ACDF versus corpectomy in octogenarians with cervical epidural abscess: early complications and outcomes with 2 years of follow-up.

PURPOSE: Cervical spinal epidural abscess (CSEA) is a rare condition, manifesting as rapid neurological deterioration and leading to early neurological deficits. Its management remains challenging, especially in patients older than 80 years. Therefore, we aimed to compare the clinical course and determine morbidity and mortality rates after anterior cervical discectomy and fusion (ACDF) versus corpectomy in octogenarians with ventrally located CSEA at two levels. METHODS: In this single-center retrospective review, we obtained the following from electronic medical records between September 2005 and December 2021: patient demographics, surgical characteristics, complications, hospital clinical course, and 90-day mortality rate. Comorbidities were assessed using the age-adjusted Charlson comorbidity index (CCI). RESULTS: Over 16 years, 15 patients underwent ACDF, and 16 patients underwent corpectomy with plate fixation. Between the two groups, patients who underwent corpectomy had a significantly poorer baseline reserve (9.0 ± 2.6 vs. 10.8 ± 2.7; p = 0.004) and had a longer hospitalization period (16.4 ± 13.1 vs. 10.0 ± 5.3 days; p = 0.004) since corpectomy lasted significantly longer (229.6 ± 74.9 min vs. 123.9 ± 47.5 min; p < 0.001). Higher in-hospital and 90-day mortality and readmission rates were observed in the corpectomy group, but the difference was not statistically significant. Both surgeries significantly improved blood infection parameters and neurological status at discharge. Revision surgery due to pseudoarthrosis was required in two patients after corpectomy. CONCLUSIONS: We showed that both ACDF and corpectomy for ventrally located CSEA can be considered as safe treatment strategies for patients aged 80 years and above. However, the surgical approach should be carefully weighed and discussed with the patients and their relatives.

Spinal segmental myoclonus following spinal surgery.

A 44-year-old male was admitted with L5/S1 spondylodiscitis complicated by a posterior epidural abscess that was compressing the thecal sac with severe narrowing of the canal and compression of the cauda equine. He underwent computed tomography (CT) guided drainage followed by L5/S1 decompression laminectomy and was started on a 6-week course of intravenous antibiotics with good response. He remained well and afebrile with inflammatory markers showing improvement. During this period, he developed intermittent myoclonic movements of right lower limb with severe pain over the back radiating to the gluteal region which hindered his rehabilitation potential. He was diagnosed with spinal segmental myoclonus based on clinical findings and history of recent spinal surgery. He was successfully treated with a course of clonazepam and continues to make functional improvements during his rehabilitation program.

Epidural Abscesses as a Complication of Interleukin-6 Inhibitor and Dexamethasone Treatment in a Patient with COVID-19 Pneumonia: A Case Report.

A 66-year-old female patient was hospitalized with severe COVID-19 pneumonia, which led to hypoxia requiring oxygen support with high-flow nasal cannulae. She received anti-inflammatory treatment with a 10-day dexamethasone 6 mg PO course and a single infusion of IL-6 monoclonal antibody tocilizumab 640 mg IV. Treatment led to gradual reduction of oxygen support. However, on Day 10, she was found to have Staphylococcus aureus bacteremia with epidural, psoas, and paravertebral abscesses as the source. Targeted history taking revealed a dental procedure for periodontitis 4 weeks prior to hospitalization as the probable source. She received an 11-week antibiotic treatment, which led to resolution of the abscesses. This case report highlights the importance of individual infection risk assessment before the initiation of immunosuppressive treatment for COVID-19 pneumonia.

Post-operative clinical course in children undergoing mastoidectomy due to complicated acute mastoiditis.

PURPOSE: To determine the immediate post-operative course and outcome of pediatric patients with complicated acute mastoiditis (CAM) following surgical treatment. METHODS: A retrospective chart review of children diagnosed with CAM who underwent mastoid surgery during 2012-2019 in a tertiary care university hospital. 33 patients, divided into 2 groups: 17 patients with sub-periosteal abscess (SPA) alone-single complication group (SCG) and 16 patients with SPA and additional complications: sigmoid sinus thrombosis (SST), peri-sinus fluid/abscess, epidural/subdural abscess, and acute meningitis-multiple complications group (MCG). RESULTS: 33 patients belong to the SCG 17(51%) and 16(49%) belonged to the MCG, respectively. 6/17(35.3%) SCG patients experienced POF vs. 12/16(75%) in the MCG (P = 0.012). At post-operative day 2 (POD2), 10/13(77%) febrile patients belonged to MCG and 3/13(23%) to SCG (P = 0.013). POF was recorded until POD6 in both groups. Seven patients, all from MCG with POF, underwent second imaging with no new findings; a total of 18 positive cultures were reported. Fusobacterium necrophorum counted for 8/18(44.5%) of all positive cultures, 7/9(77.8%) in the MCG vs. 1/9(11.1%) in the SCG, P = 0.004. Streptococcus pneumoniae was reported only in SCG (5/9, 55.5%, vs. 0/9, P = 0.008). CONCLUSION: Post-mastoidectomy fever due to CAM is not unusual and seems to be a benign condition for the first 5-6 days, following surgery. MCG patients are more prone to develop POF. F. necrophorum is more likely to be associated with MCG, and S. pneumoniae is common in SCG patients.

Antitumor necrosis factor alpha and an epidural abscess during a spinal cord stimulator trial: A case report.

Spinal cord stimulation (SCS) is commonly utilized for treatment and management of chronic intractable low back and lower extremity pain. Although SCS is an overall low-risk procedure, there are potential life-threatening complications, including surgical site infections, such as an epidural abscess. Immunosuppression, a risk factor for epidural abscess, is becoming more common as an increasing number of patients are being treated with biologics for a multitude of autoimmune disorders. One class of commonly utilized biologics is antitumor necrosis factor (anti-TNF) alpha. Whereas these drugs can provide tremendous benefit for treatment and management of autoimmune disorders, there is no clear understanding of the degree to which these medications increase a patient's risk for surgical site infection, including those associated with SCS-related procedures. We present a case of an epidural abscess that developed immediately following an SCS trial in a patient with multiple undisclosed risk factors, including the use of an anti-TNF alpha agent to treat ankylosing spondylitis. For an epidural abscess, early diagnosis is key to preventing devastating complications and the need for surgical intervention. Immunosuppression can be the result of multiple issues including cancer, HIV, and biologic agents, such as anti-TNF alpha for the management of autoimmune diseases. There is limited evidence pertaining to the development of epidural abscesses in patients on anti-TNF alpha medications who undergo SCS. Studies focused on infections in patients undergoing SCS trials and permanent implants while on anti-TNF alpha agents could provide recommendations and guidance.

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.

Fatal epidural abscess with meningitis: a rare complication of colorectal surgery.

BACKGROUND: Anastomotic leakage following colorectal surgery remains a frequent complication. We report a rare case of a fatal epidural abscess caused by a colo-epidural fistula complicating a laparoscopic proctectomy. CASE PRESENTATION: A 62 year-old-man presented with weight loss, pelvic sepsis and neurological dysfunction four months after closing of the ileostomy following a laparoscopic proctectomy for a rectal adenocarcinoma one year ago. Cross-sectional imaging confirmed an epidural abscess caused by a chronic colorectal anastomotic leak. Systemic antibiotics and laparotomy with defunctioning pelvic loop colostomy were performed. Unfortunately, this management to control the major spinal infection failed. Epidural decompression and debridement was not possible due to his poor condition and the patient subsequently died. CONCLUSION: Colo-epidural fistula can occur as a consequence of colorectal anastomotic leakage. Prior to frank neurology symptoms and sepsis, patients may present with only a low-grade fever. Without prompt and aggressive management of colo-epidural infection, this severe complication can lead to paraplegia and death.

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.

Upper Cervical Epidural Abscess Resulting in Respiratory Compromise After Lumbar Steroid Injection.

BACKGROUND: Spinal epidural abscesses have a prevalence of 3 out of every 10,000 admissions. Abscesses above the level of C2, defined as upper cervical epidural abscesses, are even rarer still. CASE REPORT: We discuss a case in which a 45-year-old male patient developed an upper cervical epidural abscess 48 h after receiving a lumbar steroid injection. The patient presented with diminished strength in all four extremities and respiratory distress secondary to the space-occupying lesion near his spinal cord. His hospital course included surgical decompression and antibiotics. He was eventually discharged to rehabilitation, but never regained full strength in his arms or legs. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients who present with back or neck pain, fever, and neurologic deficits may have epidural abscess. In some patients, neurologic deficits may include respiratory distress if the upper cervical region is involved, and these patients have the possibility of airway decompensation. The diagnostic imaging modality of choice in patients with epidural abscess is MRI with gadolinium. Management involves supportive care, broad-spectrum antibiotics, which include coverage for methicillin-resistant Staphylococcus aureus, and early neurosurgical consultation.

Disco vertebral osteomyelitis causing intradural spinal abscess with cauda equina compression.

Intradural extramedullary spinal infections causing cauda equina compression are uncommon. We report an Escherichia coli bacteraemia causing lumbar discitis and an intracanalicular collection compressing the cauda equina: initially thought to be an epidural empyema, however microsurgery revealed an intradural location. Decompression, drainage, antibiotics, and neuropathy treatment are essential management.

Epidural Abscess During a Spinal Cord Stimulator Trial: A Case Report.

BACKGROUND: Spinal cord stimulation (SCS) can be beneficial for low back and radicular pain. A short trial of SCS evaluates the potential effectiveness of this therapy for a specific patient, while also decreasing the likelihood of a failed permanent implant. While rare, an epidural abscess is difficult to diagnose based on its nonspecific and unreliable clinical presentation. CASE: We present a case of an acute-onset methicillin-sensitive Staphylococcus aureus epidural abscess 72 to 96 hours into a trial of a percutaneous spinal cord stimulator. The patient had no prior medical history of an immunocompromised state or other significant risk factors. DISCUSSION: An epidural abscess can rapidly arise from an SCS trial despite strict aseptic technique and prophylactic pre-procedural antibiotics. Spinal epidural abscesses are being detected earlier, and an increasing number of patients are being managed medically. However, it may be challenging to differentiate focal back pain from acute or chronic pain, expected post-procedural pain, and a new entity such as an abscess.

[A Case of Intracranial Epidural Abscess Secondary to Medication-Related Osteonecrosis of the Jaw].

Recently, bisphosphonate and denosumab have been widely used for the treatment of bone metastasis of breast cancer. However, medication-related osteonecrosis of the jaw(MRONJ)has often been reported as a side effect of these drugs. We experienced a rare case of intracranial epidural abscess secondary to MRONJ. The patient died of the condition, although chemotherapy was effective. The mechanism of and therapy for MRONJ have not been clarified; therefore, its prevention should be emphasized.

Spinal epidural abscess - a rare complication of Crohn´s disease: case report.

Spinal epidural abscess (SEA) is a rare disease that occurs mainly in immunocompromised patients after spinal surgery or spinal trauma and can lead to a severe neurological deficit or even death if diagnosed too late. However, cases of SEA have also been reported in patients with fistulising Crohn´s disease (CD). We present a case of a young patient with CD and a history of relapsing perianal disease followed by a complication of SEA in the thoracic spine. In close cooperation with the orthopedists and the neurologists, the gastroenterologists have successfully treated the SEA in this patient, allowing her to return back to biological treatment for CD.

Simultaneous treatment of intracranial complications of paranasal sinusitis.

PURPOSE: The objective of this study was to analyse 51 patients with intracranial complications of sinusitis treated in the Department of Otolaryngology and Laryngeal Oncology at Poznan University of Medical Sciences from 1964 to 2016. MATERIALS AND METHODS: Males made up a significant portion of study participants at 70.5%. Treatment included simultaneous removal of inflammatory focal points in the paranasal sinuses and drainage of cerebral and epidural abscesses and subdural empyemas under the control of neuronavigation preceded by the implementation of broad-spectrum antibiotics continuously for 4 weeks. Seventy-three intracranial complications were found among 51 patients. Of the 51 patients, 25 had frontal lobe abscesses (including multiple abscesses). Other complications included the following: 16 epidural abscesses, 9 subdural empyemas, 15 meningitis cases, 3 intracerebral abscesses, 3 sinus thrombosis cases and 2 patients with cerebritis. Co-occurrence of these complications worsened the state of the patient and increased the duration of treatment. Patients with frontal lobe abscesses had a better prognosis and less pronounced neurological symptoms in recent years versus earlier treatment approaches. CONCLUSIONS: Simultaneous treatment of intracranial complications of sinusitis is an effective treatment method that has minimal burden for the patient. From 1964 to 1978, three deaths (17%) were reported among patients with these complications. Since 1978, no deaths were reported in the clinic.

Oesophageal pleural fistula presenting with Parvimonas micra infection causing cervical and brain abscesses.

Parvimonas micra (P. micra) infections causing spinal cord compression are extremely rare. We report an occult oesophageal pleural fistula presenting with spinal epidural and brain abscesses resulting in severe neurological deficits caused by P. micra. Molecular detection proved to be instrumental in identifying the causative pathogen. Essential management with decompression, drainage, antibiotics and fistula repair lead to a good outcome.

Rare and Serious Complications of Sinusitis in Pediatric Patients: Epidural Abscess.

Intracranial abscess has serious mortality. Therefore, early diagnosis and treatment is important. Intracranial abscess is rarely seen as a complication of sinusitis. Specially in children it has been reported rarely. Fever and headache can indicate complications in children.

Safety and efficacy of polyetheretherketone (PEEK) cages in combination with posterior pedicel screw fixation in pyogenic spinal infection.

BACKGROUND: To date, there is growing consensus that PEEK material may be used for interbody fusion in spinal infections. Data supporting that claim are however restricted to a few very small clinical series. The aim of this study is to evaluate the outcome of surgical treatment of pyogenic spinal infections with PEEK cages in combination with posterior pedicel screw fixation. METHODS: Between 2006 and 2013, a total of 211 patients suffering from spondylodiscitis underwent surgical debridement and instrumentation. There were 52 cases where PEEK cages were used. Laboratory and physical examinations were assessed at a 3-month follow-up. Last follow-up was performed with at a minimum of 12 months after surgery via a telephone interview. RESULTS: Mean age at presentation was 67 years, with 19 (37 %) male patients and 33 (63 %) female. Distribution of the infection was lumbar in 29 (56 %%), thoracic in 3 (6 %) and cervical in 11 (21 %) cases. Nine patients (17 %) had concomitant non-contiguous spondylodiscitis. Epidural abscess was found in 17 patients (33 %); 48 (92 %%) had pain; neurological deficits were found in 20 patients (38 %). All patients in this series underwent surgical debridement with instrumentation of the spine. Postoperative intravenous antibiotics were administered for 15.4 ± 6.8 days followed by 2.9 ± 0.5 months of oral antibiotics. Complete resolution of the infection was achieved in all cases. Of the 28 patients with neurological deficits, 6 had full recovery and 10 had improved incompletely after surgery. One patient suffered from a pulmonary embolism postoperatively. There were no mortalities. CONCLUSIONS: Use of PEEK cages for interbody fusion is feasible and safe in patients suffering from a pyogenic spinal infection.

When Do You Drain Epidural Abscesses of the Spine?

BACKGROUND: How the relative volume of an epidural abscess on MRI affects outcomes with antibiotics alone has limited literature. The purpose of this study was to identify which infected epidural collections will reabsorb with antibiotics alone. Specifically, what is the critical size and enhancement on contrast MRIs to require a drainage procedure? MATERIALS AND METHODS: A retrospective review of all spinal osteomyelitis patients from 2001-2012 was performed. Inclusion criteria included appropriate initial imaging, lab results, no drainage procedures of collections, and no treatment prior to admission at an outside institution. Large size epidural abscess was defined as abscesses with a volume greater than 1400 mm3. Clearance and mortality rates were evaluated. RESULTS: The cohort consisted of 128 patients including 76 men and 52 women who had a mean age of 62 years (range, 21 to 90 years) and had a mean follow-up of 38 months (range, 24 to 72 months). Patients with a large epidural abscess had a greater clearance rate of the infection and decreased mortality rate when treated with surgery or drainage compared to patients treated with antibiotics alone [clearance: p=0.048; mortality: p=0.048]. Those small epidural abscesses had similar clearance and mortality rates when treated with surgery or drainage compared to antibiotics alone [clearance: p=0.75; mortality: p=0.13]. Patients with non-enhancing epidural abscesses had similar clearance rates-but increased mortality rates-when treated with antibiotics alone compared to surgery or drainage [clearance: p>0.9; mortality: p=0.03]. Those with enhancing epidural collections had similar clearance and mortality rates when treated with antibiotics alone compared to surgery or drainage [clearance: p=0.08, mortality: p=0.10]. CONCLUSION: Large epidural infected collections require surgery or a percutaneous drainage procedure. Clearance rates are higher and mortality rates are lower compared to non-operative management in these instances. Neurologically intact patients with a small epidural collection can be treated with antibiotics alone with good expected outcomes.

Whole cerebrospinal axis infection after lumbar epidural injection: a case report.

PURPOSE: Lumbar epidural injection is a popular treatment for degenerative lumbar disease. Although post-procedural epidural infection is rare, meningitis and epidural abscess are life-threatening conditions, and need additional medical and surgical intervention. The purpose of this article is to report a patient with fatal whole cerebrospinal axis infection after lumbar epidural injections. METHODS: A 64-year-old female patient presented with septic shock and quadriparesis. In the past, this patient had received lumbar epidural injections several times for degenerative spondylolisthesis at L4-5 in another hospital. The magnetic resonance imaging showed epidural abscess, a compressed dura and spinal cord from C1 to S2, and cerebral meningitis. We performed laminectomies and removal of the abscesses. Her mental status was diminished to a deep, drowsy state after three postoperative weeks. Brain computed tomography scans revealed hydrocephalus. Therefore, ventriculoperitoneal shunting was performed. RESULTS: Methicillin resistant Staphylococcus epidermidis was cultured from blood samples. The patient's infection was completely controlled and her mental status improved to alert; however, her quadriparesis remained. CONCLUSIONS: Although lumbar epidural injection is an effective procedure to treat lumbar radicular pain, this procedure can induce fatal complications such as sepsis and epidural abscess. LEVEL OF EVIDENCE: 5.