A rare case of Spinal Epidural Abscess following mesotherapy: a challenging diagnosis and the importance of clinical risk management. Considerations concerning uncommon risk factor for development of Spinal Epidural Abscess and its prevention.

Spinal Epidural Abscess (SEA) is a rare pyogenic infection localized between dura mater and vertebral periostium. The development of SEA is associated with the presence of medical co-morbidities and risk factors that facilitate bacterial dissemination. It is possible distinguish two type of SEA: primary SEA due to pathogen hematogenous dissemination and secondary SEA resulting from direct inoculation of pathogen. This entity, very uncommon, shows a prevalence peak between the 5th and the 7th decade of life with predominance in males. The case is a 44 years old Caucasian man with chronic low back pain, treated with physiotherapy and anti-inflammatory drugs. Following an episode of acute severe exacerbation of pain, the patient underwent four session of dorsal and lumbo-sacral area mesotherapy. One month after the last session, the patient experienced acute sever lumbar pain, radiated to left lower limb and accompanied by fever and vomiting. During hospitalization, elevated levels of white blood cells and C Reactive Protein (CRP) were found. Moreover, a vertebral magnetic resonance imaging revealed the presence of intramedullary lesion. Furthermore, methicillin sensitive staphylococcus aureus was isolated from three blood cultures and antibiotic therapy was performed. In our case the patient had the typical SEA onset, without any specific risk factors excepting the execution of four session of mesotherapy. Aim of this study is to explain risk factors for the SEA development and to clarify how act as preventive measure, because also acupuncture can promote bacterial infection.

The Role of the Anesthesiologist in Preventing Severe Maternal Morbidity and Mortality.

Anesthesiologists are responsible for the safe and effective provision of analgesia for labor and anesthesia for cesarean delivery and other obstetric procedures. In addition, obstetric anesthesiologists often have a unique role as the intensivists of the obstetric suite. The anesthesiologist is frequently the clinician with the greatest experience in the acute bedside management of a hemodynamically unstable patient and expertise in life-saving interventions. This review will discuss (1) risks associated with neuraxial and general anesthesia for labor and delivery, and (2) clinical scenarios in which the obstetric anesthesiologist is commonly called upon to function as a "peridelivery intensivist."

[Risk management in epidural anesthesia].

Epidural anesthesia has many advantages, including block of surgical stress, postoperative pain management and prevention of postoperative complications. Therefore, we should use epidural anesthesia when indicated. However, patients with preexisting spinal stenosis or lumbar radiculopathy have higher incidence of neurologic complications after epidural anesthesia. Epidural abscesses caused by epidural anesthesia are rare. However, epidural abscesses are serious complications in patients. Knowing the risk factor of epidural abscesses is important to prevent epidural abscesses, and early diagnosis and early treatment are needed when suspected. It is important to have measures for safety in performing epidural anesthesia at every hospital. Recently, we have many anesthetic techniques, including epidural anesthesia, remifentanil infusion, ultrasound-guided peripheral nerve blocks and intravenous PCA. Therefore, we should choose an anesthesia method based on the careful evaluation of the benefit and risk balance for the patient's safety to reduce the incidence of complications.

[Aseptic precautions in epidural catheterization for surgery].

We describe aseptic precautions in epidural catheterization for surgery. Every patient has to be checked for immunodeficiency, atopic dermatitis, preoperative use of antibiotics, and local infection of the epidural puncture site. Physicians who perform epidural catheterization should wear a mask and a cap and take off a wrist watch and rings on the fingers before an epidural kit is opened. Fingers and hands should be disinfected before wearing surgical gloves. The skin for epidural puncture site should be disinfected with 0.5% chlorhexidine in 80% ethanol. A micropore filter should be used when epidural catheterization is expected to remain over 24 hours.

Antibacterial activity of epidural infusions.

The incidence of epidural abscess following epidural catheterisation appears to be increasing, being recently reported as one in 1000 among surgical patients. This study was designed to investigate the antibacterial activity of various local anaesthetics and additives, used in epidural infusions, against a range of micro-organisms associated with epidural abscess. The aim was to determine which, if any, epidural infusion solution has the greatest antibacterial activity. Bupivacaine, ropivacaine and levobupivacaine crystals were dissolved and added to Mueller-Hinton Agar in concentrations of 0.06%, 0.125%, 0.2%, 0.25%, 0.5% and 1%. Fentanyl, adrenaline and clonidine were also mixed with agar in isolation and in combination with the local anaesthetics. Using a reference agar dilution method, the minimum inhibitory concentrations were determined for a range of bacteria. Bupivacaine showed antibacterial activity against Staphylococcus aureus, Enterococcus faecalis and Escherichia coli with minimum inhibitory concentrations between 0.125% and 0.25%. It did not inhibit the growth of Pseudomonas aeruginosa at any of the concentrations tested. Levobupivacaine and ropivacaine showed no activity against Staphylococcus aureus, Enterococcus faecalis and Pseudomonas aeruginosa, even at the highest concentrations tested, and minimal activity against Escherichia coli (minimum inhibitory concentrations 0.5% and 1% respectively). The presence of fentanyl, adrenaline and clonidine had no additional effect on the antibacterial activity of any of the local anaesthetic agents. The low concentrations of local anaesthetic usually used in epidural infusions have minimal antibacterial activity. While the clinical implications of this in vitro study are not known, consideration should be given to increasing the concentration of bupivacaine in an epidural infusion or to administering a daily bolus of 0.25% bupivacaine to reduce the risk of epidural bacterial growth.

Spinal epidural abscess mimicking lymphoma: a case report.

We describe a case of epidural thoracic abscess presenting similar to epidural lymphoma on imaging and review the imaging findings and clinical characteristics of both to help differentiate the two. Typical magnetic resonance imaging characteristics for epidural abscess are a heterogeneously enhancing epidural collection, which is isointense/hypointense on T1 images and hyperintense on T2 images with granulation tissue typically having a rim of enhancement with gadolinium. In contrast, typical imaging characteristics for an epidural lymphoma include an isointense/hypointense appearance on T1-weighted magnetic resonance imaging (MRI) and a hyperintense or even hypointense appearance on T2 images. Lymphomas tend to enhance uniformly and diffusely with contrast. The patient's MRI revealed a compressive thoracic epidural mass at T8-T10. The mass was hypointense on T1- and T2-weighted images and enhanced intensely and uniformly on T1 images after gadolinium injection. Additionally, abnormal hyperintense signal within the left T9-T10 facet joint was identified on T2 images. The imaging findings were felt to be most consistent with lymphoma, but the possibility of epidural abscess, and less likely, epidural hematoma were also considered. Although the patient's abscess presented similar to lymphoma on MRI, possibly the most revealing clue on imaging that infection was the likely diagnosis was hyperintense signal within the left facet joint seen on T2-weighted images. This is important as primary radiation treatment based on imaging characteristics alone, without a tissue diagnosis, is often suggested in cases of lymphoma. This mode of treatment would be contraindicated in the setting of infection. A diagnosis that is not conclusive by needle biopsy or imagine may require an open procedure for definitive diagnosis.

Percutaneous transpedicular discectomy and drainage in pyogenic spondylodiscitis.

The natural history of uncomplicated hematogenous pyogenic spondylodiscitis is self-limiting healing. However, a variable degree of bone destruction frequently occurs, predisposing the spine to painful kyphosis. Delayed treatment may result in serious neurologic complications. Early debridement of these infections by percutaneous transpedicular discectomy can accelerate the natural process of healing and prevent progression to bone destruction and epidural abscess. The purpose of this manuscript is to present our technique of percutaneous transpedicular discectomy (PTD), to revisit this minimally invasive surgical technique with stricter patient selection, and to exclude cases of extensive vertebral body destruction with kyphosis and neurocompression by epidural abscess, infected disc herniation, and foraminal stenosis. In a previously published report of 28 unselected patients with primary hematogenous pyogenic spondylodiscitis, the immediate relief of pain after PTD was 75%, and in the long-term follow-up, the success rate was 68%. Applying stricter patient selection criteria in a second series of six patients (five with primary hematogenous spondylodiscitis and one with secondary postlaminectomy-discectomy spondylodiscitis), all patients with primary hematogenous spondylodiskitis (5/5) experienced immediate relief of pain that remained sustained at 12-18 months follow-up. This procedure was not very effective, however, in the patient who suffered from postlaminectomy infection. This lack of response was attributed to postlaminectomy-discitis instability. The immediate success rate after surgery for unselected patients in this combined series of 34 patients was 76%. This technique can be impressively effective and the results sustained when applied in the early stages of uncomplicated spondylodiscitis and contraindicated in the presence of instability, kyphosis from bone destruction, and neurological deficit. The special point of this procedure is a minimally invasive technique with high diagnostic and therapeutic effectiveness.

[Epidural abscess and regional anesthesia]. / El absceso epidural y la anestesia regional.

An epidural abscess is a rare lesion whose consequences can cause high morbi-mortality, particularly in obstetrics, where it occurs in young, healthy patients. With increased use of regional anesthesia, the incidence of epidural abscess will increase. We therefore review the risk factors, most common etiology and clinical signs, which may be non-specific but are nevertheless suggestive. We also review available diagnostic methods. It may be difficult to distinguish epidural abscess from other causes of medullar compression, but prompt diagnosis is essential so that emergency surgical repair can proceed and neurological recovery will be as early and complete as possible. Appropriate antibiotic therapy should be aggressive. Basic aseptic measures are critical for preventing infection through epidural needles, as the presence of infection at the moment of puncture facilitates greater susceptibility to epidural abscess.