Spinal Epidural Abscess in Hemodialysis Patients

Abstract

SummarySpinal epidural abscess (SEA) is a rare but potentially devastating condition. We noticed an increase in the number of cases of SEA, with the majority in hemodialysis (HD) patients. This prompted a retrospective chart review of all cases of SEA admitted from 2000 to 2005 and a literature search of similar cases. We identified 19 SEA cases treated at Long Island College Hospital during this 6-year period, of which six were on HD: four were dialyzed via catheter, one via arteriovenous fistula, and in one the method of dialysis was not documented. Four patients had bacteremia with Staphylococcus aureus. Four patients presented with paresis or paralysis; only one improved. The mortality rate was 33% (2/6). We found 30 other cases of SEA in patients on HD from the literature. These 36 HD cases were compared with 85 SEA cases that were not on HD (13 from our study and 72 described in two large case series). The mortality rate was noted to be much higher in HD patients (23% [6/26] versus 7% [6/85]). Neurologic deficit at presentation was noted in 47% (17/36) of HD patients versus 69% (59/85) of non-HD patients, but neurologic improvement was higher in non-HD patients (71% [42/59] versus 29% [5/17]). This is the largest literature review of SEA in patients on HD. When compared with non-HD patients, HD patients had a higher mortality rate and were less likely to improve neurologically.

An institutional series and contemporary review of bacterial spinal epidural abscess: current status and future directions

“…Wong et al published similar results for a larger study in which mortality rate was higher among hemodialysis patients and likelihood for neurological improvement after medical or surgical intervention was decreased. 44 In our study, 10 (9.3%) SEA patients were receiving hemodialysis at the time of diagnosis. Of the 6 patients who died, 2 had received hemodialysis, adding to the many factors to be considered for SEA patients.…”

“…1,8,9,19,23,32 Additionally, higher reoperation and mortality rates are associated with renal failure and hemodialysis. 44,45 In terms of pathogenic microorganisms, overwhelmingly the most common is S. aureus, followed by Streptococcus spp. and gram-negative bacteria.…”

Metastatic Complications of Bloodstream Infections in Hemodialysis Patients

“…End‐stage renal disease has been identified as a risk factor for spinal epidural abscess. In one report, 6 of 19 cases of spinal epidural abscesses observed in a single center over a 5‐year period occurred in hemodialysis patients (54). Other recognized risk factors include diabetes mellitus, intravenous drug use, and alcoholism (53).…”

Hemodialysis catheter infection with unusual presentation and grave outcome

“…19 In addition to vertebral osteomyelitis, spinal epidural abscess, which can also complicate bacteremia from CVC without overt signs of infection at the exit site, can also cause profound neurologic deficits. 20 Clinical and laboratory signs of infection were absent throughout our patient's follow-up in both the freestanding dialysis unit and in the first 3 weeks in our dialysis unit, although the inflammatory tissue around the removed CVC and the extensive destruction of his T11 vertebra by the infectious process suggested a chronic process. The history of symptomatic vertebral osteoporosis obscured the clinical significance of the back pain, which was the only symptom experienced by the patient.…”

“…A large percentage of patients with staphylococcal vertebral osteomyelitis develop serious neurologic deficits . In addition to vertebral osteomyelitis, spinal epidural abscess, which can also complicate bacteremia from CVC without overt signs of infection at the exit site, can also cause profound neurologic deficits …”