Thoracic Epidural Abscess

Liem, Leon K.; Rigamonti, Daniele; Wolf, Aizik L.; Robinson, Walker L.; Edwards, Charles C.; DiPatri, Arthur J.

doi:10.1097/00002517-199410000-00012

Cited by 23 publications

(36 citation statements)

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“…Almost all reviews and case series on spinal epidural abscess emphasize this point [8,16,31,67,80,82,98,154,158,164,179,189,195,201,213,214,230,232,235,262,264,283,297,300,306,309,314,316,330,350,366,378,401]. Immediate therapy is necessary to prevent compression of the spinal cord and cauda equina, with the corresponding neurological lesions (Fig.…”

Section: Introductionmentioning

confidence: 99%

Spinal epidural abscess: a meta-analysis of 915 patients

Waldbaur²,

2000

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Spinal epidural abscess (SEA) was first described in the medical literature in 1761 and represents a severe, generally pyogenic infection of the epidural space requiring emergent neurosurgical intervention to avoid permanent neurologic deficits. Spinal epidural abscess comprises 0.2 to 2 cases per 10,000 hospital admissions. This review intends to offer detailed evaluation and a comprehensive meta-analysis of the international literature on SEA between 1954 and 1997, especially of patients who developed it following anesthetic procedures in the spinal canal. In this period, 915 cases of SEA were published. This review is the most comprehensive literature analysis on SEA to date. Most cases of SEA occur in patients aged 30 to 60 years, but the youngest patient was only 10 days old and the oldest was 87. The ratio of men to women was 1:0.56. The most common risk factor was diabetes mellitus, followed by trauma, intravenous drug abuse, and alcoholism. Epidural anesthesia or analgesia had been performed in 5.5% of the patients with SEA. Skin abscesses and furuncles were the most common source of infection. Of the patients, 71% had back pain as the initial symptom and 66% had fever. The second stage of radicular irritation is followed by the third stage, with beginning neurological deficit including muscle weakness and sphincter incontinence as well as sensory deficits. Paralysis (the fourth stage) affected only 34% of the patients. The average leukocyte count was 15,700/microl (range 1,500-42,000/microl), and the average erythrocyte sedimentation rate was 77 mm in the first hour (range 2-50 mm). Spinal epidural abscess is primarily a bacterial infection, and the gram-positive Staphylococcus aureus is its most common causative agent. This is true also for patients who develop SEA following spinal anesthetics. Magnetic resonance imaging (MRI) displays the greatest diagnostic accuracy and is the method of first choice in the diagnostic process. Myelography, commonly used previously to diagnose SEA, is no longer recommended. Lumbar puncture to determine cerebrospinal fluid protein concentrations is not needed for diagnosis and entails the risk of spreading bacteria into the subarachnoid space with consequent meningitis; therefore, it should not be performed. The therapeutic method of choice is laminectomy combined with antibiotics. Conservative treatment alone is justifiable only for specific indications. Laminotomy is a therapeutic alternative for children. The mortality of SEA dropped from 34% in the period of 1954-1960 to 15% in 1991-1997. At the beginning of the twentieth century, almost all patients with SEA died. Parallel to improvements in the mortality rate, today more patients experience complete recovery from SEA. The prognosis of patients who develop SEA following epidural anesthesia or analgesia is not better than that of patients with noniatrogenic SEA, and the mortality rate is also comparable. The essential problem of SEA lies in the necessity of early diagnosis, because only timely treatment is able to av...

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Section: Introductionmentioning

confidence: 99%

Spinal epidural abscess: a meta-analysis of 915 patients

Waldbaur²,

2000

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“…This disease has been reported in elderly patients, and as a complication of septic infection, spinal surgery or even coronary angioplasty. [2][3][4] Several organisms are reported to be the cause of epidural abscess, including Staphylococcus aureus, Streptococci and Klebsiella spp. 2,3,[5][6][7] Other uncommon organisms have also been reported, including Hemophilus paraphrophilus, 8 and Nisseria spp.…”

Section: Discussionmentioning

confidence: 99%

Pyogenic Spinal Epidural Abscess

et al. 1999

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A Al-Othman, A Ammar, M Moussa, FE Morsy, Pyogenic Spinal Epidural Abscess. 1999; 19(3): 241-242 Over the last 10 years, four cases of spinal epidural abscess have been admitted and treated at King Fahd University Hospital. Three of these patients were surgically treated, while one was treated conservatively. Acid-fast bacilli (AFB) were not detected in any of the cases. All four patients were put on antibiotics for periods of 4-8 weeks and showed remarkable recovery. Case 1A 17-year-old Saudi university student was admitted to our service with a short history of back pain and rapid onset of weakness in both lower limbs. The patient had a fever of 38°C, and on examination, was found to have paraparesis grade 2 in the right side and grade 3 in the left, with a sensory level at D8. He was able to control his sphincters. CT scan showed a large chest abscess extending posteriorly and laterally to the epidural space in the levels D8-D9. The patient underwent urgent surgery of laminectomy of D8 and D9, and evacuation of the abscess. The pus was examined for pyogenic organisms as well as AFB by standard laboratory methods.1 No AFB were detected by direct smear and culture. Klebsiella spp. was isolated and the patient was treated with piperacillin, meropenem and cefamandole for five weeks. The patient showed immediate improvement postoperatively, and had another operation for thoracotomy and removal of the chest abscess a week after the first surgery. He improved markedly and was discharged, walking normally after four weeks. Case 2A 22-year-old Saudi man, a known case of sickle cell disease with several months of back pain, was admitted to our hospital complaining of severe lumbar pain. He had no neurological deficit, had normal motor power and normal control of the sphincters. He was highly febrile, with a temperature of 39°C. Lumbar x-rays and CT scan showed a small epidural abscess at the level of L1-L2, extending from the thoracic cavity. No evidence of osteomyelitis was detected. The patient was treated conservatively with antibiotics (gentamycin and ceftriaxone) and painkillers (voltaren) for six weeks. He showed marked improvement and was discharged home after eight weeks. Case 3A 35-year-old Indian man was admitted to our hospital suffering from severe low back pain, fever and weakness of both lower limbs. He was partially incontinent, and sensation was reduced at the sensory level of L3. The patient reported that he was operated on at the age of six years for low back midline subcutaneous abscess. As the CT scan showed a large epidural abscess at level L3-L5, an emergency laminectomy of L3-L4 and evacuation of the abscess were performed. A drain was left in the wound for four days. There was no evidence of dermal sinus, however such a possibility could not be ruled out completely. Staphylococcus aureus was isolated from the abscess cavity. The organism was sensitive to cefazolin, and the drug was given for four weeks. No AFB was detected. The patient's condition improved and he returned to normal activities...

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“…7 ± 9 We consider an epidural infection an emergency calling for immediate surgical intervention as soon as the patient has developed even minor neurological de®cits. 8,17,18 A perfectly normal patient with just an elevated ESR and local pain may progress to complete paraplegia in as little as 2 h. 19 Our experience suggests that treatment should be started before severe neurological de®cits have developed. Chances for signi®cant neurological improvement or maintaining a neurologically intact status may decline rapidly if surgery is not performed at the earliest possible time.…”

Section: Surgery or Antibiotics?mentioning

confidence: 97%

“…7,9,10,17,22 Repeated postoperative ESR measurements and measurements of C reactive protein (CRP) may indicate successful treatment or alert the physician to a new or not su ciently treated infectious problem.…”

Section: Systemic Parameters Of Infectionmentioning

confidence: 99%

Extradural infections of the spine

Klekamp

Samii

1999

Spinal Cord

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Objectives:We have observed a recent increase in the incidence of spinal extradural infections. To determine postoperative outcome and prognosis we have undertaken a retrospective study on patients with spinal extradural abscesses between 1978 and 1996 treated in the Department of Neurosurgery at the Nordstadt Hospital in Hannover, Germany. Methods: Case records, outpatient ®les, operation notes, neuroradiological examinations and pathological reports were analysed. Neurological function was documented using a score system for each symptom. Results: Twenty-two patients underwent 24 operations during the study period. Staphylococcus aureus was the organism most commonly isolated. Patients presented after a mean history of 1.8+2.6 months with acute development of severe para-or tetraparesis and were followed up for an average period of 6+7 months. Two groups were distinguished. One group was characterized by epidural collections of pus (14 patients). Two patients in this group were not operated due to their moribund state and died from uncontrollable septicemia. Two of the remaining 12 operated patients died within 30 days after surgery due to generalized septicemia or other medical problems unrelated to the spinal involvement. Of the ten surviving patients, ®ve sustained major neurological de®cits, whereas the remaining ®ve patients made an incomplete recovery. The second group consisted of eight patients in a signi®cantly better pre-operative health condition in whom granulomatous material was obtained during the operation and the outcome was considerably better. No patient in this group died. Six patients recovered with no or mild neurological de®cits. Conclusion: Spinal extradural infections require immediate surgical intervention. Neurological outcome depends on the pre-operative neurological status. Survival is determined by the general health condition of the patient.

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Thoracic Epidural Abscess

Cited by 23 publications

References 0 publications

Spinal epidural abscess: a meta-analysis of 915 patients

Spinal epidural abscess: a meta-analysis of 915 patients

Pyogenic Spinal Epidural Abscess

Extradural infections of the spine

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