Sciatica caused by spinal epidural abscess as the initial clinical presentation of colon cancer: a rare case report and review of literature.

BACKGROUND: Colorectal cancer is one of the most frequently diagnosed forms of cancer, and it is associated with several common symptoms and signs such as rectal bleeding, altered bowel habits, abdominal pain, anemia, and unintentional weight loss. Sciatica, a debilitating condition in which the patient experiences paresthesia and pain in the dermatome of associated lumbosacral nerve roots or sciatic nerve distribution, is not considered one of these. Here we present a case of colorectal cancer manifesting symptoms of sciatica alone. CASE PRESENTATION: A 68-year-old male presented with progressive lower back pain radiating to his left thigh and calf over L5/S1 dermatome. Sciatica was suspected and initially underwent conservative treatment with analgesics. However, the symptoms progressed and MRI revealed an epidural abscess surprisingly. Surgical debridement was performed and pus culture isolated Streptococcus gallolyticus. Based on the strong association of S. gallolyticus with colorectal cancer, the presence of this pathogen prompted further tumor evaluation, even in the absence of the typical symptoms and signs. This investigation ultimately leads to the diagnosis of sigmoid adenocarcinoma. CONCLUSIONS: Although rare, sciatica caused by S. gallolyticus infection of the spinal epidural space may serve as the initial presentation of colorectal cancer. Physicians should be aware of the strong association between S. gallolyticus and colorectal cancer. Based on what we currently know about the condition; a thorough systematic assessment of occult neoplasia for patients with S. gallolyticus infection is recommended.

Treatment of Spinal Infections.

The treatment of spinal infections is not well defined, and a cursory review of the literature can lead to conflicting treatment strategies. To add to the complexity, infections can include primary infection of the spine, infection secondary to another primary source, and postoperative infections including epidural abscesses, discitis, osteomyelitis, paraspinal soft-tissue infections, or any combination. Furthermore, differing opinions often exist within the medical and surgical communities regarding the outcomes and effectiveness of varying treatment strategies. Given the paucity of defined treatment protocols and long-term follow-up, it is important to develop multidisciplinary treatment teams and treatment strategies. This, along with defined protocols for the treatment of varying infections, can provide the data needed for improved treatment of spinal infections.

[Febrile cervicalgia revealing infectious epiduritis : a case report]. / Cas clinique. Cervicalgies fébriles révélatrices d'une épidurite infectieuse.

Infectious epiduritis and epidural abscesses are relatively rare pathologies but with important neurological consequences. A low incidence associated with an insidious clinical presentation leads to frequent delays in diagnosis, which worsen the prognosis of patients with the development of neurological deficits. While the evaluation of risk factors, a careful clinical examination and biological tests can guide to the diagnosis, the key examination remains magnetic resonance imaging (MRI) while lumbar puncture remains contraindicated. Although surgery (spinal decompression) has long been the treatment of choice, the current management of patients with infectious epiduritis is debated between surgery and conservative treatment with systemic antibiotic therapy.

Les épidurites infectieuses et les abcès épiduraux sont des pathologies relativement rares, mais avec des conséquences neurologiques redoutables. Une faible incidence et une présentation clinique souvent insidieuse engendrent de fréquents retards de diagnostic qui péjorent le pronostic des patients avec le développement de déficits neurologiques. Si l'évaluation des facteurs de risque, un examen clinique scrupuleux et des analyses biologiques peuvent guider vers le diagnostic, l'examen-clé reste l'imagerie par résonance magnétique (IRM). La ponction lombaire est contre-indiquée. Bien que l'approche chirurgicale ait longtemps été le traitement de choix, un traitement plus conservateur basé sur une antibiothérapie systémique est également discuté.

Spinal fungal abscess mimicking as potts spine.

Spinal epidural abscess (SEA) is a rarest form of spinal infections and is characterized by the presence of pus in the space between the dura mater, and the osseoligamentous confines of the vertebral canal. This can cause spinal injury due to direct compression or local ischemia. The major etiology of SEA is bacterial and tuberculous in endemic regions. The incidence of fungal spinal abscess is relatively low and <5% of SEA is attributable to fungi. We, here, report a case of 77-year-old known patient of chronic renal disease on hemodialysis that presented with low-back pain for 15 days and was subsequently diagnosed with SEA by magnetic resonance imaging, and causative organism was identified as Candida by culture. The abscess was surgically drained after laminectomy. The patient improved with surgery and antifungal treatment.

Button-Hole Disco-Osteotomy Drainage-A Novel Approach for High-Risk Patients with Cervical Abscess.

Spinal epidural abscess (SEA) is a very serious infection of the central nervous system (CNS). It is of very low incidence with a peak age in the geriatric age group. Immunocompromised patients are more susceptible to SEA. It can present with significant neurological deficits, which can be permanent if not identified and treated promptly. In this case report, a 75-year-old immunocompromised patient presented with progressive spastic quadriparesis and septicemia. He was diagnosed with a case of cervical spinal epidural abscess with underlying cord compression. Anterior retropharyngeal approach and button-hole disco-osteotomy of C5-C6 was performed and the cervical SEA was drained, followed by antibiotic saline irrigation (cranially and caudally) was done, total duration of surgery was 70 min. At the time of discharge (7th postoperative day), the patient improved neurologically and sepsis had resolved.

Duration of neurological deficit and outcomes in the surgical treatment of spinal coccidioidomycosis.

OBJECTIVE: Vertebral osteomyelitis is a rare complication of coccidioidomycosis infection. Surgical intervention is indicated when there is failure of medical management or presence of neurological deficit, epidural abscess, or spinal instability. The relationship between timing of surgical intervention and recovery of neurological function has not been previously described. The purpose of this study was to investigate if the duration of neurological deficits at presentation affects neurological recovery after surgical intervention. METHODS: This was a retrospective study of all patients diagnosed with coccidioidomycosis involving the spine at a single tertiary care center between 2012 and 2021. Data collected included patient demographics, clinical presentation, radiographic information, and surgical intervention. The primary outcome was change in neurological examination after surgical intervention, quantified according to the American Spinal Injury Association Impairment Scale. The secondary outcome was the complication rate. Logistic regression was used to test if the duration of neurological deficits was associated with improvement in the neurological examination after surgery. RESULTS: Twenty-seven patients presented with spinal coccidioidomycosis between 2012 and 2021; 20 of these patients had vertebral involvement on spinal imaging with a median follow-up of 8.7 months (IQR 1.7-71.2 months). Of the 20 patients with vertebral involvement, 12 (60.0%) presented with a neurological deficit with a median duration of 20 days (range 1-61 days). Most patients presenting with neurological deficit (11/12, 91.7%) underwent surgical intervention. Nine (81.2%) of these 11 patients had an improved neurological examination after surgery and the other 2 had stable deficits. Seven patients had improved recovery sufficient to improve by 1 grade according to the AIS. The duration of neurological deficits on presentation was not significantly associated with neurological improvement after surgery (p = 0.49, Fisher's exact test). CONCLUSIONS: The duration of neurological deficits on presentation should not deter surgeons from operative intervention in cases of spinal coccidioidomycosis.

Disseminating MSSA Infection in a Preterm Infant With Rare Finding of Spinal Epidural Abscess: A Case Report.

BACKGROUND: Methicillin-susceptible Staphylococcus aureus (MSSA) occurs more frequently in the neonatal intensive care unit (NICU) than methicillin-resistant S. aureus (MRSA) and can result in comparable morbidity and mortality in the neonatal population. MSSA infection may present as pustulosis or cellulitis and evolve into bacteremia, pneumonia, endocarditis, brain abscesses, and osteomyelitis. There is a paucity of literature regarding the treatment and long-term outcomes in the premature infant. CLINICAL FINDINGS: A 32-week twin developed MSSA sepsis with presentation of pain, decreased movement of upper extremities, and global hypotonia. Blood cultures remained positive despite antibiotic coverage. PRIMARY DIAGNOSIS: The infant was admitted to the level IV NICU with the diagnosis of MSSA bacteremia, with concern for dissemination and osteomyelitis. INTERVENTIONS: Diagnostic studies included laboratory testing for sepsis evaluation, radiologic studies to evaluate for dissemination, immunologic testing to rule out complement deficiency, and hematology testing to rule out hypercoagulable conditions. OUTCOMES: Diagnostic testing showed extensive cellulitis, osteomyelitis, multiple liver abscesses, and epidural abscesses suggestive of spinal epidural abscess (SEA). Abscess debridement and irrigation on the left distal femur, left elbow, and right tibia were performed. The infant completed 8 weeks of IV antibiotic therapy. Immunologic and hematology testing was within normal limits. PRACTICE RECOMMENDATIONS: Prompt recognition and follow-up for clinical signs of sepsis are vital when caring for premature infants. Inclusion of pediatric subspecialist recommendations to assure all diagnostic studies and treatments are completed can significantly impact the patient's outcome. Long-term follow-up is needed for premature infants with the diagnosis of SEA.

Pott luck.

A 10-year-old boy presented with headache, fever, left-sided ptosis, and right-sided forehead soft tissue swelling. There was no recent history of trauma or infection. The patient had a large, fluctuant mass on the right side of his forehead, upgaze restriction, left-sided ptosis, and bilateral optic disk edema. Magnetic resonance imaging of the brain showed a frontal bone extradural fluid collection superficial to the superior sagittal sinus in keeping with an epidural abscess. There were multiple venous thromboses and thickening and enhancement of the dura, compatible with meningitis. There was right sphenoid sinusitis. This patient had Potts puffy tumor, a rare diagnosis associated with a forehead swelling from frontal bone osteomyelitis and subperiosteal abscess. It is seen in the pediatric population in association with sinusitis or trauma. Antibiotics, anticoagulation, and acetazolamide were initiated, and the epidural abscess was evacuated. The symptoms and signs resolved with treatment.

Spondylodiscitis of lumbar complicated with spinal epidural abscess caused by Parvimonas micra: A case report and literature review. / å¾®å°å°å•èƒžèŒè °æ¤Žé—´ç›˜ç‚Žå¹¶æ¤Žç®¡å† ç¡¬è†œå¤–è„“è‚¿1例及文献回顾.

Spinal infection caused by Parvimonas micra (P. micra) is a rare infection. The characteristic imageology includes spondylodiscitis, spondylitis, paravertebral abscess, and epidural abscess. One case of spondylodiscitis of lumbar complicated with spinal epidural abscess caused by P. micra was admitted to the Department of Spinal Surgery, Xiangya Hospital, Central South University on February, 2023. This case is a 60 years old man with lower back pain and left lower limb numbness. MRI showed spondylitis, spondylodiscitis, and epidural abscess. The patient underwent debridement, decompression and fusion surgery. The culture of surgical sample was negative. P. micra was detected by metagenomic next-generation sequencing (mNGS). The postoperative antibiotic treatment included intravenous infusion of linezolid and piperacillin for 1 week, then intravenous infusion of ceftazidime and oral metronidazole for 2 weeks, followed by oral metronidazole and nerofloxacin for 2 weeks. During the follow-up, the lower back pain and left lower limb numbness was complete remission. Spinal infection caused by P. micra is extremely rare, when the culture is negative, mNGS can help the final diagnosis.

A 60-Year-Old Man with Gingivitis and Poorly Controlled Diabetes Developing Low Back Pain 1 Week Following Recovery from COVID-19 Diagnosed with Spinal Abscess Due to Streptococcus oralis.

BACKGROUND Streptococcus oralis (S. oralis) is a gram-positive bacterium and component of the oral microbiota that can rarely cause opportunistic infection in the immunosuppressed. This report presents a 60-year-old man from Hong Kong with gingivitis and poorly controlled diabetes who visited his chiropractor with low back pain 2 weeks following mild COVID-19 and was diagnosed with paraspinal, psoas, and epidural abscess due to S. oralis. CASE REPORT The patient tested positive for COVID-19 when asymptomatic, then had a mild 10-day course of the illness, followed by low back pain 1 week later, prompting him to visit his primary care provider, who diagnosed sciatica and treated him with opioid analgesics. He presented to a chiropractor the following week, noting severe low back pain with radiation into the gluteal regions and posterior thighs, difficulty with ambulation, and mild neck pain. Considering the patient's diabetes, widespread symptoms, and weakness, the chiropractor ordered whole-spine magnetic resonance imaging, which suggested possible multifocal spinal abscess and referred him urgently to a spine surgeon. The surgeon conducted testing consistent with bacterial infection, and referred to an infectious disease specialist, who confirmed S. oralis spinal infection via lumbar paraspinal needle biopsy and culture. The patient was first treated with oral antibiotics, then intravenous antibiotics in a hospital. Over 4 weeks, his spinal pain improved, and laboratory markers of infection normalized. CONCLUSIONS This case illustrates an opportunistic pyogenic spinal infection including paraspinal, psoas, and epidural abscesses caused by S. oralis in an immunocompromised patient following COVID-19 illness.

Epidural abscess formation with an atypical pathogen following epidural steroid injection: A case report.

RATIONALE: Subcutaneous and epidural abscesses following epidural injection are a serious but rare complication. Epidural abscesses are typically caused by Staphylococcus aureus bacterial infection. In this case presented here, the causative bacterium was Enterococcus faecalis. PATIENT CONCERNS: A 67-year-old woman having chronic lower back and right leg pain with past history of 20 years of rheumatoid arthritis, diabetes mellitus, and osteoporosis (T-score: -2.7) visited the outpatient pain clinic. Magnetic resonance imaging (MRI) revealed L4-5 right central disc extrusion with inferior migration. We performed a continuous epidural block for 7 days without complications. After 10 days, she presented with worsened low back pain, erythematous skin change on the lower back, chilling, and elevated serum acute phase reactants. DIAGNOSIS: The diagnosis was subsequently confirmed by MRI suggesting subcutaneous and epidural abscess. Blood and pus cultures showed the growth of E. faecalis. INTERVENTIONS: Pigtail catheter drainage was performed and intravenous antibiotics (ampicillin-sulbactam) targeting E. faecalis were applied for 3 weeks. Oral antibiotics (amoxicillin/potassium clavulanate) were applied for 6 weeks after discharge. OUTCOMES: At the 2-month follow-up, improvement in both the clinical condition and serum acute phase reactants levels were noted. LESSONS: Epidural injection can lead to a subcutaneous abscess that is further extended into the epidural space. One of the key factors is the presence of comorbid conditions, including diabetes mellitus and prolonged steroid usage due to rheumatoid arthritis.

Surgical Management of Spinal Epidural Abscess in Elderly Patients: A Comparative Analysis Between Patients 65-79 Years and ≥80 Years with 3-Year Follow-Up.

BACKGROUND: Recently, the incidence of pyogenic vertebral osteomyelitis with spinal epidural abscess (SEA) has increased. However, the most appropriate surgical management remains debatable, especially for older patients. This study aimed to compare the clinical course in older patients aged between 65 and 79 years and those 80 years or older undergoing surgery for SEA. METHODS: Data on patient demographics, surgical characteristics, complications, hospital clinical course, and 90-day mortality of patients diagnosed with pyogenic vertebral osteomyelitis and SEA between September 2005 and December 2021 were collected. Comorbidities were assessed using the age-adjusted Charlson comorbidity index. RESULTS: We enrolled 45 patients aged 65-79 years and 32 patients ≥80 years. Patients ≥80 years had significantly higher rates of Charlson comorbidity index (9.2 ± 2.4) than younger patients (6.5 ± 2.5; P < 0.001). Arterial hypertension, renal failure, and dementia were significantly more prevalent in octogenarians (P < 0.05). Patients aged ≥80 years had a significantly longer length of hospitalization, while the intensive care unit stay was similar between groups. In-hospital mortality was significantly greater in those ≥80 years (n = 3, 9.4% vs. n = 0, 0.0%; P = 0.029), whereas no differences in 90-day mortality or 30-day readmission were observed. In the second-stage analysis, significant improvements in blood infection parameters and neurologic status were detected in both groups. Of adverse events, pneumonia occurred significantly more frequently in patients aged ≥80 years. CONCLUSIONS: Surgical management leads to significant improvements in both laboratory and clinical parameters in older patients. Nevertheless, a personalized medical approach is mandatory in frail patients, especially octogenarians. A clear discussion regarding the potential risk is unambiguously recommended.

Bacteroides fragilis Bacteremia Complicated by Spondylodiscitis, Spinal Epidural Abscess, and Sepsis: A Case Report.

BACKGROUND Pyogenic spondylitis comprises several clinical entities, including native vertebral osteomyelitis, septic discitis, pyogenic spondylodiscitis, and epidural abscess. The lumbar spine is most often infected, followed by the thoracic and cervical areas. It mainly develops (i) after spine surgery; (ii) from history of blunt trauma to the spinal column; (iii) from infections in adjacent structures (such as soft tissues); (iv) from iatrogenic inoculation after invasive procedures (such as lumbar puncture); and (v) from hematogenous bacterial spread to the vertebra (mainly through the venous route). Any delay in diagnosis and treatment can lead to significant spinal cord injury, permanent neurological damage, septicemia, and death. CASE REPORT We describe a 63-year-old man with no significant past medical history who presented with fever and an altered level of consciousness. Significant thoracic spine pain was also reported during the last 3 months. The final diagnosis was vertebral spondylodiscitis, contiguous spinal epidural abscess, and sepsis due to Bacteroides fragilis bacteremia. Clinical recovery was achieved after surgical decompressive therapy with abscess drainage combined with appropriate antibiotic therapy for 12 weeks. The primary focus of the infection was not clarified, despite all the investigations that were performed. CONCLUSIONS Spondylodiscitis, spinal epidural abscess, and sepsis as complications of Bacteroides fragilis bacteremia are rare in a patient without any previously known predisposing conditions and without an obvious primary focus. Early diagnosis and proper treatment of anaerobic spondylodiscitis, especially if epidural abscess and sepsis are present, are of great importance to reduce mortality and avoid long-term complications.

Pediatric spinal epidural abscess: recognition and management in the emergency department.

Although rare in children, spinal epidural abscess (SEA) is a rapidly progressive clinical entity that can lead to irreversible neurologic damage if untreated. The rarity and variability in presentation can lead to initial misdiagnosis. Diagnosis requires a high index of suspicion and is often delayed until neurologic deficits are present. This issue reviews key findings on the history and physical examination that are associated with SEA, provides guidance for the laboratory tests and imaging studies that are indicated once SEA is suspected, and discusses treatment options based on current evidence.

Update on the Diagnosis and Management of Spinal Infections.

Pyogenic spinal infections are uncommon, but their incidence has increased. Diagnosis is based on clinical, laboratory, and imaging findings. Delayed diagnosis occurs frequently and can lead to poor outcomes. Early radiographic findings are nonspecific; MRI is the best imaging study for diagnosis. The goal of treatment is to eradicate infection, prevent recurrence, preserve spinal stability, avoid deformity, relieve pain, and prevent or reverse neurologic deficit. Current guidelines recommend antibiotics be administered for 6 weeks if there is resolution of symptoms and normalization of inflammatory parameters. Surgery is required in patients with neurologic deficit, uncontrolled sepsis, spinal instability, deformity, and failure of medical treatment and to manage epidural abscess. Classic treatment of epidural abscess is surgical, but recent studies have challenged this approach. Surgical techniques used to manage these infections are varied; they include anterior, posterior, and combined approaches, and minimally invasive surgery. Current management has decreased mortality; however, the prognosis is affected by treatment failure, recurrent infection, or potential of persistent disability secondary to deformity, chronic pain, or permanent neurologic impairment.

High risk and low prevalence diseases: Spinal epidural abscess.

INTRODUCTION: Spinal epidural abscess (SEA) is a rare but serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE: This review highlights the pearls and pitfalls of SEA, including presentation, initial evaluation, and management in the emergency department (ED) based on current evidence. DISCUSSION: SEA is a suppurative infection and infectious disease emergency that may result in significant morbidity and even mortality. It is a challenging diagnosis due to its range of risk factors and variety of presentations with up to 90% of patients misdiagnosed on their first ED visit. Factors associated with increased risk of SEA include immunocompromise, bacteremia, contiguous infection (e.g., psoas muscle abscess, osteomyelitis, skin infection), and spinal instrumentation. However, the absence of risk factors cannot be used to exclude SEA. The classic triad of back pain, fever, and neurologic deficit occurs in less than 8% of cases, though back pain is a common presenting symptom. Up to half of patients experience a neurologic abnormality, but fever is absent in 50%. Laboratory assessment may assist with inflammatory markers elevated in the majority of cases. Diagnosis includes magnetic resonance imaging with and without contrast and blood cultures, and management includes spinal specialist consultation and antibiotic therapy. CONCLUSIONS: An understanding of SEA can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Evaluation and Management of Cauda Equina Syndrome.

Cauda equina syndrome is a potentially devastating spinal condition. The diagnosis of cauda equina syndrome lacks sensitivity and specificity, sometimes occurring after irreparable neurological damage has happened. Timely diagnosis and treatment is imperative for optimal outcomes and for avoiding medicolegal ramifications. Cauda equina syndrome results from conditions that compress the nerves in the lumbosacral spinal canal. Although no consensus definition exists, it generally presents with varying degrees of sensory loss, motor weakness, and bowel and bladder dysfunction (the latter of which is required to definitively establish the diagnosis). A thorough history and physical exam is imperative, followed by magnetic resonance or computed tomography imaging myelogram to aid in diagnosis and treatment. Once suspected, emergent spinal surgery referral is indicated, along with urgent decompression. Even with expeditious surgery, improvements remain inconsistent. However, early intervention has been shown to portend greater chance of neurologic recovery. All providers in clinical practice must understand the severity of this condition. Providers can optimize long-term patient outcomes and minimize the risk of litigation by open communication, good clinical practice, thorough documentation, and expeditious care.