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ABSTRACT

Spinal epidural abscess may complicate vertebral osteomyelitis. The purpose of this report is to discuss its course in two patients with sensory/motor and cognitive impairment and to demonstrate the need for its early detection. Delayed detection may lead to spinal cord injury or meningitis. It may also delay functional return and hinder intensive rehabilitation efforts. Two patients are presented.     

腰椎间盘术后椎间隙感染的治疗

目的 探讨腰椎间盘术后椎间隙感染病的治疗方法。方法 分析评价11例腰椎间盘术后椎间隙感染人的疗效。结果 9例经保守治愈,2例手术治愈,其中3例椎问未融合,伴脊柱侧弯,仍有腰部活动受限外,其余功能恢复满意,平均随访时间40±18.8个月(5个月～5年)。结论 大部分患者经保守治疗可获痊愈,对椎体破坏超过50％、有神经受损症状者可考虑手术治疗。本病重在预防。     

成人原发性椎间盘炎（8例报告与文献复习）

本文报告了成人原发性椎间盘炎８例，其中男５例，女３例，年龄平均４４．５岁。病变间隙：Ｌ１～２１例，Ｌ２～３４例，Ｌ３～Ｌ４３例。入院前误诊为腰椎结核２例，椎体肿瘤３例。病因有三大学说即：细菌感染、无菌性炎症和自身免疫性反应，多数倾向于血源性细菌感染。讨论了临床特点、诊断与鉴别诊断及治疗问题。作者认为ＣＲＰ和ＥＳＲ较体温血象更敏感、更准确，可作为观察疗效的有效指标。本病应与腰椎结核、椎体肿瘤及退行性改变加以鉴别，ＭＲＩ有助于本病的诊断。保守治疗以卧床、大剂量广谱抗菌素治疗为主。经皮椎间盘镜行病灶清除及活检术有助于诊断和治疗。对椎体破坏超过５０％有神经受损症状、保守治疗无效者，手术病灶清除术同时可植骨融合，以增加脊柱稳定性。     

Spinal infection: a case report

Objective:

To present a case of a patient with spinal infection (SI) and highlight the chiropractor’s role in the prevention or minimization of devastating complications of SI.

Background:

Recent literature trends suggest an increasing prevalence of SI. Patients with SI most commonly present with unremitting progressive back pain and may or may not have fever or neurological signs. To avoid negative post-infection sequelae, establishing an early diagnosis and treatment is crucial.

Clinical Features:

A 29-year-old female diagnosed with L5-S1 disc herniation with impingement of the right S1 nerve root opted for surgical management. Iatrogenic bowel perforation during her spinal surgery resulted in contamination of the spinal surgical site, and findings in keeping with disco-osteomyelitis with epidural and paraspinal phlegmon formation were visualized on contrast enhanced MRI.

Conclusion:

Recent trends of increased spinal infection urge a heightened awareness by the chiropractor. The chiropractor can provide early diagnosis and supportive multidisciplinary care for such patients.     

硬脊膜外置管应用抗生素对兔硬脊膜外脓肿的治疗效果

目的 通过建立兔硬脊膜外脓肿模型,对静脉注射抗生素与经硬脊膜外置管持续应用抗生素的疗效进行比较,探讨硬脊膜外脓肿的治疗效果.方法 建立兔硬脊膜外置管模型,将16只兔随机分为3组:静脉应用抗生素组(A组)(n=6),硬脊膜外应用抗生素组(B组)(n=6),脓肿对照组(C组)(n=4).注入细菌建立硬脊膜外脓肿模型,记录体重、体温和血清C反应蛋白(CRP)值;取兔脊髓、背根神经节和神经根,行光镜、透射电镜(TEM)病理学检查.结果 静脉实验组、硬脊膜外实验组兔用药前后血清CRP值有显著性差异(P＜0.05).结论 静脉注射抗生素与经硬脊膜外置管持续注入抗生素,两组用药后均有效;硬脊膜外持续注入抗生素治疗方法可行且有效.     

Infection as a Cause of Spinal Cord Compression: A Review of 36 Spinal Epidural Abscess Cases

A retrospective survey of 36 cases treated in the Department of Neurosurgery, Hacettepe University Hospitals since 1970 was performed. Clinical presentation, aetiology and outcome of this rare disease compared to recently published series. All cases were admitted with signs of neural compression. Clinical and laboratory data suggesting an infectious origin were present only in 4 cases. Radiological investigation including magnetic resonance imaging in 10 patients, were not confirmative for an epidural abscess except for two cases. All cases underwent urgent surgical decompression and tuberculous abscess either in granulation or pus form was found in the majority. Overall mortality rate was 5.8%. Outcome was closely related to the neurological condition on admission rather than the underlying infectious origin. When compared with recently reported series, our cases demonstrated a significant divergence in terms of clinical presentation, pathogenesis and outcome. The most probable reason for this discrepancy is that risk factors for compromised immunity or systemic infection were much less than the other series and mycobacterium tuberculosis is the responsible agent in the majority which has a much more favourable outcome than non-spesific infections.     

腰椎间盘炎的预防及治疗

目的：探讨术后腰椎间盘炎的预防及治疗。方法：1992年4月～2002年10月收治术后腰椎间盘炎11例，L3、4 2例，L4、5 5例，L5S1 4例。6例经保守治疗，5例手术治疗。结果：经0．5～10年随访，平均随访4年3个月，疗效满意。结论：腰椎间盘炎是腰椎间盘手术后一种严重的并发症，只要发现及时，处理正确，可获得满意疗效。     

Complete recovery of acute paraplegia due to pyogenic thoracic spondylodiscitis with an epidural abscess

Summary Pyogenic spondylodiscitis associated with epidural abscess is a rare but serious problem in spinal surgery, because it may cause a severe morbidity or mortality, if the diagnosis is established late and the treatment is inadequate. A case of pyogenic thoracic spondylodiscitis associated with epidural abscess whose symptoms progressed over two months from back pain to acute paraplegia was presented. Magnetic resonance imaging of the spine suggested the presence of T9–10 spondylodiscitis with partial destruction of the T9 and T10 vertebral bodies and concomitant epidural abscess. Treatment consisting of surgical debridement of infected vertebrae and disc material, fusion and anterior spinal instrumentation was performed. Microbiological culture of the material revealed infection with Staphylococcus aureus and after 3 months of antibiotic treatment, recovery was almost complete. Based on a thorough review of the literature and the case presented in this report, it is concluded that accurate and prompt diagnosis requires high index of suspicion followed by a combination of adequate surgical and conservative treatment prevents severe morbidity in cases of nonspecific pyogenic spondylodiscitis associated with epidural abscess. Correspondence: Dr. Mehmet Turgut, Cumhuriyet Mahallesi, Cumhuriyet Caddesi, No: 6 Daire: 7, TR-09020 Aydın, Turkey.     

Postoperative spinal wound infections and postprocedural diskitis

BACKGROUND/OBJECTIVE: Postprocedural infections are a significant cause of morbidity after spinal interventions. METHODS: Literature review. An extensive literature review was conducted on postprocedural spinal infections. Relevant articles were reviewed in detail and additional case images were included. RESULTS: Clinical findings, laboratory markers, and imaging modalities play important roles in the detection of postprocedural spinal infections. Treatment may range from biopsy and antibiotics to multiple operations with complex strategies for soft tissue management. CONCLUSIONS: Early detection and aggressive treatment are paramount in managing postprocedural spinal infections and limiting their long-term sequelae.     

腰椎间盘术后椎间盘炎的诊断与治疗

目的：介绍腰椎间盘术后椎间盘炎的临床特点,讨论治疗方法。方法：对１３例术后椎间盘炎临床资料回顾,分析常见诊治失误原因。依靠临床体征、血沉、Ｃ—反应蛋白、Ｘ线、ＣＴ或ＭＲＩ建立早期诊断。非手术治疗治愈１０例,手术治疗治愈３例。结果：术后１１例随访６～３６个月。９例恢复原工作,４例遗有慢性腰痛或腰椎活动受限,２例不能胜任体力劳动。结论：早期诊断应重视术后再发剧烈腰痛的特殊体征。血沉、Ｃ—反应蛋白是提示感染或观察疗效的指标。Ｘ线、ＣＴ、ＭＲＩ有诊断价值。多数患者经严格卧床,大剂量广谱抗生素治疗效果满意。保守无效,炎症扩散出现相应临床症状者,应行病灶清除术。     

Extensive Spinal Epidural Abscess Resulting in Complete Paraplegia Treated by Selective Laminectomies and Irrigation

BackgroundSpinal epidural abscess (SEA) is an uncommon clinical entity that is often subject to delayed diagnosis and suboptimal treatment. Untreated disease leads to compression of the spinal cord, resulting in devastating complications.Case PresentationA 56‐year‐old man visited our hospital for progressive lower back and lower extremity pain of several days'' duration. Significant pyrexia (39.5°C) and elevated C‐reactive protein (89.2 mg/L) were detected during admission, but no positive neurological examination findings were observed. Magnetic resonance imaging revealed pyogenic discitis at L3–4. Despite the administration of directed antibiotic therapy, the patient''s condition rapidly deteriorated, culminating in complete paraplegia secondary to an extensive SEA from L4 to C7. Emergency spinal decompression surgery was canceled due to his poor clinical condition and refusal of informed consent. After further deterioration, he consented to two‐level selective laminectomies and irrigation.ConclusionsIn contrast with prior case reports, this case illustrates the natural history of an extensive SEA during conservative and late surgical treatment. Early diagnosis and timely surgical decompression are of great importance for extensive SEA.     

腰椎间盘术后椎间隙感染的防治

目的：探讨腰椎间盘术后椎间隙感染的病因、临床、诊治及预防等方面的问题。方法：分析１１例腰椎间盘术后并发椎间隙感染的临床资料。结果：经３０天～１３９ 天,平均７５．５天的保守治疗,所有病人均达痊愈。结论：医源性感染和病人抵抗力低下是该并发症最重要的致病因素,长时间顽固性难治性腰痛、活动受限是其主要特点。其诊断主要依赖于临床表现血沉加快,腰椎Ｘ线、ＣＴ扫描及ＭＲＩ检查等。强调早期发现和保守治疗。严格遵守无菌原则,合理使用抗生素是预防该病的关键。     

Pyogenic Vertebral Osteomyelitis after Acute Bacterial Prostatitis: A Case Report

A case of pyogenic vertebral osteomyelitis after acute bacterial prostatitis in a 78-year-old man is reported. The rarity and subtle clinical presentation of this condition, and the delayed appearance of radiologic signs of progression to destructive osteomyelitis, contributed to a significant delay in diagnosis. An arterial blood culture positive for bacterial growth during the episode of acute prostatitis suggested that bacteremia might result from hematogenous spread of the infection to the vertebral column via the venous system. Since intensive antimicrobial therapy proved ineffective, debridement of the first and second lumbar vertebral bodies, and anterior spinal fusion from the twelfth thoracic to the third lumbar vertebrae were performed. The patient's high fever and severe lumbago subsided immediately after the surgery. The possibility of development to pyogenic vertebral osteomyelitis should be kept in mind when treating a serious genitourinary tract infection.     

Management of postoperative spinal infections

Postoperative surgical site infection (SSI) is a common complication after posterior lumbar spine surgery. This review details an approach to the prevention, diagnosis and treatment of SSIs. Factors contributing to the development of a SSI can be split into three categories: (1) microbiological factors; (2) factors related to the patient and their spinal pathology; and (3) factors relating to the surgical procedure. SSI is most commonly caused by Staphylococcus aureus. The virulence of the organism causing the SSI can affect its presentation. SSI can be prevented by careful adherence to aseptic technique, prophylactic antibiotics, avoiding myonecrosis by frequently releasing retractors and preoperatively optimizing modifiable patient factors. Increasing pain is commonly the only symptom of a SSI and can lead to a delay in diagnosis. C-reactive protein and magnetic resonance imaging can help establish the diagnosis. Treatment requires acquiring intra-operative cultures to guide future antibiotic therapy and surgical debridement of all necrotic tissue. A SSI can usually be adequately treated without removing spinal instrumentation. A multidisciplinary approach to SSIs is important. It is useful to involve an infectious disease specialist and use minimum serial bactericidal titers to enhance the effectiveness of antibiotic therapy. A plastic surgeon should also be involved in those cases of severe infection that require repeat debridement and delayed closure.     

术后椎间盘炎的早期CT观察

椎间盘髓核摘除术后并发椎间盘炎．临床比较少见．但是一个严重的并发症。本组１４例，男９例，女５例。腰４，５椎间盘炎９例，腰５～骶１椎间盘炎５例．术后５～１０天出现症状．平均７．６天．术后３一１０天行ＣＴ检查．平均７．１天ＣＴ显示椎体软骨板破坏，有缺损，椎体边缘呈毛刷状．参差不齐．椎体后缘有空洞形成．椎间隙内有残留气体．椎旁软组织肿胀。ＣＴ显示椎管内神经根稍有水肿．硬膜囊无受压现象．文章讨论了术椎间盘炎的发病率和病因及ＣＴ在椎间盘炎诊断中的价值，ＣＴ能为临床早期判断术后有无椎间盘炎提供可靠的影像学证据．指导临床选用适当的处理方法．     

Isolated subacute tuberculous spinal epidural abscess of the cervical spine: a brief report of a special case

A tuberculous spinal epidural abscess is seen rarely as a late complication of Pott’s disease or in immunocompromised patients. Such abscesses in isolation are rare indeed and very uncommon in the developed and developing world. We report a patient with an isolated subacute tuberculous spinal epidural abscess without disc or vertebral involvement and no primary focus or risk factors associated with the development of spinal tuberculosis.     

Cervical spondylodiscitis from an ingested pin: a case report

In the pediatric literature, only 1 case of cervical spondylodiscitis from an ingested foreign body is reported and this was caused by a blunt radiolucent foreign body. The authors now describe a unique case of a 13-year-old teenaged boy who presented with neck pain 6 days after accidental ingestion of a sewing pin. Uncomplicated removal of this pin was followed in 36 days by the development of cervical spondylodiscitis that failed conservative management and required surgical debridement and arthrodesis. Physicians should be aware of the possibility of this complication in any patient that presents with neck pain after foreign body ingestion.     

Spontaneous spinal epidural haematomas

Summary The spontaneous spinal epidural haematoma (SSEH) is a rarity, but the severe and permanent motor disability underlines its importance.From 1957 seven cases of SSEH have been diagnosed and operated on in the National Institute of Neurosurgery, Budapest. These cases are analysed and discussed.The clinical picture began with local pain of the spine and radicular signs but some hours or days later paraparesis or paraplegia and incontinence developed. In the discussed cases the neurological deficit progressed to complete para- or tetraplegia in 5 cases. Only 2 patients had partial spinal transverse lesions on admission. All patients underwent myelography to detect the spinal space occupying lesion and were operated on soon. Three patients recovered completely, 2 remained partly and 2 totally paralysed.The outcome depended mainly on the timing of neurological deficiency. If the neurological signs existed less than 8 hours the patients recovered completely or fairly well while the prognosis was poor if the transverse lesion persisted longer than 24 hours.The authors stress the importance of correct and fast decisions at the first medical examination for the outcome of this disease, because only immediate transfer to a neurosurgical department gives a chance of good recovery.