Breast ultrasound: An opportunity to detect unsuspected pleural and pulmonary abnormalities.

PURPOSE: While scanning women for breast US, is possible to observe changes in the appearance of the pleural line or in the most superficial portion of the lung. The objective of this single-center, prospective study was to determine the prevalence of a variety of pleural and pulmonary US findings during routine breast US. METHODS: In this study, there were 200 women undergoing standard breast US examination. The presence of pleural and pulmonary abnormalities in these cases was recorded. Two off-site reviewers confirmed the presence of pleura and lung changes. RESULTS: There was no abnormal finding in 168 out of 200 cases (84%) while there were one or more abnormal findings in 32 cases (16%). Pleural effusion was observed in 0.5% of cases, thickening of the pleural line 5% of cases, irregularity of the pleural line in 6% of cases, increased number of vertical artifacts in 9% of cases, subpleural nodulations in 2% of cases, and lung consolidation in 0.5%. CONCLUSION: Pleural and lung changes are not uncommon during breast US. Operators performing breast US examinations should be aware of the possibility to identify unsuspected pleuro-pulmonary abnormalities.

Complications Subsequent to Urinary Tract Stent Placement: An Overview Focusing on the Imaging of Cancer Patients.

Ureteral involvement by a tumor is common, and both partial and complete obstructions can result in symptoms that are distressing and debilitating, especially in cancer patients for whom the resection of the primary tumor is not considered an option. Maintaining ureteric patency in these patients is a challenge. In addition, in cases where a patient has undergone nephroureterectomy due to primary transitional cell cancer, it becomes necessary to decompress the urinary tract to preserve the contralateral kidney from irreversible damage. This is possibly due to ureteral stenting, both retrograde and anterograde, and percutaneous nephrostomy (PCN). Since imaging plays an important role in the routine monitoring of stents, their more and more increasing use requires radiologists to be familiar with these devices, their correct position, their potential complications, and their consequences. The aim of this review is to offer a comprehensive review of the imaging features of some urinary stents and to show the complications encountered in cancer patients as a direct consequence of an invasive diagnostic or therapeutic procedure. Specifically, we focus on ureteral stents and PCN.

Spinal Cord Stimulation Meets Them All: An Effective Treatment for Different Pain Conditions. Our Experience and Literature Review.

IntroductionSpinal Cord Stimulation (SCS) is an emerging minimally invasive technique which uses neuromodulation to manage different forms of intractable pain. SCS is a well-established option for the treatment of various pain conditions, and nowadays, indications are ever increasing.Materials and MethodsIn this study, we present our case series of 49 patients who underwent SCS at our Institution for the treatment of pain from different etiologies, and discuss our 10-year experience in SCS. For the purpose of this study, we also performed a systematic review of current indications and new perspectives in SCS.ResultsAmong our case series, patients were differentiated into two groups upon prior spinal surgery: patients who had undergone prior spinal surgery for back pain were defined as the "FBSS (failed back surgery syndrome) group," instead patient suffering from different types of pain but who had never undergone surgery were defined as the "naive group." As regards clinical response to SCS, 20 patients out of 36 (55.56%) were classified as responders in the FBSS group; in the "naïve" group, 10 patients out of 13 (76.92%) were classified as responders. Among the "not responders" group, several patients suffered from infections.Of the recent literature about SCS, 2124 records were screened and 37 studies were finally included in the qualitative synthesis for our systematic review.DiscussionIn case of FBSS, surgical revision is often associated with a high morbidity and corresponding low rates of success. Unfortunately, patients affected by chronic pain often become refractory to conservative treatments. Spinal Cord Stimulation (SCS) is nowadays considered as an effective therapy for several chronic and neuropathic pain conditions, such as failed back surgery syndrome. As regards the economic impact of SCS, implantation of an SCS system results in short-term costs increase, but the annual cumulative costs decrease during the following years after implantation, when compared to the costs of conventional management. Beyond the application for the treatment of FBSS, SCS has also been used for the treatment of other types of chronic non-oncological pain such as neuropathic pain and chronic back pain ineligible for surgical intervention. This evidence paved the way to establishing the potential role of SCS also for the treatment of oncological pain. However, the effectiveness and relative safety of SCS for cancer-related pain has not yet been adequately established.ConclusionsSpinal Cord Stimulation is a well-established treatment option in for FBSS. Beyond that, SCS has also been used for the treatment of "naive" patients, suffering from other types of chronic, both oncological and non-oncological, medical-refractory pain such as neuropathic pain and chronic back pain ineligible for surgical intervention.

Surgical Highways to the Craniovertebral Junction: Is It Time for a Reappraisal?

BACKGROUND: The craniovertebral junction (CVJ) can be affected by a variety of congenital or acquired anomalies. Because of its complexity, a careful evaluation of bones and ligamentous structures in all three planes is required. This can be achieved by studying the CVJ in terms of several anatomical and radiological lines that have been visualized to facilitate understanding of its surgical anatomy. In this study we aimed to review the state-of-the art craniometric CVJ lines and approaches. METHODS: In December 2016 a PubMed search was performed, including the search terms 'CVJ surgical approach/line', 'cervical approach', 'craniometric measurement', 'CVJ anatomy' and 'ventral/dorsal/far-lateral approach'. Anatomical and radiological lines and angles evaluated on traditional radiography, computed tomography (CT) scanning or magnetic resonance imaging (MRI) in the axial/sagittal/coronal views were included and described. RESULTS: Several measurements and radiological landmarks were included to evaluate the anatomy of the CVJ. They were fully described and categorized on the basis of the anatomical plan and the surgical or diagnostic purpose they are used for. CONCLUSION: Among the numerous radiological measurements described, it has been shown that McRae's line, Chamberlain's line, McGregor's line, the Redlund-Johnell method and Ranawat's line are the most widely used and reliable ones for evaluating skull base craniometry. Secondly, the hard palate line (HPL), nasoaxial line (NAxL) and palatine-inferior dental arch line (PIA) are used to preoperatively assess the ventral endonasal or transoral surgical approaches. Thirdly, the C7 slope has been demonstrated as a reliable predictor of occipitocervical and spinopelvic alignment in CVJ fusion.

Spinal Cord Stimulation: An Alternative Concept of Rehabilitation?

BACKGROUND: Chronic low back and leg pain is a disabling condition, affecting, in most cases, older patients with congenital or acquired spinal stenosis or patients with failed back surgery syndrome. Spinal cord stimulation has been introduced as an effective therapeutic option for those patients who have previously been operated without significant clinical benefits, or for all those patients who are ineligible for traditional surgery. METHODS: We report our experience with ten patients treated with spinal cord stimulation plus medication and physical therapy between November 2014 and September 2015. Inclusion criteria were: previous surgical treatments for lumbar stenosis and metameric instability and persistent or ingravescent disabling low back and leg pain, with a mean duration of symptoms of at least 18 months. A visual analog scale (VAS) was employed for back and leg pain, and the Oswestry Disability Index (ODI) score was determined, and findings were analyzed after 6 months. FINDINGS: No intra- or postoperative complication was recorded. The mean VAS score for back pain decreased from 7.5 to 2.9, while leg VAS decreased from 8.2 to 3.0. Analysis of ODI values showed evident improvement in daily life activities, ranging from a median value of 75.7% to 32.7 % after the stimulation. CONCLUSION: Spinal cord stimulation has a recognized impact on the pain and on the quality of life of patients with failed back surgery syndrome.

Reconstruction of Vertebral Body After Radiofrequency Ablation and Augmentation in Dorsolumbar Metastatic Vertebral Fracture: Analysis of Clinical and Radiological Outcome in a Clinical Series of 18 Patients.

BACKGROUND: Painful spinal metastases usually occur in malignant neoplastic disease. Treatment for bone metastases has been largely conservative, and it includes the use of high doses of analgesics, radiotherapy, chemotherapy, hormone therapy, and bisphosphonates; however, results are sometimes transient and ineffective. In the presence of neurological involvement a surgical strategy should be considered. Recently, percutaneous procedures such as radiofrequency ablation, vertebroplasty, and kyphoplasty have been introduced as palliative techniques to treat painful vertebral metastases [3, 11, 25]. METHODS: In our study we combined the use of radiofrequency ablation with vertebroplasty in the treatment of dorsolumbar metastatic vertebral fractures in order to examine the relationship between restoration of the vertebral structure and decrease in pain. From January 2014 to March 2015 we retrospectively analyzed 18 patients with malignant vertebral lesions who underwent radiofrequency ablation with vertebroplasty followed by cementoplasty, with posterior transpedicle fixation on levels near the lesions. The parameters examined were: demographics, pain relief, and the distribution of polymethylmethacrylate (PMMA) determined by the mean Saliou filling score; all complications were recorded. FINDINGS: The mean age of the patients was 55.72 years (range 34-69); average operative time was 60.4 min (range, 51-72). The average pain index score (visual analog score; VAS) decreased significantly from 8.05 at baseline to 3.0 (p < 0.05) after 6 months. The Saliou filling score revealed a distribution of PMMA in the vertebral body that was satisfactory (12-18) in eight patients, mediocre (6-12) in seven patients, and inadequate (0-6) in the remaining three patients. In two vertebrae, minimal asymptomatic cement leakage occurred in the lateral recess without neurological damage. No pulmonary embolism and no visceral or neural damage was recorded. CONCLUSION: Radiofrequency ablation combined with vertebroplasty seems to achieve rapid and lasting improvement in clinical symptoms in patients with malignant vertebral lesions. There was wide diffusion of PMMA in the vertebral body, with a mean cement volume of 4.5 ml.

EMG-Guided Percutaneous Placement of Cement-Augmented Pedicle Screws for Osteoporotic Thoracolumbar Burst Fractures.

BACKGROUND: Percutaneous techniques have increasingly gained popularity in recent years. The application of technological innovation, including neuromonitoring techniques, has the potential to increase the safety and efficacy of these procedures. METHODS: Thirty patients suffering from osteoporotic dorsolumbar burst fracture were prospectively enrolled in this study. The patients underwent percutaneous fenestrated pedicle screw fixation augmented with polymethylmethacrylate (PMMA) injection. A novel surgeon-dedicated neuromonitoring device was used in order to increase the safety and the accuracy of the screw insertion. A second group of 30 patients who did not undergo neuromonitoring during percutaneous pedicle screw placement, matched for demographic characteristics, constituted the control group. FINDINGS: A total of 296 screws were inserted. All treated patients had a good outcome, documented by an improvement in visual analogue scale (VAS) scores. Excellent trajectories were achieved in all patients. Cobb's angle and anterior vertebral height were satisfactorily restored in all study group patients. Three misplaced screws in three patients and a case of PMMA leakage without neurological deficits were observed in the control group, whereas no complication was recorded in the study group (p = 0.03). CONCLUSIONS: Neuromonitoring in cement-augmented percutaneous pedicle screw placement appears to improve surgeon confidence during surgery, reducing the risk of screw misplacement or cement leakage.

Black hole sign migration in short-term brain CT scans: A possible link with clot evolution and histology.

The black hole sign (BHS) is a rare radiological sign seen in the hyperacute phase of bleeding. It manifests within a hemorrhage in early hours, with limited studies exploring clot formation and evolution over a short duration. Despite various hypothesized mechanisms, the precise lifetime and dynamics of black hole sign development remain unclear. We describe the rare finding of a black hole sign within a deep brain hemorrhage, initially observed in the lateral portion of the clot during the first CT scan. Remarkably, in a subsequent CT scan, just 1 hour later, the BHS migrated towards the inner edge. Notably, while the hemorrhage size remained largely unchanged within this short timeframe, hyperacute bleeding led to increased perihematomal edema and sulci flattening. Histopathological features of the "evolving clot" are initially characterized by heightened cellularity. This increased cell density renders the hematoma less resistant to compressive forces, such as heightened endocranial pressure, offering a plausible explanation for the crushing and displacement of the BHS. Our study sheds light on the unique radiological progression of BHS within a deep brain ICH, emphasizing its association with dynamic clot formation and the consequential impact on surrounding structures.

Coexistence of mastoid, frontal and vertebral hemangiomas in a patient with diabetic neuropathy: Possible correlation between diabetic angiopathy and intraosseous neoangiogenesis.

Bony hemangiomas are benign vascular lesions with an expansive growth; usually they tend to obliterate the entire bony cavity. They are typical lesion of the spinal bones, but they can rarely arise within other bones of the neurocranium. Diabetic microangiopathy is a condition characterized by the development of aberrant vessel tangles anastomosed to each other due to dysregulated neoangiogenesis. We report the case of a 56-year-old woman, suffering from type 2 diabetes mellitus, admitted to the neurology department due to a reported worsening of paresthesias and dysesthesias of the upper and lower limbs. She performed a contrast-enhanced brain CT scan that showed the presence, at the level of the right mastoid process, of an hypervascular angioma. A subsequent MRI study of the brain and spine showed the presence of multiple bone angiomas, at the level of the right frontal theca and C7, Th3, and Th7 vertebral bodies. Due to the absence of further symptoms and clinical and radiological signs of intracranial compression, the patient did not perform surgery. A radiological follow-up was advised. Although possible pathophysiological correlations between diabetes and vertebral hemangiomas are mentioned in literature, vascular lesions of this type involving vertebrae and skull base simultaneously can be discovered in a patient with chronic diabetic disease. As long as these lesions remain asymptomatic, surgical treatment is not indicated, and the patient is followed over time with radiological follow-up.

Use of new microcirculation software allows the demonstration of dermis vascularization.

AIMS: Current ultrasound (US) Doppler techniques cannot demonstrate the vascularization of the dermis. The purpose of this study was to investigate whether the new Superb Vascular Imaging (SMI) and Microvascular Flow (MV-Flow) techniques improve the detection of normal dermis vessels. SMI and MV-Flow were compared side-by-side to conventional power-Doppler (PD) imaging. METHODS: By using US, 50 healthy volunteers were evaluated at level of five body areas: forehead, forearm, palm, buttock, and thigh. Two off-site operators evaluated the images to assess the difference between SMI and PD imaging and between MV-Flow and PD imaging in terms of dermis flow amount. A 0-3 scoring system was adopted. RESULTS: SMI scored grade 0 in 0% of body areas, grade 1 in 58%, grade 2 in 33%, and grade 3 in 9%. In comparison with SMI, PD scored grade 0 in 38% of body areas, grade 1 in 56%, grade 2 in 6%, and grade 3 in 0%. MV-Flow scored grade 0 in 0% of body areas, grade 1 in 52%, grade 2 in 43%, and grade 3 in 6%. Comparted to MV-Flow, PD scored grade 0 in 53% of body areas, grade 1 in 34%, grade 2 in 13%, and grade 3 in 0%. The difference in terms of sensitivity was statistically significant for all the body areas investigated. CONCLUSIONS: We found both SMI and MV-Flow to be superior to PD imaging and capable to demonstrate normal vascularization of the dermis.

The Impact of Single-Level ACDF on Neural Foramen and Disc Height of Surgical and Adjacent Cervical Segments: A Case-Series Radiological Analysis.

Background: ACDF has become one of the established procedures for the surgical treatment of symptomatic cervical spondylosis, showing excellent clinical results and effective improvements in neural functions and neck pain relief. The main purpose of ACDF is neural decompression, and it is considered by some authors as an indirect result of the intervertebral distraction and cage insertion and the consequent restoration of the disc space and foramen height. Methods: Radiological data from 28 patients who underwent single-level ACDF were retrospectively collected and evaluated. For neural foramen evaluation, antero-posterior (A-P) and cranio-caudal (C-C) diameters were manually calculated; for intervertebral disc height the anterior, centrum and posterior measurement were calculated. All measurements were performed at surgical and adjacent (above and below) segments. NRS, NDI and also the mJOA and Nurick scale were collected for clinical examination and complete evaluation of patients' postoperative outcome. Results: The intervertebral disc height in all its measurements, in addition to the height (C-C diameter) of the foramen (both right and left) increase at the surgical segment when comparing pre and postop results (p < 0.001, and p = 0.033 and p = 0.001). NRS and NDI radiculopathy scores showed improved results from pre- to post-op evaluation (p < 0.001), and a negative statistical correlation with the improved disc height at the surgical level. Conclusions: The restoration of posterior disc height through cage insertion appears to be effective in increasing foraminal height in patients with symptomatic preoperative cervical foraminal stenosis.

CT Coronary Angiography: Technical Approach and Atherosclerotic Plaque Characterization.

Coronary computed tomography angiography (CCTA) currently represents a robust imaging technique for the detection, quantification and characterization of coronary atherosclerosis. However, CCTA remains a challenging task requiring both high spatial and temporal resolution to provide motion-free images of the coronary arteries. Several CCTA features, such as low attenuation, positive remodeling, spotty calcification, napkin-ring and high pericoronary fat attenuation index have been proved as associated to high-risk plaques. This review aims to explore the role of CCTA in the characterization of high-risk atherosclerotic plaque and the recent advancements in CCTA technologies with a focus on radiomics plaque analysis.

Use of High-Frequency Transducers in Breast Sonography.

Sonography companies have recently developed high-frequency transducers (20-30 MHz) to image the skin and small joints. In this pictorial review, we present a number of settings where these probes can be usefully employed to scan the breast. These include skin abnormalities of the breast and axilla; nipple-areolar complex abnormalities; superficial breast parenchyma abnormalities; breast parenchyma abnormalities in subjects with implants; very small female breasts; peripheral areas in breasts of any size; pre-puberal breasts; male breasts; post-mastectomy chest wall; and intraoperative breast sonography. Comparatively, side-by-side images obtained with conventional breast frequencies and high frequencies are shown.

White Cord Syndrome After Cervical or Thoracic Spinal Cord Decompression. Hemodynamic Complication or Mechanical Damage? An Underestimated Nosographic Entity.

The ischemia/reperfusion mechanism is believed to be responsible for parenchymal damage caused by temporary hypoperfusion and worsened by the subsequent attempt of reperfusion. This represents a true challenge for physicians of several fields, including neurosurgeons. A limited number of papers have shed the light on a rare pathologic condition that affects patients experiencing an unexplained neurologic deficit after spine surgery, the so-called "white cord syndrome." This entity is believed to be caused by an "ischemia/reperfusion" injury on the spinal cord, documented by a postoperative intramedullary hyperintensity on T2-weighted magnetic resonance imaging sequences. To date, the cases of white cord syndrome reported in literature mostly refer to cervical spine surgery. However, the analysis of several reviews focusing on spine surgery outcome suggests postoperative neurologic deficits of new onset could be charged to a mechanism of ischemia/reperfusion, even if the physiopathology of this event is seldom explored or at least discussed. The same neuroradiologic finding can suggest mechanical damage due to inappropriate surgical manipulation. On this purpose, we performed a systematic review of the literature with the aim to identify and analyze all the factors potentially contributing to ischemic/reperfusion damage of the spinal cord that may potentially complicate any spinal surgery, without distinction between cervical or thoracic segments. Finally, we believe that postoperative neurologic deficit after spinal surgery constituting the "white cord syndrome" could be under-reported; both neurosurgeons and patients should be fully aware of this rare but potentially devasting complication burdening cervical and thoracic spine surgery.

Focused Ultrasound in Neuroscience. State of the Art and Future Perspectives.

Transcranial MR-guided Focused ultrasound (tcMRgFUS) is a surgical procedure that adopts focused ultrasounds beam towards a specific therapeutic target through the intact skull. The convergence of focused ultrasound beams onto the target produces tissue effects through released energy. Regarding neurosurgical applications, tcMRgFUS has been successfully adopted as a non-invasive procedure for ablative purposes such as thalamotomy, pallidotomy, and subthalamotomy for movement disorders. Several studies confirmed the effectiveness of tcMRgFUS in the treatment of several neurological conditions, ranging from motor disorders to psychiatric disorders. Moreover, using low-frequencies tcMRgFUS systems temporarily disrupts the blood-brain barrier, making this procedure suitable in neuro-oncology and neurodegenerative disease for controlled drug delivery. Nowadays, tcMRgFUS represents one of the most promising and fascinating technologies in neuroscience. Since it is an emerging technology, tcMRgFUS is still the subject of countless disparate studies, even if its effectiveness has been already proven in many experimental and therapeutic fields. Therefore, although many studies have been carried out, many others are still needed to increase the degree of knowledge of the innumerable potentials of tcMRgFUS and thus expand the future fields of application of this technology.

The role of hemostatic devices in neurosurgery. A systematic review.

Hemostasis represents a fundamental step in every surgical procedure. During neurosurgical procedures, proper and robust hemostasis into confined spaces can significantly reduce the odds of perioperative complications. Over the decades, multiple methods have been applied, and several medical devices have been developed to promote and guarantee proper hemostasis. This study presents a systematic review of the most used intraoperative hemostatic methods and devices in neurosurgery. Insightful research was performed on the PubMed database according to the PRISMA guidelines. This comprehensive review of scientific literature represents a synoptic panel where the most used intraoperative hemostatic methods and devices available today in neurosurgery are classified and described.

Management of Spinal Bone Metastases With Radiofrequency Ablation, Vertebral Reinforcement and Transpedicular Fixation: A Retrospective Single-Center Case Series.

Spine is a frequent site of bone metastases, with a 8.5 months median survival time after diagnosis. In most cases treatment is only palliative. Several advanced techniques can ensure a better Quality of Life (QoL) and increase life expectancy. Radiofrequency ablation (RFA) uses alternating current to produce local heating and necrosis of the spinal lesion, preserving the healthy bone. RFA is supported by vertebral reinforcement through kyphoplasty and vertebroplasty in order to stabilize the fracture with polymethylmethacrylate (PMMA) injection, restoring vertebral body height and reducing the weakness of healthy bone. The aim of this study is to demonstrate the efficacy and advantages of RFA plus vertebral reinforcement through PMMA vertebroplasty and fixation in patients affected by bone spinal metastases. We retrospectively analyzed 54 patients with thoraco-lumbar metastatic vertebral fractures admitted to our Unit between January 2014 and June 2020. Each patient underwent RFA followed by PMMA vertebroplasty and transpedicle fixation. We evaluated pain relief through the Visual Analogue Scale (VAS) Score and PMMA vertebral filling based on the mean Saliou filling score. Analysis of variance (ANOVA) was used to test pain relief with statistical significance for p<0.05. A total of 54 patients (median age 63,44 years; range 34-86 years), with a total of 63 infiltrated vertebrae, were treated with RFA, PMMA vertebroplasty and transpedicular screw fixation; average operative time was 60.4 min (range 51-72). The preoperative average VAS score decreased significantly from 7.81 to 2.50 (p < 0.05) after 12 months. Based on Saliou filling score, filling was satisfactory (12-18) in 20 vertebrae (31,7%), mediocre (6-11) in 33 vertebrae (52,4%), inadequate (0-5) in 10 vertebrae (15,9%). A consistent PMMA filling of vertebral bodies was successfully achieved with significant pain relief. Concomitant RFA, PMMA vertebroplasty and pedicle screw fixation represent a safe and effective technique for the management of spinal metastases, improving clinical outcome and pain control.

Brain Mapping-Aided SupraTotal Resection (SpTR) of Brain Tumors: The Role of Brain Connectivity.

Brain gliomas require a deep knowledge of their effects on brain connectivity. Understanding the complex relationship between tumor and functional brain is the preliminary and fundamental step for the subsequent surgery. The extent of resection (EOR) is an independent variable of surgical effectiveness and it correlates with the overall survival. Until now, great efforts have been made to achieve gross total resection (GTR) as the standard of care of brain tumor patients. However, high and low-grade gliomas have an infiltrative behavior and peritumoral white matter is often infiltrated by tumoral cells. According to these evidences, many efforts have been made to push the boundary of the resection beyond the contrast-enhanced lesion core on T1w MRI, in the so called supratotal resection (SpTR). SpTR is aimed to maximize the extent of resection and thus the overall survival. SpTR of primary brain tumors is a feasible technique and its safety is improved by intraoperative neuromonitoring and advanced neuroimaging. Only transient cognitive impairments have been reported in SpTR patients compared to GTR patients. Moreover, SpTR is related to a longer overall and progression-free survival along with preserving neuro-cognitive functions and quality of life.

All that glitters is not gold: A spinal epidural empyema following epidural steroid injection.

BACKGROUND: Therapeutic epidural spinal injections (ESIs) of steroids are one of the most common nonsurgical management modalities employed for alleviating pain due to chronic persistent lumbar spinal disease. However, it is well documented that they have significant risks and complications without any long-term efficacy. ESI may result in epidural empyema which may be difficult to diagnose with delays resulting in significant permanent neurological sequelae. CASE DESCRIPTION: A 45-year-old female presented with a lumbar spinal epidural empyema after receiving ESI for low back and right leg pain due to a lumbar disc herniation. Laboratory studies showed elevations of multiple inflammatory markers, and the MR documented a significant lumbar epidural empyema contributing to significant thecal sac compression. Clinically, the patient had an acute cauda equina syndrome warranting emergency surgery consisting of a laminectomy for debridement/decompression followed by long-term antibiotic treatment. CONCLUSION: Epidural empyema is a major potential complication of lumbar ESI. Multiple markedly elevated inflammatory markers (WBC, ESR, CRP, and procalcitonin) and MRI evidence of an epidural empyema necessitates emergent surgical intervention to limit morbidity, neurological sequelae, and mortality.