/05/2022] Open
Abstract
Spinal epidural abscesses are insidious infections spread via hematologic, contiguous, or iatrogenic routes. On average, spinal epidural abscesses span two to four vertebral segments and are most commonly localized to the thoracic region. Fever, back pain, and neurological deficits are the most common clinical manifestations. However, the triad of these findings are not always detected. Patients may present with subtle symptoms leading to misdiagnosis and poor prognosis. We present a case of a large, anteriorly located, spinal epidural abscess in a patient originally admitted for dyspnea and confusion.
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Affiliation(s)
- Kyle L Barner
- Internal Medicine, Kansas City University of Medicine and Biosciences, Kansas City, USA
| | - Kyle M Yuquimpo
- Internal Medicine, Kansas City University of Medicine and Biosciences, Kansas City, USA
| | - David A McMillan
- Internal Medicine, Kansas City University of Medicine and Biosciences, Kansas City, USA
| | - Evan M Shaw
- Internal Medicine, University of Kansas Medical Center, Kansas City, USA
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36
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Yang X, Guo R, Lv X, Lai Q, Xie B, Jiang X, Dai M, Zhang B. Challenges in diagnosis of spinal epidural abscess: A case report. Medicine (Baltimore) 2019; 98:e14196. [PMID: 30702572 PMCID: PMC6380696 DOI: 10.1097/md.0000000000014196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 12/14/2018] [Accepted: 12/24/2018] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Spinal epidural abscess (SEA) is a rare condition that shows a high prevalence in immunocompromised patients. The clinical presentation of SEA includes the "classic triad" of pain, fever, and neurological dysfunction. However, these nonspecific features can lead to a high rate of misdiagnosis. SEA may lead to paralysis or even death; thus, prognosis of these patients remains unfavorable. PATIENT CONCERNS We report a case of a multilevel (T6-T12) SEA in a 22-year-old woman. DIAGNOSIS The patient was initially diagnosed with spinal tuberculosis at a local hospital based on a history of tuberculosis exposure, as well as radiography and computed tomography. Histopathological examination of the tissue resected during laminectomy confirmed the diagnosis of SEA in this patient. INTERVENTIONS The patient underwent multilevel laminectomy combined with long-term antibiotic therapy. OUTCOMES Physical examination performed 16 months postoperatively revealed that superficial and deep sensation was restored to normal levels in the lower extremities with improvement in the patient's motor function (muscle strength 2/5). LESSONS This case report indicates that whole spine magnetic resonance imaging is warranted in patients with SEA and that prompt surgical intervention is important at symptom onset. Long-term antibiotic therapy is also essential postoperatively.
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Affiliation(s)
| | | | - Xin Lv
- Department of Orthopedics
| | - Qi Lai
- Department of Orthopedics
| | | | - Xiaozhen Jiang
- Department of pathology, The First Affiliated Hospital of Nanchang University, No. 17 Yong Wai Zheng Street, Nanchang, Jiangxi, China
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Rosinsky P, Mandler S, Netzer N, Ady M, Elmaliache D, Sagiv S, Ben-Galim P. Antibiotic-Resistant Spondylodiscitis With Canal Invasion and Aggressive Evolution to Epidural Abscess: A Case Series of Spontaneous Occurrence in 16 Patients. Int J Spine Surg 2019; 12:743-750. [PMID: 30619679 DOI: 10.14444/5093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background The study aimed to assess the effectiveness of antibiotic treatment for spondylodiscitis, its failure rates, and the need for surgical intervention. Methods This is a retrospective study of patients who presented with spontaneous deep spinal infections and spondylodiscitis between 2011 and 2013. Clinical, bacteriologic, and radiographic data during hospitalization were analyzed. Results A total of 16 patients presented with deep spinal infections during the study period; 15 of them presented with spontaneous pyogenic spondylodiscitis, and 1 presented with epidural abscess. Median age was 68 years (range, 50-80 years), and 6 (38%) were healthy young laborers. None of the patients were immunocompromised. On admission all patients presented with pain, there was fever in 3 patients (19%), and there was elevated blood C-reactive protein, white blood cell count and erythrocyte sedimentation rate, with a mean of 147 ± 83.1 mg/L, 11.65 ± 5.6 × 103/μL, 93.6 ± 35.1 mm/h, respectively. A total of 15 patients (94%) developed infections that were refractory to appropriate culture-specific intravenous antibiotic treatment (mean, 10.2 days); 8 patients (50%) deteriorated neurologically and required wide surgical decompression. Complications included widespread epidural free gas in 2 patients (12%), multiple bilateral psoas abscesses in 2 patients (12%), kyphotic segmental instability in 4 patients (25%), and inferior vena cava septic thrombi in 1 patient (6%). A total of 3 patients (19%) died within 6 months; 7 of 13 surviving patients still had residual neurologic deficits at the 6-month follow-up. Conclusions Spondylodiscitis may be resistant to antibiotic treatment and may evolve into epidural abscess via extension of the infection and pus into the spinal canal, necessitating repetitive surgical treatment due to neurologic and clinical deterioration, and expansion of the persistent infection with a mass effect. Increased vigilance for this condition and its misleading initial presentations is warranted.
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Affiliation(s)
| | - Shay Mandler
- Department of Orthopaedic Surgery, Rehovot, Israel
| | - Niv Netzer
- Department of Orthopaedic Surgery, Rehovot, Israel
| | - Meital Ady
- Imaging, Kaplan Medical Center, Rehovot, Israel
| | | | - Shaul Sagiv
- Department of Orthopaedic Surgery, Rehovot, Israel
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Poredska K, Zbořil V, Prokopová L, Kučerová L, Dastych M, Richter S, Praksová P, Dolina J, Kunovský L. Spinal epidural abscess - a rare complication of Crohn´s disease: case report. Vnitr Lek 2019; 65:712-714. [PMID: 31906677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Spinal epidural abscess (SEA) is a rare disease that occurs mainly in immunocompromised patients after spinal surgery or spinal trauma and can lead to a severe neurological deficit or even death if diagnosed too late. However, cases of SEA have also been reported in patients with fistulising Crohn´s disease (CD). We present a case of a young patient with CD and a history of relapsing perianal disease followed by a complication of SEA in the thoracic spine. In close cooperation with the orthopedists and the neurologists, the gastroenterologists have successfully treated the SEA in this patient, allowing her to return back to biological treatment for CD.
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Abstract
RATIONALE Nocardial spinal epidural abscess is rare. The diagnosis is often difficult to make and, if delayed, poses a high risk of long-term disability. Nocardial spinal epidural abscess with severe lumbar disc herniation has not previously been reported. PATIENT CONCERNS A 50-year-old man presented with progressive lumbago and leg pain for 6 weeks after receiving acupuncture therapy, and then the patient suddenly occurred urine retention after walking. DIAGNOSES Clinical examination revealed sign of cauda equina syndrome. Magnetic resonance imaging (MRI) revealed a Lumbar(L)4 to L5 disc herniation, L3 to Sacrum(S)1 epidural abscess, and L2 to S1 paravertebral abscess. The causative organism was Nocardia farcinica. INTERVENTIONS An urgent paravertebral abscess debridement and right L4 to L5 laminectomy were performed. Simultaneously, the disc tissue protruding into the spinal canal was removed, as well as irrigation and drainage. And antimicrobial treatment was continued for 12 months. OUTCOMES Fortunately, the patient was able to walk with a cane and urinate autonomously without a catheter, although this remained difficult 7 days after surgery. After 1 year of treatment, the patient has recovered completely and returned to work. LESSONS Nocardial spinal epidural abscess with severe lumbar disc herniation is extremely rare. Pain from spinal degenerative diseases often masks the early symptoms of spinal infection. It's worth noting that invasive treatment of spine is a way of causing spinal nocardial infection.
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Affiliation(s)
- Fei Ma
- Department of Spine Surgery
| | | | | | | | | | | | - Yin Huan Ding
- Department of Medical laboratory, The Affiliated Hospital of Southwest Medical University, Luzhou City, China
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Stewart L, Sinha S, Madsen PJ, Glaser L, Chen HI, Culyba MJ. Spinal epidural abscess caused by Gardnerella vaginalis and Prevotella amnii. ACTA ACUST UNITED AC 2018; 26:237-9. [PMID: 30140147 DOI: 10.1097/IPC.0000000000000565] [Citation(s) in RCA: 5] [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] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We report a case of spinal epidural abscess (SEA) in a 58-year-old woman who had recently been diagnosed with gonococcal infection, but did not receive guideline-recommended therapy. She presented with back pain and signs and symptoms of pelvic inflammatory disease (PID). MRI of the spine demonstrated epidural abscess extending from L4-L5 to T10. She underwent T10-L1 and L3-L4 laminectomies for evacuation of the abscess and Gardnerella vaginalis and Prevotella amnii were isolated from the abscess fluid cultures. Our case demonstrates SEA as a rare, but morbid complication of PID and highlights the pathogenic potential of the anaerobic flora associated with PID.
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Abstract
Background Surgical site infections following spinal surgery, including spinal abscesses, are rare but serious as they are major causes of morbidity, and even mortality. They are, however, rarely attributed to infected, retained surgical cottonoids or sponges (textiloma or gossypiboma) inadvertently left in an operative field. Case Description A 53-year-old female with a history of two prior spinal operations at the L4-S1 levels (11 and 2 years previously) presented over a few weeks with the acute onset of a cauda equina syndrome (e.g., paraparesis and acute urinary incontinence). The patient demonstrated a mildly elevated white blood cell count (12,600/mm3) and abnormally increased C-reactive protein level that correlated with the magnetic resonance imaging that showed a dorsal epidural abscess extending from the L4 to S1 levels. At surgery, an encapsulated posterior epidural abscess was drained. Surgical findings included a granulomatous lesion consistent with a retained surgical cottonoid and was removed from the antero-inferior portion of the abscess wall at S1. Culture of the thick fibrotic abscess wall grew Klebsiella oxytoca. After 2 months of ciprofloxacin, the patient's infection cleared but the motor deficit only partially resolved. Conclusion Most spinal textilomas (gossypibomas) are aseptic and are found in paraspinal areas without neurological symptoms or sequelae. These lesions may remain silent for years and may only rarely cause neurologic or infectious symptoms/signs. Notably, textilomas following spinal surgery may be largely avoided if proper cottonoid and sponge counts are done prior to closing spinal wounds.
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Affiliation(s)
- Ali Akhaddar
- Department of Neurosurgery, Avicenne Military Hospital of Marrakech, Mohammed V University in Rabat, Rabat, Morocco
| | - Hassan Baallal
- Department of Neurosurgery, Avicenne Military Hospital of Marrakech, Mohammed V University in Rabat, Rabat, Morocco
| | - Abderrahim Elktaibi
- Department of Histopathology, Avicenne Military Hospital of Marrakech, Mohammed V University in Rabat, Rabat, Morocco
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Yang CS, Zhang LJ, Sun ZH, Yang L, Shi FD. Acute prevertebral abscess secondary to intradiscal oxygen-ozone chemonucleolysis for treatment of a cervical disc herniation. J Int Med Res 2018; 46:2461-2465. [PMID: 29584512 PMCID: PMC6023037 DOI: 10.1177/0300060518764186] [Citation(s) in RCA: 5] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective We herein present a case involving a prevertebral abscess complicated by a spinal epidural abscess (SEA) secondary to intradiscal oxygen–ozone chemonucleolysis for treatment of a cervical disc herniation. Methods A 67-year-old woman with a history of intradiscal oxygen–ozone chemonucleolysis developed numbness and weakness in her right upper and bilateral lower extremities followed by urinary retention. Her symptoms did not respond to intravenous antibiotics alone. Magnetic resonance imaging of the cervical region revealed an extensive SEA anterior to the spinal cord, spinal cord myelopathy due to anterior compression by the lesion, and a prevertebral abscess extending from C2 to T1. She underwent surgical drainage and irrigation. Results The patient was successfully treated with surgical drainage and systemic antibiotic therapy without kyphosis. Streptococcus intermedius was detected within the abscess. All clinical symptoms except for the sensory deficit in the left leg were relieved. Conclusions The safety of intradiscal oxygen–ozone therapy requires further assessment. High-dose intravenous antibiotics should be initiated empirically at the earliest possible stage of prevertebral and epidural abscesses. Surgical drainage may be a rational treatment choice for patients with a prevertebral abscess complicated by an SEA and spinal cord myelopathy.
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Affiliation(s)
- Chun-Sheng Yang
- 1 Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Lin-Jie Zhang
- 1 Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Zhi-Hua Sun
- 2 Department of Radiology, Tianjin Medical University General Hospital Tianjin, China
| | - Li Yang
- 1 Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Fu-Dong Shi
- 1 Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China.,3 Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
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Abstract
Edwardsiella tarda is commonly isolated from aquatic environments and a variety of animals. We present the first case of E. tarda bacteremia with psoas and epidural abscess. The patient was a 65-year-old woman with recurrent gastric cancer who had frequently consumed raw fish and grilled eel. She was successfully treated with antimicrobials and surgery. We also review reports published in English regarding E. tarda bacteremia in Japan and the experience at our hospital. On the basis of this review, we conclude that the major underlying disease leading to E. tarda bacteremia is malignancy and that the gastrointestinal tract is the most commonly affected organ. The overall mortality rate due to E. tarda bacteremia in our review was 38.1% (8/21). Although E. tarda bacteremia is rare, clinicians should be aware of this fatal food-borne infection.
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Affiliation(s)
- Kiyozumi Suzuki
- Division of General Medicine, Department of Internal Medicine, Nihon University School of Medicine, Japan
| | - Mitsuru Yanai
- Division of General Medicine, Department of Internal Medicine, Nihon University School of Medicine, Japan
| | - Yuta Hayashi
- Division of General Medicine, Department of Internal Medicine, Nihon University School of Medicine, Japan
| | - Hiromasa Otsuka
- Division of General Medicine, Department of Internal Medicine, Nihon University School of Medicine, Japan
| | - Kimitoshi Kato
- Division of General Medicine, Department of Internal Medicine, Nihon University School of Medicine, Japan
| | - Masayoshi Soma
- Division of General Medicine, Department of Internal Medicine, Nihon University School of Medicine, Japan
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Hanifah J, Joehaimey J, Yusof MI. A Good Short-term Outcome in Delayed Decompression of Cauda Equina Syndrome in Klebsiella pneumoniae Spinal Epidural Abscess: A Case Report. Malays Orthop J 2017; 11:85-88. [PMID: 29021888 PMCID: PMC5630060 DOI: 10.5704/moj.1707.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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] [Indexed: 11/05/2022] Open
Abstract
Spinal epidural abscess is a severe, generally pyogenic, infection of the epidural space of spinal cord or cauda equina. The swelling caused by the abscess leads to compression or vascular disruption of neurological structures that requires urgent surgical decompression to avoid significant permanent disability. We share a rare case of Klebsiella pneumoniae spinal epidural abscess secondary to haematogenous spread of previous lung infection that presented late at our centre with cauda equina syndrome that showed good short-term outcome in delayed decompression. A 50-year old female presented with one-week history of persistent low back pain with progressively worsening bilateral lower limb weakness for seven days and urinary retention associated with saddle anesthesia of 2-day duration. Magnetic resonance imaging with contrast of the lumbo-sacral region showed an intramuscular collection of abscess at left gluteus maximus and left multifidus muscle with a L3-L5 posteriorly placed extradural lesion enhancing peripherally on contrast, suggestive of epidural abscess that compressed the cauda equina. The pus was drained using the posterior lumbar approach. Tissue and pus culture revealed Klebsiella pneumoniae, suggestive of bacterial infection. The patient made immediate improvement of muscle power over bilateral lower limbs postoperative followed by ability to control micturition and defecation the 4th post-operative day. A good short-term outcome in delayed decompression of cauda equine syndrome is extremely rare. Aggressive surgical decompression combined with antibiotic therapy led to good short-term outcome in this patient despite delayed decompression of more than 48 hours.
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Affiliation(s)
- J Hanifah
- Department of Orthopaedics, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - J Joehaimey
- Department of Orthopaedics, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - M I Yusof
- Department of Orthopaedics, Universiti Sains Malaysia, Kubang Kerian, Malaysia
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Crum-Cianflone NF, Lam PV, Ross-Walker S, Rosen LB, Holland SM. Autoantibodies to Granulocyte-Macrophage Colony-Stimulating Factor Associated With Severe and Unusual Manifestations of Cryptococcus gattii Infections. Open Forum Infect Dis 2017; 4:ofx211. [PMID: 29181420 PMCID: PMC5695620 DOI: 10.1093/ofid/ofx211] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [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: 06/19/2017] [Accepted: 09/26/2017] [Indexed: 12/18/2022] Open
Abstract
Cryptococcus gattii infections, especially including those with severe clinical manifestations, may be related to underlying host immunologic factors. We present 2 cases with autoantibodies to granulocyte-macrophage colony-stimulating factor (GM-CSF), a key cytokine in macrophage function. Immunologic evaluation for anti-GM-CSF antibodies may be important to inform management and counseling.
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Affiliation(s)
- Nancy F Crum-Cianflone
- Internal Medicine Department.,Infectious Disease Division.,Infectious Disease Division, Naval Medical Center San Diego, San Diego, California
| | | | | | - Lindsey B Rosen
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Steven M Holland
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
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46
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Khursheed N, Dar S, Ramzan A, Fomda B, Humam N, Abrar W, Singh S, Sajad A, Mahek M, Yawar S. Spinal epidural abscess: Report on 27 cases. Surg Neurol Int 2017; 8:240. [PMID: 29026676 PMCID: PMC5629861 DOI: 10.4103/sni.sni_105_17] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [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: 03/15/2017] [Accepted: 07/26/2017] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Spinal epidural abscess, although an uncommon disease, often correlates with a high morbidity owing to significant delay in diagnosis. METHODS In a prospective 5-year study, the clinical and magnetic resonance (MR) findings, treatment protocols, microbiology, and neurological outcomes were analyzed for 27 patients with spinal epidural abscess. RESULTS Patients were typically middle-aged with underlying diabetes and presented with lumbar abscesses. Those undergoing surgical intervention >36 h after the onset of symptoms had poor neurological outcomes. CONCLUSION Early recognition and timely evacuation of spinal abscesses minimized neurological morbidity and potential mortality.
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Affiliation(s)
- Nayil Khursheed
- Department of Neurosurgery, Sheri-Kashmir-Institute of Medical Sciences, Kashmir, India
| | - Sultan Dar
- Department of Neurosurgery, Sheri-Kashmir-Institute of Medical Sciences, Kashmir, India
| | - Altaf Ramzan
- Department of Neurosurgery, Sheri-Kashmir-Institute of Medical Sciences, Kashmir, India
| | - Bashir Fomda
- Department of Microbiology, Sheri-Kashmir-Institute of Medical Sciences, Kashmir, India
| | - Nisar Humam
- Department of Neurosurgery, Sheri-Kashmir-Institute of Medical Sciences, Kashmir, India
| | - Wani Abrar
- Department of Neurosurgery, Sheri-Kashmir-Institute of Medical Sciences, Kashmir, India
| | - Sarbjit Singh
- Department of Neurosurgery, Sheri-Kashmir-Institute of Medical Sciences, Kashmir, India
| | - Arif Sajad
- Department of Neurosurgery, Sheri-Kashmir-Institute of Medical Sciences, Kashmir, India
| | - Masood Mahek
- Department of Neurosurgery, Sheri-Kashmir-Institute of Medical Sciences, Kashmir, India
| | - Shoaib Yawar
- Department of Neurosurgery, Sheri-Kashmir-Institute of Medical Sciences, Kashmir, India
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Abstract
OBJECTIVE Spinal epidural abscesses (SEAs) can be difficult to diagnose and may result in neurological compromise or even death. Delays in diagnosis or treatment may worsen the prognosis. While SEA presents a high risk for litigation, little is known about the medicolegal ramifications of this condition. An enhanced understanding of potential legal implications is important for practicing spine surgeons, emergency medicine physicians, and internists. METHODS The VerdictSearch database, a large legal-claims database, was queried for "epidural abscess"-related legal cases. Demographic and clinical data were examined for all claims; any irrelevant cases or cases with incomplete information were excluded. The effects of age of the plaintiff, sex of the plaintiff, presence of a known infection, resulting paraplegia or quadriplegia, delay in diagnosis, and delay in treatment on the proportion of plaintiff rulings and size of payments were assessed. RESULTS In total, 56 cases met the inclusion criteria. Of the 56 cases, 17 (30.4%) were settled, 22 (39.3%) resulted in a defendant ruling, and 17 (30.4%) resulted in a plaintiff ruling. The mean award for plaintiff rulings was $5,277,468 ± $6,348,462 (range $185,000-$19,792,000), which was significantly larger than the mean award for cases that were settled out of court, $1,914,265 ± $1,313,322 (range $100,000-$4,500,000) (p < 0.05). The mean age of the plaintiffs was 47.0 ± 14.4 years; 23 (41.1%) of the plaintiffs were female and 33 (58.9%) were male. The proportion of plaintiff verdicts and size of monetary awards were not affected by age or sex (p > 0.49). The presence of a previously known infection was also not associated with the proportion of plaintiff verdicts or indemnity payments (p > 0.29). In contrast, juries were more likely to rule in favor of plaintiffs who became paraplegic or quadriplegic (p = 0.03) compared with plaintiffs who suffered pain or isolated weakness. Monetary awards for paraplegic or quadriplegic patients were also significantly higher (p = 0.003). Plaintiffs were more likely to win if there was a delay in diagnosis (p = 0.04) or delay in treatment (p = 0.006), although there was no difference in monetary awards (p > 0.57). Internists were the most commonly sued physician (named in 13 suits [23.2%]), followed by emergency medicine physicians (named in 8 [14.3%]), and orthopedic surgeons (named in 3 [5.4%]). CONCLUSIONS This investigation is the largest examination of legal claims due to spinal epidural abscess to date. The proportion of plaintiff verdicts was significantly higher in cases in which the patient became paraplegic or quadriplegic and in cases in which there was delay in diagnosis or treatment. Additionally, paralysis is linked to large sums awarded to the plaintiff. Nonsurgeon physicians, who are often responsible for initial diagnosis, were more likely to be sued than were surgeons.
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Affiliation(s)
- J Mason DePasse
- Division of Spine Surgery, Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Roy Ruttiman
- Division of Spine Surgery, Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Adam E M Eltorai
- Division of Spine Surgery, Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Mark A Palumbo
- Division of Spine Surgery, Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Alan H Daniels
- Division of Spine Surgery, Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Abstract
RATIONALE Ingestion of a fishbone is a common cause of esophageal injury, but spinal epidural abscess (SEA) is a rare condition due to the esophageal penetration by a swallowed fishbone. Prompt diagnosis can be seldom made owing to incomplete patient history taking and difficulties in imaging evidence identification. PATIENT CONCERNS We describe the case of a 62-year-old woman who was stuck in her throat by a fishbone, and complained of back pain, paresis of the lower limbs and fever, successively. To our knowledge, this is the first case report that we know of thoracic SEA caused by fishbone perforation. DIAGNOSES About 20 days after the onset of severe back pain, she was diagnosed with SEA based on the clinical presentation and imaging findings. INTERVENTIONS Antibiotic therapy and rehabilitation therapy were carried out afterwards. However, due to exacerbation of her condition, surgical intervention had to be taken eventually. OUTCOMES It is quite unfortunate for this patient to have a poor prognosis due to a delayed diagnosis and an improper management. LESSONS A number of lessons can be learnt from this case.
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Oh GS, Abou-Al-Shaar H, Arnone GD, Barks AL, Hage ZA, Neckrysh S. Spinal epidural abscess in a patient with piriformis pyomyositis. Surg Neurol Int 2016; 7:S911-S913. [PMID: 28028447 PMCID: PMC5159689 DOI: 10.4103/2152-7806.194518] [Citation(s) in RCA: 4] [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: 01/16/2016] [Accepted: 07/23/2016] [Indexed: 11/26/2022] Open
Abstract
Background: Spinal epidural abscess resulting from piriformis pyomyositis is extremely rare. Such condition can result in serious morbidity and mortality if not addressed in a timely manner. Case Description: The authors describe the case of a 19-year-old male presenting with a 2-week history of fever, low back pain, and nuchal rigidity. When found to have radiographic evidence of a right piriformis pyomyositis, he was transferred to our institution for further evaluation. Because he demonstrated rapid deterioration, cervical, thoracic, and lumbar magnetic resonance imaging scans were emergently performed. They revealed an extensive posterior spinal epidural abscess causing symptomatic spinal cord compression extending from C2 to the sacrum. He underwent emergent decompression and abscess evacuation through a dorsal midline approach. Postoperatively, he markedly improved. Upon discharge, the patient regained 5/5 strength in both upper and lower extremities. Cultures from the epidural abscess grew methicillin-sensitive Staphylococcus aureus warranting a 6-week course of intravenous nafcillin. Conclusion: A 19-year-old male presented with a holospinal epidural abscess (C2 to sacrum) originating from piriformis pyomyositis. The multilevel cord abscess was emergently decompressed, leading to a marked restoration of neurological function.
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Affiliation(s)
- Gerald S Oh
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Gregory D Arnone
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Ashley L Barks
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Ziad A Hage
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Sergey Neckrysh
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
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Andrés-Cano P, Vela T, Cano C, García G, Vera JC, Andrés-García JA. Cervical Spondylodiscitis After Oxygen-Ozone Therapy for Treatment of a Cervical Disc Herniation: a Case Report and Review of the Literature. HSS J 2016; 12:278-283. [PMID: 27703423 PMCID: PMC5026656 DOI: 10.1007/s11420-016-9500-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 03/02/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Pablo Andrés-Cano
- Orthopaedic Surgery and Traumatology Department, Hospital Universitario Virgen del Rocío, Av. Manuel Siurot, s/n, 41013 Sevilla, Spain
| | - Tomás Vela
- Orthopaedic Surgery and Traumatology Department, Hospital Universitario Puerta del Mar, Cádiz, Cádiz Spain
| | - Claudio Cano
- Orthopaedic Surgery and Traumatology Department, Hospital Universitario Puerta del Mar, Cádiz, Cádiz Spain
| | - Gaspar García
- Orthopaedic Surgery and Traumatology Department, Hospital Universitario Puerta del Mar, Cádiz, Cádiz Spain
| | - Juan Carlos Vera
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM USA
| | - Jose Antonio Andrés-García
- Orthopaedic Surgery and Traumatology Department, Hospital Universitario Puerta del Mar, Cádiz, Cádiz Spain
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