A Rare Multilevel Spinal Epidural Abscess With Streptococcus agalactiae in an Adult With Uncontrolled Diabetes: A Case Report.

Spinal epidural abscess (SEA) is a rare, life-threatening infection that typically presents with fever, back pain, and neurologic deficits. Although most commonly caused by Staphylococcus aureus, this case reviews a rare occurrence of a multilevel SEA caused by Streptococcus agalactiae in a 62-year-old female with uncontrolled type II diabetes mellitus. The patient initially presented with lower back pain and was subsequently diagnosed with a SEA complicated by hyperglycemia. A prompt diagnosis with magnetic resonance imaging (MRI) revealed extensive abscess formation, leading to emergent neurosurgical intervention. Streptococcus agalactiae was identified as the causative organism through culture. The report emphasizes the challenges of early detection of SEA and highlights the importance of considering unusual pathogens in high-risk patients. Timely management is crucial to prevent permanent neurologic deficits and to achieve favorable outcomes.

Tophaceous gout of the cervical and thoracic spine with concomitant epidural infection.

Tophaceous gout of the spine is an underappreciated source of back pain in patients with or without neurological decline. It has been reported to occur in the cervical, thoracic and lumbar spine. Rarely, does it occur at more than one region of the spine. Advanced imaging with magnetic resonance imaging and computed tomography are usually not helpful in differentiating between infection, malignancy and gout. Clinician should have a high suspicion of spinal gout in patients with history of gout who presents with renal insufficiency, presence of peripheral tophi on exam, with elevated serum uric acid and creatinine levels, erythrocyte sedimentation rate and C-reactive protein. Here we present a case of a 23-year-old male with history of gout and chronic renal disease with progressive weakness in his lower extremities with new urinary incontinence who was found to have spinal gout with epidural infection of both the cervical and thoracic spine. Our patient was successfully managed with surgical decompression followed by medical treatment with antibiotics and steroids.

Pan-spinal infection: a case series and review of the literature.

BACKGROUND: Panspinal infection usually presents with fever, back pain, neurological deficit, and in advanced cases multi-organ failure and septic shock. The choice of treatment for panspinal infection is challenging because these patients are usually medically unstable with severe neurological compromise. The objective of this study is to review management and long term outcomes for patients with panspinal infection. METHODS: A retrospective review of patients with panspinal infection treated in our center over a 5-year period [Jan 2010-Dec 2014] and a review of the current published literatures was undertaken. RESULTS: We identified 4 patients with panspinal infection. One case was managed medically due to high perioperative risk, whilst the other three were managed surgically whilst on antibiotic therapy. All 3 cases managed surgically improved neurologically and infection subsided, whereas the patient managed medically did not change neurologically and infection subsided. CONCLUSIONS: Patients with panspinal infection should be treated surgically unless the medical risk of surgery or anaesthesia is prohibitive.

Is there a difference in neurologic outcome in medical versus early operative management of cervical epidural abscesses?

BACKGROUND CONTEXT: The ideal management of cervical spine epidural abscess (CSEA), medical versus surgical, is controversial. The medical failure rate and neurologic consequences of delayed surgery are not known. PURPOSE: The purpose of this study is to assess the neurologic outcome of patients with CSEA managed medically or with early surgical intervention and to identify the risk factors for medical failure and the consequences of delayed surgery. STUDY DESIGN/SETTING: Retrospective electronic medical record (EMR) review. PATIENT SAMPLE: Sixty-two patients with spontaneous CSEA, confirmed with advanced imaging, from a single tertiary medical center from January 5 to September 11. OUTCOME MEASURES: Patient data were collected from the EMR with motor scores (MS) (American Spinal Injury Association 0-100) recorded pre/posttreatment. Three treatment groups emerged: medical without surgery, early surgery, and those initially managed medically but failed requiring delayed surgery. METHODS: Inclusion criteria: spontaneous CSEA based on imaging and intraoperative findings when available, age >18 years, and adequate EMR documentation of the medical decision-making process. Exclusion criteria: postoperative infections, Pott disease, isolated discitis/osteomyelitis, and patients with imaging findings suggestive of CSEA but negative intraoperative findings and cultures. RESULTS: Of the 62 patients included, 6 were successfully managed medically (Group 1) with MS increase of 2.3 points (standard deviation [SD] 4.4). Thirty-eight patients were treated with early surgery (Group 2) (average time to operating room 24.4 hours [SD 19.2] with average MS increase 11.89 points [SD 19.5]). Eighteen failed medical management (Group 3) requiring delayed surgery (time to OR 7.02 days [SD 5.33]) with a net MS drop of 15.89 (SD 24.9). The medical failure rate was 75%. MS change between early and delayed surgery was significant (p<.001) favoring early surgery. Risk factors and laboratory data did not predict medical failure or posttreatment MS because of the high number of medical failures when abscess involves the cervical epidural space. CONCLUSIONS: Early surgery results in improved posttreatment MS compared with medical failure and delayed surgery. In our patients, the failure rate of medical management was high, 75%. Based on our results, we recommend early surgical decompression for all CSEA.

Influence of protective measures after epidural catheter disconnection on catheter lumen colonization: an in vitro study.

BACKGROUND: Epidural anaesthesia provides excellent pain therapy and reduces postoperative morbidity and mortality. Epidural haematoma and infection are catastrophic complications of this therapy. Following accidental catheter disconnection the choice is between reconnection and premature treatment termination. There is little experimental or clinical data guiding clinical decision-making after epidural catheter disconnection. AIM: Investigation of the in vitro effects of clinically applied safety measures after epidural catheter disconnection. METHODS: The proximal 20mm of epidural catheters were submerged into a suspension of 1 × 10(8)cfu Staphylococcus epidermidis. Catheters were treated by the following potentially preventive measures: (i) cutting 2 cm distal to the level of contamination, (ii) disinfection by spray-wipe, or (iii) employing ropivacaine 0.75% as flushing solution instead of normal saline. All measures were used alone, in a dual combination or all together as a triple intervention (N = 10 catheters in each group). Control catheters were not treated. After 24h of culturing, bacterial growth of the eluates was recorded. FINDINGS: All control catheters showed positive cultures. All 49 eluates of catheters that were cut as a single, dual or triple intervention remained sterile. Disinfection prevented bacterial growth in eluate of only six catheters in single or dual interventions. Ropivacaine did not prevent any bacterial growth. CONCLUSION: Only cutting of epidural catheters 20 mm distal to the level of contamination completely prevented bacterial growth. Disinfection might further reduce risk as an additive measure. This supports the clinical practice of catheter shortening and reconnection. The safe window of time and length of shortening needs to be further investigated.