Vertebral Osteomyelitis complicated with Epidural Absceses
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Vertebral Osteomyelitis complicated with Epidural Absceses
GEORGE SAPKASPROFESSOR AT ORTHOPAEDICS
Metropolitan Hospital
Athens Greece
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Cases
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1st caseJ. Chr.M 69 – Retired Civil servant
Symptoms Neurologic deficitCervical Pain Low fever
Laboratory Neutroph. ↑SR 40
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MRI
Unknown origin
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Treatment
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Transoral
Pus evacuation
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Post op. CT scan
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Post op. MRI
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Occipito-cervical stabilization
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2nd Post op. CT scan
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2nd Post op. MRI (6mts)
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Post op. 3D scan (3yrs)
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Follow up
Culture staphylococous aureous
Antibiotics i-v for 2 mtsorally for 4 mtsFull neurologic recovery
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2nd caseMa. Pal.F 56 – Lawyer
Symptoms Neurologic deficitCervical Pain Low fever
LaboratoryNeutroph. ↑SR 50
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56X-rays
Unknown origin
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MRI
33
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MRI
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Anterior procedureVertebrectomy - PUS evacuation + Stabilization
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Posterior stabilization
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2nd Post op. MRI
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Follow up
Pus culture (staphylococous aureous)Antibiotics i-v for 2 mts orally for 6 mts
Complete neurologic recovery
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3rd caseEV. PY.M 56 – Industrial labor
Symptoms Neurologic deficitThoracic Pain Low fever
LaboratoryNeutroph. ↑SR 45
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Unknown Origin
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Follow up
Pus culture (staphylococous aureous)Antibiotics i-v for 2 mts orally for 6 mts
Complete neurologic recovery
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4th caseD.N.M 61– Cardiologist
Symptoms Severe Neurologic deficit Intensive Thoracic-lumbar Pain High fever
Laboratory Neutroph. ↑ SR 60
PMH Heavy smoker Diabetes melitus Recent Elbow Furuncle (untreated)
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Elbow furuncle
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33
4 4
04/06/2007
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04/06/2007
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04/06/2007
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13/06/2007
3
4
3
4
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13/06/2007
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Anterior PUS evacuation
Bilaterally
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Laminectomies PUS evacuation
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Post posterior PUS evacuation
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Follow up
Pus culture (staphylococous aureous)Antibiotics i-v for 2 mts orally for 7 mts
Complete neurologic recovery
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Conclusions
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Epidural abscesses
Of the spinal column is a rare but potentially devastating disease.When recognized early and treated appropriately the outcome can be excellentHowever the mortality is as high as 20% even in modern series
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Surgical therapyDecompression of the neural elements and drainage of purulent material or debridement of granulation tissue is recognized as the best method to prevent neurologic deficits and if performed quickly after the onset of deficits, may allow full recovery.
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Delay in surgical drainage and decompression has repeatedly been associated with high morbidity and mortality. Given the life-threatening nature of subdural empyema,decompression of epidural abscess is uniformly considered an emergency.
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SPINAL EPIDURAL, AND
SUBDURAL - INTRAMEDULAR ABSCESSES
GEORGE SAPKAS PROFESSOR AT ORHTOPAEDICS
Metropolitan Hospital
Athens Greece
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Epidural abscesses
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Subdural abscesses
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Intramedullar abscesses
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Historical review1761 Morgagni first to allude pyogenic infection in the spinal epidural space(Feldenzer et al. Neurosurgery 1987)1820 Bergamaschi first description (Hlavin et al. Neurosurgery 1990)1892 (Unknown) first surgical drainage1901 Barth first successful drainage(Hlavin et al. Neurosurgery 1990)
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Epidemiology2 cases per 10.000 hospital admissions per year(Hlavin et al. Neurosurgery 1990)The peak age incidence is in the sixth and seventh decade of life(Danner et al. Rev infection disease 1987)(Wheeler et al. Clin Infect, disease 1992)Rare in the pediatric population(Rubin et al. Pediatric infect disease 1993)
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Comorbid conditions
Diabetes mellitusIntravenous drug useChronic renal failureAlcoholism Cancer
(Redekop et al. Can J. Neurol. Sci 1992)
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Source of infection
Skin and soft tissue 25% Previous spinal surgery Osteomyelitis Spinal traumaUrinary tractsRespiratory tracts
(Redekop et al. Can J. Neurol. Sci 1992)Unknown and not indentified 16% - 40%
(Hlavin et al. Neurosurgery 1990)(Redekop et al. Can J. Neurol. Sci 1992)
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Etiologic agent
(Hlavin et al. Neurosurgery 1990)(Redekop et al. Can J. Neurol. Sci 1992)
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Pathophysiology The spinal epidural space is a metameric segmental structure in which some areas are filled with fat and veins and other areas the dura is in direct contact with bone or ligamentIn addition individual metameres are septated preventing free communication between the anterior and posterior epidural space (Redekop et al. Can J. Neurol. Sci 1992)
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The majority of epidural abscesses are from hematogenous spread and are localized posteriorly
(Redekop et al. Can J. Neurol. Sci 1992)
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Cases associated with: Discitis Vertebral osteomyelitis
typically involve the anterior epidural space
and
cont.
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In few cases that are commonly post-surgical, the abscess may be circumferential because of disruption of the normal anatomic septations
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The extend of the abscess is usually limited with an average of 3 to 4 vertebral segments
(Del Curling et al. Neurosurgery 1990)(Hlavin et al. Neurosurgery 1990)
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Location
Cervical 15%Thoracic 50%Lumbar 34%
Posterior 80%Anterior 20%
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The precise pathophysiologic cause of the neurological impairment is not knownRapid and irreversible deterioration
prompted several authors to postulate an ischemic mechanism either from arterial occlusion or venous stasis
(Baker et al. N. Engl J Med 1975)
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Recent studies indicate that the progressive neurologic deficits were secondary to compression
(Feldenzer et al. Neurosurgery 1987)(Feldenzer et al. Neurosurgery 1988)
It is most likely that the cause of neurological deficit is multi factorial with compression been the major component
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Diagnosis
Onset of symptoms usually occurs within hours to days but may be more chronic in nature, presenting with weeks to months of symptoms. The microbiology often dictates the pace of progression.
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If left untreated, the progression of symptoms is usually sequential: back pain (70-100%), radicular irritation (50%), motor weakness (30-40%) sphincter incontinence (30-40%) sensory changes (12%), then paralysis (6-48%) fever is frequently present especially in acute
phases
(Redekop et al. Can J. Neurol. Sci 1992)(Maslen et al. Arch inten Med 1993)
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Tuberculous abscesses
The clinical presentation is slightly different Back pain ~ 100%The prodrome is longer Leukocytosis frequently absent Fever - // -The patients are usually younger than
patients with bacterial abscesses
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Differential diagnosisSpondylosis or disk syndromesEpidural Hematoma Leptomeningeal Carcinomatosis Metastatic Disease to the SpineSpinal Cord Hemorrhage or InfarctionSubdural Hematoma or EmpyemaHIV-1 Associated Vacuolar MyelopathyTropical Myeloneuropathies Vitamin B-12 Associated Neurological Diseases Alcohol (Ethanol) Related Neuropathy
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Laboratory studiesLeukocytosis, (left shift), anemia. In one retrospective analysis, leukocytosis was present in only 60% of patients.Blood cultures positive in 60%. ESR and CRP elevated.Lumbar puncture relatively contraindicated (risk of spreading the bacteria into the subarachnoid space). Usually reveals inflammation, cultures positive in 25% of cases.
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Imaging studies
Plain radiographs occasionally demonstrate osteomyelitis but are of almost no utility. Spinal MRI is the procedure of choice (sensitivity 95%, specificity 92%).Gadolinium enhancement increases sensitivity and enables better differentiation between abscess and surrounding neurological structures. CT-guided needle aspiration may be used to obtain material for analysis.
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Plain radiographs
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MRI
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Treatment
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Medical therapyMedical management with appropriate antibiotics has been successful in several reportsPotential candidates : Lumbar epidural
abscess with no neurologic deficitand bacteriologic agent has been cultured
(Wheller et al. Clin Inf Des. 1992)
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Proposed criteria for exclusive medical treatment in spinal epidural abscesses
Poor surgical candidates because of sever concomitant medical problemsCases in which the abscess involves a considerable length of spinal canal and who have epiduritis from the cervical to the lumbar levelPatients not suffering from severe loss of spinal cord or cauda equina functionPatients with complete paralysis for more 3 days
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The length of suggested medical therapy is at least 8 to 12 weeks of intravenous antibioticsfollowed by oral agents
(Leys et al. Ann Neurol. 1985)
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Management Initiate empirical therapy; must continue for 3 – 4 weeksCeftriaxone (ROCEPHIN) 2g x 2Ceftazidime (SOLVETAN) 2g x 3Cefazolin (BIOZOLIN) 2g x3
+Meropenem (MERONEM) 1g x 3 (antipseudomonal)
±Metronidazole (FLAGYL) 500mg x 3
±Gentamycin (GARAMYCIN) 80mg x3 in D/W 5% (if post – op or IV drug user or endocarditis)
±Vancomycin (VONCON) 1g x 2 (MRSA)
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Operative treatment
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Posterior decompression
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Posterior decompression and stabilization
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Anterior decompression ± stabilization
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