The incidence of epidural abscess following epidural analgesia in open abdominal aortic aneurysm repair

INTRODUCTION

Complications of epidural catheterisation can cause significant morbidity. Epidural abscess following epidural catheterisation is rare and the reported incidence is variable. The purpose of this study was to review the incidence of epidural abscess in patients undergoing open abdominal aortic aneurysm (AAA) repair.

PATIENTS AND METHODS

A retrospective case note review of all patients having open AAA repair over a 5-year period.

RESULTS

A total of 415 patients underwent open AAA repair between January 2003 and March 2008. Of these, 290 were elective procedures and 125 were for ruptured aneurysms. Six patients underwent postoperative magnetic resonance imaging of the spine for clinical suspicion of an epidural abscess. Two of these (0.48%) had confirmed epidural abscess and two superficial infection at the epidural site.

CONCLUSIONS

The incidence of epidural abscess following epidural analgesia in patients undergoing open AAA repair within our department was 0.48%. Although a rare complication, epidural abscess can cause significant morbidity. Epidural abscesses rarely develop before the third postoperative day.     

Dorsal Epidural Intervertebral Disk Herniation With Atypical Radiographic Findings: Case Report and Literature Review

Background/Objective:

Intervertebral disk herniation is relatively common. Migration usually occurs in the ventral epidural space; rarely, disks migrate to the dorsal epidural space due to the natural anatomical barriers of the thecal sac.

Design:

Case report.

Findings:

A 49-year-old man presented with 1 week of severe back pain with bilateral radiculopathy to the lateral aspect of his lower extremities and weakness of the ankle dorsiflexors and toe extensors. Lumbar spine magnetic resonance imaging with gadolinium revealed a peripheral enhancing dorsal epidural lesion with severe compression of the thecal sac. Initial differential diagnosis included spontaneous hematoma, synovial cyst, and epidural abscess. Posterior lumbar decompression was performed; intraoperatively, the lesion was identified as a large herniated disk fragment.

Conclusions:

Dorsal migration of a herniated intervertebral disk is rare and may be difficult to definitively diagnose preoperatively. Dorsal disk migration may present in a variety of clinical scenarios and, as in this case, may mimic other epidural lesions on magnetic resonance imaging.     

Independent predictors of spinal epidural abscess recurrence

Background Context

Recurrence of spinal epidural abscess (SEA) after treatment is an important cause of continued morbidity for patients.

Spontaneous epidural hematoma of thoracic spine presenting as Brown-Séquard syndrome: report of a case with review of the literature

Background

Spontaneous spinal epidural hematoma (SSEH) is an uncommon clinical entity. It produces a severe neurological deficit and prompt decompression is usually the first choice of treatment. Brown-Séquard syndrome is commonly seen in the setting of spinal trauma or an extramedullary spinal neoplasm, but rarely caused by SSEH.

Methods

Case report and literature review.

Findings

A previously healthy man presented with Brown-Séquard syndrome below T5–T6 cord segment secondary to spontaneous epidural hematoma. He opted for conservative treatment, which was followed by rapid resolution.

Conclusions

Although Brown-Séquard syndrome as a presenting feature of SSEH is rare, it does exist in exceptional case, which should be taken into consideration for differential diagnosis. Prompt surgical decompression is an absolute surgical indication widely accepted for patient with progressive neurological deficit. However, SSEH presenting with incomplete neurological insult such as Brown-Séquard syndrome might have a benign course. Successful non-operative management of this problem does not make it a standard of care, and surgical decompression remains the standard treatment for SSEH.     

Para-iliac actinomycetoma presenting as sarcoma,a late complication of appendicitis: A case report

INTRODUCTION

Actinomycosis is known to mimic several types of neoplasms, leading to morbid surgical interventions.

PRESENTATION OF CASE

We report the particular case of an extensive right para-iliac actinomycetoma presenting as a sarcoma, which to our knowledge has not yet been described in the literature, in a patient with previous ruptured appendicitis. Thanks to the collaborative work between the orthopedic and general surgeons, pathologist and microbiologist, the diagnosis of actinomycosis was made pre-operatively, saving this 15-year-old patient from a tumor resection protocol.

DISCUSSION

Actinomycetomas have often been reported to present in the same way as several abdominal and gynecological neoplasms, and on rare occasions been described as mimicking other soft-tissue sarcomas, leading to unnecessary morbid tumor resection protocols. The most common cause of abdominal actinomycosis is perforated appendicitis, and may present several years later.

CONCLUSION

While faced with a soft tissue mass transgressing tissue planes and possibly extending to the region of the right lower quadrant, especially with a history of previous perforated appendicitis, one should consider the possibility of an abscess caused by pathogens of intestinal origin, including the gram positive anaerobe Actinomycosis israelii. Failure to actively search for this pathogen, which is not detectable with routine staining techniques and may take up to 1–2 weeks to isolate, may lead to unnecessary morbid surgical procedures.     

Spontaneous spinal epidural hematoma with hemiparesis mimicking acute cerebral infarction: two case reports

Context

Acute hemiparesis is a common initial presentation of ischemic stroke. Although hemiparesis due to spontaneous spinal epidural hematoma (SSEH) is an uncommon symptom, a few cases have been reported and misdiagnosed as cerebral infarction.

Design

Case reports of SSEH with acute hemiparesis.

Findings

In these two cases, acute stroke was suspected initially and administration of intravenous alteplase therapy was considered. In one case, the presentation was neck pain and in the other case, it was Lhermitte''s sign; brain magnetic resonance imaging (MRI) and magnetic resonance angiography were negative for signs of ischemic infarction, hemorrhage, or arterial dissection. Cervical MRI was performed and demonstrated SSEH.

Conclusion

Clinicians who perform intravenous thrombolytic treatment with alteplase need to be aware of this possible contraindication.     

Spinal Schistosomiasis: Differential Diagnosis for Acute Paraparesis in a US Resident

Background:

Spinal schistosomiasis is a severe presentation of Schistosoma mansoni infection, which is endemic in South America, the Middle East, and sub-Saharan Africa. With increasing international travel, a disease can spread from an endemic area to another part of the world easily.

Objective:

To present a case of a US resident who developed acute paraparesis due to spinal schistosomiasis after traveling to sub-Saharan Africa.

Participant:

A 45-year-old woman presented with abdominal pain radiating into the bilateral lower extremities. She was diagnosed with a pelvic mass and underwent an urgent hysterectomy with right salpingo-oopherectomy. Postoperatively, she developed progressive weakness with worsening pain in her bilateral lower extremities and neurogenic bladder. Magnetic resonance imaging showed an abnormal T2 hyperintense signal in the entire spinal cord below the T3 level with abnormal contrast enhancement from T9 through the conus medullaris. Spinal fluid analysis showed lymphocytic pleocytosis and elevated protein. The patient was diagnosed with transverse myelitis. Subsequently, a detailed history revealed a visit to Ethiopia 2 years earlier. Tests for S mansoni were positive. After treatment with praziquantel and prednisone, her neurologic function began to improve.

Conclusions:

An increasing incidence of international travel is increasing the likelihood of US physicians'' encountering this treatable condition. Travelers with spinal schistosomiasis may not have symptoms of systemic infection. Therefore, it is important to include spinal schistosomiasis in the differential diagnosis of acute inflammatory myelopathy, particularly with a history of travel to endemic areas.     

Salmonella prostatitis in a man with spinal cord injury

Context

Prostatitis is a very unusual manifestation of Salmonella urinary tract infection and has not been reported in men with spinal cord injury (SCI).

Findings

A 57-year-old man with paraplegia and a history of recurrent symptomatic urinary tract infections presented with Salmonella typhimurium prostatitis. Clinical and sonographic examination of the urinary tract, as well as urinalysis including microbiologic examination, revealed no relevant abnormalities. The microbiologic analysis of the ejaculate revealed growth of monophasic Salmonella enterica ssp. enterica serotype 4,12:i:-. A 6-week course of antibiotic treatment was initiated. There were no recurrent symptomatic urinary tract infections during follow-up.

Conclusion

Salmonellosis is a reportable disease and carriers have to refrain from activities in the food sector. Therefore, Salmonella prostatitis should be considered and excluded in men with SCI and a history of recurrent urinary tract infection who use intermittent catheterization for bladder management.     

Novel xylan-controlled delivery of therapeutic proteins to inflamed colon by the human anaerobic commensal bacterium

Introduction

Growth factors such as keratinocyte growth factor-2 (KGF-2) and transforming growth factor-beta (TGF-β) are important immunoregulatory and epithelial growth factors. They are also potential therapeutic proteins for inflammatory bowel disease. However, owing to protein instability in the upper gastrointestinal tract, it is difficult to achieve therapeutic levels of these proteins in the injured colon when given orally. Furthermore, the short half-life necessitates repeated dosage with large amounts of the growth factor, which may have dangerous side effects, hence the importance of temporal and spatial control of growth factor delivery.

Methods

The human commensal gut bacterium, Bacteroides ovatus, was genetically engineered to produce human KGF-2 or TGF-β ₁ (BO-KGF or BO-TGF) in a regulated manner in response to the dietary polysaccharide, xylan. The successful application of BO-KGF or BO-TGF in the prevention of dextran sodium sulphate induced murine colitis is presented here.

Results

This novel drug delivery system had a significant prophylactic effect, limiting the development of intestinal inflammation both clinically and histopathologically. The ability to regulate heterologous protein production by B ovatus using xylan is both unique and an important safety feature of this drug delivery system.

Conclusions

The use of genetically engineered B ovatus for the controlled and localised delivery of epithelial growth promoting and immunomodulatory proteins has potential clinical applications for the treatment of various diseases targeting the colon.     

Electrophrenic pacing and decannulation for high-level spinal cord injury: a case series

Background

In 1997, guidelines were developed for the management of high-level ventilator-dependent patients with spinal cord injury who had little or no ventilator-free breathing ability (VFBA). This article describes the three categories of patients, the decannulation criteria, and the successful decannulation of four patients with no VFBA and electrophrenic/diaphragm pacing, using these criteria.

Method

Case series.

Conclusion

Lack of VFBA in patients with high-level spinal cord injury does not mandate tracheostomy or electrophrenic/diaphragm pacing.     

Genomic insights into abdominal aortic aneurysms

Introduction

An individual’s genetic background plays a significant role in his or her chances of developing an abdominal aortic aneurysm (AAA). This risk is likely to be due to a combination of multiple small effect genetic factors acting together, resulting in considerable difficulty in the identification of these factors.

Methods

Methods for the identification of genetic factors associated with disease are usually based on the analysis of genetic variants in case-control studies. Over the last decade, owing to advances in bioinformatics and laboratory technology, these studies have progressed from focusing on the examination of a single genetic variant in each study to the examination of many millions of variants in a single experiment. We have conducted a series of such experiments using these methods.

Results

Our original methods using candidate gene approaches led to the initial identification of a genetic variant in the interleukin-10 gene associated with AAA. However, further studies failed to confirm this association and highlighted the necessity for adequately powered studies to be conducted, as well as the need for confirmatory studies to be performed, prior to the acceptance of a variant as a risk for disease. The subsequent application of genomic techniques to our sample set, in a global collaboration, has led to the identification of three robustly verified risk loci for AAA in the LRP1, LDLR and SORT1 genes.

Conclusions

Genomic studies of AAA have led to the identification of new pathways involved in the pathogenesis of AAA. The exploration of these pathways has the potential to unlock new avenues for therapeutic intervention to prevent the development and progression of AAA.     

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.     

Idiopathic thyroid abscess

INTRODUCTION

Thyroid abscesses are uncommon because the gland is relatively resistant to developing infection due to its rich blood supply, well-developed capsule and high iodine content. However, clinicians must be aware of this differential to make an early diagnosis.

PRESENTATION OF CASE

We present the case of a patient who required urgent operative resection as definitive treatment for a thyroid abscess secondary to infection with Staphylococcus aureus.

DISCUSSION

Although this is rare, a thyroid abscess left untreated can lead to serious morbidity. Therefore, clinicians must be aware of the presenting features and therapeutic options.

CONCLUSION

Thyroid abscess is an uncommon diagnosis but can lead to significant morbidity. Therefore clinicians must be aware of the diagnosis in order to institute early aggressive management.     

Alterations in respiratory mechanics after laparoscopic and open surgical procedures

Objective

To compare the effects of laparoscopic and open surgical procedures on postoperative strength and respiratory mechanics.

Design

Prospective cohort study.

Setting

Adult university hospital.

Participants

Fifty-one women aged 21 to 62 years scheduled to undergo elective cholecystectomy or hysterectomy (or related procedures), otherwise in good health.

Intervention

Open or laparoscopic cholecystectomy or hysterectomy (or related procedures).

Main Outcome Measures

Maximum voluntary handgrip strength (HGS), forced vital capacity (VC), forced expiratory volume in 1 second (FEV₁), and maximal inspiratory pressure (MIP) were each measured preoperatively and on the first postoperative morning. A visual analogue pain scale score was evaluated in relation to performance of the postoperative strength and respiratory measurements.

Results

VC, FEV₁ and MIP, but not HGS, were decreased after surgery. Postoperative VC, FEV₁ and MIP were lower after open procedures than after laparoscopic procedures and after cholecystectomy than after hysterectomy (all p < 0.001). Pain scores were lower after laparoscopic than after open procedures (p < 0.005) and could account in part for differences in postoperative respiratory mechanics.

Conclusions

Cholecystectomy and hysterectomy do not result in generalized muscle weakness, unlike more major abdominal procedures. Postoperative alterations in respiratory mechanics are related to the site of the surgery, the use of an open versus a laparoscopic approach and postoperative pain.     

Triparesis caused by gas-containing extensive epidural abscess secondary to Aeromonas hydrophila infection of a thoracic vertebroplasty: a case report

Background context

Aeromonas hydrophila is a motile gram-negative non-sporeforming rod with facultative anaerobic metabolism. Except for gastrointestinal disease, skin and soft-tissue infections represent the second most common site of human Aeromonas infections. However, to our knowledge, A. hydrophila infection of the spine has not been reported to date.

Purpose

To report the first case of A. hydrophila spinal infection of the T7 vertebra after vertebroplasty.

Study design

Case report.

Methods

A 72-year-old man was transferred to our emergency department with chief complaints of severe midthoracic pain and triparesis. He had undergone vertebroplasty for a painful vertebral fracture at T7 5 weeks before transfer. Magnetic resonance imaging showed an infection of the T7 vertebroplasty and an extensive epidural abscess. The epidural abscess originating from the infected T7 vertebroplasty extended from the T8 to the C4 epidural space. Computed tomography demonstrated sparsely scattered gas in the epidural abscess, strongly suggestive of an anaerobic infection.

Results

Emergency multilevel laminectomies from C5 to T8 and a posterior instrumentation from T3 to T10 were performed. A. hydrophila was isolated from the blood cultures. The patient was treated with intravenous ampicillin/sulbactam. Posterior decompression and stabilization in combination with appropriate antibiotic treatment completely resolved the neurologic deficit and infection without the need for further anterior corpectomy of the infected T7 vertebroplasty.

Conclusions

This is the first reported case of spine infection caused by A. hydrophila. The infection developed after vertebroplasty for the management of a painful vertebral fracture. Triparesis occurred rapidly due to an extensive epidural abscess containing gas. Emergency decompression and stabilization in combination with appropriate antibiotic treatment achieved a successful clinical outcome.     

Cryosurgery for malignant tumours of the liver

Objective

To evaluate the safety and efficacy of ultrasound-guided cryosurgery to treat malignant tumours of the liver.

Design

A prospective nonrandomized trial. The follow-up was complete and ranged from 8 to 35 months.

Setting

A university-affiliated hospital.

Patients

Ten patients with secondary malignant tumours of the liver; 1 with primary hepatoma.

Interventions

Computed portography for preoperative staging; laparotomy and ultrasonographic examination of the liver; cryosurgical ablation of liver tumours with or without a concomitant resection. Thirteen procedures were performed on 11 patients.

Main Outcome Measures

Preoperative morbidity, disease-free and overall survival.

Results

Of 24 lesions frozen, the procedure on 4 lesions was considered a technical failure because of persistent disease. There were no perioperative deaths. One patient had a liver abscess that resolved with percutaneous drainage. One patient had a biliary fistula that resolved spontaneously, and one had a transient rise in the serum creatinine level. Of 11 patients treated, 7 had a recurrence in the liver (persistent disease in 2 and new liver metastases in 5); 2 of these patients died. One patient died of distant disease with no local recurrence. At the time of writing, one patient was alive with extrahepatic disease and no local recurrence and two were free of disease.

Conclusions

Cryosurgery of the liver is a relatively safe procedure that allows treatment of otherwise un-resectable malignant disease. Proof of long-term benefit requires further experience and follow-up.     

Biocompatibility of Ricinus communis polymer with addition of calcium carbonate compared to titanium. Experimental study in guinea pigs

Objective

The aim of the present investigation was to determine whether the difference in inflammatory tissue reaction between the Riccinus communis (castor) polymer with calcium carbonate and the titanium implant is statistically significant.

Methods

Thirty-two Cavia porcellus were allocated into four groups of eight animals each. We implanted the two types of materials in the retroperitoneal space of all the animals. They were euthanized at 7, 20, 30 and 40 days after surgery, and an histological study of the samples was conducted.

Results

All implants showed characteristics of chronic inflammation regardless of the material and timepoint of evaluation. There was no statistically significant difference between Pm+CaCO₃ and Ti with regard to the presence of granulation tissue, tissue congestion, histiocytes, lymphocytes, neutrophils, giant cells, and fibrosis (P> 0.05).

Conclusion

The castor oil polymer plus calcium carbonate implant was not statistically different from the titanium implant regarding inflammatory tissue reaction.     

Intractable Pruritus After Traumatic Spinal Cord Injury

Background:

This report describes a young woman with incomplete traumatic cervical spinal cord injury and intractable pruritus involving her dorsal forearm.

Method:

Case report.

Findings:

Anatomic distribution of the pruritus corresponded to the dermatomal distribution of her level of spinal cord injury and vertebral fusion. Symptoms were attributed to the spinal cord injury and possible cervical root injury. Pruritus was refractory to all treatments, including topical lidocaine, gabapentin, transcutaneous electrical nerve stimulation, intravenous Bier block, stellate ganglion block, and acupuncture.

Conclusions:

Further understanding of neuropathic pruritus is needed. Diagnostic workup of intractable pruritus should include advanced imaging to detect ongoing nerve root compression. If diagnostic studies suggest radiculopathy, epidural steroid injection should be considered. Because the autonomic nervous system may be involved in complex chronic pain or pruritic syndromes, sympatholysis via such techniques as stellate ganglion block might be effective.     

Epidemiology of clostridium difficile and vancomycin-resistant Enterococcus colonization in patients on a spinal cord injury unit

Background/objective

Patients with spinal cord injury (SCI) are at risk of acquiring colonization with Clostridium difficile and vancomycin-resistant Enterococcus (VRE) due to prolonged hospitalization and frequent antimicrobial use. We examined the frequency of stool, skin, and environmental contamination with C. difficile and VRE in hospitalized patients with SCI.

Methods

We performed a cross-sectional study of 22 hospitalized patients with SCI with no symptoms of C. difficile infection. Stool samples, skin, and environmental sites were cultured for C. difficile and VRE, and polymerase chain reaction ribotyping was performed for C. difficile isolates. Fisher''s exact test was used to compare the proportions of skin and environmental contamination among stool carriers and non-carriers. Univariate analysis was used to assess factors associated with asymptomatic carriage of C. difficile.

Results

Of 22 asymptomatic patients, 11 (50%) were asymptomatic carriers of toxigenic C. difficile and 12 (55%) were carriers of VRE. In comparison with non-carriers, asymptomatic carriers of toxigenic C. difficile had higher rates of skin (45 versus 9%) (P = 0.07) and environmental contamination (55 versus 9%) (P = 0.03) and longer length of stay (median, 57 versus 6 days; P = 0.04). A majority of skin and environmental C. difficile isolates from individuals were identical to isolates from stool. In comparison with non-carriers, patients with VRE stool colonization had non-significant trends toward more frequent skin (27 versus 9%) and environmental (18 versus 9%) contamination.

Conclusion

Asymptomatic stool carriage of toxigenic C. difficile and VRE was common on an acute-care SCI unit. Asymptomatic carriers of toxigenic C. difficile had frequent skin and environmental contamination, suggesting the potential to contribute to transmission.     

Lumbar vertebral hemangioma mimicking lateral spinal canal stenosis: Case report and review of literature

Context

Hemangiomas are the commonest benign tumors of the spine. Most occur in the thoracolumbar spine and the majority are asymptomatic. Rarely, hemangiomas cause symptoms through epidural expansion of the involved vertebra, resulting in spinal canal stenosis, spontaneous epidural hemorrhage, and pathological burst fracture.

Findings

We report a rare case of a 73-year-old woman, who had been treated for two months for degenerative neurogenic claudication. On admission, magnetic resonance imaging and computed tomographic scans revealed a hemangioma of the third lumbar vertebra protruding to the epidural space producing lateral spinal stenosis and ipsilateral nerve root compression. The patient underwent successful right hemilaminectomy for decompression of the nerve root, balloon kyphoplasty with poly-methyl methacrylate (PMMA) and pedicle screw segmental stabilization. Postoperative course was uneventful.

Conclusion

In the elderly, this rare presentation of spinal stenosis due to hemangiomas may be encountered. Decompression and vertebral augmentation by means balloon kyphoplasty with PMMA plus segmental pedicle screw fixation is recommended.