Upper cervical epidural abscess with emphasis on diabetes as a risk factor: a case report.

BACKGROUND: An upper cervical spine epidural abscess (UCEA) is an epidural abscess that develops in the area between the occiput and the second cervical spine (axis). It is a rare diagnosis that carries the risk of instability of the atlantoaxial joint, and its management is not well-defined. It is known that the skin is the most common source of infection, and that diabetes mellitus (DM) is the most frequently reported risk factor. In this case, we present a patient diagnosed with UCEA, who achieved full neurological recovery postoperatively despite having neurological deficits for over five days prior to surgery. CASE PRESENTATION: We report the case of a 56-year-old male patient with no history of any prior medical conditions, who presented with headache, neck pain, and weakness of the left side. The weakness started approximately three days prior to his presentation. His initial work up revealed hyperglycemia and elevated HbA1c of 86 mmol/mol (10%). Magnetic resonance imaging (MRI) of the cervical spine revealed spondylitis of the C2 spine with an abscess at the craniocervical junction. He underwent a two-staged surgical approach: decompression and stabilisation. The patient achieved full motor recovery approximately three months postoperatively. CONCLUSIONS: We recommend screening for DM when a spinal epidural abscess (SEA) is diagnosed without readily identifiable risk factors. The optimal management in most SEA cases is surgical, which is particularly true for UCEA because of the risk of atlantoaxial joint instability. Full neurological recovery is possible even when the patient has been having deficits for more than five days.

Spinal epidural abscess as predicting factor for the necessity of early surgical intervention in patients with pyogenic spondylitis.

BACKGROUND: Pyogenic spondylitis is a condition with low incidence that can lead to neurological sequelae and even life-threatening conditions. While conservative methods, including antibiotics and bracing, are considered the first-line treatment option for pyogenic spondylitis, it is important to identify patients who require early surgical intervention to prevent progressive neurologic deficits or deterioration of the systemic condition. Surgical treatment should be considered in patients with progressive neurologic deficits or deteriorating systemic condition. However, currently, there is a lack of treatment guidelines, particularly with respect to whether surgical treatment is necessary for pyogenic spondylitis. This study aims to analyze the radiological epidural abscess on MRI and clinical factors to predict the need for early surgical intervention in patients with pyogenic spondylitis and provide comprehensive insight into the necessity of early surgical intervention in these patients. METHODS: This study retrospectively reviewed 47 patients with pyogenic spondylitis including spondylodiscitis, vertebral osteomyelitis, epidural abscess, and/or psoas abscess. All patients received plain radiographs, and a gadolinium-enhanced magnetic resonance imaging (MRI) scan. All patients have either tissue biopsies and/or blood cultures for the diagnosis of a pathogen. Demographic data, laboratory tests, and clinical predisposing factors including comorbidities and concurrent other infections were analyzed. RESULTS: We analyzed 47 patients, 25 of whom were female, with a mean age of 70,7 years. MRI revealed that 26 of 47 patients had epidural abscesses. The surgical group had a significantly higher incidence of epidural abscess than the non-surgical group (p = 0.001). In addition, both CRP and initial body temperature (BT) were substantially higher in the surgical group compared to the non-surgical group. There was no significant difference between the surgical group and the non-surgical group in terms of age, gender, comorbidities, and concurrent infectious disorders, as well as the number of affected segments and affected spine levels. However, the surgical group had lengthier hospital stays and received more antibiotics. CONCLUSION: The presence of an epidural abscess on MRI should be regarded crucial in the decision-making process for early surgical treatment in patients with pyogenic spondylitis in order to improve clinical outcomes.

Campylobacter coli infection causes spinal epidural abscess with Guillain-Barré syndrome: a case report.

BACKGROUND: Guillain-Barré syndrome (GBS) and spinal epidural abscess (SEA) are known as mimics of each other because they present with flaccid paralysis following an infection; however, they differ in the main causative bacteria. Nevertheless, the two diseases can occur simultaneously if there is a preceding Campylobacter infection. Here, we report the first case of SEA with GBS following Campylobacter coli infection. CASE PRESENTATION: A 71-year-old Japanese man presented with progressive back pain and paralysis of the lower limbs following enteritis. Magnetic resonance imaging showed a lumbar epidural abscess that required surgical decompression; therefore, surgical drainage was performed. Blood cultures revealed the presence of C. coli. Despite surgery, the paralysis progressed to the extremities. Nerve conduction studies led to the diagnosis of GBS. Anti-ganglioside antibodies in the patient suggested that GBS was preceded by Campylobacter infection. Intravascular immunoglobulin therapy attenuated the progression of the paralysis. CONCLUSIONS: We report a case of SEA and GBS following Campylobacter infection. A combination of the two diseases is rare; however, it could occur if the preceding infection is caused by Campylobacter spp. If a cause is known but the patient does not respond to the corresponding treatment, it is important to reconsider the diagnosis based on the medical history.

Imaging characteristics and CT sensitivity for pyogenic spinal infections.

BACKGROUND/OBJECTIVE: Contrast-enhanced magnetic resonance imaging (MRI) is the preferred imaging modality for diagnosing pyogenic spinal infection (PSI), but it is not always available. Our objective was to describe pyogenic spinal infection imaging characteristics in patients presenting to a community emergency department (ED) and estimate the computed tomography (CT) sensitivity for these infections. METHODS: We examined the MRI reports from a cohort of 88 PSI patients whom we enrolled in a prospective cohort study and report the prevalence of each PSI type (spinal epidural abscess/infection, vertebral osteomyelitis/discitis, septic facet, and paravertebral abscess/infection) according to contemporary nomenclature. In a 14 patient subcohort who underwent both CT and MRI studies, we report the sensitivity for each PSI from a post hoc blinded overread of the CT imaging by a single neuroradiologist. RESULTS: Of the 88 PSI patients, the median age was 55 years, and 31% were female. The PSI prevalence included: spinal epidural abscess/infection (SEA) in 61(69%), vertebral osteomyelitis/discitis (VO/D) in 54 (61%), septic facet (SF) in 15 (17%), and paravertebral abscess/infection (PVA) in 53 (60%). Of the SEAs, 82% (50/61) were associated with other spinal infections, while 18% (11/61) were isolated SEAs. The overall CT sensitivity in a masked overread was 79% (11/14) for any PSI, 83% (10/12) for any infection outside the spinal canal, and only 18% (2/11) for SEA. CONCLUSION: Patients found to have vertebral osteomyelitis/discitis, septic facet, and paravertebral infections frequently had a SEA coinfection. CT interpretation by a neuroradiologist had moderate sensitivity for infections outside the spinal canal but had low sensitivity for SEA.

Cervical Epidural Abscess: A Blind Spot for Postmortem Computed Tomography.

ABSTRACT: Spinal epidural abscess is an uncommon condition, which may have serious complications, including neurological sequelae and death. Classical symptoms include spinal pain, fever, and neurological deficit; however, diagnosis is difficult and requires a high degree of clinical suspicion. Antemortem magnetic resonance imaging (MRI) scanning is the gold-standard diagnostic tool. Computed tomography (CT) is less sensitive and as such, postmortem CT may miss the diagnosis. We report a case of Staphylococcus aureus cervical epidural abscess presenting as neck pain and causing flaccid paralysis and subsequently death. Antemortem MRI showed a small epidural collection, spinal cord edema, and fluid in the adjacent cervical disc and facet joints; however, these findings could not be appreciated on postmortem CT. Postmortem examination, guided by the antemortem imaging, was able to confirm a cervical spinal epidural abscess; however, similar deaths may occur before medical presentation. This case demonstrates a limitation of postmortem imaging in diagnosing spinal epidural abscess and highlights that such cases may be missed.

Spinal brucellosis with large circumscribed paraspinal and epidural abscess formation: a case report.

Human Brucellosis is a bacterial infection caused by species of Brucella, which can involve multiple organs and tissues. Spinal epidural abscesses are rare and may be complicated by potentially life threatening neurological or vascular compromise. We report a 21-year-old female with spinal brucellosis complicated by lumbar spondylodiscitis, epidural abscess and a large right-sided paraspinal abscess extended from L4 to sacrum. The diagnosis was based on laboratory and magnetic resonance imaging results, symptoms and her occupation. Ultrasound guided needle aspiration and percutaneous abscess drainage was performed, followed by 8 weeks of combination antibiotic therapy. Our therapeutic strategy in this rare case can cause us to reach a greater clearance rate of the infection.

[Spondylodiscitis and epidural abscesses]. / Spondylodiszitis und epiduraler Abszess.

CLINICAL/METHODOLOGICAL PROBLEM: Spondylodiscitis is an inflammation of the intervertebral disc, which in adults is generally associated with spondylitis of the adjacent vertebrae. It often presents clinically with nonspecific symptoms such as back or neck pain. It may be caused by various pathogens, especially bacteria. One or more vertebral segments can be affected. The infection can spread to surrounding compartments and can lead to epidural abscesses. Radiology, in particular magnetic resonance imaging (MRI), plays an important role in the diagnostic work-up and in the follow-up to monitor response to therapy. Treatment consists of conservative (antibiotics) and invasive approaches, including surgery. Interventional puncture and drainage is a promising alternative to surgery, especially in early stages of abscess formation. STANDARD RADIOLOGICAL METHODS: Magnetic resonance imaging (MRI), computed tomography (CT), nuclear medical procedures, conventional x­ray. PERFORMANCE: MRI has the highest value. CT and nuclear medical procedures can be used as a supplement to MRI and in patients with contraindications for MRI. PRACTICAL RECOMMENDATIONS: With adequate diagnosis and therapy, spondylodiscitis has a good prognosis. In addition to targeted or calculated drug therapy, invasive treatment is the main focus, especially for epidural abscesses. Interventional radiological drainage can represent a less invasive alternative to surgical treatment.

Hyperbaric oxygen for intracranial abscess.

The term "intracranial abscess" (ICA) includes cerebral abscess, subdural empyema, and epidural empyema, which share many diagnostic and therapeutic similarities and, frequently, very similar etiologies. Infection may occur and spread from a contiguous infection such as sinusitis, otitis, mastoiditis, or dental infection; hematogenous seeding; or cranial trauma. In view of the high morbidity and mortality of ICA and the fact that hyperbaric oxygen therapy (HBO2) is relatively non-invasive and carries a low complication rate, the risk-benefit ratio favors adjunct use of HBO2 therapy in selected patients with intracranial abscess.

Spinal epidural abscess in children: a case-based review.

BACKGROUND: Pediatric spinal epidural abscess is a major suppurative infection of the central nervous system. It is an extremely rare pathology carrying serious risk of permanent neurological sequelae if is not properly treated. METHODS AND RESULTS: All the pertinent literature was analyzed, focused on pediatric cases of spinal epidural abscess and its peculiar features. Two illustrative cases are also presented. The first case is that of a 9-year old girl who took medical attention, when she was already paraplegic. Despite prompt surgical evacuation and good neuroradiological outcome and intensive rehabilitation, motor deficits did not recover after surgery. The second case was that of a 14-year old girl who presented with fever, neck pain, and torticollis. Prompt diagnosis, decompressive surgery, and 6 weeks of antibiotics allowed good neurological outcome. CONCLUSIONS: The management of spinal epidural abscess includes evacuation of the abscess with decompression of the spinal cord and prolonged antibiotic treatment. The presence of neurological deficit and the delay in the initiation of proper treatment are the two factors that more worsen prognosis.

Time-to-completed-imaging, survival and function in patients with spinal epidural abscess: Description of a series of 34 patients, 2015-2018.

INTRODUCTION: Spinal epidural abscess (SEA) is a rare and life-threatening infection with increasing incidence over the past two decades. Delays in diagnosis can cause significant morbidity and mortality among patients. OBJECTIVE: The objective of this study was to describe trends in time-to-imaging and intervention, risk factors, and outcomes among patients presenting to the emergency department with SEA at a single academic medical center in Portland, Oregon. METHODS: This retrospective cohort study analyzed data from patients with new SEA diagnosis at a single hospital from October 1, 2015 to April 1, 2018. We describe averages to time-to-imaging and interventions, and frequencies of risk factors and outcomes among patients presenting to the emergency department with SEA. RESULTS: Of the 34 patients included, 7 (20%) died or were discharged with plegia during the study period. Those who died or were discharged with plegia (n = 7) had shorter mean time-to-imaging order (20.8 h versus 29.2 h). Patients with a history of intravenous drug use had a longer mean time-to-imaging order (30.2 h versus 23.7 h) as compared to those without intravenous drug use. Patients who died or acquired plegia had longer times from imaging completed to final imaging read (20.9 h versus 7.1 h), but shorter times from final imaging read to surgical intervention among patients who received surgery (4.9 h versus 46.2 h). Further, only three (42.9%) of the seven patients who died or acquired plegia presented with the three-symptom classic triad of fever, neurologic symptoms, and neck or back pain. CONCLUSIONS: SEA is a potentially deadly infection that requires prompt identification and treatment. This research provides baseline data for potential quality improvement work at the study site. Future research should evaluate multi-center approaches for identifying and intervening to treat SEA, particularly among patients with intravenous drug use.

Spinal Epidural Abscess in an Infant Presenting as Fever and Respiratory Distress.

A 9-month-old healthy female presented during winter to the emergency department with a chief complaint of fever and prominent respiratory symptoms. She was discharged on oseltamivir with a presumptive diagnosis of influenza. She returned to the emergency department 2 days later with continued fever and more upper respiratory symptoms. She was admitted for intravenous hydration to the observation unit with a diagnosis of viral illness (with viral testing that returned positive for adenovirus) and dehydration. When her high fevers continued, bloodwork that was concerning for leukocytosis, elevated inflammatory markers, and elevated alkaline phosphatase was obtained. During her workup for fever, a full body magnetic resonance imaging was performed, which revealed the diagnosis of a C3 to L5 spinal epidural abscess. This case demonstrates the difficulty of making this important diagnosis in a preverbal child presenting with a concurrent virus during winter viral season.

Spinal stenosis caused by epidural and paraspinal abscess due to brucella Infection.

Human brucellosis is a common zoonotic infectious disease in the world. Spinal epidural abscess development in brucellosis is a rare but serious complication. We aimed to discuss the clinical, radiological and serological findings of the spinal stenosis caused by epidural and paraspinal abscess due to brucella infection. Treatment of the abscess usually consists of surgical drainage, decompression and antibiotherapy. In our case, since the Brucellar spinal epidural abscess was diagnosed in the early period, it was improved with medical treatment without any surgical intervention. In the early diagnosis of the disease, serology and culture as well as magnetic resonance imaging are extremely important..

Update on spinal epidural abscess.

PURPOSE OF REVIEW: Spinal epidural abscess (SEA) is still a rare but potentially very morbid infection of the spine. In recent years, the incidence has risen sharply but the condition remains a medical conundrum wrought with unacceptably long diagnostic delays. The outcome depends on timely diagnosis and missed opportunities can be associated with catastrophic consequences. Management and outcomes have improved over the past decade. This review focuses on risk factors and markers that can aid in establishing the diagnosis, the radiological characteristics of SEA on MRI and their clinical implications, as well as the importance of establishing clear indications for surgical decompression. RECENT FINDINGS: This once exclusively surgically managed entity is increasingly treated conservatively with antimicrobial therapy. Patients diagnosed in a timely fashion, prior to cord involvement and the onset of neurologic deficits can safely be managed without decompressive surgery with targeted antimicrobial therapy. Patients with acute cord compression and gross neurologic deficits promptly undergo decompression. The greatest therapeutic dilemma remains the group with mild neurological deficits. As failure rates of delayed surgery approach 40%, recent research is focused on predictive models for failure of conservative SEA management. In addition, protocols are being implemented with some success, to shorten the diagnostic delay of SEA on initial presentation. SUMMARY: SEA is a potentially devastating condition that is frequently missed. Protocols are put in place to facilitate early evaluation of back pain in patients with red flags with appropriate cross-sectional imaging, namely contrast-enhanced MRI. Efforts for establishing clear-cut indications for surgical decompression of SEA are underway.

Spinal epidural abscess caused by Pasteurella multocida mimicking aortic dissection: a case report.

BACKGROUND: Pasteurella multocida (P. multocida) forms part of the normal flora of many animals. Although it is a common causative agent of skin and soft tissue infection after an animal bite or scratch, in rare cases it can cause spinal infections in humans. CASE PRESENTATION: A 68-year-old immunocompetent woman presented with fever and sudden onset of severe back pain mimicking aortic dissection. No findings related to the pain were revealed on enhanced computed tomography or initial magnetic resonance imaging (MRI) of the spine. The patient was found to be bacteremic with P. multocida, although she had no apparent injury related to animal contact. Repeated evaluation by MRI with gadolinium-contrast established the diagnosis of spinal epidural abscess. The patient was cured by the rapid initiation of antimicrobial therapy without surgery. CONCLUSIONS: We describe the successful treatment of an individual with a spinal epidural abscess due to P. multocida without surgery. P. multocida infections may occur as sudden presentations. Obtaining the patient history of recent animal contact is essential. Repeated MRI evaluation may be required when spinal infections are suspected. To the best of our knowledge, this is the first report which describes a case of spinal epidural abscess due to this organism.

Review and case report demonstrate that spontaneous spinal epidural abscesses are rare but dangerous in childhood.

AIM: A spinal epidural abscess (SEA) is a rare paediatric bacterial infection, with possible devastating neurological sequelae. We explored localisation in the cervical segment, which is unusual, but more dangerous, than other SEAs. METHODS: We describe 22 cases (12 male) of paediatric SEAs without risk factors: 21 from a literature search from 2000 to 2017 and a 30-month-old boy with a spontaneous cervical SEA due to Group A Streptococcus. RESULTS: The average age was eight years and the symptoms were mainly fever, back pain and motor deficit, with an aetiological diagnosis in 68%. Methicillin-sensitive Staphylococcus aureus was isolated in six patients, methicillin-resistant Staphylococcus aureus in two, Staphylococcus aureus with unknown susceptibility patterns in three and Group A Streptococcus in four. All patients underwent gadolinium-enhanced magnetic resonance imaging and most abscesses were localised in the thoracic and lumbar areas. More than half (59%) underwent surgery to remove pus and granulation tissue and nine were just treated with antimicrobial therapy for an average of 5.3 weeks. Most patients had good outcomes. CONCLUSION: SEAs were underestimated in children due to the rarity and spectrum of differential diagnoses. Timely diagnosis, immediate antibiotics, spinal magnetic resonance imaging and prompt neurosurgical consultations were essential for favourable outcomes.

Pediatric cervical epidural abscess in a 4-year-old patient: a case-based update.

PURPOSE: The purpose of this study was to review a case comprised of a cervical spinal epidural abscess, cervical and thoracic paraspinous edema, and widening of the right thoracic neural foramen secondary to a phlegmon. METHODS: We reviewed the case of a spinal epidural abscess managed medically in a 4-year-old male and performed a review of the literature with 15 other cases that have previously been reported. RESULTS: The current mainstay of treatment is largely variant but generally falls into a laminectomy-based surgical approach or longstanding antibiotics. Our review of the literature concluded that there are currently no clear guidelines established to recommend treatment, and current practice is largely based on the discretion of the pediatric neurosurgeon. CONCLUSIONS: Based on the literature review, and our personal case illustration, we conclude that an antibiotic-based treatment is a valid approach for therapy if initiated promptly in a pediatric patient with no neurological deficit.

Usefulness of dynamic contrast-enhanced magnetic resonance images for distinguishing between pyogenic spondylitis and tuberculous spondylitis.

PURPOSE: Dynamic contrast-enhanced (DCE)-MRI is used for examining the features of malignant tumours in radiology, and we can obtain more information in terms of the diffusion of the media over the course of time. The purpose of this study was to clarify the usefulness of DCE-MRI for distinguishing pyogenic spondylitis (PS) and tuberculous spondylitis (TB). METHODS: Forty-five consecutive patients diagnosed with PS (68.6 ± 11.1 years old, males 30 and females 15) and 14 with TB (73.9 ± 9.1 years old, males 6 and females 8) were involved. DCE-MRI consisted of serial six sagittal images which were taken every 20 s after intravenous gadolinium administration. Degree of enhancement, presence of epidural abscess, presence of necrosis in vertebra, presence of enhancement in disc lesion, pattern of diffusion, and maximum contrast index were examined and compared between PS and TB. RESULTS: Degree of enhancement, percentage of epidural abscess, and percentage of necrosis in vertebra were 2.1 ± 0.5 and 1.8 ± 0.8, 60.7% and 100%, 50.0% and 66.7% for PS and TB, respectively, without statistical difference. Maximum contrast index, percentage of the diffusion pattern from the disc, and percentage of enhanced disc were 108.1 ± 22.3 and 78.2 ± 35.6 s, 89.3% and 0%, and 53.6% and 0% for PS and TB, respectively, with statistical significance. CONCLUSIONS: This study indicated that longer maximum contrast index, higher likelihood of diffusion pattern from the disc, and higher likelihood of enhanced disc are more specific to PS than TB. This less invasive imaging technique is useful for more accurate diagnosis of PS and TB. These slides can be retrieved under Electronic Supplementary Material.