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Infectious and inflammatory processes of the spinal column are discussed, including disc space infection, osteomyelitis, epidural abscess, arachnoiditis, and rheumatoid arthritis. The relative sensitivity and specificity of various imaging modalities, as well as the imaging characteristics and utility of these various modalities are given. Emphasis is placed on the use of magnetic resonance imaging.
In conclusion, major complications after neuraxial techniques are rare but can be devastating to the patient and the anesthesiologist. Prevention and management begin during the preoperative visit with a careful evaluation of the patient's medical history and appropriate preoperative discussion of the risks and benefits of the available anesthetic techniques. Alternative anesthetic techniques, such as peripheral regional techniques or general anesthesia, should be considered for patients at increased risk for neurologic complications following neuraxial block. The decision to perform a regional anesthetic technique on an anesthetized patient must be made with care, as these patients are unable to report pain on needle placement or injection of local anesthetic. Efforts should also be made to decrease neural injury in the operating room through careful patient positioning. Postoperatively, patients must be followed closely to detect potentially treatable sources of neurologic injury, including expanding spinal hematoma or epidural abscess, constrictive dressings, improperly applied casts, and increased pressure on neurologically vulnerable sites. New neurologic deficits should be evaluated promptly by a neurologist, or neurosurgeon, to document formally the patient's evolving neurologic status, arrange further testing or intervention, and provide long-term follow-up.
BACKGROUND AND OBJECTIVES: Patients with severe and noncancer pain were treated with prolonged epidural infusions of analgesics in their homes, and the incidence of infection was determined. METHODS: In 504 adult patients, 3,164 polyamide lumbar epidural catheters were infused with analgesics of low-dose bupivacaine and fentanyl intermittently from 2 to 80 days at their home. When patients developed fever, headache, back pain, and leukocytosis, the presence of infection was confirmed by either computed tomographic scan, epidurogram, or sonogram. RESULTS: Nine infections (0.27%) occurred. Of these, two were epidural abscesses, two were fascitis, and five were cellulitis. Staphylococcus epidermidis was cultured in every case. All of them were treated with 1.5 g intravenous cefuroxime sodium every 8 hours. None of the patients required surgical intervention. In a subgroup of patients treated with the first 1,462 infused catheters, seven infections developed (0.4%), whereas in the subsequent 1,702 cases that received prophylactic penicillin or erythromycin, in 6-day cycles, there were only two infections (0.11%). CONCLUSIONS: Temporary epidural infusions of analgesics up to 80 days are feasible in ambulatory patients with a low rate of infections. Preliminary observations appear to indicate that prophylactic antibiotics given intermittently further reduce the feasibility of infections. However, these observations may not apply to longer-lasting epidural infusions.
The presentation and clinical course for hematogenous vertebral osteomyelitis and postoperative discitis is presented. The treatment is primarily conservative care in the form of immobilization and parenteral antibiotics. The indications for surgery are rare and should be reserved for patients resistant to treatment or with septic course, abscess formation, or neurologic deficits. In these cases, the infectious process has generally involved the adjacent vertebrae or the neural elements. Surgery usually involves an anterior approach. The principles of surgical treatment involve debridement of necrotic tissue, decompression of neural elements, and stabilization of the spine. The outcome of patients with vertebral osteomyelitis and secondary discitis in general is favorable when appropriate treatment is rendered. Extension of the infection to the spinal canal in the form of an epidural abscess is also reviewed.
Cervical spine infection is a term used to encompass osteomyelitis, discitis and epidural abscess. Most cases are caused by Staphylococcus aureus but other organisms have been isolated. The most frequent source is hematogenous spread from a nearby or distant source. Diagnosis is often confusing. The most common symptom is worsening back or neck pain that increases with movement. Patients may have motor or sensory changes if there is compression of the nerve roots or spinal cord. If the condition is not treated promptly, it may progress to irreversible neurologic deficit. Positive blood cultures and an elevated erythrocyte sedimentation rate (ESR) may be seen. Radiologic findings may include a paravertebral swelling, a destruction of the vertebral end plates and adjacent portions of the bodies and disc space and the presence of an epidural mass. Treatment includes radical surgical intervention for debridement and decompression to stabilize the spine in conjunction with 8-12 weeks of intravenous antibiotics. Closed continuous local antibiotic irrigation with a gravity control outflow system has been used.
Postoperative neurological sequelae in patients that have received epidural anaesthesia are not necessarily caused by the epidural anaesthetic technique. As a whole, adverse neurological outcomes following epidural anaesthesia may be subdivided into 3 different ethiological categories. A first category involves events that are not at all caused by the epidural, but merely due to the interference of anaesthesia and/or surgery with a preexisting medical condition. A second category includes mishaps such as backache, arachnoiditis, and post-dural puncture headache that are solely due to the epidural anaesthesia. Finally, epidural anaesthesia may be a contributory factor in the development of post-anaesthetic complications attributable to a pre-existing medical condition that are triggered by anaesthesia, surgery or childbirth. These complications include some of the most dramatic sequelae of major neuraxial blockade, such as spinal epidural abscess, spinal infarction, and spinal hematoma. Although extremely rare, the latter complications often result in permanent major neurological deficits. The present manuscript is a review of the most recent, literature addressing post-anaesthetic sequelae, and will discuss their incidence, pathophysiology, clinical course, diagnosis, prevention, and treatment.
BACKGROUND AND OBJECTIVES: The pain following total knee arthroplasty can be associated with significant morbidity, especially in the elderly. Regional anesthetic techniques attenuate or eliminate postoperative pain, which may reduce this morbidity. METHODS: A 74-year-old patient with history of an epidural abscess underwent elective bilateral total knee arthroplasty for degenerative joint disease. Bilateral lumbar plexus catheters were placed via the fascia iliaca compartments. Lidocaine was infused postoperative through both catheters, and serum lidocaine levels were followed. RESULTS: The patient received significant postoperative pain relief based on physical and subjective examination. There were no complications or untoward effects related to the technique. CONCLUSION: Lumbar plexus blockade with continuous local anesthetic infusion via the fascia iliaca compartment is an effective means of providing postoperative analgesia after total knee arthroplasty when epidural analgesia is contraindicated.
Several neurological complications have been described after epidural anaesthesia, including direct trauma to the spinal cord or nerve roots, epidural haematoma, meningitis, epidural abscess, spinal cord infarction. neurologic toxicity of injected agents. In obstetric practice, these complications are very uncommon. However, their real occurrence may be underrated, partly for medicolegal reasons. Different complication mechanisms are described; they should be kept in mind while evaluating post block neurological deficits so that prompt corrective measures can be taken whenever appropriate to prevent permanent damage.
BACKGROUND: Frontal bone osteomyelitis is considered to be rare but it may develop intracranial complications such as subperiosteal abscess that appears as a painful fluctuated forehead tumor (Pott's puffy tumor). METHODS: We reviewed retrospectively the clinical history of those patients showing frontal swelling tumour in our Neurosurgery and Infectious Diseases Departments between July 1994 and December 1997 and whose definitive diagnosis was cranial osteomyelitis. RESULTS: We reported five cases of patients who had been submitted to a neurosurgical operation between 9 months and 27 years ago. The main clinical features were intermittent painful frontal swelling episodes (with or without fever). These episodes were self-limited or limited after short trend of antibiotics. Imaging techniques were necessary for the diagnosis and especially in order to exclude intracranial complications (such as epidural abscess found in two patients). The ascertain diagnosis is made by debriding, histological studies and cultures from the material. Staphylococcus aureus was isolated in three of the patients, Haemophilus influenzae in one patient and Pseudomonas aeruginosa in the other one. All patients were treated with surgery and specific antibiotic therapy during twelve weeks minimum, being definitively cured. CONCLUSIONS: It is not well know the etiopathogenic mechanism concerning this rare disease. We remark the importance of a prompt diagnosis because of the high frequency of intracranial complications as well as combined treatment: surgery and long term antibiotic therapy (not less than 8 weeks), is necessary to cure the disease.
Subperiosteal abscess of the orbit (SPA) in childhood is an uncommon but serious sequela of sinusitis, with partial or complete visual loss as the most common complication. Traditional management of SPA has combined systemic antibiotics with immediate surgical drainage. The records of 120 children admitted from 1982-1986 with the diagnosis of periorbital or orbital cellulitis were reviewed. Ten cases of SPA were documented by CT scan (8%). Antecedent ethmoid sinusitis was present in all cases. Five SPA patients were managed with intravenous antibiotics and nasal decongestants alone. All had complete clinical and radiographic resolution without complication. The remaining 5 patients underwent surgical drainage. Two patients required immediate drainage due to total ophthalmoplegia upon presentation. One case of postoperative epidural abscess occurred one week after external fronto-ethmoidectomy among these two patients. The remaining 3 patients did not respond adequately to medical therapy alone and underwent surgical drainage without complication. Length of hospital stay in both medical and surgical groups was similar. We conclude that SPA can be safely managed by medical therapy alone in selected cases. Criteria for surgical intervention of documented SPA while on optimal medical therapy should include: worsening of visual acuity or ocular motility, or failure to improve clinically within 48 h. The presence of SPA alone should no longer be considered an absolute indication for surgery.
Computed tomographic data were studied in 50 patients with evolutional forms of tuberculous spondylitis and 3 patients with its sequels. 95% of the patients were operated on. Cross sections displayed 3 variants of vertebral body destruction in tuberculous spondylitis. The vertebral canal was evaluated in 28 patients with neurological disorders and in 22 patients without them. Epidural abscess was revealed in all the patients with neurological disorders and in 12 patients without them. There was a relationship of the severity of neurological disorders as classified by Frankel et al. to the degree of stenosis of the vertebral canal, to the presence of its reserve space, and to the extent of vertebral and spinal lesion. The informative value of computed tomography in detecting spinal cord compression was 98.1 +/- 1.8%.
An infected fistula was observed in a woman (Age: 69 years, weight: 60 kg, height: 159 cm) 14 days after insertion and 8 days after removal of a peridural catheter inserted preoperatively for postoperative analgesia after nephrectomy (carcinoma). Due to haemodynamic problems in the early postoperative period no analgetic or local anaesthetic medication was applied via the peridural catheter. After unsuccessful antibiotic and surgical treatment the women was transferred to the Neurosurgical department five weeks after nephrectomy. Magnetic resonance imaging of the lumbar region showed a fistula (Segment L2/L3) reaching the epidural space but no epidural spreading or epidural abscess. Partial laminectomy L2/L3 was performed and the fistula excised under continuous antibiotic treatment with ofloxacin. Up until 21 months after the operation no recidivation occurred. Exact details of catheter insertion and catheter treatment in the postoperative period are not available; the fact, that no bactericide [9] local anaesthetic agents were applied, might have favoured the occurrence of this infection. Infectious complications have to be taken into consideration for the indication of peridural catheters in the perioperative period.
A 79-year-old man with herpes zoster was referred to our hospital for pain control. He was a survivor of the atomic bombing of Hiroshima, and had a history of cerebral infarction and hypertension. A cervical epidural catheter was placed for continuous analgesic infusion. After 20 days of catheterization, he gradually developed a high fever and confusion, and complained of nausea and headaches. An urgent blood examination revealed a white blood cell count of 15,200 mm-3 and a C-reactive protein of 32.4 mg.dl-1. The catheter was removed and antibiotic therapy was started. Repeated magnetic resonance imaging could not confirm epidural abscess formation. The bacterial culture of the cerebrospinal fluid was negative, but the cultures of the blood, the catheter tip, and the nasal cavity swab were positive for methicillin-resistant Staphylococcus aureus. Although intravenous vancomycin was administered, systemic inflammation persisted. The patient consecutively suffered varied disorders such as acute renal failure, disseminated intravascular coagulation, and gastrointestinal bleeding. Although symptomatic treatment had been prolonging his life, 58 days after the catheter removal, the patient suddenly developed cerebellopontine infarction, which made mechanical ventilation necessary. He remained unconscious until his death 117 days after the catheter removal. We discussed the possible pathogenetic mechanisms of the present case.
BACKGROUND CONTEXT: Selective transforaminal epidural injections are frequently employed in the treatment of pain emanating from the spine. Complication rates are typically low and include paresthesia, hematoma, epidural abscess, meningitis, arachnoiditis and inadvertent subdural or subarachnoid injection. Persistent paraplegia after lumbar transforaminal block has been recently reported. Undetected intra-arterial injection has been implicated as a possible cause. PURPOSE: We present a case of massive cerebellar infarction after uneventful selective cervical transforaminal block. Intra-arterial injection of corticosteroid is implicated with focus on particulate size of compound versus blood vessel dimension. Light microscopic data are presented to confirm the potential for embolic vascular occlusion. STUDY DESIGN/SETTING: Case report; light microscopic data. PATIENT SAMPLE: A patient underwent selective transforaminal block on the right at the C5-C6 level. There was C5-C6 disc herniation documented by magnetic resonance imaging and C6 radiculopathy by electromyographic studies. OUTCOME MEASURES: Patient follow-up from medical office records. METHODS: Needle placement at the C5-C6 foramen on the right was confirmed by biplanar fluoroscopy and injection of contrast medium. Frequent heme-negative aspirations were documented. RESULTS: In this patient, quadriparesis ensued shortly after injection of corticosteroid solution. The patient was admitted to the neurosurgical intensive care unit and ultimately underwent brainstem decompressive surgery when focal neurologic deficits became evident. Working diagnosis was massive cerebellar infarct. Light microscopic data are presented to illustrate particulate size in corticosteroid solutions and potential for embolic microvascular occlusion. Corticosteroid suspensions (and to a lesser extent solutions) contain large particles capable of occluding metarterioles and arterioles. CONCLUSIONS: We present a case of quadriparesis and brainstem herniation after selective cervical transforaminal block. We propose a potential role for corticosteroid particulate embolus during unintended intra-arterial injection as a potential mechanism.
Pyogenic osteomyelitis of the cervical spine was successfully treated without bone grafting in 11 of 12 patients. Staphylococcus aureus was the most common organism. Four of the patients were heroin addicts, and six others had received parenteral injections under medical supervision. The patients were immobilized promptly, and after diagnostic procedures, cultures, and drainage when appropriate, they were treated with antibiotics, which led to spontaneous fusion in the 11 who survived. In the preantibiotic era, these infections frequently evolved into "epidural abscess", with resultant cord compression leading to permanent paralysis or death. Therefore, early differential diagnosis from tuberculosis or cancer is necessary. Today, with early diagnosis, immobilization, an anterior surgical approach when necessary, and the appropirate antibiotic, cure without neurological deficit should be the rule.
OBJECTIVES: To describe our experience, including selection criteria and complication rates, using microvascular free tissue transfer to repair large skull base defects and to determine if complication rate and posttreatment survival justify the use of this technique. DESIGN: Retrospective review of clinical cohort. SETTING: Tertiary care medical center. PATIENTS: A consecutive sample of patients undergoing ablative surgery with repair of cranial base defects with free tissue transfer from 1995 to 2004. All the patients' defects involved intracranial exposure. MAIN OUTCOME MEASURES: Rate of local and systemic complications, postoperative survival, and recurrence rate. RESULTS: The study population comprised 40 patients. Fifteen (38%) of the patients' defects were in the anterior cranial base, and 26 (65%) were in the middle cranial base. We used 5 types of free tissue flap, with a success rate of 95%. Our rate of perioperative mortality, meningitis, stroke, cerebrospinal fluid leak, epidural abscess, and osteomyelitis was 0%. We had 7 local complications and 4 systemic complications requiring increased length of hospital stay. Including microvascular problems, 12 patients had complications, for an overall complication rate of 30%. Follow-up ranged from 1 to 96 months, with a mean of 24 months. The tumor recurrence rate was 30%, and disease-specific survival was 81% at a mean 24-month follow-up. CONCLUSIONS: We did not experience any perioperative mortality or intracranial morbidity. Our low complication rate in combination with our tumor recurrence rate and rate of patient survival justify the use of free tissue transfer as an option in the closure of appropriate cranial base defects.
OBJECTIVE: To evaluate the complications of anterior craniofacial resection and correlate their impact with tumor control status. DESIGN: We conducted a retrospective review of 32 consecutive, operable patients' records seen over a 6-year period, requiring 35 procedures. SETTING: Academic tertiary referral medical center. PARTICIPANTS: Twenty-six patients (81%) had malignant lesions (esthesioneuroblastoma, squamous cell carcinoma, and a group of miscellaneous malignant tumors). Six patients had various benign neoplasms. INTERVENTION: The surgical approach involved bifrontal craniotomy coupled with lateral rhinotomy in 19 cases (61%), facial degloving in 10 cases (32%), a total rhinectomy in one case, and endoscopic sinusectomy without facial incision in two cases. OUTCOME MEASURE: Clinically noted complications and oncologic outcome. RESULTS: There was one avoidable perioperative death indirectly associated with the patient's procedure. Nine patients suffered significant intracranial neurological complications such as tension pneumocephalus and delayed epidural abscess. All of these complications were managed successfully. Of patients with malignant tumors, 13 (52%) are alive with no evidence of disease and one is alive with recurrence after a mean follow-up period of 28.9 months. The 10 patients who succumbed to disease had a mean postoperative survival of 22.9 months. CONCLUSIONS: In contrast to the perspective of only a decade ago, we conclude that craniofacial resection is a relatively safe, versatile, and effective procedure for surgical management of tumors involving the anterior skull base.
OBJECTIVES: To determine the complications of extensive cranial-base resection requiring free-tissue transfer (FTT) and the effect of these resections on local control and survival among patients with malignant neoplasms of the skull base. BACKGROUND: Before the advent of FTT, cranial-base surgery was often limited by our inability to adequately repair defects comprising communication between the central nervous system and upper aerodigestive tract. The use of FTT in cranial-base resections was therefore assessed to determine whether the improved procedure (ie, extensive resections) would improve local control and prolong survival. DESIGN: A retrospective review of 39 consecutive craniofacial resections with FTT reconstruction in patients with malignant neoplasms involving the cranial base. PATIENTS: All 39 patients had malignant neoplasms, including 20 squamous cell carcinomas, eight basal cell carcinomas, two melanomas, two neuroendocrine carcinomas, two adenoid cystic carcinomas, and various other malignant neoplasms. Resections involved the anterior, middle, or posterior cranial fossa in 19 patients (49%), 10 patients (26%), and three patients (8%) of cases, respectively. The remaining seven surgeries (18%) involved resection of more than one of these cranial base sites. RESULTS: Early (< 14 days after surgery) complications occurred in 14 (36%) of 39 patients. Major complications included failure of microvascular anastomosis (n = 1), pneumonitis (n = 3), perioperative myocardial infarction (n = 1), and cerebrovascular accident (n = 1). The microvascular anastomosis failure was promptly treated with surgical intervention. Two patients (5%) experienced late postoperative complications; one had cellulitis at the donor site, and the other had pneumonitis. No perioperative deaths or complications such as meningitis, epidural abscess, or tension pneumocephalus occurred. The 2-year disease-specific survival rate was 55%, and the 2-year local control rate, 49%; both were determined by the Kaplan-Meier method. The nine patients who died of their disease had a median survival of 9 months. Log-rank testing showed that pathologically positive margins and transdural pathology were the most significant predictors of local recurrence and death of disease. CONCLUSIONS: Contemporary surgical approaches provide an opportunity for wide surgical excision of dura and skull-base structures that normally separate the intracranial and extracranial cavities. These major skull-base resections can be reconstructed safely and effectively with FTT. Patients with malignant neoplasms of the dura and skull base should be approached with the understanding that transdural disease portends an increased risk of local recurrence and death of disease.