Extradural Abscess Complicating Extradural Anaesthesia for Caesarean Section

Abstract

Extradural abscess has been described infrequently as a complication of extradural anaesthesia and analgesia. We describe an abscess that developed 5 days after operation in a patient who had extradural anaesthesia for Caesarean section and postoperative analgesia, and review the literature on extradural abscess complicating extradural catheterization, including a discussion on pathogenesis, clinical presentation, diagnosis and management. There have now been 16 reported cases of extradural catheter-related extradural abscess. Only one previous case has been in obstetric practice, despite the widespread use of these techniques in this specialty. A disproportionate number of cases have involved thoracic catheters. Duration of catheterization ranged from 40 h to 6 weeks, the majority of catheters being in place for 5 days or less. The time from catheter placement to development of symptoms ranged from 72 h to 5 months. The causative organism was isolated in 11 cases: Staphylococcus aureus was identified in nine (82%) and Staphylococcus epidermidis in two (18%). Outcome was reported in 15 cases, of which seven (47%) had a full or near full recovery and eight (53%) had a persistent neurological deficit. One case was managed successfully without surgery. Fifty percent of all cases have been reported in the past 5 years. With the increasing use of extradural techniques for anaesthesia and analgesia, this serious complication may be seen more frequently in the future.

Spinal epidural abscess: a meta-analysis of 915 patients

“…In all, there is a low incidence of infectious complications following anesthesiological procedures in the epidural and spinal spaces [25]. In this metaanalysis of 854 patients, there were 42 cases of SEA following catheter epidural anesthesia, nine following spinal anesthesia, and five following "single shot" injections into the epidural space (Table 1) [24,36,39,45,57,70,79,86,104,106,117,122,128,142,152,186,213,215,225,233,241,256,259,260,265,278,304,318,335,342,351,352,362,365,382,385].…”

“…The lower proportion of Staphylococcus aureus in the above mentioned publications from the 1990s on SEA patients from the USA could reflect a worldwide shift in bacteria in this age of antibiotics and isn't necessarily due to a predilection of certain subgroups of patients with SEA for other infectious agents. References 4,13,16,33,35,36,38,50,57,58,66,70,74,80,92,96,100,110,116,117,137,143,148,154,156,170,176,178,180,184,186,187,193,204,206,215,227,232,237,244,245,250,253,256,264,265,271,293,…”

“…There were 18 patients with Staphylococcus aureus, four with Staphylococcus epidermidis, two with Pseudomonas aeruginosa, and one each with coagulase-negative Staphylococci and Pyocyaneus species. Among the 915 patients, only nine received spinal or peridural anesthesia by single-shot injections [24,45,57,94,128,186,256,317,382]. In one case, trigger point infiltration had been performed in the paraspinal cervical region at five different trigger points [94].…”

“…The use of regional spinal and epidural anesthesiaeven in patients with comorbidity factors such as diabetes mellitus -may be one reason for the observed prevalence of SEA according to Du Pen et al [87], Ngan Kee et al [256], and Pegues et al [278], who predict a continued increase in cases of SEA in the future. However, not all clinicians share this view [56,78,119,167,257,360,392].…”

A paraspinal abscess following spinal anaesthesia for caesarean section and patient-controlled epidural analgesia for postoperative pain

“…1,4 There have been many case reports of epidural abscess after epidural analgesia. [5][6][7][8][9][10][11][12] The reported incidence in obstetric patients has varied. For example, two early series reported incidences of 0.2 and 3.7 per 100 000, 13 patients.…”