Brucellar spinal epidural abscess

Spinal epidural abscesses account for approximately one of every 10, 000 admissions to tertiary hospitals. The midthoracic vertebrae are the most frequently affected, whilst the cervical spine is involved in fewer patients. Staphylococcus aureus is identified as the cause in most cases of epidural abscess; other bacteria responsible include Gram-negative bacteria, Streptococcus species and Brucella species. We report the case of a patient with cervical spondylodiscitis at level C4-C5 and an epidural abscess which was compressing the spinal cord and the retropharyngeal space. The previous symptoms of brucellosis were atypical. We discuss the clinical manifestations, diagnosis, treatment and prognosis of the case.     

Acute spinal epidural abscess

A case of acute spinal epidural abscess is reported demonstrating many of the important features in the natural history of the disorder. The pathological changes in the cord at the level of the lesion are described. A series of 12 patients is reviewed. The average interval between the initial consultation and the onset of complete paralysis is 5 days and it is essential that the diagnosis is made during this period. Two indicators of prognosis are discussed--the duration of complete paralysis and the extent of sensory disturbance.     

Acute spinal epidural abscess

Summary An anterolateral cervical epidural abscess occurred in the course of a septicaemia caused by Staphylococcus aureus. Early diagnosis, before permanent neurological signs developed, was provided by CT scan without myelography. Total recovery occurred with antibiotic therapy alone.     

脊髓硬膜外脓肿的诊断和治疗

脊髓硬膜外脓肿(spinal epidural abscess, SEA)是硬脊膜外间隙的化脓性感染,由于大量脓液积聚及肉芽组织增生导致脊髓受压,出现相应的临床表现,是神经外科少见的急症之一,临床误诊率及致残率均较高.1972年1月至2003年6月,我科共收治本病患者13例,现结合文献对其诊断及治疗情况进行讨论.     

Spontaneous spinal epidural abscess in a neonate

Spinal epidural abscess is uncommon in neonates and infants, and is usually related to previous lumbar puncture or epidural anaesthesia. Diagnosis is often delayed because of the non-specific presentation. We present a 7-week-old girl who developed paraplegia 3 weeks after transient fever and a self-limiting skin rash. MR imaging revealed an epidural contrast-enhancing lesion compressing the spinal cord. At operation, an organised granulated abscess was identified with Staphylococcus aureus the causative organism. Laminectomy and removal of the organised abscess and systemic intravenous antibiotics resulted in complete neurological recovery. The patient did not develop late spinal deformity following the decompressive laminectomy. The rapid onset of paraplegia can often be missed in such a young child but should be promptly investigated, as surgical treatment of cord compression carries an excellent prognosis for neurological recovery. We review the literature on the initial presentation, usual investigations, causative organisms and surgical management of paediatric spinal epidural abscesses.     

脊柱硬膜外脓肿的诊断和外科治疗

概述 脊柱硬膜外脓肿(spinal epidural abscess,SEAs)在临床上较少见[1],发病率约在(0.2～1.3)/1万个住院患者.它通常可导致严重的脊髓功能损伤.滥用静脉药品和脊柱手术等是发病的重要因素.SEAs的典型症状是发热、局限性的背部疼痛和进行性的神经体征.     

急性硬脊膜外脓肿的诊断和治疗

急性硬脊膜外脓肿是椎管内硬脊膜外脂肪组织和静脉丛的化脓性感染,由于硬脊膜外间隙内大量脓液积聚,造成脊髓受压,出现急性横贯性脊髓损害的临床表现,是神经外科急症之一,误诊率及致残率较高.我院及第三军医大学新桥医院1990年1月至今收治本病患者12例,现对其诊断和治疗进行讨论.     

Diagnosis and management of spinal epidural abscess.

Twenty-five patients with spinal epidural abscess were treated at the University of Western Ontario hospitals between July 1980 and July 1990. There were eighteen males (72%) and seven females (28%), with a median age of 60 years. Concurrent illness resulting in immunocompromise was present in 60%. Eleven presented with complete myelopathy, thirteen had limb weakness, and one had no neurological deficit. In twenty cases the abscess consisted of frankly purulent material, while in five the epidural collection consisted of chronic granulation tissue. Staphylococcus aureus was isolated in 64% of the abscesses. Twenty-seven surgical procedures were performed on 21 patients. Ten cases occurred in the cervical spine (40%), seven in the thoracic spine (28%), three in both the cervical and thoracic spine (12%) and five in the lumbosacral spine (20%). Fourteen patients (56%) retained or recovered ambulation and there were five deaths (20%). The progression from back and radicular pain to weakness and eventual paralysis continues to be characteristic of spinal epidural infection. Morbidity and mortality remain unacceptably high because of delay in diagnosis and treatment. Magnetic resonance imaging is the radiological investigation of choice for the diagnosis of spinal epidural abscess. Prompt intervention, before the development of severe neurological deficits, can improve outcome. Immediate surgical drainage combined with antibiotics remains the treatment of choice.     

Anterior cervical spinal epidural abscess in an infant

Spinal epidural abscess (SEA) is rare in children, especially in newborns and infants, groups in which only very few cases have been reported. Because of the nonspecificity of presenting symptoms in children the diagnosis may be delayed, resulting in major permanent neurological deficits. In this paper, we report a case of cervical SEA in a 6-week-old infant who initially presented with fever and developed quadriparesis 19 days prior to admission. After emergency anterior decompression of the abscess the neurological function was improved immediately. Five months after surgery the neurological status was normal, an MR study showing disappearance of the epidural abscess and spinal cord indentation, and progressive fusion of the C3, C4 and C5 vertebral bodies. Anterior decompression without bone graft can provide an excellent prognosis in case of an anterior cervical SEA in infants. Received: 9 June 1998 Revised: 27 July 1998     

Non-granulomatous spinal epidural abscess: a rehabilitation perspective.

Spinal epidural abscess (SEA) as a cause of back pain, fever, and neurological deficits has been recognised. Reports of this entity have increased in recent years, possibly likely secondary to increasing intravenous drug abuse. Most patients recover without neurological sequelae. Recent reports in fact indicate that those with persistent deficit have a much poorer prognosis for survival. As a result, few patients with SEA are seen in spinal injury rehabilitation programmes. Our 5 years experience with SEA was reviewed. Thirteen patients were admitted with residual neurological deficits following a course of prolonged antibiotic therapy. Of these most had progressive neurological improvement with only 3 of 4 remaining Frankel class A and 3 of 7 Frankel class C. The only mortalities (2) were secondary to the underlying medical problems. Most patients were discharged home.     

Acquired neuromyotonia in a patient with spinal epidural abscess

We report a case of acquired neuromyotonia in a patient with Staphylococcus aureus septicemia and a spinal epidural abscess. Autoantibodies to voltage-gated potassium channels, which are associated with acquired neuromyotonia, were present during the patient's acute illness but became undetectable on clinical recovery. The spinal epidural abscess may have triggered the production of these specific autoantibodies, resulting in clinically and electromyographically detectable neuromyotonia. © 1998 John Wiley & Sons, Inc. Muscle Nerve 21:672–674, 1998.     

A case of acute cervical epidural abscess]

Spinal epidural abscess (SEA) is a rare condition with potentially devastating consequences and more aggressive diseases than previously recognized. We report a case with cervical epidural abscess treated successfully by emergent neural decompression. A 49-year-old man presented with fever and cervical pain. An magnetic resonance imaging (MRI) showed an epidural abscess at C5-6. His condition deteriorated with the development of complete sensory loss and tetraparesis. Emergent anterior neural decompression was performed, and pus was aspirated which grew Staphylococcus aureus. Adequate antibiotics were administered, and the patient showed remarkable improvement of neurological signs and symptoms. He underwent reconstruction surgery 3 weeks after the first operation, and returned to his original job 3 months after the operation. Prompt diagnosis and satisfactory surgical decompression are essential to avoid irreversible neurological sequelae in epidural abscess of the cervical spine.     

CT guided aspiration of a cervical spinal epidural abscess.

The management of spinal epidural abscess has changed over the last few years. Originally treatment was thought to be urgent surgical evacuation. In the more recent literature less invasive techniques have been suggested. We present a case, where a cervical epidural abscess at the C2 level was treated with CT guided aspiration and antibiotic therapy. This has not been previously reported.     

Syrinx formation secondary to cervical epidural abscess]

We report a patient with syrinx formation secondary to cervical epidural abscess, cervical spondylitis, cervical discitis and meningitis. A 53-year-old woman developed sudden fever, headache and neck pain. On admission, neurological evaluation showed limitation of cervical motion, meningeal irritation, and exaggerated muscle stretch reflexes in all four extremities. Cerebrospinal fluid cell count was 832/mm3 and protein was 771 mg/dl. Bacterial culture of the cerebrospinal fluid showed Staphylococcus aureus. A cervical MRI scan with Gd-enhancement revealed focal high intensity signal in the T2-weighted and FLAIR images, at the anterior meninges of the C3-8 segments, the vertebral bodies of C5-6 and the intervertebral disks of C5-6 segment. Her diagnosis was cervical epidural abscess, cervical spondylitis, cervical discitis and meningitis. Antibiotics and steroids improved her symptoms. Six weeks after the onset of symptoms, a cervical MRI scan showed narrowing and synarthrosis in the intervertebral space between C5 and C6. MRI and myelo CT scans demonstrated a newly-formed syrinx from C3-C 7. This was an interesting case of syrinx formation secondary to cervical epidural abscess.     

Anterior interbody fusion for cervical osteomyelitis: Reversal of quadriplegia after evacuation of epidural spinal abscess

Interbody fusion for stabilization of the cervical spine after osteomyelitic destruction of the body of C5 vertebra is reported in a patient with quadriplegia and sphincter disturbances secondary to an epidural abscess. The successful union of the bone graft along with complete neurological recovery after anterior decompression and evacuation of the epidural mass seem to justify the procedure.     

Communicating syringomyelia and syringobulbia after surgery of a spinal epidural tuberculoma]

In a 46 year old patient a syringomyelia and syringobulbia were diagnosed clinically 18 years after a transverse lesion of the cord and removal of an epidural spinal tuberculoma. Post-myelographic CT and NMR scans showed a communicating syringomyelia and syringobulbia. A flavectomy was performed and a syringopleural shunt implanted. The operation was successful by neuroradiological criteria. Clinically there was a worsening of the spastic gait during one-year follow up. Neuroradiological findings and etiology of the syrinx are discussed, and a causal relationship to the tuberculoma is proposed.     

Adult spinal epidural abscess: clinical features and prognostic factors

Twenty-nine adult patients with spinal epidural abscess (SEA), aged 31–73 years, have been identified over a period of 8 years. The 29 SEA patients included 21 men and eight women with a mean age of 54 years. Initial diagnosis of SEA was made in only 17% of our patients and another 48% of patients were initially suggested of having infection or mass of the spine. Spinal pain and fever were the two most common clinical features shared among our patients. The two most common pathogens were Staphylococcus aureus and Mycobacterium tuberculosis, which were found in 62% of patients. Twenty-seven patients received surgical intervention and antibiotic treatment for SEAs, one of which succumbed to meningitis. Two patients without neurological abnormalities received conservative treatment alone and survived. The number of patients, which showed improvement of symptoms, included all seven patients with neck/back pain without neurologic deficits, all 15 patients with paraparesis, 10 of 13 patients with bladder/bowel dysfunction with or without motor deficits, and none of the five with plegia. Preoperative plegia was identified as a poor prognostic factor, and patients with SEA continue to show high rates of morbidity and mortality. Thus, in order to improve the therapeutic outcome of patients with SEA, early diagnosis and management are mandatory to treat the patients before the deterioration of neurologic deficit occurs.     

Nonsurgically treated cervical brucellar epidural abscess causing spinal cord compression

Cervical spinal cord compression due to brucellar epidural abscess is extremely rare, with only 13 previously reported cases. We present another case of cervical spinal epidural abscess causing spinal cord compression. Diagnostic tools and treatment options are discussed.     

Two cases of spinal epidural lipomatosis]

Two cases of spinal epidural lipomatosis (SEL) were reported. Patient 1 was on oral corticosteroid and patient 2 was obese and had prostate cancer. Patient 1 was a 45-year-old man diagnosed as sarcoid myelopathy at C 5/6 vertebral body levels and had been placed on oral corticosteroid therapy for 14 months. He showed spastic paraplegia, hypesthesia below C 4 level with distal dominancy and dysesthesia below Th 6 level. MRI revealed epidural lipomatosis from Th 3 to Th 9 vertebral bodies, which presented high in T 1 weighted image (WI) and T 2 WI, and non-signal in STIR image. On axial image spinal cord was compressed by this mass. Patient 2 was a 73-year-old man with spastic paraplegia, and superficial and deep sensory disturbances below Th 6. He had been obese (BMI 26.1) upon admission. He was diagnosed as prostate cancer with bone metastasis. On MRI of the thoracic spine revealed epidural mass of high in T 1 WI and T 2 WI, and non-signal in STIR image. SEL is a rare condition known as hyperplasia of normal fat tissue in epidural space which sometimes compresses the spinal cord or spinal nerve roots resulting in neurologic deficit. SEL should be kept in mind as having possible neurologic complications in obese patients or ones on long term steroid therapy.