Microbiological Evaluation of the Extension Wire and Percutaneous Epidural Lead Anchor Site Following a "2-Stage Cut-Down" Spinal Cord Stimulator Procedure.

OBJECTIVES: There are concerns regarding bacterial colonization of the temporary extension leads and subsequent infection risk using the 2-stage cut-down approach in spinal cord stimulation (SCS). We sought to quantify the extent of bacterial colonization of the temporary extension wire and percutaneous epidural lead anchor site. MATERIALS AND METHODS: We conducted a cross-sectional observational study recruiting a pragmatic sample of 25 consecutive patients listed for a cut-down trial of SCS. We excluded patients undergoing revision procedures and those who had previously received a spinal cord stimulator. The primary outcome measure was the rate and type of colonization of the extension wires and lead anchor site. RESULTS: No surgical site infections were recorded in any of the patients and no late infections subsequent to insertion of the implantable pulse generator. Overall, 24% of patients grew organisms from the temporary extension wire. Five patients grew coagulase-negative Staphylococcus aureus, and 1 patient grew Enterococcus faecalis. There were no positive wound cultures from the anchor site of the epidural lead. CONCLUSIONS: Despite the high colonization rate of the temporary extension wire, there were no surgical site infections. We conclude that provided appropriate strategies for the management of surgical site infections are implemented, the 2-stage cut-down procedure is a safe approach that is not associated with a higher incidence of infection.

Fusobacterium septicemia complicated by cerebral subdural and epidural empyemas: a rare case of Lemierre syndrome.

BACKGROUND: Lemierre syndrome is characterized by postanginal septicemia and internal jugular vein thrombophlebitis with secondary septic emboli, typically to the lungs. The central nervous system (CNS) is rarely involved. OBJECTIVE: To present a case of Lemierre syndrome featuring cerebral subdural and epidural empyemas. CASE REPORT: This case report describes the case of a 17-year-old youth with cerebral subdural and epidural empyemas. The findings of chest computed tomography of the neck and the blood cultures were compatible with Lemierre syndrome. The patient recovered well after antibiotic treatment and surgical debridement. CONCLUSION: Lemierre syndrome can result in infection spreading to the CNS, including cerebral subdural and epidural empyemas. This disease entity should be included in the differential diagnoses of CNS bacterial infections.

The clinical characteristics, therapeutic outcome, and prognostic factors of non-tuberculous bacterial spinal epidural abscess in adults: a hospital-based study.

PURPOSE: Nontuberculous bacterial spinal epidural abscess (SEA) is a serious infectious disease of spines. Despite proper management, SEA remains a disease of high morbidity. The epidemiological data in southern Taiwan is still lacking. METHODS: We analyzed the clinical features, laboratory data, magnetic resonance imaging findings, and therapeutic results of 45 bacterial SEA patients, collected during a study period of six years (2003- 2008). RESULTS: The 45 adult SEA patients, 32 were men and 13 women, aged 17-81 years (mean = 62 years). Thoracic and lumbosacral spines were the most commonly affected segments. Staphylococcus aureus was the most commonly implicated pathogen, accounting for infections in 67% (29/43) of the culture-proven cases, and 41% (12/29) of the S. aureus strains were oxacillin resistant. Gram-negative pathogens were implicated in 30% (13/43) of the culture-proven cases. Of the 45 patients, 19 underwent antibiotic treatment alone and 26 underwent medical and surgical treatments. The therapeutic results showed that 28 patients had a good prognosis and 17 had a poor prognosis. The significant prognostic factors included higher age, presence of diabetes mellitus and chronic heart disease, and initial presentation of altered consciousness. CONCLUSION: S. aureus was the most commonly implicated pathogen of adult SEA, and most S. aureus strains were oxacillin resistant. A relatively high incidence of Gram-negative infection was observed in this study. The epidemiological characteristics of the implicated pathogens must receive special consideration when selecting the empirical antibiotics. Despite adequate management, many adults with bacterial SEA had a high incidence of poor prognosis.

Isolated subacute tuberculous spinal epidural abscess of the cervical spine: a brief report of a special case.

A tuberculous spinal epidural abscess is seen rarely as a late complication of Pott's disease or in immunocompromised patients. Such abscesses in isolation are rare indeed and very uncommon in the developed and developing world. We report a patient with an isolated subacute tuberculous spinal epidural abscess without disc or vertebral involvement and no primary focus or risk factors associated with the development of spinal tuberculosis.

Epidural tuberculosis involving the entire spine.

We discuss an elderly male who developed severe back pain, rapidly progressing paraparesis and urinary retention consequent to L5-S1 spinal tuberculosis with dissemination of epidural tubercular abscess and granulation tissue to the cervical, thoracic, lumbar and sacral region. The initial diagnosis of lumbo-sacral pathology with high thoracic extension was tackled by an L5 laminectomy and decompression along with saline flushing and evacuation of the thoraco-lumbar and sacral epidural abscess with the aid of a catheter passed superiorly and inferiorly. He developed neck pain and upper limb weakness subsequently and was found to have extensive extradural cervical compression by granulation tissue. He underwent C4-7 laminectomy and decompression of the cord. He was started on four-drug anti-tubercular treatment. At 6-month follow-up, he had marked neurological improvement. MRI screening of the entire spine showed complete resolution of the disease. Contiguous epidural involvement of the entire spine by tubercular pathology has never been reported before. We suggest that screening of the entire spine should be considered in select cases of spinal tuberculosis based on symptomatology.

Spinal Epidural Abscess in Children: Case Report and Review of the Literature.

BACKGROUND: Spinal epidural abscess (SEA) is a rare but serious infection in the epidural space along the spinal cord. SEA should be considered in patients with backache, fever, neurological deficits and/or spinal tenderness. Early diagnosis is imperative to prevent permanent neurological sequelae. CASE DESCRIPTION: We report a case of lumbar SEA in a 13-year-old girl who was immunocompetent and presented with spinal tenderness, back pain and 4 days of fever. A lumbar magnetic resonance imaging demonstrated an epidural abscess from L3-S1. She had emergent surgical intervention. Cultures grew methicillin-susceptible Staphylococcus aureus. She was also given long-term systemic antibiotics and she made a complete recovery within 2 months. CONCLUSIONS: SEA in an immunocompetent pediatric without risk factors is an extremely rare condition. In the English-language literature, there are only 30 reported cases in the past 19 years; our case brings the total to 31. Non-surgical treatment has been successful in both adult and pediatric patients under certain conditions. Still, there exists a risk of deterioration with non-surgical management, even in patients for whom treatment is begun in the absence of neurologic deficits. Tracking neurological deficits in children can be challenging, particularly in young children who are non-verbal and not yet ambulating, and a reliable neurologic examination is a critical component of non-surgical care. In consideration of these facts and the accelerated time frame of deterioration, once neurologic deficits are present, surgery plus systemic antibiotics remains the standard of care for pediatric SEA patients, with each individual case meriting review of the full clinical picture.

Large paraspinal abscess as a complication of infliximab therapy in Crohn's disease.

We report a 36-year-old man who developed a large epidural and paraspinal abscess as a complication of infliximab therapy being used for underlying Crohn's disease. Cultures of the collection grew methicillin-susceptible Staphylococcus aureus, and treatment consisted of abscess drainage, prolonged intravenous and oral flucloxacillin and temporary withholding of his infliximab. While infection-related complications are well described with infliximab therapy, this is the first description of a large paraspinal abscess with epidural extension.

Acute pyogenic diskitis (spondylodiskitis) in adults.

Most cases of back pain are the result of degenerative changes in the spine or are related to musculoskeletal elements. Pyogenic infections of the back can be subcategorized into cases involving the paraspinal epidural space, vertebral bodies, or the intervertebral disk spaces. Any region of the spine may be the site of diskitis, although the process most commonly involves the lumbar spine. Most cases of diskitis are managed with conservative therapy, including antibiotics and spinal immobilization using braces or corsets. Surgical therapy is generally reserved for patients with neurological complications, spinal instability, or progressive spinal deformity or those who fail to respond clinically to antibiotic therapy alone.

Frontal bone and epidural tuberculosis.

Cranial bone and epidural tuberculosis is rare manifestation extrapulmonary tuberculosis. The incidence of tuberculosis of calvaria is on the rise in developing countries because of malnutrition, poor socioeconomic conditions, and immunodeficiency. We present the clinical features, radiology, histopathology, and surgical findings of a case of tuberculosis of the frontal bone with epidural extension. A 46 year-old female had presented with a history of painless right frontal swelling for the previous 4 months. The patient was operated on at a peripheral center for swelling in the right frontal region. In postoperative period, a leak that did not reply to nonspecific antibiotic therapy developed on the lesion. Right frontal epidural effusion was found in the patient who presented our clinic. Histopathological and microbiological examination suggested a diagnosis of tuberculosis.

Invasive Pulmonary Aspergillosis in the Epidural Space in a Patient with Acute Myelogenous Leukemia with Myelodysplasia-related Changes: A Case Study and Literature Review of Vertebral Aspergillosis in Japan.

Vertebral aspergillosis is a rare infectious disease with a high mortality rate. We herein report a 70-year-old woman with acute myelogenous leukemia with myelodysplasia-related changes, nontuberculous mycobacteriosis, and bronchiectasis who presented with a fever and cough. Her clinical symptoms and laboratory test results suggested febrile neutropenia and pneumonia. However, her clinical course was further complicated by lower extremity weakness. Magnetic resonance imaging of the spine showed consolidation contiguously spreading toward the epidural space between the T4 and T5. Cytological testing of the pleural effusion revealed Aspergillus fumigatus. We also review and summarize previously reported cases of vertebral aspergillosis in Japan.

Compressive spinal epidural mass caused by Propionibacterium acnes.

BACKGROUND CONTEXT: Propionibacterium acnes is a gram-positive and facultative anaerobe bacillus that is found within sebaceous follicles of the human skin and recognized as a cause of infections after spinal surgery. To our knowledge, there has been no previously reported case of symptomatic compressive chronic inflammatory epidural mass caused by P. acnes in a patient with no prior spinal procedures. PURPOSE: This study aimed to describe a case of primary spinal infection by P. acnes. STUDY DESIGN: This study is a case report of a condition not previously described in the literature. METHODS: We present the history, physical examination, laboratory, radiographic, and histopathologic findings of a chronic inflammatory epidural mass caused by P. acnes in an immunocompetent adult male with no history of spinal surgery. RESULTS: A 51-year-old man presented to our clinic with sudden onset bilateral lower extremity weakness, inability to ambulate, and urinary retention. His past clinical history was remarkable only for hernia and left knee surgery but no spinal surgery. A year earlier, he had an infected draining abscess of the right axilla that was successfully managed medically. At presentation, his serum erythrocyte sedimentation rate and C-reactive protein were moderately elevated. Pan-spine magnetic resonance imaging was notable for a circumferential epidural mass from C5 to T6. He underwent emergent decompression; the mass was removed and sent for culture and pathologic evaluation. Cultures from all three specimens collected during surgery grew P. acnes, and the patient was successfully managed on intravenous ceftriaxone, while pathology revealed a chronic inflammatory reactive process. CONCLUSIONS: This is the first reported case of a primary spinal mass with chronic inflammatory features caused by P. acnes. In cases of epidural mass of unknown origin, both pathologic specimens and cultures should be obtained as slow-growing organisms may mimic oncologic processes.

CT-Guided Biopsy in Suspected Spondylodiscitis--The Association of Paravertebral Inflammation with Microbial Pathogen Detection.

OBJECTIVES: To search for imaging characteristics distinguishing patients with successful from those with futile microbiological pathogen detection by CT-guided biopsy in suspected spondylodiscitis. METHODS: 34 consecutive patients with suspected spondylodiscitis underwent CT-guided biopsy for pathogen detection. MR-images were assessed for inflammatory infiltration of disks, adjacent vertebrae, epidural and paravertebral space. CT-images were reviewed for arrosion of adjacent end plates and reduced disk height. Biopsy samples were sent for microbiological examination in 34/34 patients, and for additional histological analysis in 28/34 patients. RESULTS: Paravertebral infiltration was present in all 10/10 patients with positive microbiology and occurred in only 12/24 patients with negative microbiology, resulting in a sensitivity of 100% and a specificity of 50% for pathogen detection. Despite its limited sensitivities, epidural infiltration and paravertebral abscesses showed considerably higher specificities of 83.3% and 90.9%, respectively. Paravertebral infiltration was more extensive in patients with positive as compared to negative microbiology (p = 0.002). Even though sensitivities for pathogen detection were also high in case of vertebral and disk infiltration, or end plate arrosion, specificities remained below 10%. CONCLUSIONS: Inflammatory infiltration of the paravertebral space indicated successful pathogen detection by CT-guided biopsy. Specificity was increased by the additional occurrence of epidural infiltration or paravertebral abscesses.

An unusual presentation of epidural Acinetobacter infection.

OBJECTIVE: We report a case of spinal-cord compression caused by epidural fat infection with Acinetobacter. The initial magnetic resonance imaging (MRI) scan suggested epidural hematoma or abscess, although both were absent at surgery. CASE REPORT: A 60-year-old man had a thoracic epidural sited at the level of T8/9 for postoperative analgesia after major abdominal surgery. A mixture of bupivacaine 0.1% and fentanyl 2 microg/mL was infused at a rate of 10 mL/h for 48 hours postoperatively. The epidural catheter was then removed, but 24 hours later, the patient still had weakness and numbness in his lower limbs. An MRI scan showed cord compression secondary to a hematoma or abscess from the level of T6 to T11. At laminectomy, no hematoma or abscess was found, but edematous epidural fat was excised. This fat was sent for culture and Acinetobacter was grown. Appropriate antibiotic therapy was given. Over a period of 12 months, the patient has regained near-normal power and sensation. CONCLUSION: Epidural Acinetobacter infection may present atypically without signs of meningism. MRI imaging may be confusing in these infections and lead to incorrect radiological diagnoses. Spinal-cord compression, as a complication of epidural catheter placement, does not have to be caused by hematoma or abscess.

Spinal epidural abscess: an analysis of 24 cases.

BACKGROUND: Despite advances in neuroimaging and neurosurgical care, spinal abscess remains a challenging problem with mortality rates ranging from 4.6% to 31% in recent series. METHODS: Between January 1986 and December 2003, 24 patients with spinal epidural abscess were treated. Seventeen were men and 7 were women at the average age of 47.5 years. Concurrent illnesses that result in immunodepression such as diabetes and infections occurred in 62% of the case patients. All patients had back pain, 16 had muscle weakness, 9 had paresthesias, and 8 had sphincteral changes. Twenty-one patients underwent surgical procedures. In 11 case patients, the abscess had a frankly purulent material, and, in 5, the epidural lesion consisted of granulation tissue; the other 5 case patients had a combination of the 2. Three patients were treated conservatively. Staphylococcus aureus was isolated in 57% of the case patients. The lumbar spine was affected in 11 patients; the cervical spine, in 3. RESULTS: Fifteen patients recovered their normal neurological functions but 4 remained with some neurological disability. No deaths occurred in this series. CONCLUSIONS: Immediate surgical drainage of the abscess, before the development of severe neurological deficit, combined with specific antibiotics remains the treatment of choice.

Spinal epidural abscess and meningitis following short-term epidural catheterisation for postoperative analgaesia.

We present a case of a patient with a spinal epidural abscess (SEA) and meningitis following short-term epidural catheterisation for postoperative pain relief after a laparoscopic sigmoid resection. On the fifth postoperative day, 2 days after removal of the epidural catheter, the patient developed high fever, leucocytosis and elevated C reactive protein. Blood cultures showed a methicillin-sensitive Staphylococcus aureus infection. A photon emission tomography scan revealed increased activity of the spinal canal, suggesting S. aureus meningitis. A gadolinium-enhanced MRI showed a SEA that was localised at the epidural catheter insertion site. Conservative management with intravenous flucloxacillin was initiated, as no neurological deficits were seen. At last follow-up, 8 weeks postoperatively, the patient showed complete recovery.

A 15-year-old with back pain, fever, and leg numbness.

Spinal epidural abscess (SEA) is an uncommon entity. We report an adolescent presenting with fever and back pain beginning 3 months after a leg abscess. This case highlights several important aspects of the diagnosis and care of patients with SEA. As illustrated by this case, plain radiographs and computed tomography of the spine can miss the diagnosis, thus when spinal epidural abscess is suspected, magnetic resonance imaging is the imaging modality of choice. Epidural abscesses most commonly arise from hematological dissemination, with Staphylococcus aureus being the most often cultured organism. Surgical intervention early combined with the administration of proper antibiotics leads to the best outcome.

Diagnosis and management of spinal epidural abscess.

Twenty-five patients with spinal epidural abscess were treated at the University of Western Ontario hospitals between July 1980 and July 1990. There were eighteen males (72%) and seven females (28%), with a median age of 60 years. Concurrent illness resulting in immunocompromise was present in 60%. Eleven presented with complete myelopathy, thirteen had limb weakness, and one had no neurological deficit. In twenty cases the abscess consisted of frankly purulent material, while in five the epidural collection consisted of chronic granulation tissue. Staphylococcus aureus was isolated in 64% of the abscesses. Twenty-seven surgical procedures were performed on 21 patients. Ten cases occurred in the cervical spine (40%), seven in the thoracic spine (28%), three in both the cervical and thoracic spine (12%) and five in the lumbosacral spine (20%). Fourteen patients (56%) retained or recovered ambulation and there were five deaths (20%). The progression from back and radicular pain to weakness and eventual paralysis continues to be characteristic of spinal epidural infection. Morbidity and mortality remain unacceptably high because of delay in diagnosis and treatment. Magnetic resonance imaging is the radiological investigation of choice for the diagnosis of spinal epidural abscess. Prompt intervention, before the development of severe neurological deficits, can improve outcome. Immediate surgical drainage combined with antibiotics remains the treatment of choice.

Epidural spinal infection. Variability of clinical and magnetic resonance imaging findings.

STUDY DESIGN: This study evaluates the magnetic resonance characteristics of spinal epidural abscesses and their associated disc space infections. OBJECTIVES: The results were correlated with history, clinical, and laboratory findings to provide guidelines for early and appropriate diagnosis of epidural spinal infections. SUMMARY OF BACKGROUND DATA: Imaging signs of spinal infections have been reported before, but not with special attention to early clinical and imaging findings. METHODS: Thirteen patients (10 men, 3 women; age range, 32-64 years) with progressive sensorimotor deficit were studied. All patients had a neurologic examination after admission and a magnetic resonance imaging scan done within the first 48 hours. In all cases, T1-weighted images before and after administration of gadolinium were obtained. T2-weighted images were acquired in eight cases as well. Ten patients subsequently underwent open surgery; in three cases, a percutaneous biopsy and drainage was performed. RESULTS: Cervical discitis was found in five patients, and thoracic discitis was seen in another five cases. Three patients had an epidural infection without a concomitant discitis. Neurologic and clinical findings varied considerably. Despite clinical signs of spinal cord involvement, a spinal cord lesion was demonstrated only once. Signal change in T2-weighted images may be the first sign of disc space infection. Because a neurologic deficit may occur before any change is visible, follow-up examinations may be required if epidural infection is suspected on clinical grounds. CONCLUSIONS: Magnetic resonance imaging is the appropriate method for diagnostic work-up of progressive neurologic deficit resulting from epidural infection.

Hematogenous pyogenic spinal infections and their surgical management.

STUDY DESIGN: Mainly a retrospective study of 101 cases of pyogenic spinal infection, excluding postoperative infections. Data were obtained through medical record review, imaging examination, and patient follow-up evaluation. SUMMARY OF BACKGROUND DATA: Hematogenous pyogenic spinal infection has been described variously as spondylodiscitis, discitis, vertebral osteomyelitis, and epidural abscess. Recommended treatment options have included conservative methods (antibiotics and bracing) and surgical intervention. However, a comprehensive classification that would aid in diagnosis, treatment planning, and prognosis has not yet been devised. OBJECTIVES: To analyze the bacteriology, pathologic entities, complications, and results of treatment options for pyogenic spinal infection. METHOD: All patients received plain radiographs, gadolinium-enhanced magnetic resonance imaging scans, and bone/gallium radionuclide studies. All patients had tissue biopsies. Bacteriology, hematology, and predisposing factors were analyzed. All patients received intravenous and oral antibiotics. A total of 58 patients underwent surgery. Patient outcomes were correlated with clinical status, with treatment method and, where applicable, with location and nature of epidural compression. Statistical analyses were performed. RESULTS: Spondylodiscitis occurred most commonly with primary epidural abscess, spondylitis, discitis, and pyogenic facet arthropathy, all occurring rarely. Staphylococcus aureus was the main organism. Infection elsewhere was the most common predisposing factor. Leukocyte counts were elevated in 42.6% of spondylodiscitis cases. The erythrocyte sedimentation rate was elevated in all cases of epidural abscess. There were 35 cases of epidural abscess (frank abscess, 29; granulation tissue, 6). Epidural abscess complicating spondylodiscitis occurred most often in the cervical spine, followed by thoracic and lumbar areas. The rate of paraplegia or paraparesis also was highest in cervical and thoracic regions. There were no cases of quadriplegia. All patients with either epidural granulation tissue or paraparesis recovered completely after surgical decompression. Only 18% of patients with frank epidural abscess and 23% of patients with paralysis recovered completely after surgical decompression. Patients with spondylodiscitis who were treated nonsurgically reported residual back pain more often (64%) than patients treated surgically (26.3%). CONCLUSIONS: Pyogenic spinal infection can be thought of as a spectrum of disease comprising spondylitis, discitis, spondylodiscitis, pyogenic facet arthropathy, and epidural abscess. Spondylodiscitis is more prone to develop epidural abscesses in the cervical spine (90%) than the thoracic (33.3%) or lumbar (23.6%) areas. Thecal sac neurocompression has a greater chance of causing neurologic deficit in the thoracic spine (81.8%). Treatment of neurologic deficit caused by epidural abscess is prompt surgical decompression, with or without fusion. Patients with frank abscess had less favorable outcomes than those with granulation tissue, and paraplegia responded to treatment more poorly than paraparesis. Surgery was preferable to nonsurgical treatment for improving back pain.