Holospinal epidural abscess of the spinal axis: two illustrative cases with review of treatment strategies and surgical techniques

Abstract

<jats:p>Despite the increasing prevalence of spinal infections, the subcategory of holospinal epidural abscesses (HEAs) is extremely infrequent and requires unique management. Panspinal imaging (preferably MRI), modern aggressive antibiotic therapy, and prompt surgical intervention remain the standard of care for all spinal axis infections including HEAs; however, the surgical decision making on timing and extent of the procedure still remain ill defined for HEAs. Decompression including skip laminectomies or laminoplasties is described, with varied clinical outcomes. In this review the authors present the illustrative cases of 2 patients with HEAs who were treated using skip laminectomies and epidural catheter irrigation techniques. The discussion highlights different management strategies including the role of conservative (nonsurgical) management in these lesions, especially with an already identified pathogen and the absence of mass effect on MRI or significant neurological defects.</jats:p> <jats:p>Among fewer than 25 case reports of HEA published in the past 25 years, the most important aspect in deciding a role for surgery is the neurological examination. Nearly 20% were treated successfully with medical therapy alone if neurologically intact. None of the reported cases had an associated cranial infection with HEA, because the dural adhesion around the foramen magnum prevented rostral spread of infection. Traditionally a posterior approach to the epidural space with irrigation is performed, unless an extensive focal ventral collection is causing cord compression. Surgical intervention for HEA should be an adjuvant treatment strategy for all acutely deteriorating patients, whereas aspiration of other infected sites like a psoas abscess can determine an infective pathogen, and appropriate antibiotic treatment may avoid surgical intervention in the neurologically intact patient.</jats:p>

Catheter-based Minimally Invasive Evacuation of Extensive Spinal Epidural Abscess: A Technical Report

“…Multiple laminectomies have been reported for extensive SEA [17] but minimally invasive decompression, combined with catheter irrigation and drainage, may be preferable as it potentially reduces iatrogenic instability, postoperative pain, and blood loss [9, 11]. This is important in the management of SEA since it often afflicts patients with numerous comorbidities [18].…”

“…To reduce operative morbidity, multilevel SEAs can be drained through a limited open approach allowing blind epidural catheter irrigation and aspiration [8, 9]. Limited exposure of the dural canal during SEA surgery offers a greater chance for stability preservation and reduced morbidity.…”

Pediatric Holocord Epidural Abscess Treated with Apical Laminotomies with Catheter-directed Irrigation and Drainage

“…The available literature is limited due to the relative rarity of this presentation, and extended decompression carries greater operative and delayed iatrogenic risks. Management options include skip laminectomies, laminoplasties, percutaneous drainage, and medical management [6-8]. More recently, apical laminotomies with irrigation and drainage have been described in a small number of adult patients [2, 3].…”

L5 Fracture Dislocation Secondary to Cold Abscess Treated by Posterior Corpectomy With Expandable Cage Placement

“…Approximately 26,000-65,000 people are affected by vertebral osteomyelitis annually, and 30%-70% present with no signs of prior infection [ 1 ]. Epidural abscess development is a known complication of vertebral osteomyelitis in as many as 10%-20% of cases [ 2 ]. The mortality rate of spinal infections may be as high as 20%, stressing the importance of early recognition and intervention [ 3 ].…”