Paraplegia subsequent to administration of tissue plasminogen activator and intravenous heparin following myocardial infarction--a case report

A case involving spinal epidural hematoma following tissue plasminogen activator and intravenous heparin therapy administered after acute myocardial infarction is reported here. The symptoms of spinal epidural hematoma following thrombolytic therapy are outlined and a recommended course of action for arriving at a definitive diagnosis of suspected epidural hematoma is provided.     

Diagnostic pitfalls in osteomyelitis of the odontoid process: case report

BACKGROUND

Pyogenic osteomyelitis of the odontoid process is a very rare disease associated with a variety of clinical symptoms, and previous reports have stressed the difficulties inherent in making the diagnosis. The authors present a case of osteomyelitis of the odontoid process with epidural abscess in which magnetic resonance imaging (MRI) was used in the diagnosis, assessment of the extent of concomitant epidural abscess, treatment effect, and long-term follow-up.

CASE DESCRIPTION

A 68-year-old male was admitted to our hospital with cervical pain, neck stiffness, and fever. Although the diagnosis was missed at the beginning, the patient was diagnosed with osteomyelitis of the odontoid process with a paravertebral epidural abscess by MRI. The patient became asymptomatic after 3 months of antibiotic therapy.

CONCLUSION

Pyogenic osteomyelitis of the odontoid process is a rare condition requiring a high index of suspicion for diagnosis. MRI examination should be considered in the diagnosis in patients with neck pain combined with fever. Serial MRI during and after antibiotic therapy provided an objective assessment of the healing rate of the lesions.     

Aggressive thoracic actinomycosis complicated by vertebral osteomyelitis and epidural abscess leading to spinal cord compression

STUDY DESIGN: Report of a successfully diagnosed and treated case of spinal cord compression due to epidural actinomycosis. OBJECTIVE: To illustrate that proper use of imaging strategy can greatly facilitate diagnosis and management of this rare condition. SUMMARY OF BACKGROUND DATA: Spinal actinomycosis causing epidural abscess and significant spinal cord compression is an uncommon condition. Although diagnosis is difficult, favorable results are widely reported when specific therapy is instituted. METHODS: A 32-year-old Chinese man had extensive dorsal thoracic soft tissue swelling and lower limb weakness. Collapse of the T5 vertebral body was found on plain radiographs with mediastinal infiltrates on chest radiograph. It took magnetic resonance imaging (MRI) to fully delineate the epidural abscess and dorsal muscular abscesses, which were not depicted by computed tomographic (CT) scan. Diagnosis was made by examination of CT-guided aspirate and tissue recovered during surgery by a microbiologist. The patient received high-dose intravenous penicillin and prompt spinal decompression once diagnosis of actinomycosis was confirmed. RESULTS: The dorsal muscular abscesses and upper thoracic epidural abscess resolved rapidly after intravenous antibiotics and surgical drainage. This was well documented by follow-up MRI and the full recovery of motor power and lower limb sensation in the patient. CONCLUSIONS: High clinical suspicion and proper use of imaging data led to timely diagnosis of this rare case of mediastinal, epidural, and intramuscular thoracic actinomycosis. Specific antibiotic therapy and timely, well-targeted surgical intervention greatly improve the outcome of this condition.     

Paraplegia Subsequent to Administration of Tissue Plasminogen Activator and Intravenous Heparin Following Myocardial Infarction-A Case Report

Abstract

A case involving spinal epidural hematoma following tissue plasminogen activator and intravenous heparin therapy administered after acute myocardial infarction is reported here. The symptoms of spinal epidural hematoma following thrombolytic therapy are outlined and a recommended course of action for arriving at a definitive diagnosis of suspected epidural hematoma is provided.     

Spinal epidural hematoma occurrence in the absence of known risk factors: a case series

Spinal epidural hematoma in the absence of coagulopathy or anticoagulation therapy is an extremely rare occurrence, with a reported incidence of less than 1 in 1 million. We present seven cases of documented epidural hematoma in the absence of coagulopathy or anticoagulation therapy to alert the clinician to consider spinal or epidural hematoma when suspicious signs and symptoms are present after neuraxial block in the absence of coagulopathy or anticoagulation therapy. The need for immediate diagnosis and therapy is emphasized as the only potential for meaningful recovery.     

Hyperbaric therapy for a postpartum patient with prolonged epidural blockade and tomographic evidence of epidural air

We used the epidural technique "loss of resistance to air" to provide labor analgesia in a healthy parturient. Inadequate analgesia required epidural catheter replacement using the same technique. Delayed recovery of sensory and motor blockade postpartum necessitated computed tomography and magnetic resonance imaging studies. These revealed 4-6 mL of air in the epidural space with no evidence of thecal compression. On the advice of the neurologist, this patient underwent hyperbaric therapy 14 h after the discontinuation of the epidural infusion. The patient made a complete recovery and was discharged without neurologic sequelae. It is possible that epidural air delayed the absorption of local anesthetics as a result of a reduction in the vascular surface area. Although a cause and effect relationship between epidural air and prolonged neurological block cannot be categorically established, the use of "loss of resistance to air" technique complicated the differential diagnosis. IMPLICATIONS: We report a case of prolonged motor and sensory block after labor analgesia using "loss of resistance to air" technique. The presence of epidural air on tomography resulted in the patient undergoing hyperbaric therapy. The use of loss of resistance to air technique complicated the differential diagnosis of prolonged sensory and motor block.     

Epidural lipomatosis simulating an epidural abscess: case report and literature review

A case of epidural lipomatosis in a 49-year-old man presenting with paraparesis, midthoracic pain, and Staphylococcus aureus pneumonia is reported. The patient had been on low dose corticosteroid therapy for 7 years for rheumatoid arthritis. The clinical and myelographic findings suggested a diagnosis of epidural abscess, but the only abnormality discovered at operation was abundant fatty tissue in the dorsal epidural space significantly compressing the spinal cord, and this was partially removed. Postoperative neurological improvement suggested that the lipomatosis was responsible for the spinal cord compression and dysfunction. If this diagnosis had been suspected, it might have been confirmed by magnetic resonance imaging or postmyelography computed tomographic scanning. With such a diagnosis, an alternative treatment could have been to decrease the steroid dose, observe for clinical improvement, and perhaps avoid operation.     

Pott's puffy tumour in a 5-year old boy: the role of ultrasound and contrast-enhanced CT imaging; surgical case report

We report a case of Pott's puffy tumour, a subperiosteal abscess of the frontal bone associated with an underlying frontal osteomyelitis, in a 5-year-old boy. Ultrasonography played a crucial role in the diagnosis of our patient, suggesting the presence of a Pott's puffy tumour with epidural abscess by showing a subperiosteal abscess associated with erosion of the frontal bone. Subsequently, the diagnosis of Pott's puffy tumour with epidural abscess was confirmed by contrast-enhanced CT scanning. Prompt neurosurgical intervention with drainage of abscesses and debridement of bone sequestrate, together with prolonged antibiotic therapy, significantly contributes to a favorable outcome.     

A case of pineal pure germinoma metastasized to the lumbosacral extradural space 8 years after initial therapy. Case report and review of literature

An 11-year-old boy first presented with a pineal tumor identified by neuroimaging but without positive serum or cerebrospinal fluid markers. The tumor disappeared after the craniotomy and following cranial irradiation. The pathologic diagnosis of the tumor was of a pure germinoma. Eight years later he returned to the hospital with spinal epidural metastasis from the pineal germinoma and required surgery. Intraoperative findings showed that the spinal tumor was solitarily located in the epidural space. Pathologically the tumor was a pure germinoma metastasis. He was treated by a combination of whole spinal irradiation and chemotherapy. The tumor disappeared after the therapy. A pineal germinoma occasionally disseminates through the ventricular system and spinal subarachnoid region. However, a solitary spinal epidural metastasis from pineal germinoma has rarely been reported. Regarding the route of this metastasis, we speculate that the CSF dissemination of the germinoma cells occurred first and some of those cells were trapped in the spinal nerve sleeve and extended into the epidural space.     

Spontaneous cervical paraspinal and epidural giant abscess in a child--case report--

A 10-year-old girl presented with a very rare paraspinal and spinal epidural abscess manifesting as fever, and neck pain and stiffness. Initially, she was treated under a diagnosis of meningitis for 3 weeks. However, she developed monoparesis of the right upper extremity, and was referred for neurosurgery. Magnetic resonance imaging revealed an epidural and paraspinal lesion intensely enhanced by gadolinium. The patient underwent urgent surgery for C2-3 laminectomy and abscess drainage, followed by broad spectrum antibiotic therapy. She was discharged and followed up in the outpatient clinic. Two months later, the paraspinal abscess recurred with great increase in size. A second operation was performed and 150 ml pus was drained. Streptococcus anginosus was grown in the culture. The patient fully recovered after long-term targeted antibiotic therapy. Such abscesses are very rare in children, especially in the cervical region. The correct diagnosis can be difficult to establish but early treatment is essential for a good prognosis.     

Paraplegia after epidural anesthesia in a patient with peripheral vascular disease: case report and review of the literature with a description of an original technique for hematoma evacuation

Epidural hematoma after epidural anesthesia is a rare and uncommon complication in patients with peripheral vascular disease who require perioperative anticoagulation therapy. A low index of suspicion makes its diagnosis difficult and often delayed. Treatment usually involves extensive laminectomy, increasing the chances for patient complications. In this article, the authors report a case of epidural hematoma with secondary paraplegia after epidural anesthesia. Also described is an original technique for evacuating the epidural space.     

Epidural dextran-40 and paramethasone injection for treatment of spontaneous intracranial hypotension

PURPOSE: This report describes treatment with epidural dextran-40 and paramethasone injection of postural headache resulting from spontaneous intracranial hypotension in a pregnant patient. CLINICAL FEATURES: A 39-yr-old pregnant woman consulted the pain clinic for the assessment of a debilitating postural headache which was non-responsive to conventional analgesic treatment. Clinical findings and cranial magnetic resonance imaging indicated the diagnosis of spontaneous intracranial hypotension syndrome. Treatment with an epidural blood patch was not undertaken for several reasons. A lumbar epidural injection with dextran-40 and paramethasone led to a significant improvement in the symptoms and allowed a progressive discontinuation of adjuvant treatment with oral steroids, with complete resolution of symptoms. CONCLUSION: We report a case of spontaneous intracranial hypotension in a pregnant patient successfully treated by epidural injection of dextran-40 and paramethasone, with adjuvant oral steroid therapy. Clinical trials are warranted to establish the efficacy of this treatment as an alternative to the epidural blood patch administration.     

Iatrogenic Spinal Epidural Abscess

Background: Iatrogenic epidural abscess complicating neuro-axial blockade is rare, but carries significant morbidity and mortality if diagnosis is delayed. First documented in 1974, this disorder is now well described in the literature, and is increasing in incidence.

Methods: A literature review was undertaken using Medline, all relevant papers on this rare, but important, complication of spinal epidural anesthesia or analgesia were used.

Results: Widespread use of neuro-axial techniques in the peri-operative period such as epidural analgesia has probably contributed to improved surgical outcome but has also led to an increased incidence of complications. Epidural abscess or epidural catheter sepsis has previously been thought to occur rarely but recent publications suggest that it may be more frequent. Predisposing factors include old age, diabetes mellitus, alcoholism, cancer, and acquired immunodeficiency syndrome. The signs and symptoms of epidural abscess may be nonspecific: including back pain, sepsis, with varying neurological deficits, which may present late. Magnetic resonance imaging (MRI) provides the most accurate definitive diagnosis. The treatment of choice in most patients is early neurosurgical decompression and antibiotic therapy. The most common causative organism in spinal epidural abscess is Staphylococcus aureus. Prompt diagnosis and specific therapy are the most important prognostic factors for a successful outcome.

Conclusion: Iatrogenic spinal epidural abscess is a rare but serious complication which should be brought to the attention of all surgeons and anesthetists.     

Postoperative spinal epidural empyema. Clinical and computed tomography features.

Epidural empyema is a rare complication of elective spinal surgery. Four such cases are described. The clinical features of this postoperative complication were surprisingly vague and misleading. Fever was uncommon. Local inflammatory signs or rapid neurologic deterioration were absent. Computerized tomography proved useful in diagnosis and follow-up. Unlike spontaneous spinal epidural abscess, postoperative spinal epidural empyema had a benign course. Causative bacteria were miscellaneous. Surgical evacuation of the purulent collection and appropriate antibiotic therapy resulted in cure in all cases.     

A review of neuraxial epidural morbidity: experience of more than 8,000 cases at a single teaching hospital

BACKGROUND: The true incidence of serious neuraxial complications such as epidural hematoma or abscess after postoperative epidural infusions is still uncertain, in part due to inconsistencies in multicenter data collection. METHODS: Prospective data were collected over 16 yr from the authors' Acute Pain Service, which is based in a large tertiary teaching institution with a nonobstetric general surgical population. RESULTS: Over this period, 8,210 epidural catheters were inserted for postoperative analgesia and 32 computed tomography or magnetic resonance imaging scans were undertaken to exclude potential neuraxial complications. From these, two spinal hematomas (1:4,105) and six epidural abscesses (1:1,368) were diagnosed. Only one patient required surgical decompression. There were no long-term neurologic sequelae in any patient. In the past 6 yr, the frequency of investigation and diagnosis of epidural abscess has increased. Overall, the combined rate of epidural abscess or hematoma was 1:1,026, (0.1%; 95% confidence interval, 0.04-0.19%) with a need for operative intervention of 1:8,210 (0.01%; 95% confidence interval, 0.0-0.07%). CONCLUSIONS: Spinal hematoma was very rare (< 0.05%). Epidural abscess was also rare (< 0.1%) but remains a potentially serious complication. Early diagnosis, using magnetic resonance imaging in patients with appropriate clinical indicators, before the onset of neurologic signs, enables conservative therapy in many cases and may help to prevent the development of serious neurologic sequelae.     

Postpartum postural headache due to superior sagittal sinus thrombosis mistaken for spontaneous intracranial hypotension

PURPOSE: To describe a case of superior sagittal sinus thrombosis in the puerperal period and the difficulties encountered in the diagnosis and management. CLINICAL FEATURES: A 29-yr-old multiparous woman presented with a postural headache four weeks after a normal pregnancy and vigorous delivery. Initial presentation suggested spontaneous intracranial hypotension (SIH) since there was no history of epidural or spinal anesthesia, or trauma or surgery to her back or neck. Conservative therapy was initially offered and then a lumbar epidural blood patch (LEBP) was performed, although it failed to relieve the postural headache. A dural leak could not be demonstrated but an MRV (magnetic resonance venography) revealed a superior sagittal sinus thrombosis (SSST). Although anticoagulant therapy was immediately initiated, the neurologist remained convinced that the postural headache was secondary to SIH, and, consequently, a second epidural blood patch was requested. Anesthesia was reluctant to perform an LEBP at this point and suggested continuing anticoagulation until a subsequent MRV demonstrated recannalization of the SSST. This advice was followed and the postural headache resolved spontaneously with intravenous anticoagulation. CONCLUSION: The present case illustrates the importance of a multidisciplinary approach to the management of this rare complication of pregnancy. This case also highlights the importance of reviewing the differential diagnosis when considering treatment of a postural headache in the puerperium.     

连续硬膜外镇痛后发生严重皮肤炎性反应一例报告

消毒液、胶带或者导管本身所引起的皮肤反应是留置硬膜外导管时的一种非常罕见，但又十分重要的危险因素。本文报道了一例经腹会阴联合手术的患者术后连续硬膜外镇痛发生的严重皮肤炎性反应。我们强调正确诊断和及时有效处理的重要性。     

A severe inflammatory cutaneous reaction after continuous epidural analgesia

A very rare, but important, risk factor in placement of epidural catheters is skin reactions to the antiseptic solution, adhesive tape, or the catheter itself. We describe a case of a severe inflammatory cutaneous reaction after continuous epidural analgesia used after an abdominal perineal resection. We highlight the importance of making the proper diagnosis and initiating timely therapy.