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The history of a patient with neurological deficit symptoms secondary to a spinal epidural abscess connected with psoas abscess and several fistulas on the buttocks is described. Etiology, diagnosis, and treatment are discussed. Percutaneous drainage of the spinal epidural abscess is suggested as an alternative to surgery.
Spinal epidural abscess (SEA) is a rare condition; consequently, the clinical significance of early diagnosis often is overlooked. The challenge with SEA is not its treatment, but achieving early diagnosis before neurological symptoms occur. Once neurological deficits are present, immediate treatment must be implemented to prevent deterioration that can result in paralysis. The common SEA signs and symptoms are fever, back pain, and radicular symptoms that can progress to weakness and paralysis. Magnetic resonance imaging is the imaging of choice for diagnosis. Treatments include antibiotics and surgical evacuation of the abscess if neurologic deficits are present. Nurses play a major role in caring for SEA patients by identifying those at risk, preventing complications, and collaborating with a multidisciplinary team to prepare patients for rehabilitation.
We describe a diabetic woman with an epidural abscess and associated bilateral psoas abscesses which simulated the clinical course of diabetic bilateral proximal plexopathy. We emphasize three aspects: 1) the rarity of associated epidural abscess and bilateral psoas abscesses, 2) the rarity of the germ isolated (Streptococcus bovis), and 3) the diagnostic difficulties when both processes are associated, particularly in patients with an underlying disease that may simulate other common, clinical pictures.
Two cases of epidural abscess as a complication of frontal sinusitis are presented. The diagnoses were suspected on the basis of history and were confirmed by magnetic resonance imaging and computed tomography. Both patients were treated successfully by means of surgery and intravenous antibiotics. One patient developed meningitis in the postoperative course and was treated by changing the antibiotic regimen. However, further follow-up in the outpatient clinic by physical examinations and brain computed tomography scans showed no longterm neurologic complications in either case. Intracranial suppuration, including epidural abscesses, can complicate acute and chronic frontal sinusitis. These complications are diagnosed by maintaining a high index of suspicion and using the appropriate neuroimaging studies without delay.
Acute spinal epidural abscess is found to be relatively rare and may be getting rarer since antibiotics have been widely used. An early diagnosis and prompt surgical treatment are still important to prevent severe neurological deficit such as paraplegia. A characteristic case is presented. Eighteen years old boy showed acute progression of paraplegia and rectourinary difficulty with complete spinal block at T 6-7 intervertebral space on myelography, who had suffered from multiple infectious lacerations on his face and hands two months previously. There was complete recovery of neurological signs following removal of epidural abscess with granulation tissue and spinal decompression by lamineotomy through T 5-7, and supplimentary antibiotic therapy for the organism (Staphylococcus aureus). To our knowlodge, this will be the first case report in this country, which has been obtained successful recovery after surgical treatment in such an acute case.
We present a 71-year-old male in whom an epidural abscess developed within a short temporal interval after an epidural anesthetic. Due to different locations of the abscess and the site of the epidural puncture, the diagnosis was quite problematic. The initial symptoms consisted of pain in the shoulder-neck region, elevated temperature, and leucocytosis 1 week after the puncture was performed. The further course presented a picture of high spinal paralysis with respiratory insufficiency and massive cardiovascular problems. Magnetic resonance imaging of the cervical spine confirmed the suspected diagnosis of an epidural abscess (Fig. 1). Due to the reduced general condition of the patient, an operation was initially not possible. After the patient's condition had stabilized under antibiotic therapy with penicillin G, vancomycin, and gentamycin, exploration of the abscess area was performed. Histologic studies showed granulomatous tissue resulting from the previous inflammation. During the subsequent course of the disease, the clinical symptoms did not regress significantly. The patient required prolonged mechanical ventilation and died of recurrent bronchopulmonary infections after 5 months of intensive care treatment. The probable pathogenesis of the abscess as well as the diagnostic and therapeutic aspects are discussed in summary.
We report the cases of two patients with the very uncommon clinical finding of two noncontiguous spinal epidural abscesses, which were located in the cervical and lumbar spine. In each case the diagnosis of the second spinal abscess was made by MRI only after the appearance of a new neurological deficit. Decompressive spinal surgery and intravenous antibiotic therapy led to complete recovery in one patient; the other patient was moderately disabled. As epidural spinal abscesses can occur at noncontiguous sites, MRI of the entire spine may be necessary in selected cases.
A 59-year-old man with a history of diabetes mellitus (NIDDM) presented with fever, back pain and weakness in the left lower limb. Three weeks later he suddenly developed flaccid paraklegia, a sensory deficit below the abdomen and sphincter dysfunction. MR images of the spinal cord showed an extensive anterior spinal epidural abscess extending from the seventh cervical to the twelfth thoracic spine and osteomyelitis in the lower thoracic spines. He died of pulmonary infection one year after the disease onset. Postmortem examination revealed a large empyema in the lung. On neuropathological examination, small multiple hemorrhagic or ischemic lesions were found in the basal ganglia and the pons. The spinal cord was markedly atrophic in the lumbar cord. However, there was neither compression deformity in the cord nor occlusion in the anterior spinal artery. Throughout the thoracic cord, rarefaction and focal cavity formation was selectively present in the gray matter, particularly the posterior horns. In the white matter, vacuolar changes were seen peripherally as well as Wallerian degeneration in the lateral and anterior corticospiral tracts and in the fascicles gracilis bilaterally. The mechanisms inducing the cord damage in cases of epidural spinal abscess have been speculated to be either direct compression by the abscess or the secondary circulatory disturbance in the cord due to compression. In our case, the cord showed necrotizing poliomyelopathy, which was similar to that of ischemic myelopathy found in the cases of cardiac arrest or dissecting aneurysm of the aorta. Autopsy study of spinal cord lesion associated with epidural abscess has been limited in number and our case should contribute to the understanding of the pathomechanism of such myelopathy.
Progressive symptoms of caudal compression (flaccid paraparesis, sensory disorders), accompanied by severe pain and fever, developed over a few days in a 26-year-old man with Crohn's disease for 11 years. Spinal computed tomography, performed under the diagnosis of herniated disc, revealed intraspinal soft tissue, as well as gas in the spinal canal (L2-S3) and the paravertebral muscles. This led to the diagnosis of acute epidural abscess and a laminectomy was performed (at L4-S2). Intraspinally there was thickened, bluish fatty tissue; thick pus exuded between dura and the sacral roots. Suction-irrigation of the spinal canal was undertaken via an epidural drain. Postoperative contrast infusion into the colon demonstrated a fistula directed towards the sacrum. The postoperative course was complicated by severe respiratory impairment of which the patient died.--Epidural abscess is a rare complication of Crohn's disease. Because of its poor prognosis early diagnosis with magnetic resonance imaging or computed tomography should be undertaken in every patient with Crohn's disease who has back pain, fever or, particularly, symptoms of spinal compression.
Symptoms clinical course, and also statistical data are recroded for a 60-year-old man with a chronic epidural abscess in the lumbar vertebrae 3/4 following a lumbar puncture. Acute and chronic epidural intraspinal abscesses are discussed in relation to the relevant literature.
The case of a 72-year-old woman suffering from chronic otitis media is presented. This insulin dependent diabetic patient was under steroid therapy for collagenosis and suffered from chronic polysinusitis. After two preceding drainages of the mastoid (antrotomy and mastoidectomy), the patient developed putrid mastoiditis followed by Bezold's abscess, an epidural abscess and thrombosis of the sigmoid sinus. Lateral petrosectomy and drainage of the neck were performed, but the patient again developed an abscess with extension to the lateral skull base, the foramen magnum and the upper cervical spine. After a further operation with extensive drainage and a three-month course of antibiotic treatment with ceftriaxon, the infection finally healed. A germ of the Streptococcus milleri group was identified.
A 10-year-old girl presented with a very rare paraspinal and spinal epidural abscess manifesting as fever, and neck pain and stiffness. Initially, she was treated under a diagnosis of meningitis for 3 weeks. However, she developed monoparesis of the right upper extremity, and was referred for neurosurgery. Magnetic resonance imaging revealed an epidural and paraspinal lesion intensely enhanced by gadolinium. The patient underwent urgent surgery for C2-3 laminectomy and abscess drainage, followed by broad spectrum antibiotic therapy. She was discharged and followed up in the outpatient clinic. Two months later, the paraspinal abscess recurred with great increase in size. A second operation was performed and 150 ml pus was drained. Streptococcus anginosus was grown in the culture. The patient fully recovered after long-term targeted antibiotic therapy. Such abscesses are very rare in children, especially in the cervical region. The correct diagnosis can be difficult to establish but early treatment is essential for a good prognosis.
We present four cases of iatrogenic epidural spinal abscess directly caused by externally introduced catheters or probes. In two patients the infection spread per continuum, in the other two patients due to haematogenous dissemination. Clinical presentation in each case included generalized malaise with fever, signs of meningeal inflammation and focal neurological signs at the spinal level. The diagnosis was made on the basis of inflammatory changes in the cerebral spinal fluid and localization of the abscess by means of computer and magnetic resonance tomography. A broad-spectrum antibiotic regimen included a penicillinase-resistant preparation because of the frequent involvement of Staphylococcus aureus. It is our experience that a good outcome is dependent on early and specific treatment.
STUDY DESIGN: Mainly a retrospective study of 101 cases of pyogenic spinal infection, excluding postoperative infections. Data were obtained through medical record review, imaging examination, and patient follow-up evaluation. SUMMARY OF BACKGROUND DATA: Hematogenous pyogenic spinal infection has been described variously as spondylodiscitis, discitis, vertebral osteomyelitis, and epidural abscess. Recommended treatment options have included conservative methods (antibiotics and bracing) and surgical intervention. However, a comprehensive classification that would aid in diagnosis, treatment planning, and prognosis has not yet been devised. OBJECTIVES: To analyze the bacteriology, pathologic entities, complications, and results of treatment options for pyogenic spinal infection. METHOD: All patients received plain radiographs, gadolinium-enhanced magnetic resonance imaging scans, and bone/gallium radionuclide studies. All patients had tissue biopsies. Bacteriology, hematology, and predisposing factors were analyzed. All patients received intravenous and oral antibiotics. A total of 58 patients underwent surgery. Patient outcomes were correlated with clinical status, with treatment method and, where applicable, with location and nature of epidural compression. Statistical analyses were performed. RESULTS: Spondylodiscitis occurred most commonly with primary epidural abscess, spondylitis, discitis, and pyogenic facet arthropathy, all occurring rarely. Staphylococcus aureus was the main organism. Infection elsewhere was the most common predisposing factor. Leukocyte counts were elevated in 42.6% of spondylodiscitis cases. The erythrocyte sedimentation rate was elevated in all cases of epidural abscess. There were 35 cases of epidural abscess (frank abscess, 29; granulation tissue, 6). Epidural abscess complicating spondylodiscitis occurred most often in the cervical spine, followed by thoracic and lumbar areas. The rate of paraplegia or paraparesis also was highest in cervical and thoracic regions. There were no cases of quadriplegia. All patients with either epidural granulation tissue or paraparesis recovered completely after surgical decompression. Only 18% of patients with frank epidural abscess and 23% of patients with paralysis recovered completely after surgical decompression. Patients with spondylodiscitis who were treated nonsurgically reported residual back pain more often (64%) than patients treated surgically (26.3%). CONCLUSIONS: Pyogenic spinal infection can be thought of as a spectrum of disease comprising spondylitis, discitis, spondylodiscitis, pyogenic facet arthropathy, and epidural abscess. Spondylodiscitis is more prone to develop epidural abscesses in the cervical spine (90%) than the thoracic (33.3%) or lumbar (23.6%) areas. Thecal sac neurocompression has a greater chance of causing neurologic deficit in the thoracic spine (81.8%). Treatment of neurologic deficit caused by epidural abscess is prompt surgical decompression, with or without fusion. Patients with frank abscess had less favorable outcomes than those with granulation tissue, and paraplegia responded to treatment more poorly than paraparesis. Surgery was preferable to nonsurgical treatment for improving back pain.
OBJECTIVES: To study imaging changes associated with spinal tuberculosis (ST) over time and evaluate their association with clinical and laboratory data. METHODS: Between 1997 and 2004, patients with proven ST in our institution were prospectively enrolled and treated for 1 year. Clinical and laboratory data were collected at baseline and every 3 months. Computed tomography (CT) and magnetic resonance imaging (MRI) were performed at baseline. MRI was performed at least twice during treatment and at the end of treatment. RESULTS: Nineteen patients were enrolled; neurological signs were present at baseline in 14 patients (74%). Initial MRI/CT findings comprised (in percentages of patients) the following: paravertebral abscesses (100/100); intradiscal abscesses (47/0); and epidural abscesses (82/24) with spinal cord compression (64/18) or radicular compression (36/0). Edema of the vertebral body was observed on initial MRI in all the patients. Full follow-up data were available for 15 patients: all were cured with a mean follow-up of 25 months after the end of treatment. Weight gain was nearly maximal at 6 months, and pain relief was achieved within 9 months. C-reactive protein returned to normal after 3 months. On MRI, all epidural abscesses disappeared within 9 months; paravertebral abscesses disappeared after 3, 6, and 12 months in 45, 50, and 85% of patients, respectively. Vertebral body signal converted to a fatty signal in 75% of cases at 12 months. CONCLUSIONS: Significant imaging abnormalities can persist after successful treatment of ST. These findings suggest that MRI need not be repeated in patients with clinical and laboratory improvement.
BACKGROUND AND PURPOSE: Spinal epidural abscesses are major complications of epidural anesthesia, and their MR features have been reported. In patients receiving continuous infusion via an epidural catheter, MR findings may mimic those of spinal epidural abscess in the absence of infection. The purpose of this study was to assess the spinal MR findings associated with continuous epidural anesthesia. METHODS: Spinal MR findings in five consecutive patients receiving continuous epidural anesthesia were retrospectively evaluated. Axial and sagittal T1- and T2-weighted spin-echo and contrast-enhanced fat-suppressed T1-weighted spin-echo images were obtained. Infection was ruled out on microbiologic analysis three patients and on follow-up in two. Each lesion was evaluated for its MR signal intensity, location, extent, delineation, and enhancement pattern. In three patients, follow-up MR imaging was performed within 5-150 days, and the images were compared. RESULTS: Posterior epidural lesions were identified in all five patients. The lesions were isointense to hypointense relative to the spinal cord on T1-weighted images, isointense relative to CSF on T2-weighted images, and well enhanced on enhanced T1-weighted images. The anomalous enhancement involved two to seven vertebral bodies. In one patient, the enhanced lesion slightly compressed the spinal cord. On follow-up MR imaging, the epidural lesions decreased in two patients and did not change in one. CONCLUSION: Continuous epidural anesthesia can result in MR findings similar to those of epidural abscess, even in the absence of infection.
Interbody fusion for stabilization of the cervical spine after osteomyelitic destruction of the body of C5 vertebra is reported in a patient with quadriplegia and sphincter disturbances secondary to an epidural abscess. The successful union of the bone graft along with complete neurological recovery after anterior decompression and evacuation of the epidural mass seem to justify the procedure.
STUDY DESIGN: Retrospective. OBJECTIVES: To determine the incidence, clinical presentation, diagnostic laboratory values, imaging characteristics, and optimal treatment of hematogenous pyogenic facet joint infections. SUMMARY OF BACKGROUND DATA: There are 27 documented cases of hematogenous pyogenic facet joint infections. Data regarding incidence, clinical presentation, diagnosis, and treatment response are incomplete because of the paucity of reported cases. METHODS: This is a retrospective study of all cases of hematogenous pyogenic facet joint infection treated at one institution. Data from previous publications were combined with the present series to identify pertinent clinical characteristics and response to treatment. RESULTS: A total of six cases (4%) of hematogenous pyogenic facet joint infection were identified of 140 cases of hematogenous pyogenic spinal infection at our institution. Combining all reported cases reveals the following: The average patient age is 55 years. Ninety-seven percent of cases occur in the lumbar spine. Epidural abscess formation complicates 25% of the cases of which 38% develop severe neurologic deficit. Erythrocyte sedimentation rate and C-reactive protein are elevated in all cases. Staphylococcus aureus is the most common infecting organism. Magnetic resonance imaging is accurate in identifying the septic joint and associated abscess formation. Percutaneous drainage of the involved joint has a higher rate of success (85%) than treatment with antibiotics alone (71%), but the difference is not significant (P = 0.37). CONCLUSIONS: Hematogenous pyogenic facet joint infection is a rare but underdiagnosed clinical entity. Facet joint infections may be complicated by abscess formation in the epidural space or in the paraspinal muscles. Uncomplicated cases treated with percutaneous drainage and antibiotics may fare better than those treated with antibiotics alone. Cases complicated by an epidural abscess and severe neurologic deficit should undergo immediate decompressive laminectomy.