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.

First confirmed case of spondylodiscitis with epidural abscess caused by Parvimonas micra.

Parvimonas micra was renamed species as within Gram-positive anaerobic cocci and rarely causes severe infections in healthy people. We report the first confirmed case of spondylodiscitis with epidural abscess caused by P. micra in a healthy women. The patient has a pain in low back and anterior left thigh. Magnetic resonance imaging and computed tomography detected the affected lesion at the L2 and L3 vertebral bodies. All isolates from the surgical and needle biopsy specimens were identified as P. micra by 16S rRNA and MALDI-TOF. In this case, P. micra showed high sensitivity to antimicrobial therapy. She was successfully treated with debridement and sulbactam/ampicillin, followed by oral metronidazole for a total of 10 weeks. The causative microorganisms of spondylodiscitis are not often identified, especially anaerobic bacteria tend to be underestimated. On the other hand, antimicrobial therapy for spondylodiscitis is usually prolonged. Accordingly, we emphasize the importance of performing accurate identification including anaerobic bacteria.

Infectious etiologies of myelopathy.

Myelopathy refers to a spinal cord disorder that presents with motor and/or sensory deficits. Infectious agents that cause myelopathy do so by either direct infection of neural structures (e.g., polio), a parainfectious mechanism (with a presumed autoimmune pathogenesis), or as a result of involvement of structures adjoining the spinal cord, which may cause a compressive myelopathy. This review of infectious causes of myelopathy focuses on pathogens that are most relevant to clinicians in North America.

Spinal epidural abscess.

BACKGROUND: Spinal epidural abscess is an uncommon disease with a relatively high rate of associated morbidity and mortality. The most important determinant of outcome is early diagnosis and initiation of appropriate treatment. OBJECTIVES: We aim to highlight the clinical manifestations, describe the early diagnostic evaluation, and outline the treatment principles for spinal epidural abscess in the adult. DISCUSSION: Spinal epidural abscess should be suspected in the patient presenting with complaints of back pain or a neurologic deficit in conjunction with fever or an elevated erythrocyte sedimentation rate. Gadolinium-enhanced magnetic resonance imaging is the diagnostic modality of choice to confirm the presence and determine the location of the abscess. Emergent surgical decompression and debridement (with or without spinal stabilization) followed by long-term antimicrobial therapy remains the treatment of choice. In select cases, non-operative management can be cautiously considered when the risk of neurologic complications is determined to be low. CONCLUSION: Patients with a spinal epidural abscess often present first in the emergency department setting. It is imperative for the emergency physician to be familiar with the clinical features, diagnostic work-up, and basic management principles of spinal epidural abscess.

Epidural abscesses of the CNS.

Epidural abcessess can involve the intercranial or spinal compartments and can result in potentially devastating neurological injuries. Although rare, incidence of spinal epidural abscesses (SEAs) is increasing as predisposing factors such as injected-drug use, chronic immunosuppression, and spinal surgery become more common. Whereas symptoms of SEAs can include fever, back pain, and neurological dysfunction, the presentation of intracranial epidural abscesses (ICEAs) is less well defined. Neuroimaging narrows the potential diagnoses and enables prompt empirical therapy until specific microbiological diagnosis is made. Surgical intervention is an integral part of treatment for epidural abscesses in patients with neurological symptoms or who have not responded to medical management. Prognosis for both SEAs and ICEAs is typically poor because of delayed diagnosis and intervention and is dependent on the neurological status at the time of diagnosis. Increased clinical awareness can greatly improve outcomes by helping to diagnose patients earlier.

Spinal epidural abscess due to Staphylococcus aureus: clinical manifestations and outcomes.

BACKGROUND AND PURPOSE: Despite advances in diagnosis and treatment, spinal epidural abscess due to Staphylococcus aureus remains a challenge to clinicians. In this study, we describe the clinical features and outcomes of patients with spinal epidural abscess due to S. aureus. METHODS: Thirty one cases of spinal epidural abscess due to S. aureus treated at the National Taiwan University Hospital from January 2001 to December 2006 were retrospectively reviewed, using a standardized case collection form. Spinal epidural abscess was diagnosed by computed tomography or magnetic resonance imaging of the spine. RESULTS: The median age of subjects was 55 years (range, 20 to 90 years) and the male-to-female ratio was 4.2. All patients had spine pain and 18 (58.1%) had fever. Lumbar or lumbosacral region was the most frequently involved site of spinal epidural abscess (61.3%), and 83.9% of the patients also had vertebral osteomyelitis. Sixteen patients (51.6%) were treated successfully with antibiotics alone for a median duration of 70 days (range, 23 to 274 days), whereas the median duration of antibiotic therapy in patients undergoing surgical intervention was 102 days (range, 40 to 227 days). Renal failure, malignancy or underlying comorbid illness estimated by Charlson score was predictive of a poor prognosis with treatment failure or mortality. CONCLUSION: Although medical treatment alone might benefit selected patients with spinal epidural abscess due to S. aureus and minimal neurologic sequelae, close monitoring of the evolution of neurologic deficits with radiographic imaging follow-up is necessary, since the rate of progression of neurologic impairment is difficult to predict.

Epidural abscess of the cervical spine with atypical manifestations: a report of two cases.

BACKGROUND: Epidural abscess of the cervical spine is a medical and surgical emergency, especially when it is located at cervical area, considering this critical anatomic location. Although there is the so-called triad of epidural abscess (fever, local pain, and neurologic deficits), these are not sensitive enough to detect spinal abscess early and prevent significant morbidity and mortality. REVIEW SUMMARY: We report 2 fatal cases of cervical spine epidural abscess with atypical manifestations. Patient 1 presented as an ascending paraparesis without signs of upper motor neuron involvement. The initial presentation was only lumbago and paraparesis. Patient 2 presented as a pure motor monoparesis of the lower limbs with lumbago. However, both had no neck pain or percussion tenderness initially. There was also no fever in patient 1. The diagnosis was made on the fourth and eighth days, respectively. They both had longstanding diabetes mellitus (DM) and presumably were not well controlled. Diabetic neuropathy and an immunocompromised status resulted in delayed diagnosis. Neither received surgical intervention. Both patients died despite correct empiric antibiotic therapy. CONCLUSION: A high index of suspicion is most important in making a rapid, correct diagnosis of spinal epidural abscess (SEA) when a patient presents with local spinal pain and has risk factors like DM. The classic symptom triad of SEA is not sensitive enough for early detection, so a erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) and CRP can be used to improve the accurate diagnosis. Spinal MRI should be performed as soon as possible. When patients present with neurologic deficits, surgical intervention is essential if there is no contraindication.

Epidural abscess, discitis and vertebral osteomyelitis caused by Neiserria subflava.

Neisseria subflava is generally regarded as commensal flora of the oropharyngeal tract and usually non-pathogenic. There are, however, reports of invasive disease such as bacteremia, endocarditis, sepsis, meningitis, septic arthritis and discitis caused by this organism. This paper presents the first reported case of an epidural abscess caused by Neiserria subflava.

Errors in Diagnosis of Spinal Epidural Abscesses in the Era of Electronic Health Records.

PURPOSE: With this study, we set out to identify missed opportunities in diagnosis of spinal epidural abscesses to outline areas for process improvement. METHODS: Using a large national clinical data repository, we identified all patients with a new diagnosis of spinal epidural abscess in the Department of Veterans Affairs (VA) during 2013. Two physicians independently conducted retrospective chart reviews on 250 randomly selected patients and evaluated their records for red flags (eg, unexplained weight loss, neurological deficits, and fever) 90 days prior to diagnosis. Diagnostic errors were defined as missed opportunities to evaluate red flags in a timely or appropriate manner. Reviewers gathered information about process breakdowns related to patient factors, the patient-provider encounter, test performance and interpretation, test follow-up and tracking, and the referral process. Reviewers also determined harm and time lag between red flags and definitive diagnoses. RESULTS: Of 250 patients, 119 had a new diagnosis of spinal epidural abscess, 66 (55.5%) of which experienced diagnostic error. Median time to diagnosis in error cases was 12 days, compared with 4 days in cases without error (P <.01). Red flags that were frequently not evaluated in error cases included unexplained fever (n = 57; 86.4%), focal neurological deficits with progressive or disabling symptoms (n = 54; 81.8%), and active infection (n = 54; 81.8%). Most errors involved breakdowns during the patient-provider encounter (n = 60; 90.1%), including failures in information gathering/integration, and were associated with temporary harm (n = 43; 65.2%). CONCLUSION: Despite wide availability of clinical data, errors in diagnosis of spinal epidural abscesses are common and involve inadequate history, physical examination, and test ordering. Solutions should include renewed attention to basic clinical skills.

Imaging for spine tumors and new applications.

OBJECTIVES: Discuss intramedullary, intradural/extramedullary, and extradural spinal tumors including imaging characteristics with emphasis on MR and advances in treatment. METHODS: Literature and institutional review. RESULTS: Spinal tumors: intramedullary, intradural/extramedullary, and extradural, comprise a wide range of histological tumors with an even wider range of clinical symptoms and prognostic features. They are relatively rare and if left untreated, can cause serious neurological deficits and disability. An accurate diagnosis is therefore crucial in determining prognosis and directing therapy. Magnetic resonance imaging (MRI) has revolutionized the diagnosis of intraspinal tumors, allowing for early detection and improved anatomical localization. Magnetic resonance has also become an integral part in staging of both primary and metastatic neoplasms of the spine for guiding therapy and is an excellent modality for follow-up. Advances in MRI (perfusion and molecular imaging) may help refine and describe these neoplasms for accurate treatment and prognosis in the future. Surveillance protocols and role of magnetic resonance are not well established. CONCLUSIONS: Magnetic resonance plays an integral role in evaluation of spinal tumors with increasing role in staging and treatment.

Spinal epidural abscess with a rapid course in young healthy infantry recruits with multiple skin lacerations.

In recent years, there has been high prevalence of Staphylococcus aureus (S. aureus) infection among soldiers in the Israeli military, with devastating sequelae in several cases. Emergency department physicians have developed a high level of suspicion for spinal epidural abscess (SEA) in patients presenting known risk factors; however, SEA is a particularly elusive diagnosis in young healthy adults with no history of drug abuse. We review three cases of SEA secondary to methicillin-sensitive S. aureus (MSSA) infection in young healthy soldiers without known risk factors. We retrospectively reviewed clinical files of soldiers treated at our Medical Center from 2004-2015 to identify patients diagnosed with SEA. Those aged less than 30years with no history of intravenous drug use, spine surgery or spine trauma were included in the study. Three young army recruits met the inclusion criteria. These young men developed SEA through extension of MSSA infection to proximal skin and soft tissue from impetigo secondary to skin scratches sustained during "basic" training. All presented with mild nuchal rigidity and severe persistent unremitting lancinating radicular pain. Although healthy at baseline, they had a severe, rapidly progressive course. Following urgent surgery, two patients recovered after rehabilitation; one remained with paraparesis at late follow-up. Neurological deficits and systemic evidence of S. aureus infection progressed rapidly in these young healthy SEA patients with no history of drug abuse, emphasizing the critical role of timely MRI, diagnosis, and surgery.

Cervical spinal epidural abscess following acupuncture and wet-cupping therapy: A case report.

OBJECTIVE: Report of an uncommon complication of acupuncture and wet cupping. METHODS: A 54-year-old man presented with neck pain and fever. Magnetic resonance imaging of the cervical spine revealed an epidural abscess at C4 to T2. RESULTS: The symptoms related to epidural abscess resolved partially after treatment with antibiotics. CONCLUSION: Acupuncture and wet-cupping therapy should be taken into consideration as a cause of spinal epidural abscesses in patients who present with neck pain and fever. Furthermore, acupuncture and wet-cupping practitioners should pay attention to hygienic measures.

Cervical Facet Joint Infection and Associated Epidural Abscess with Streptococcus intermedius from a Dental Infection Origin A Case Report and Review.

Pyogenic cervical facet joint infections are rare and such infections from a dental origin are even less common. Of these few cases, none have described infection with Streptococcus intermedius as the pathogen. A 65-year-old orthopaedic surgeon complained of fevers, right-sided radiating neck pain, stiffness, swelling, erythema, and right upper extremity weakness one month after he had broken a crown over his right mandibular premolar, a continued source of pain. Imaging of the cervical spine showed a right C4-C5 facet inflammatory arthropathy and a small epidural abscess that was cultured and initially treated with intravenous antibiotics. The oral maxillofacial surgery team performed an extraction of the infected, symptomatic tooth. For continued right upper extremity weakness, the patient underwent C4-C5 laminoforaminotomy and irrigation and debridement of the right C4-C5 facet joint. After 6 weeks of intravenous antibiotics, the patient's infectious and inflammatory markers had normalized. By 4 months, he had regained full strength at his upper extremity and a painless and full range of motion of his cervical spine.Pyogenic cervical facet joint infection is very rare and potentially dangerous. A high clinical suspicion and appropriate imaging, including magnetic resonance imaging, are important for correct diagnosis. Prompt medical and surgical treatment may avert complications, and although the patient presented made a complete recovery, patients may be left with neurological compromise.

Spinal epidural abscess: an analysis of 24 cases.

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

Candida albicans spinal epidural abscess secondary to prosthetic valve endocarditis.

A 56-year-old woman, with underlying rheumatic heart disease status post mitral valve replacement, presented with fever, low back pain radiating to right leg, and congestive heart failure. Magnetic resonance imaging detected an L5-S1 spinal epidural abscess. A vegetation on prosthetic mitral valve was found by transesophageal echocardiography. Cultures of epidural aspirate, surgical specimen, and blood all grew Candida albicans. She received surgical drainage of the spinal epidural abscess and i.v. amphotericin B 1 mg/kg/day for eight weeks. Clinical symptoms improved gradually and she was discharged without neurologic sequelae. She remained well and continued to lead an active life two years after discharge.

Surgical strategies for vertebral osteomyelitis and epidural abscess.

Pyogenic vertebral discitis and osteomyelitis (PVDO) has become an increasing problem for the spine surgeon. Despite recent advances in medical care and improved diagnostic neuroimaging, PVDO remains a major cause of illness and death in the elderly population. Infection of the spinal column often presents insidiously; however, if not treated appropriately and in a timely manner it can lead to severe neurological impairment, systemic septicemia, and progressive spinal deformity. In this paper the authors review the epidemiological and pathophysiological features and the clinical presentation of PVDO. Conventional medical therapy is described, with a particular focus on the methods of diagnosis. Surgical strategies for PVDO are then presented based on the literature and according to the practice of the senior author (S.L.O.), with an emphasis placed on structural considerations, implant selection, and techniques for augmenting vascular tissue to the site of infection.

Comparison of operative and nonoperative management of spinal epidural abscess: a retrospective review of clinical and laboratory predictors of neurological outcome.

OBJECT: Spinal epidural abscess (SEA), once considered a rare occurrence, has showed a rapid increase in incidence over the past 20-30 years. Recent reports have advocated for conservative, nonoperative management of this devastating disorder with appropriate risk stratification. Crucial to a successful management strategy are decisive diagnosis, prompt intervention, and consistent follow-up care. The authors present a review of their institutional experience with operative and nonoperative management of SEA to assess morbidity and mortality and the accuracy of microbiological diagnosis. METHODS: A retrospective analysis of patient charts, microbiology reports, operative records, and radiology reports was performed on all cases involving patients admitted with the diagnosis of SEA between July 1998 and May 2009. RESULTS: Seventy-seven cases were reviewed (median patient age 51.4 years, range 17-78 years). Axial pain was the most common presenting symptom (67.5% of cases). Presenting signs included focal weakness (55.8%), radiculopathy (28.6%), and myelopathy (5.2%). Abscesses were localized to the lumbar, thoracic, and cervical spine, respectively, in 39 (50.6%), 20 (26.0%), and 18 (23.4%) of the patients. Peripheral blood cultures were negative in 32 (45.1%) of 71 patients. Surgical site or interventional biopsy cultures were diagnostic in 52 cases (78.8%), with concordant blood culture results in 36 (60.0%). Methicillin-resistant Staphylococcus aureus (MRSA) was the most frequent isolate in 24 cases (31.2%). The mean time from admission to surgery was 5.5 days (range 0-42 days; within 72 hours in 66.7% of cases). Outcome data were available in 72 cases. At discharge, patient condition had improved or resolved in 57 cases (79.2%), improved minimally in 6 (8.3%), and showed no improvement or worsening in 9 (12.5%). Patient age and premorbid weakness were the only factors found to be significantly associated with outcome (p = 0.04 and 0.012, respectively). CONCLUSIONS: These results strongly support immediate surgical decompression combined with appropriately tailored antibiotic therapy for the treatment of symptomatic SEA presenting with focal neurological deficit. The nonsuperiority discovered in other patient subsets may be due to allocation biases between surgically treated and nonsurgically treated cohorts. The present data demonstrate the accuracy of peripheral blood culture for the prediction of causative organisms and confirm patient age as a predictor of outcomes.

Citrobocter kasori spinal epidural abscess: a rare occurrence.

Pyogenic spinal epidural abscess Is an uncommon Infectious occurrence. Clinical prospects of pyogenic spinal epidural abscess are graver if not promptly diagnosed and treated appropriately. A case of spinal epidural abscess has been presented with sinus tract formation at L4-L5 level, of pyogenic aetiology that progressed to paraplegia over the course of the disease. MRI pointed towards an epidural abscess extending from T12 vertebral level to S1 vertebral level. Surgical decompression in the form of laminectomy and evacuation of pus was done and antibiotics were given according to culture and sensitivity. Histopathological analysis revealed the acute suppurative nature of the abscess. Citrobacter kasori was isolated on pus culture. Pyogenic epidural abscess with causative organism being Citrobacter kasori has least been documented.