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PubMed1991

Paul Broca and the first craniotomy based on cerebral localization.

Paul Broca (1824-1880) was a well-known French surgeon-anthropologist-neurologist. Best known for his work on cerebral cortical localization and speech mechanisms, Broca also carefully worked out skull and scalp localization for underlying cortical regions. In 1871, Broca treated a man who had sustained a scalp laceration from a blow to the head without loss of consciousness or skull fracture. The patient exhibited a nonfluent aphasia about 1 month after injury and became progressively obtunded and eventually comatose. Suspecting an intracranial abscess, Broca trephined at the region of the left third frontal convolution and drained an epidural abscess. The patient improved transiently but died a few days later. Autopsy showed a left-sided, predominantly frontal purulent meningoencephalitis. Broca's other neurosurgical contributions included various surgical cases, methods for scalp localization of the cerebral convolutions, extensive studies of skull and brain abnormalities, thermoencephalography, and the stimulation of younger surgical colleagues and neurologists to make practical use of cerebral localization.

Abscess↗
PubMed1999

A case of cervical Brucella spondylitis with paravertebral abscess and neurological deficits.

Spondylitis is one of the more frequent osteoarticular complications of Brucella infection, but cervical spine involvement is rare. We report here a case of cervical Brucella spondylitis with paravertebral anterior epidural abscess which resulted in neurological deficits. The diagnosis is based on clinical history supported by Brucella serology, radiological findings and histological evidence.

Abscess↗
PubMed1983

Masked mastoiditis.

With the advent of broad-spectrum antibiotics, the clinical course of middle ear disease has been altered. One result has been the occasional suppression of the presenting signs and symptoms of mastoiditis secondary to acute middle ear disease, causing the clinician to have a false sense of security following apparent resolution of the middle ear infection. The course may be so insidious that the first awareness of the mastoiditis may be following presentation of an intracranial complication such as meningitis, lateral sinus thrombosis, or brain abscess. The authors report 9 patients seen in the past 5 years with masked mastoiditis, ranging in age from 4 months to 43 years. The presenting symptoms were all vague and non-classical; however, intracranial complications of meningitis, facial paralysis, brain abscess, and papilledema were present on admission in 7 patients, and another 2 patients had unsuspected epidural abscess upon surgical exploration. The mastoid radiographs were uniformly positive, while the CT scan was positive in 3/9 patients. All patients recovered following mastoidectomy and intracranial therapy except one patient who expired after brain herniation. The clinician is urged to maintain a high suspicion of masked mastoiditis in the high-risk patient, including newborn, diabetic, elderly, immunosuppressed or debilitated patients.

Adolescent↗
PubMed1999

Brucella disc infection mimicking lumbar disc herniation: a case report.

Brucellosis is a zoonotic disease and still a major health problem in many geographical areas. In this paper a forty year-old woman with spinal brucellosis associated with epidural abscess formation and mimicking lumbar disc herniation is presented. Compression of spinal nerve root(s) by epidural masses due to brucella disc infection is a rare condition and should be kept in mind in differential diagnosis of lumbar disc herniation. The crucial role of magnetic resonance imaging in differential diagnosis is also emphasised.

Adult↗
PubMed1995

[Spinal epidural empyemas].

We report ten patients harbouring spinal epidural abscess, aiming to evaluate the factors that may lead to an early diagnosis and that can eventually influence the prognosis. There were seven males and 3 females, with ages comprised between 17 and 66 years. Abscesses were localised mainly in the dorsal region. The most important predisposing factors were infections or other disorders know to be related with compromise of the immunological system. Back pain with or without signs of spinal cord involvement was the most frequent clinical presentation. The pretreatment average time was 16,3 days. Staphylococcus aureus was the most commun organism isolated. Erythrocyte sedimentation rate (ERS) was uniformly elevated, being the most important laboratory data for the diagnosis of this situation. Diagnosis was frequently made on clinical grounds but it was always confirmed by myelography with computed tomography or magnetic resonance. All patients were submitted to surgical drainage. Two patients recovered totally, 5 partially, 2 did not recover at all and 1 died. We conclude that the prognosis is related to the surgical delay and that it depends on the identification of the predisposing factors and the recognition of a clinical picture of spinal cord involvement associated to an elevated ESR. Magnetic resonance is the most reliable imaging technique.

Abscess↗
PubMedDate not supplied

Complications associated with epidural steroid injections.

BACKGROUND AND OBJECTIVES: Warnings about the hazards of epidural steroid injections occasionally appear in both medical and lay literature despite a lack of objective data to support such concerns. This literature review was undertaken to survey reports of adverse reactions associated with that procedure. METHODS: The following types of publications from peer-reviewed medical literature was surveyed: reports on series of epidural and subarachnoid steroid injections for sciatica; reports of adverse effects of epidural and subarachnoid steroid injections for sciatica; review articles on epidural and subarachnoid steroid injections; and studies of the behavioral and histologic effects of epidural steroids and their vehicle in animals. RESULTS: Several cases of aseptic meningitis, arachnoiditis, and bacterial meningitis and one case of conus medullaris syndrome have been reported after subarachnoid steroid injections. Most of these complications occurred after multiple subarachnoid injections. Two cases of epidural abscess, one case of bacterial meningitis, and one case of aseptic meningitis have been reported following epidural steroid injections. Subarachnoid drug placement could not be ruled out in the meningitis cases. CONCLUSIONS: There are few published reports of serious complications following epidural steroid injections. There are a few published reports of complications following subarachnoid steroid injections, most of which were associated with multiple injections over a prolonged time period.

Animals↗
PubMed1984

Intracranial complications of frontal sinusitis. A report of two cases.

Two cases are reported of intracranial complications of sinusitis, unusual nowadays. They were caused by osteomyelitis of the frontal bone following chronic frontal sinusitis. These cases were distinguished by complete destruction of the posterior wall of the sinus involved: in one of the cases there was an acute central neurological disturbance caused by a cerebral abscess; in the other patient, who came for consultation because of a Pott's Puffy tumour, a sizeable epidural abscess was found.

Adult↗
PubMed2004

[Brain abscess secondary to rhinosinusitis. Therapeutical modalities. Exposition of one case].

Brain abscess (BA) as complication of sinusitis represent around 3% of the cases. Other suppurative intracraneal complications such as epidural abscess, subdural empyema and meningitis are more common than BA. The frontal and ethmoid sinuses form an integral part of anterior and to a lesser extent middle skull base to which the dura is intimately related. Thrombophlebitis of veins associated with paranasal sinuses is considered to be the main route of intracraneal spread of infection. However, osteitis is an uncommon mechanism that typically involves frontal sinus. Chronic sinusitis more than fulminant course of acute sinusitis is often responsible for BA. Epidemiology of BA has changed with the increasing incidence of this infection in inmunocompromised patient and the decreasing incidence related to sinus infection. Mortality rate of BA were around 35-55% before CT scan era and with surgical excision as the rule of surgical treatment.

Anti-Bacterial Agents↗
PubMed2004

Thoracic intradural Aspergillus abscess formation following epidural steroid injection.

We report an extremely unusual iatrogenic infection of the spinal canal with Aspergillus fumigatus that resulted in intradural abscess formation following epidural steroid injection in an immunocompetent young individual. Although the imaging findings of the infection were relatively nonspecific, MR imaging not only allowed for a prompt diagnosis, but also helped in surgical localization to the intradural compartment. Complications from the use of these injections are briefly discussed.

Abscess↗
PubMed2005

Lumbar facet joint infection associated with epidural and paraspinal abscess: a case report with review of the literature.

A case of lumbar facet joint infection associated with epidural and paraspinal abscess is presented. A 57-year-old man was hospitalized with severe low back pain that radiated into the bilateral buttocks and legs. The patient had a temperature of 37.3 degrees C, and the biochemical inflammatory parameters were elevated. Initially on admission, we administered antibiotics intravenously. However, pain increased, fever elevated gradually, and bladder-bowel disturbance appeared. Magnetic resonance imaging (MRI) showed effusion in the widened facet joint, paraspinal muscles, and epidural space, which compressed the theca severely. We performed an immediate surgical debridement combined with thorough antibiotic therapy and achieved excellent results. MRI was useful for precise diagnosis and operative planning.

Epidural Abscess↗
PubMed2003

Small risk of serious neurologic complications related to lumbar epidural catheter placement in anesthetized patients.

UNLABELLED: Previous studies have identified pain during needle/catheter placement or during the injection of local anesthetic as a risk factor for the development of persistent paresthesias after regional anesthetic techniques. The performance of regional blockade on anesthetized patients theoretically increases the risk of postoperative neurologic complications, because these patients are unable to respond to painful stimuli. In this study, we evaluated the frequency of neurologic complications in 4298 thoracic surgical patients undergoing lumbar epidural catheter placement while under general anesthesia. Catheters were placed immediately after the induction and tracheal intubation or on completion of the surgical procedure, before emergence. Most epidural catheters (4220, or 98.2%) were used solely for postoperative analgesia; only 78 (1.8%) epidural catheters were used for intraoperative anesthesia. In 4239 (98.6%) patients, an opioid alone was administered. The remaining 56 (1.3%) patients received a local anesthetic or local anesthetic/opioid mixture epidurally. Analgesia was graded as excellent or good in 92.2% of patients. Side effects included sedation in 455 (10.6%), nausea or emesis in 328 (7.6%), pruritus in 116 (2.7%), and respiratory depression (pH or=50 mm Hg) in 308 (7.2%) patients. The mean duration of epidural analgesia was 2.4 +/- 0.8 days (range, 0-10.7 days). There were no neurologic complications, including spinal hematoma, epidural abscess or catheter site infections, radicular symptoms, or persistent paresthesias (95% confidence interval, 0%-0.08%). In one patient, the epidural catheter broke during removal, and a portion was retained. The patient was notified; no long-term sequelae were noted. Six patients developed new neurologic symptoms or postoperative worsening of a previous neurologic condition unrelated to epidural catheterization. We conclude that the risk of neurologic complications associated with lumbar epidural catheter placement in anesthetized patients is small. However, the relative risk of this practice, compared with epidural catheter placement in awake patients, is unknown. IMPLICATIONS: We report no neurologic complications in 4298 patients undergoing epidural catheter placement while under general anesthesia. Although the risk of neurologic complications associated with lumbar epidural catheter placement in anesthetized patients is small, the relative risk compared with epidural catheterization in awake patients is unknown.

Adolescent↗
PubMed1998

Suppurative intracranial complications of sinusitis.

OBJECTIVES: To familiarize the contemporary surgeon with the pathogenesis, diagnosis, and appropriate management of suppurative intracranial complications of sinusitis. STUDY DESIGN: Retrospective chart review. METHODS: All patients admitted to the University of Virginia Health Sciences Center with a diagnosis of intracranial suppuration between 1992 and 1997 were reviewed. RESULTS: One hundred seventy-six cases were identified, of which 15 patients had 22 suppurative intracranial complications of sinusitis. These were epidural abscess (23%), subdural empyema (18%), meningitis (18%), cerebral abscess (14%), superior sagittal sinus thrombosis (9%), cavernous sinus thrombosis (9%), and osteomyelitis (9%). CONCLUSIONS: The diagnosis of suppurative intracranial complications of sinusitis requires a high index of suspicion and confirmation by imaging. Central to the success of treatment is the management of the primary source of sepsis within the paranasal sinuses in combination with neurosurgical drainage and intravenous antibiotics. This approach has resulted in a mortality rate of 7% and morbidity of 13%, which compare favorably with previous series.

Adolescent↗
PubMed1997

[Postoperative complications of anterior and middle skull base surgery].

The authors present the postoperative complications of skull base surgery based on a 10-year experience with 26 patients operated on via the supraorbital trans-basal or orbitozygomatic approach. The lesions included 19 malignant tumors and seven benign tumors. Postoperative cerebrospinal (CSF) leak occurred in one of the two patients in whom the dural defects were repaired with a fascia lata graft. None of the remaining 24 patients who were repaired with a musculopericranial flap suffered postoperative CSF leak. Three patients developed epidural abscess, but no infection was seen in the patients who had been reconstructed with a vascularized musculo-cutaneous flap to occlude the dead space. Preoperative radiation therapy correlated with a high incidence of postoperative infection. Cranial nerve deterioration or palsy occurred in four patients. Intraoperative injury of the internal carotid artery occurred in one patient who developed severe neurological deterioration. After an average follow-up period of 40 months (range 12 to 109 months), 68% of patients with malignant tumors and 100% of patients with benign tumors were alive with no evidence of recurrence.

Abscess↗
PubMed1984

Septic complications of chemonucleolysis.

The authors present two cases of septic complications after chemonucleolysis with chymopapain. One patient developed overt aortic valve failure. The second patient suffered an epidural abscess.

Adult↗
PubMed2001

[Postpartum neurologic complications following delivery with peridural analgesia. Case report with literature review].

Regional analgesia provides effective pain relief during delivery. Postpartal neurological deficits may be due to pressure of the fetal head on nerve structures at the pelvic rim or may be a complication of epidural analgesia. Nerve injuries due to spontaneous delivery and instrumental delivery are much more common than neurological deficits from epidural analgesia such as epidural hematoma or epidural abscess. The pattern of nerve damage is usually unilateral and non segmental. This case report describes the differential diagnosis of neurological deficit after spontaneous delivery under epidural analgesia and a discussion of the recent literature. Finally recommendations for the treatment of neurological deficits after delivery under epidural analgesia are presented.

Adult↗
PubMed1999

Paraplegia, a severe complication to epidural analgesia.

We report four cases where continuous epidural analgesia resulted in epidural abscesses (EA) causing spinal cord damage and paraplegia. The first symptom of EA was intense back pain, which developed 0-20 days after removal of the epidural catheter. The diagnosis of EA was not made prior to the development of severe neurologic disturbances in any of the patients. In all cases there was a time lag of 2-4 days between the first symptoms and institution of the appropriate treatment.

Accidental Falls↗
PubMedDate not supplied

Gadolinium-enhanced MR in spinal infection.

The purpose of this study was to determine what advantages the use of paramagnetic contrast material might have in evaluating patients clinically suspected of having spinal infection. To determine this we prospectively examined with noncontrast and contrast magnetic resonance (MR) 33 such patients and correlated the MR diagnoses with clinical and pathologic data. Our results showed the following advantages of gadolinium-enhanced MR: it (a) provided excellent anatomical delineation of all epidural abscesses, routinely differentiating them from the adjacent compressed thecal sac even when this was not possible by noncontrast MR; (b) increased observer confidence in the diagnosis of disk space infection and osteomyelitis in patients with equivocal noncontrast MR; (c) localized those portions of paraspinal masses most likely to yield a positive percutaneous biopsy; and (d) identified active infections from those that had responded adequately to antibiotic therapy. We conclude that contrast MR is a valuable adjunct to noncontrast MR when diagnosis, anatomical clarity, and/or lesion activity requires further elucidation.

Abscess↗