A Protocol-Based Approach to Spinal Epidural Abscess Imaging Improves Performance and Facilitates Early Diagnosis

Madhuripan, Nikhil; Hicks, Richard J.; Feldmann, Edward; Rathlev, Niels K.; Salvador, Doug; Artenstein, Andrew W.

doi:10.1016/j.jacr.2017.09.041

Cited by 11 publications

(10 citation statements)

References 7 publications

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“…Age, early diagnosis, and the extent of neurological involvement are the three main prognostic markers in SEA patients. 8 Tuberculous spondylitis accounts for less than 1% of all tuberculosis infections, the extreme form of skeletal tuberculous is considered, with potential neurological symptoms due to compression of the neural structures by abscess, bone fragments, fibrosis, and vascular problem. 8,9 It can also contribute to spinal deformity, substantial destruction, and instability of the vertebral structure.…”

Section: Discussionmentioning

confidence: 99%

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Spinal Cord Injury in Tuberculous Spinal Epidural Abscess Patient with Deficiency of Vitamin D : A Case Report with Literature Review

et al. 2022

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Background: Spinal cord injury is not only caused by trauma but also by non-trauma, such as spinal epidural abscess (SEA). Tuberculous SEA is a rare infectious disorder, a delayed diagnosis associated with morbidity and mortality. The problems of tuberculous SEA is not only infection but also neurological deficit, axial back pain, pathological fracture, deformity, and socioeconomic and psychogenic problem. There are a few cases of SEA caused by Mycobacterium tuberculosis, mostly caused by Staphylococcus aureus with decreasing body’s defense mechanism caused by a deficiency of vitamin D. This study aimed to evaluate the neurological recovery of non-traumatic spinal cord injury caused by spinal tuberculosis with spinal epidural abscess and vitamin D deficiency that treated with vitamin D as an adjuvant. Case Report: A 31-year-old female came to the orthopedic clinic with paraparesis ASIA grade C, axial back pain, and spinal deformity for three months, with vitamin D levels of 15.5 ng/ml. MRI showed epidural abscess at the level of the 10th-11th thoracic vertebrae, spondylodiscitis of the 10th-11th thoracic vertebrae accompanied by paraspinal abscess of the 8th thoracic vertebrae to the 1st lumbar vertebra. The diagnosis was confirmed by cultured and histopathological examination. The treatment was surgery, followed by anti-TB drugs and daily vitamin D 5000 IU for one year. After one year of follow-up, the patient returned to work without a neurological deficit and axial back pain. Conclusion: This report describes the importance of early diagnosis and proper treatment of spinal cord injury in tuberculous SEA with a deficiency of vitamin D.

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Section: Discussionmentioning

confidence: 99%

“…17-19 Vitamin D deficiency requires daily administration of oral vitamin D to improve the immune system. 8 The length and initial severity of the neurologic deficit are correlated with the extent of neurologic recovery following surgery. The mortality rate of this case is around 2%-20%.…”

Section: Discussionmentioning

confidence: 99%

Spinal Cord Injury in Tuberculous Spinal Epidural Abscess Patient with Deficiency of Vitamin D : A Case Report with Literature Review

et al. 2022

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“…A recent protocol-based approach to emergent MRI to diagnose SEA includes five risk factors (intravenous drug use, indwelling vascular catheter, spinal procedure or infection within six months, antimicrobial treatment within 30 days, and infectious focus elsewhere), resulted in an immediate identification and reduction of time required in the identification of patients with suspected SEA. Thus, the use of the protocol seemingly facilitates the early diagnosis of SEA (52) .…”

Section: Strategies For Early Diagnosis and Appropriate Managementmentioning

confidence: 99%

“…By summarizing the aforementioned and referring recent recommendations (52) , (53) , (54) , we proposed a simple algorithm for the early diagnosis of SEA ( Figure 6 ). At first, severe back pain is an essential symptom to make clinicians suspect SEA because most patients complain of severe localized back pain.…”

Section: Strategies For Early Diagnosis and Appropriate Managementmentioning

confidence: 99%

Spinal Epidural Abscess: A Review Highlighting Early Diagnosis and Management

Tetsuka

Suzuki

Ogawa

et al. 2019

JMA J

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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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“…[5][6][7][8][9][10] Although magnetic resonance imaging (MRI) with gadolinium contrast is 96% sensitive and 93% specific for PSI, it is not an easily administered test. It requires 4-8 hours for test results, 11 is uncomfortable in some patients, contributes to ED crowding, and is not available at all facilities where back pain is evaluated. 6,10,12,13 Currently there are no clinical prediction tools to estimate PSI risk, [14][15][16][17] no agreement on C-reactive protein (CRP) cut-off levels to indicate imaging, 18 and no uniform recommendations regarding MRI use.…”

Section: Introduction Backgroundmentioning

confidence: 99%

A Clinical Prediction Tool for MRI in Emergency Department Patients with Spinal Infection

Shroyer

Davis

April

et al. 2021

WestJEM

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Introduction: Patients with pyogenic spinal Infection (PSI) are often not diagnosed at their initial presentation, and diagnostic delay is associated with increased morbidity and medical-legal risk. We derived a decision tool to estimate the risk of spinal infection and inform magnetic resonance imaging (MRI) decisions. Methods: We conducted a two-part prospective observational cohort study that collected variables from spine pain patients over a six-year derivation phase. We fit a multivariable regression model with logistic coefficients rounded to the nearest integer and used them for variable weighting in the final risk score. This score, SIRCH (spine infection risk calculation heuristic), uses four clinical variables to predict PSI. We calculated the statistical performance, MRI utilization, and model fit in the derivation phase. In the second phase we used the same protocol but enrolled only confirmed cases of spinal infection to assess the sensitivity of our prediction tool. Results: In the derivation phase, we evaluated 134 non-PSI and 40 PSI patients; median age in years was 55.5 (interquartile range [IQR] 38-70 and 51.5 (42-59), respectively. We identified four predictors for our risk score: historical risk factors; fever; progressive neurological deficit; and C-reactive protein (CRP) ≥ 50 milligrams per liter (mg/L). At a threshold SIRCH score of ≥ 3, the predictive model’s sensitivity, specificity, and positive predictive value were, respectively, as follows: 100% (95% confidence interval [CI], 100-100%); 56% (95% CI, 48-64%), and 40% (95% CI, 36-46%). The area under the receiver operator curve was 0.877 (95% CI, 0.829-0.925). The SIRCH score at a threshold of ≥ 3 would prompt significantly fewer MRIs compared to using an elevated CRP (only 99/174 MRIs compared to 144/174 MRIs, P <0.001). In the second phase (49 patient disease-only cohort), the sensitivities of the SIRCH score and CRP use (laboratory standard cut-off 3.5 mg/L) were 92% (95% CI, 84-98%), and 98% (95% CI, 94-100%), respectively. Conclusion: The SIRCH score provides a sensitive estimate of spinal infection risk and prompts fewer MRIs than elevated CRP (cut-off 3.5 mg/L) or clinician suspicion.

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A Protocol-Based Approach to Spinal Epidural Abscess Imaging Improves Performance and Facilitates Early Diagnosis

Cited by 11 publications

References 7 publications

Spinal Cord Injury in Tuberculous Spinal Epidural Abscess Patient with Deficiency of Vitamin D : A Case Report with Literature Review

Spinal Cord Injury in Tuberculous Spinal Epidural Abscess Patient with Deficiency of Vitamin D : A Case Report with Literature Review

Spinal Epidural Abscess: A Review Highlighting Early Diagnosis and Management

A Clinical Prediction Tool for MRI in Emergency Department Patients with Spinal Infection

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