Extensive spinal epidural abscess treated with “apical laminectomies” and irrigation of the epidural space: report of 2 cases

Abstract

<jats:p>Spinal epidural abscess (SEA) is a rare but often devastating infection of the epidural space around the spinal cord. When an SEA is widespread, extensive decompression with laminectomy is often impossible, as it may subject the patient to very long operative times, extensive blood loss, and mechanical instability. A technique called “skip laminectomy” has been described in the literature, in which laminectomies are performed at the rostral and caudal ends of an abscess that spans 3–5 levels and a Fogarty catheter is used to mechanically drain the abscess, much like in an embolectomy. In this report of 2 patients, the authors present a modification of this technique, which they call “apical laminectomies” to allow for irrigation and drainage of an extensive SEA spanning the entire length of the vertebral column (C1–2 to L5–S1).</jats:p> <jats:p>Two patients presented with cervico-thoraco-lumbar SEA. Laminectomies were performed at the natural apices of the spine, namely, at the midcervical, midthoracic, and midlumbar spine levels. Next, a pediatric feeding tube was inserted in the epidural space from the thoracic laminectomies up toward the cervical laminectomy site and down toward the lumbar laminectomy site, and saline antibiotics were used to irrigate the SEA. Both patients underwent this procedure with no adverse effects. Their SEAs resolved both clinically and radiologically. Neither patient suffered from mechanical instability at 1 year after treatment.</jats:p> <jats:p>For patients who present with extensive SEAs, apical laminectomies seem to allow for surgical cure of the infectious burden and do not subject the patient to extended operating room time, an increased risk of blood loss, and the risk of mechanical instability.</jats:p>

Timing and prognosis of surgery for spinal epidural abscess: A review

“…(JNS 2015) reported 2 cases in which apical laminectomies (e.g., an alternative to skip laminectomies) provided irrigation/drainage of extensive C1–C2 to L5–S1 SEA [ Table 3 ]. [ 1 ] First, a pediatric feeding tube was placed epidurally in the mid thoracic spine (apical laminectomy). The catheter was then both directed cephalad toward the mid cervical, and subsequently caudally toward the mid lumbar laminectomy sites.…”

“…Most SEA patients, ranging in age from their mid 50s to mid 60s, present with the classical triad of fever (50%), spinal pain (47.1–100%), and weakness (19–55.8%). [ 1 8 24 27 29 ] Major clinical risk factors predisposing to SEA include; diabetes (15–35.8%), advanced age (>50, 65, or 80), renal disease (30.2%), vascular disease (31.3%), smoking 23%, cancer history (16%), intravenous (IV) drug abuse (10–39.1%), alcohol abuse (4%), sepsis (15–40%) (methicillin resistant Staphylococcus aureus [MRSA] or methicillin sensitive S. aureus [MSSA]), and positive cultures (59.3–70.7%) [Tables 1 – 3 ]. [ 9 12 24 26 29 ] Laboratory, diagnostic, and neurological criteria that prompt early surgery include; elevated white blood cell count (WBC > 12.5) C-reactive protein (CRP) (>115), positive blood cultures, magnetic resonance imaging (MRI)/computed tomographic (CT) images of cord compression, and neurological deficits [e.g., 19– 45%]).…”

Recent developments in the treatment of spinal epidural abscesses

“…To avoid heavy blood loss and excessive exposure of patient’s internal tissues to the open environment, laminectomies completed at midlumbar, mid-thoracic, and mid-cervical levels were successful in treating extensive epidural abscesses. 40 Tubular retractor systems used for microsurgery can be efficient for irrigation of extensive epidural abscesses. 41 A 59-year-old woman with an extensive ventral SEA in the cervical and upper thoracic region had a midline trough burred into the vertebrae and disc spaces.…”

What are we waiting for? An argument for early surgery for spinal epidural abscesses

“…Spine surgeons certainly acknowledge the clinical triad (e.g., fever [50%], spinal pain [92–100%], and neurological deficits [47%]) required for establishing the diagnosis of a SEA. [ 1 6 12 14 15 ] We also appreciate the multiple factors that contribute to the risk of developing a SEA; advanced age (>65 or 80), diabetes (15–30%), cancer, intravenous drug abuse (25%), smoking (23%), elevated white blood cell count (WBC >12.5), high C-reactive protein (CRP >115), positive blood cultures, magnetic resonance imaging (MRI)/computed topographic (CT) documented cord compression, and significant neurological deficits/some degree of paralysis (e.g., 19–45%). [ 7 9 12 13 14 15 ]…”