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BACKGROUND Pyogenic spondylitis comprises several clinical entities, including native vertebral osteomyelitis, septic discitis, pyogenic spondylodiscitis, and epidural abscess. The lumbar spine is most often infected, followed by the thoracic and cervical areas. It mainly develops (i) after spine surgery; (ii) from history of blunt trauma to the spinal column; (iii) from infections in adjacent structures (such as soft tissues); (iv) from iatrogenic inoculation after invasive procedures (such as lumbar puncture); and (v) from hematogenous bacterial spread to the vertebra (mainly through the venous route). Any delay in diagnosis and treatment can lead to significant spinal cord injury, permanent neurological damage, septicemia, and death. CASE REPORT We describe a 63-year-old man with no significant past medical history who presented with fever and an altered level of consciousness. Significant thoracic spine pain was also reported during the last 3 months. The final diagnosis was vertebral spondylodiscitis, contiguous spinal epidural abscess, and sepsis due to Bacteroides fragilis bacteremia. Clinical recovery was achieved after surgical decompressive therapy with abscess drainage combined with appropriate antibiotic therapy for 12 weeks. The primary focus of the infection was not clarified, despite all the investigations that were performed. CONCLUSIONS Spondylodiscitis, spinal epidural abscess, and sepsis as complications of Bacteroides fragilis bacteremia are rare in a patient without any previously known predisposing conditions and without an obvious primary focus. Early diagnosis and proper treatment of anaerobic spondylodiscitis, especially if epidural abscess and sepsis are present, are of great importance to reduce mortality and avoid long-term complications.

Although rare in children, spinal epidural abscess (SEA) is a rapidly progressive clinical entity that can lead to irreversible neurologic damage if untreated. The rarity and variability in presentation can lead to initial misdiagnosis. Diagnosis requires a high index of suspicion and is often delayed until neurologic deficits are present. This issue reviews key findings on the history and physical examination that are associated with SEA, provides guidance for the laboratory tests and imaging studies that are indicated once SEA is suspected, and discusses treatment options based on current evidence.

Introduction: Spinal epidural abscess (SEA) is a rare but serious condition that carries with it a high rate of morbidity and mortality., Objective: This review highlights the pearls and pitfalls of SEA, including presentation, initial evaluation, and management in the emergency department (ED) based on current evidence., Discussion: SEA is a suppurative infection and infectious disease emergency that may result in significant morbidity and even mortality. It is a challenging diagnosis due to its range of risk factors and variety of presentations with up to 90% of patients misdiagnosed on their first ED visit. Factors associated with increased risk of SEA include immunocompromise, bacteremia, contiguous infection (e.g., psoas muscle abscess, osteomyelitis, skin infection), and spinal instrumentation. However, the absence of risk factors cannot be used to exclude SEA. The classic triad of back pain, fever, and neurologic deficit occurs in less than 8% of cases, though back pain is a common presenting symptom. Up to half of patients experience a neurologic abnormality, but fever is absent in 50%. Laboratory assessment may assist with inflammatory markers elevated in the majority of cases. Diagnosis includes magnetic resonance imaging with and without contrast and blood cultures, and management includes spinal specialist consultation and antibiotic therapy., Conclusions: An understanding of SEA can assist emergency clinicians in diagnosing and managing this potentially deadly disease., Competing Interests: Declaration of Competing Interest None., (Published by Elsevier Inc.)

Background: Spinal Epidural Abscesses (SEAs) are traditionally seen as a surgical emergency. However, SEAs can be discovered in entirely asymptomatic patients. This presents a dilemma for the attending clinician as to whether to subject these patients to significant surgery. This systematic review updates the evidence surrounding the efficacy of non-operative SEA management by means of intravenous antibiotics ± radiologically-guided aspiration., Aims: 1. To assess failure rates of medical therapy for SEA. The absolute definition of 'failure' used by the study was recorded, and comparisons made. 2. To review of risk factors for success/failure of medical treatment for SEA., Methods: A database search with the MESH term 'epidural abscess' and keywords ['treatment' OR 'management'] were used., Results: 14 studies were included. The number of SEA patients managed non-operatively ranged from 19 to 142. There was significant heterogeneity across the studies. Pooled Failure of Medical Therapy (FMT) (defined as any poor outcome) was 29.40%. When FMT = mortality the pooled rate was 11.49%. Commonly cited risk factors for FMT included acute neurological compromise, diabetes mellitus, increasing age and Staphylococcus aureus., Conclusion: SEA will always be a condition mostly managed surgically. Despite this, there is growing evidence that non-operative management can be possible in the correct patients. The key is in patient selection - patients with any of the above-mentioned risk factors have the potential to deteriorate further on medical treatment and have a worse outcome than if they had undergone emergency surgery straight away. Ongoing research will hopefully further investigate this crucial step., Competing Interests: Declaration of Competing Interest None Declared., (Crown Copyright © 2020. Published by Elsevier Ltd. All rights reserved.)

Clinical/methodological Problem: Spondylodiscitis is an inflammation of the intervertebral disc, which in adults is generally associated with spondylitis of the adjacent vertebrae. It often presents clinically with nonspecific symptoms such as back or neck pain. It may be caused by various pathogens, especially bacteria. One or more vertebral segments can be affected. The infection can spread to surrounding compartments and can lead to epidural abscesses. Radiology, in particular magnetic resonance imaging (MRI), plays an important role in the diagnostic work-up and in the follow-up to monitor response to therapy. Treatment consists of conservative (antibiotics) and invasive approaches, including surgery. Interventional puncture and drainage is a promising alternative to surgery, especially in early stages of abscess formation., Standard Radiological Methods: Magnetic resonance imaging (MRI), computed tomography (CT), nuclear medical procedures, conventional x‑ray., Performance: MRI has the highest value. CT and nuclear medical procedures can be used as a supplement to MRI and in patients with contraindications for MRI., Practical Recommendations: With adequate diagnosis and therapy, spondylodiscitis has a good prognosis. In addition to targeted or calculated drug therapy, invasive treatment is the main focus, especially for epidural abscesses. Interventional radiological drainage can represent a less invasive alternative to surgical treatment.

We aimed to determine available evidences in the literature regarding surgical approaches and methods, timing of surgical interventions, duration of perioperative antibiotics, and duration of nonsurgical treatments (antibiotics administration) in patients with upper cervical (occiput-C2) epidural abscess (UCEA). We performed a literature review of the articles on surgical interventions and antibiotic therapy to treat UCEA, searching the PubMed database for relevant articles published in the English language (as of March 2020). In total, 53 patients with UCEA were identified. Permanent limb paralysis or death was observed in 1/15 (6.7%) patients who received the transoral approach and 2/15 (13.3%) patients who received the transcervical approach, 1/26 (3.8%) patients who underwent surgery before the onset of paralysis, and 2/4 (50.0%) patients who underwent surgery after the onset of paralysis. In 85%-89% of cases, antibiotic administration was continued for 6-12 weeks, which was determined by the confirmation of reduced inflammatory response and/or abscess disappearance on imaging. Differences in surgical approaches may not be associated with the incidence of permanent limb paralysis or death. Surgical interventions before limb paralysis onset are recommended in UCEA patients. In perioperative and nonoperative treatments, antibiotic administration for 6-12 weeks may be supported based on the confirmation of reduced inflammatory response and/or abscess disappearance on imaging. Further investigations are needed., Competing Interests: The authors declare that there are no conflicts of interest.

The term "intracranial abscess" (ICA) includes cerebral abscess, subdural empyema, and epidural empyema, which share many diagnostic and therapeutic similarities and, frequently, very similar etiologies. Infection may occur and spread from a contiguous infection such as sinusitis, otitis, mastoiditis, or dental infection; hematogenous seeding; or cranial trauma. In view of the high morbidity and mortality of ICA and the fact that hyperbaric oxygen therapy (HBO2) is relatively non-invasive and carries a low complication rate, the risk-benefit ratio favors adjunct use of HBO2 therapy in selected patients with intracranial abscess., Competing Interests: The authors of this paper declare no conflicts of interest exist with this submission., (Copyright© Undersea and Hyperbaric Medical Society.)

Visits to the family physician, a specialist, and the ED prompted us to look beyond the initial diagnosis of acute otitis media.

An infection of the spinal epidural space, spinal epidural abscess (SEA) is a potentially devastating entity that is rising in incidence. Its insidious presentation, variable progression, and potential for precipitous neurologic decline make diagnosis and management of SEA challenging. Prompt diagnosis is key because treatment delay can lead to paralysis or death. Owing to the nonspecific symptoms and signs of SEA, misdiagnosis is alarmingly common. Risk factor assessment to determine the need for definitive MRI reduces diagnostic delays compared with relying on clinical or laboratory findings alone. Although decompression has long been considered the benchmark for SEA, considerable risk associated with spinal surgery is noted in an older cohort with multiple comorbidities. Nonoperative management may represent an alternative in select cases. Failure of nonoperative management is a feared outcome associated with motor deterioration and poor clinical outcomes. Recent studies have identified independent predictors of failure and residual neurologic dysfunction, recurrence, and mortality. Importantly, these studies provide tools that generate probabilities of these outcomes. Future directions of investigation should include external validation of existing algorithms through multi-institutional collaboration, prospective trials, and incorporation of powerful predictive statistics such as machine learning methods.

Study Design: Retrospective cohort study., Objective: To develop a comprehensive understanding of the prognostic value of laboratory markers on morbidity and mortality following epidural abscess., Summary of Background Data: Spinal epidural abscess is a serious medical condition with high rates of morbidity. The value of laboratory data in forecasting morbidity and mortality after epidural abscess remains underexplored., Methods: We obtained clinical data on patients treated for epidural abscess at two academic centers from 2005 to 2017. Our primary outcome was the development of one or more complications within 90-days of presentation, with mortality a secondary measure. Primary predictors included serum albumin, serum creatinine, platelet-lymphocyte ratio, and ambulatory status at presentation. We used multivariable logistic regression techniques to adjust for confounders. The most parsimonious set of variables influencing both complications and mortality were considered to be clinically significant. These were then examined individually and in combination to assess for synergy along with model-discrimination and calibration. We performed internal validation with a bootstrap procedure using sampling with replacement., Results: We included 449 patients in this analysis. Complications were encountered in 164 cases (37%). Mortality within 1-year occurred in 39 patients (9%). Regression testing determined that serum albumin, serum creatinine, and ambulatory status at presentation were clinically important predictors of outcome, with albumin more than 3.5 g/dL, creatinine less than or equal to 1.2 mg/dL, and independent ambulatory function at presentation considered favorable characteristics. Patients with no favorable findings had increased likelihood of 90-day complications (odds ratio [OR] 5.43; 95% confidence intervals [CI] 1.98, 14.93) and 1-year mortality (OR 8.94; 95% CI 2.03, 39.37). Those with one favorable characteristic had greater odds of complications (OR 4.00; 95% CI 2.05, 7.81) and mortality (OR 5.71; 95% CI 1.60, 20.43)., Conclusion: We developed a nomogram incorporating clinical and laboratory values to prognosticate outcomes after treatment for epidural abscess. The results can be used in shared-decision making and counseling., Level of Evidence: 3.

Spinal tuberculosis (TB) is a disease of high morbidity that is associated with deformity and neurological sequelae, especially in growing children. Children diagnosed with spinal TB need to be monitored closely for clinical improvements. Previous history of antituberculous therapy (ATT), poor adherence to previous ATT, contact with persons having known drug-resistant (DR) TB, or clinical worsening despite regular ATT are strong indicators for the diagnosis of DR TB of the spine. We report a case of spinal DRTB in a two year old child with no previous history of ATT and contact with a person on irregular treatment for drug sensitive TB that did not show regression of the spinal lesions despite standard ATT., Competing Interests: Declaration of competing interest All authors have none to declare., (Copyright © 2019 Tuberculosis Association of India. Published by Elsevier B.V. All rights reserved.)

Despite its clear definition, Lemierre's syndrome is frequently used to describe any septic thrombophlebitis of the jugular vein. We report a Lemierre-like syndrome caused by Staphylococcus aureus without an oropharyngeal infection and present a systematic synthesis of reported cases to date of Lemierre-like syndrome caused by S. aureus . In addition to our case, 24 cases were found. In contrast to the classical picture, S. aureus is associated with an oropharyngeal infection in less than half of the cases. Another striking feature is the significant proportion of patients being very young and the fact that all 25 cases were published in the last 17 years. S. aureus is a rare, but emerging cause of Lemierre-like syndrome. Adequate patient care rests on a high index of suspicion, prompt initiation of antibiotic therapy and early detection and management of metastatic abscesses.BULLET POINT SUMMARYThe term Lemierre's syndrome should be reserved for the classic triad of bacteraemia caused by anaerobic pathogens (primarily Fusobacterium necrophorum ), evidence of internal jugular venous thrombosis, and a history of recent oropharyngeal infection.Similar syndromes not caused by anaerobic organisms or without history of an oropharyngeal infection should be named Lemierre-like syndrome and may be a more challenging diagnosis. Staphylococcus aureus is a cause of Lemierre-like syndrome, especially in very young children (<2 years old).The Staphylococcus aureus Lemierre-like syndrome is an emerging clinical syndrome.Adequate patient care is based on a high index of suspicion, prompt initiation of broad-spectrum antibiotics and active detection and management of metastatic abscesses.

Spinal epidural abscess (SEA) is a rare disease that occurs mainly in immunocompromised patients after spinal surgery or spinal trauma and can lead to a severe neurological deficit or even death if diagnosed too late. However, cases of SEA have also been reported in patients with fistulising Crohn´s disease (CD). We present a case of a young patient with CD and a history of relapsing perianal disease followed by a complication of SEA in the thoracic spine. In close cooperation with the orthopedists and the neurologists, the gastroenterologists have successfully treated the SEA in this patient, allowing her to return back to biological treatment for CD.

Objective: To describe a case of successful management of epidural-subdural abscess and severe meningitis with secondary brain herniation in a dog., Case Summary: A rhino-sinusotomy was performed in a 3-year-old mixed-breed dog for management of refractory sinonasal aspergillosis. Initial recovery was good, but the dog became acutely stuporous 36 hours after surgery. Evidence of increased intracranial pressure with brain herniation and midline shift secondary to an epidural abscess was observed on magnetic resonance imaging. Decompressive craniectomy and drainage of the abscess was performed. Intensive nursing care and physiologic support was performed with consciousness returning 7 days after initial stupor. The dog was discharged 14 days after craniectomy and was ambulatory with support., New/unique Information Provided: Intracranial abscesses are rarely described in dogs and few had a successful outcome reported. All previous reports have been of brain abscesses or empyema, rather than a combination of epidural and subdural abscessation. Additionally, the process of sino-rhinotomy for management of aspergillosis has not been previously linked to intracranial abscess formation. To the authors' knowledge, this is the first report of successful management of an epidural-subdural abscess and suggests that even with cases with low modified Glasgow Coma Scale scores outcome may be positive., (© Veterinary Emergency and Critical Care Society 2019.)

Background: Streptococcus agalactiae is an uncommon microorganism that causes spinal epidural abscess (SEA) and usually affects individuals with a predisposing condition or potential source of infection., Case Description: We present the case of an immunocompetent 53-year-old patient with an unremarkable past medical history who developed progressive low extremity weakness, bowel and bladder dysfunction and genital sensory impairment. A neurological exam on admission revealed flaccid proximal paraparesis, T10 sensory level, atonic anal sphincter and normal myotatic reflexes. Urgent neuroimaging showed a large thoracic epidural spinal abscess. Laminectomy and abscess drainage were immediately performed and systemic antibiotic treatment was initiated. Abscess cultures revealed Streptococcus agalactiae. After an exhaustive workup no predisposing factors or local or systemic source for the infection were found., Conclusions: We report a singular case of spinal epidural abscess caused by Streptococcus agalactiae in a healthy patient with no predisposing factors. This case also highlights the importance of an early diagnosis and treatment to obtain a better neurological outcome., (Copyright © 2019 Elsevier España, S.L.U. All rights reserved.)

Competing Interests: Competing interests: None declared.

Background: Aspergillus terreus, a saprophytic fungus, is recognized as an emerging pathogen in various infections in humans. However, bone and joint involvement is uncommon. To the best of our knowledge, only seven cases of spondylodiscitis caused by Aspergillus terreus have been reported previously in humans. We report a case of a patient with Aspergillus terreus spondylodiscitis following an abdominal stab wound., Case Presentation: A 74-year-old Japanese man with no particular medical history fell from a ladder and sustained a left abdominal stab wound from an L-shaped metal peg. Computed tomography showed the trace of the L-shaped metal peg from the left abdomen to the left rib and left kidney. The scan also showed an anterolateral bone avulsion of the left side of the T12 vertebral body, as well as fractures of the L1 left transverse process and the left 10th-12th ribs. He was hospitalized and treated with conservative therapy for 6 weeks. He was readmitted to the hospital with complaints of sudden back pain, numbness of both legs, and inability to walk 13 weeks after the fall. Magnetic resonance imaging findings were typical of spondylodiscitis. Gadolinium-enhanced T1-weighted magnetic resonance imaging indicated increased signal intensity at T11-T12 vertebral bodies and severe cord compression and epidural abscess at T11-T12 associated with infiltration of soft paravertebral tissues. On the seventh day after admission, he underwent partial laminectomy at T11 and posterior fusion at T9 to L2. The result of his blood culture was negative, but Aspergillus terreus was isolated from the material of T11-T12 intervertebral disc and vertebral bodies. His Aspergillus antigen was positive in a blood examination. Histological examination showed chronic suppurative osteomyelitis. On the 35th day after admission, he underwent anterior fusion at T11 and T12 with a rib bone graft. For 5 months, voriconazole was administered, and he wore a rigid corset. Posterior partial laminectomy at T11 and anterior fusion at T11 and T12 resulted in a good clinical course. The patient's neurological dysfunction was completely recovered, and his back pain disappeared. Two years after the operation, computed tomography was performed and showed bone fusion at T11 and T12. Magnetic resonance imaging revealed no evidence of increased signal intensity at T11-T12 vertebral bodies and severe cord compression and epidural abscess at T11-T12., Conclusions: To our knowledge, this is the first report of spondylodiscitis caused by Aspergillus terreus after an abdominal penetrating injury. The histological finding of chronic suppurative osteomyelitis and the radiological findings strongly suggested direct inoculation of Aspergillus terreus.

Purpose of Review: Spinal epidural abscess (SEA) is still a rare but potentially very morbid infection of the spine. In recent years, the incidence has risen sharply but the condition remains a medical conundrum wrought with unacceptably long diagnostic delays. The outcome depends on timely diagnosis and missed opportunities can be associated with catastrophic consequences. Management and outcomes have improved over the past decade. This review focuses on risk factors and markers that can aid in establishing the diagnosis, the radiological characteristics of SEA on MRI and their clinical implications, as well as the importance of establishing clear indications for surgical decompression., Recent Findings: This once exclusively surgically managed entity is increasingly treated conservatively with antimicrobial therapy. Patients diagnosed in a timely fashion, prior to cord involvement and the onset of neurologic deficits can safely be managed without decompressive surgery with targeted antimicrobial therapy. Patients with acute cord compression and gross neurologic deficits promptly undergo decompression. The greatest therapeutic dilemma remains the group with mild neurological deficits. As failure rates of delayed surgery approach 40%, recent research is focused on predictive models for failure of conservative SEA management. In addition, protocols are being implemented with some success, to shorten the diagnostic delay of SEA on initial presentation., Summary: SEA is a potentially devastating condition that is frequently missed. Protocols are put in place to facilitate early evaluation of back pain in patients with red flags with appropriate cross-sectional imaging, namely contrast-enhanced MRI. Efforts for establishing clear-cut indications for surgical decompression of SEA are underway.

Atraumatic spinal emergencies often present a diagnostic and management dilemma for health care practitioners. Spinal epidural abscess, cauda equina syndrome, and spinal epidural hematoma are conditions that can insidiously present to outpatient medical offices, urgent care centers, and emergency departments. Unless a high level of clinical suspicion is maintained, these clinical entities may be initially misdiagnosed and mismanaged. Permanent neurologic sequela and even death can result if delays in appropriate treatment occur. A focused, critical review of 34 peer-reviewed articles was performed to identify current data about accurate diagnosis of spinal emergencies. This review highlights the key features of these 3 pathological entities with an emphasis on appropriate diagnostic strategy to intervene efficiently and minimize morbidity., (Copyright © 2018. Published by Elsevier Inc.)

OBJECTIVEFew studies have been published specifically examining intravenous drug abuse (IVDA)-associated spinal epidural abscesses (SEAs), an unfortunate sequela of the opioid crisis in the United States. Here, the authors examined a series of patients with IVDA-associated SEAs in order to shed light on this challenging disease entity.METHODSThis study is a retrospective chart review of patients presenting with IVDA-associated SEAs at the authors' institution from 2013 to 2018, spanning the statewide implementation of opioid-prescribing restrictions.RESULTSA total of 45 patients presented with IVDA-associated SEAs; 46.5% presented with a neurological deficit. Thirty-one patients underwent surgery for neurological deficit, failure of medical therapy, or both. Nineteen surgical patients underwent a fusion procedure along with decompression. The complication rate was 41.9%, and the mortality rate was 6.7%. The average length of stay was 27.6 days. Patients who underwent surgery within 24 hours of onset of neurological symptoms trended toward more improvement in their American Spinal Cord Association Impairment Scale grade than those who did not (0.5 vs -0.2, p = 0.068). Methicillin-resistant Staphylococcus aureus was isolated as the causative pathogen in 57.8% of patients. Twenty-three patients (51.5%) kept their scheduled clinic follow-up appointments. Of the fusion patients with adequate follow-up, 5 showed bony arthrodesis and 3 had pseudarthrosis. The rate of IVDA-associated SEAs increased after opioid-prescribing restrictions were put in place, from 0.54 cases per month to 1.15 cases per month (p = 0.017).CONCLUSIONSPatients with IVDA-associated SEAs are challenging to treat, with high complication rates and poor follow-up. This disease is increasing in frequency, and opioid-prescribing restrictions did not slow that rise. Community outreach to promote prevention, early medical attention, and medication compliance would benefit this largely publicly funded patient population.

Study Design: A retrospective case series., Objective: The aim of this study was to report the immunosuppression and secondary bacterial infection after dengue viral infection and the predilection of these infections in the spine. This can trigger further research in to this fact. The possibility of change in the serotype of dengue virus, which are neurotropic, may be looked into., Summary of Background Data: This is the largest case series of epidural abscess with or without spondylodiscitis within 6 weeks following dengue virus infection., Methods: We performed a retrospective review of all the eight cases treated for epidural abscess with or without spondylodiscitis within 6 weeks following dengue virus infection in our center during the period of 3 months from June 2017 to August 2017., Results: Of the eight cases, three of them were infected with Methicillin Resistant Saphylococcus Aureus and all of them grew the bug in the blood culture. Three of them had Methicillin Sensitive Staphylococcus Aureus (MSSA), one with MSSA septicemia, and one had associated Elizabeth Kingia meningoseptica infection and one patient had positive Acid Fast Bacilli stained in smears. Two patients were infected with pseudomonas. Some patients had multiple site abscess and epidural abscess without spondylodiscitis. Five of them had neurological deficit, which recovered with abscess drainage and antibiotic treatment. The Erythrocyte Sedimentation rate, C-Reactive Protein, and serum ferritin were elevated in these patients., Conclusion: This is a large case series of epidural abscess with or without spondylodiscitis within 6 weeks following dengue virus infection. The predilection of dengue virus for the neural tissue should be further investigated. Post dengue immunosuppression also needs further study., Level of Evidence: 4.

Rationale: Nocardial spinal epidural abscess is rare. The diagnosis is often difficult to make and, if delayed, poses a high risk of long-term disability. Nocardial spinal epidural abscess with severe lumbar disc herniation has not previously been reported., Patient Concerns: A 50-year-old man presented with progressive lumbago and leg pain for 6 weeks after receiving acupuncture therapy, and then the patient suddenly occurred urine retention after walking., Diagnoses: Clinical examination revealed sign of cauda equina syndrome. Magnetic resonance imaging (MRI) revealed a Lumbar(L)4 to L5 disc herniation, L3 to Sacrum(S)1 epidural abscess, and L2 to S1 paravertebral abscess. The causative organism was Nocardia farcinica., Interventions: An urgent paravertebral abscess debridement and right L4 to L5 laminectomy were performed. Simultaneously, the disc tissue protruding into the spinal canal was removed, as well as irrigation and drainage. And antimicrobial treatment was continued for 12 months., Outcomes: Fortunately, the patient was able to walk with a cane and urinate autonomously without a catheter, although this remained difficult 7 days after surgery. After 1 year of treatment, the patient has recovered completely and returned to work., Lessons: Nocardial spinal epidural abscess with severe lumbar disc herniation is extremely rare. Pain from spinal degenerative diseases often masks the early symptoms of spinal infection. It's worth noting that invasive treatment of spine is a way of causing spinal nocardial infection.

Intracranial empyema is a rare but serious complication of sinusitis in children. Myelodysplastic/myeloproliferative syndromes (MMS), including juvenile myelomonocytic leukemia (JMML), can lead to immunosuppression, thus favouring infections. We report the case of a sphenoid sinogenic retro-clival extradural empyema in a 14-year-old female patient associated with JMML. Treatment consisted in an endonasal transphenoidal drainage of the empyema associated with intravenous antibiotherapy. The patient was thereafter enrolled in chemotherapeutic treatment with Azacitidine. The disease progressed to blast phase, indicating bone marrow graft. This is the first reported case of an endocranial complication of bacterial sinusitis associated with MMS in a child., (Copyright © 2018. Published by Elsevier B.V.)

Purpose of Review: Brain abscesses and spinal epidural abscesses are serious, potentially life-threatening infections of the central nervous system. This article outlines the clinical presentation, evaluation, and management of brain abscesses and spinal epidural abscesses, with a specific focus on bacterial infections., Recent Findings: The overall incidence of brain abscesses has declined, in part because of fewer brain abscesses associated with otogenic infections. However, emerging patient populations at high risk for brain abscess include those with a history of penetrating head trauma, neurosurgery, or immunodeficiency. Improved mortality rates for brain abscess are attributable to modern diagnostic imaging, stereotactic-guided aspiration, and newer antimicrobials that readily penetrate into the central nervous system and abscesses. Brain MRI is more sensitive than CT for brain abscess, particularly in the early stages, but CT remains more widely available and can adequately identify potential abscesses and confirm response to treatment. With the advent of minimally invasive neurosurgical techniques, surgical excision is often employed only for posterior fossa, multiloculated, or superficial well-circumscribed abscesses. In select clinical scenarios, conservative medical management may be a safe alternative to a combined surgical and medical approach. Unlike brain abscess, the incidence of spinal epidural abscess is on the rise and has been attributed to higher prevalence of predisposing factors, including spinal procedures and instrumentation., Summary: Successful diagnosis and management of brain abscess and spinal epidural abscess requires a collaborative approach among neurologists, neurosurgeons, radiologists, and infectious disease physicians. The foundation of management of brain abscess includes surgical intervention for diagnostic purposes if a pathogen has not been identified or for decompression of larger abscesses or those with mass effect and significant surrounding edema; appropriate dosing and adequate duration of an antimicrobial regimen tailored to the presumptive source of infection and available culture data, and eradication of the primary source of infection. For spinal epidural abscesses, neurologic status at the time of presentation is directly related to outcomes, underscoring the importance of prompt recognition and intervention.

Background Context: Recurrence of spinal epidural abscess (SEA) after treatment is an important cause of continued morbidity for patients., Purpose: The purpose of this study was to identify independent predictors of recurrence of SEA., Study Design/setting: This was a retrospective, case-control study., Patient Sample: Patients 18 years or older with a diagnosis of SEA admitted to our hospital system during the study period were included in the study sample., Outcome Measures: The outcome measure was recurrence of SEA, defined as a reaccumulation of pus or infected granulation tissue in the epidural space after initial treatment., Methods: All patients older than 18 years admitted to our hospital system with a diagnosis of SEA from 1993 to 2016 were identified, and explanatory variables and outcomes were collected retrospectively. Patients 18 years or older diagnosed with SEA were included. We excluded patients whose treatment was initiated at an outside institution. Bivariate and multivariate analyses were performed to identify independent predictors of recurrence., Results: We identified 1,053 patients with SEA. We only considered patients to be recurrence-free if they had no documented recurrence with greater than 20 weeks of follow-up. Five hundred thirty-four patients were recurrence-free and 38 had documented recurrence, yielding 572 patients who were included in this analysis. Bivariate and multivariate analyses identified three independent predictors of recurrence: history of intravenous drug use, fecal incontinence or retention, and local spinal wound infection., Conclusions: Patients with SEA who have a history of intravenous drug use, bowel dysfunction at presentation, or concurrent local spinal wound infection are at increased risk of disease recurrence. These patients ought to be closely followed up after discharge, with frequent serial imaging and aggressive antibiotic treatment., (Copyright © 2018. Published by Elsevier Inc.)

Background: Cervical spondylodiscitis with spinal epidural abscess (SEA) is not a rare medical condition and usually requires urgent decompression of neural structures and stabilization of the spine followed by antibiotic therapy for the prevention of severe neurologic deficits., Case Description: In this report, we present a 43-year-old male patient with the chief complaint of neck pain and intermittent fever accompanying by slight dysphagia. After 2 weeks, he felt mild and transient numbness on the left upper limb. He had a history of esophageal intervention under endoscopy. Magnetic resonance imaging disclosed diffuse hyperintensity in the left paraesophageal and prevertebral tissues and a space-occupying lesion within the spinal canal. The esophagography revealed a saclike barium collection parallel to the upper esophagus herniating out from the posterior wall without evident leakage. Neither surgical decompression nor drainage was chosen by this patient; conservative treatment with antibiotic administration was managed to achieve a good neurologic recovery and remarkable resolution of the epidural abscess. During antibiotic therapy and dietary restriction, the symptoms of diverticulitis was also managed expectantly., Conclusions: Physicians need to be aware of this rare case of SEA secondary to esophageal diverticulitis. An early diagnosis and prompt administration of antibiotics is a key factor to avoid neurologic deterioration for the treatment of SEA caused by diverticulitis. Endoscopic or surgical repair of diverticulum may be warranted to avoid the recurrence of such infection., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective We herein present a case involving a prevertebral abscess complicated by a spinal epidural abscess (SEA) secondary to intradiscal oxygen-ozone chemonucleolysis for treatment of a cervical disc herniation. Methods A 67-year-old woman with a history of intradiscal oxygen-ozone chemonucleolysis developed numbness and weakness in her right upper and bilateral lower extremities followed by urinary retention. Her symptoms did not respond to intravenous antibiotics alone. Magnetic resonance imaging of the cervical region revealed an extensive SEA anterior to the spinal cord, spinal cord myelopathy due to anterior compression by the lesion, and a prevertebral abscess extending from C2 to T1. She underwent surgical drainage and irrigation. Results The patient was successfully treated with surgical drainage and systemic antibiotic therapy without kyphosis. Streptococcus intermedius was detected within the abscess. All clinical symptoms except for the sensory deficit in the left leg were relieved. Conclusions The safety of intradiscal oxygen-ozone therapy requires further assessment. High-dose intravenous antibiotics should be initiated empirically at the earliest possible stage of prevertebral and epidural abscesses. Surgical drainage may be a rational treatment choice for patients with a prevertebral abscess complicated by an SEA and spinal cord myelopathy.

Purpose: The objective of this study was to analyse 51 patients with intracranial complications of sinusitis treated in the Department of Otolaryngology and Laryngeal Oncology at Poznań University of Medical Sciences from 1964 to 2016., Materials and Methods: Males made up a significant portion of study participants at 70.5%. Treatment included simultaneous removal of inflammatory focal points in the paranasal sinuses and drainage of cerebral and epidural abscesses and subdural empyemas under the control of neuronavigation preceded by the implementation of broad-spectrum antibiotics continuously for 4 weeks. Seventy-three intracranial complications were found among 51 patients. Of the 51 patients, 25 had frontal lobe abscesses (including multiple abscesses). Other complications included the following: 16 epidural abscesses, 9 subdural empyemas, 15 meningitis cases, 3 intracerebral abscesses, 3 sinus thrombosis cases and 2 patients with cerebritis. Co-occurrence of these complications worsened the state of the patient and increased the duration of treatment. Patients with frontal lobe abscesses had a better prognosis and less pronounced neurological symptoms in recent years versus earlier treatment approaches., Conclusions: Simultaneous treatment of intracranial complications of sinusitis is an effective treatment method that has minimal burden for the patient. From 1964 to 1978, three deaths (17%) were reported among patients with these complications. Since 1978, no deaths were reported in the clinic.

Background: Prompt diagnosis and treatment are critical in spinal epidural abscess, as delay can lead to paralysis or death. The initial management decision for spinal epidural abscess is not always clear, with the literature showing conflicting results. When considering nonoperative management, it is crucial to avoid failure of treatment, given the neurologic compromise incurred through failure. Unfortunately, data regarding risk factors associated with failure are scarce., Methods: All patients admitted to our hospital system with a diagnosis of spinal epidural abscess from 1993 to 2016 were identified. Patients who were ≥18 years of age and were initially managed nonoperatively were included. Explanatory variables and outcomes were collected retrospectively. Bivariate and multivariable analyses were performed on these variables to identify independent predictors of failure of nonoperative treatment. A nomogram was constructed to generate a risk of failure based on these predictors., Results: We identified 367 patients who initially underwent nonoperative management. Of these, 99 patients underwent medical management that failed. Multivariable logistic regression yielded 6 independent predictors of failure: a presenting motor deficit, pathologic or compression fracture in affected levels, active malignancy, diabetes mellitus, sensory changes, and dorsal location of abscess. We constructed a nomogram that generates a probability of failure based on the presence of these factors., Conclusions: By quantifying the risk of failure on the basis of the presence of 6 independent predictors of treatment failure, our nomogram may provide a useful tool for the treatment team when weighing the risks and benefits of initial nonoperative treatment compared with operative management., Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Here we report a rare case of lumbar spine epidural abscess and facet joint septic arthritis caused by Streptococcus agalactiae, which had spread to the iliopsoas muscles, leading to urine retention., Case Presentation: A 68-year-old woman with low back pain experienced a sudden onset of bilateral lower limb weakness, it was followed 14 days later by urine retention. At consultation, magnetic resonance imaging and identification of serum β-hemolytic streptococci provided a diagnosis of Streptococcus agalactiae infection. She was started on antibiotics. Despite diminishing signs of inflammation, preoperative MRI showed an epidural mass at T12-L4 compressing the cord and involving the paravertebral muscles as well. Group B beta-hemolytic streptococci were detected in both urine and blood. Because of bilateral lower limb weakness and urine retention, T12-L4 hemilaminectomy was performed. The L3/L4 intertransverse ligament resected and abscess drained. Histopathology revealed that inflammatory cells had invaded the facet joint. Group B beta-hemolytic streptococci were identified, confirming the diagnosis. The patient continued with the antibiotics postoperatively, and her health rapidly improved., Conclusion: Lumbar spine epidural abscess and facet joint septic arthritis caused by Streptococcus agalactiae is a clinical emergency, with significant morbidity and mortality especially with delayed diagnosis. A delay in both diagnosis and aggressive treatment can lead to not only severe neurological deficit but also to septicaemia, multiorgan failure, and even death.

A 70-year-old man was admitted to our hospital for a penile circumcision due to phimosis using continuous dose spinal anaesthesia. On postoperative day 10 he came to the emergency department with a superficial abscess localised at the injection site of the spinal catheter. He was treated with intravenous antibiotics for 10 days, and the superficial abscess was incised and drained. Ten days later, the patient was readmitted to the emergency department with complaints of back pain and fever. A repeat MRI scan of his lumbar sacral area was done and showed epidural abscesses without any compression of the medulla or the myelum. The patient did not have any signs of spinal cord or nerve root compression at that time. He was treated with intravenous antibiotics with resolution of symptoms., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

A 66-year-old woman presented with a 4-day history of fever, lethargy, neck and lower back pain. Neurological examination revealed mild quadraparesis. In view of this, MRI whole spine with contrast was performed and showed extensive spinal epidural abscess extending from the cervical to lumbar region causing compression of the thecal sac, spinal cord and nerves. The patient received multiple laminectomies to decompress the spinal cord and required a prolonged course of intravenous flucloxacillin as Staphylococcus aureus was cultured from three sets of blood cultures. Although spinal epidural abscess is rare, it is important for clinicians to have a high index of suspicion; so appropriate imaging is performed to determine the diagnosis. Patient age, degree of thecal sac compression and duration of symptoms are all independently associated with poor outcome. 1 ., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

We report the case of a patient with multiple empyema present throughout his body, including chronic sinusitis and chronic suppurative otitis media, as well as subsequent epidural empyema, all caused by Streptococcus intermedius. A 38-year-old man presented with chief complaints of headache, left ear discharge, and nasal congestion. Imaging studies revealed pansinusitis, soft tissue signs in the mastoid cells, and otitis media. The patient was treated with meropenem hydrate, 6g/day. While clinical findings indicated improvement of the sinusitis, his headache did not improve. Further examination with contrast computerized tomography (CT) 'a chest radiography' blood cultures were performed, and the patient was diagnosed with multiple empyema (with an epidural empyema, pulmonary suppuration) caused by S. intermedius. Subsequent burr hole drainage was implemented to drain the epidural empyema. Long-term administration was required to treat pulmonary suppuration. While they remain rare, there has been a recent upward trend in the frequency of cases in which a young, previously healthy patient has developed multiple empyema throughout their body despite the absence of complicating diseases that pose an immune deficiency risk, such as diabetes or infection with the human immunodeficiency virus (HIV). In order to properly diagnose and treat patients presenting with multiple empyema infection with S. intermedius should be included in the differential diagnosis., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Background: Spinal epidural abscesses are uncommon but potentially devastating infections that often elude early diagnosis. An increasing incidence has been suggested; however, few contemporary data are available regarding risk factors and epidemiologic trends over time., Methods: A retrospective study of spinal epidural abscesses from 2004 to 2014 at a large academic hospital was conducted. Cases were identified using International Classification of Diseases, Ninth Revision (ICD-9) code 324.1, and a review of medical and radiographic records was performed to confirm each case. Data collected included sociodemographics, medical history, suspected route of infection, treatments, and outcome., Results: The incidence was 5.1 cases for each 10,000 admissions, with no significant changes during the study period. The route of infection was identified in 52% of cases, with bacteremia as the most common (26%), followed by recent surgery/procedure (21%) and spinal injection (6%). An identifiable underlying risk factor was present in 84% of cases, most commonly diabetes and intravenous drug use. A causative organism was identified in 84% of cases, most commonly Staphylococcus aureus; methicillin-resistant isolates accounted for 25% of S. aureus cases. All cases received intravenous antibiotic therapy, and 73% underwent a drainage procedure. Fifteen percent had an adverse outcome (8% paralysis and 7% death)., Conclusions: The incidence of spinal epidural abscesses may be increasing, with the present study demonstrating a ≥5-fold higher rate compared with historical data. Although the outcome in most cases was favorable, spinal epidural abscesses continue to cause substantial morbidity and mortality and should remain a "not to be missed diagnosis.", (Copyright © 2017 Elsevier Inc. All rights reserved.)

OBJECTIVE Spinal epidural abscesses (SEAs) can be difficult to diagnose and may result in neurological compromise or even death. Delays in diagnosis or treatment may worsen the prognosis. While SEA presents a high risk for litigation, little is known about the medicolegal ramifications of this condition. An enhanced understanding of potential legal implications is important for practicing spine surgeons, emergency medicine physicians, and internists. METHODS The VerdictSearch database, a large legal-claims database, was queried for "epidural abscess"-related legal cases. Demographic and clinical data were examined for all claims; any irrelevant cases or cases with incomplete information were excluded. The effects of age of the plaintiff, sex of the plaintiff, presence of a known infection, resulting paraplegia or quadriplegia, delay in diagnosis, and delay in treatment on the proportion of plaintiff rulings and size of payments were assessed. RESULTS In total, 56 cases met the inclusion criteria. Of the 56 cases, 17 (30.4%) were settled, 22 (39.3%) resulted in a defendant ruling, and 17 (30.4%) resulted in a plaintiff ruling. The mean award for plaintiff rulings was $5,277,468 ± $6,348,462 (range $185,000-$19,792,000), which was significantly larger than the mean award for cases that were settled out of court, $1,914,265 ± $1,313,322 (range $100,000-$4,500,000) (p < 0.05). The mean age of the plaintiffs was 47.0 ± 14.4 years; 23 (41.1%) of the plaintiffs were female and 33 (58.9%) were male. The proportion of plaintiff verdicts and size of monetary awards were not affected by age or sex (p > 0.49). The presence of a previously known infection was also not associated with the proportion of plaintiff verdicts or indemnity payments (p > 0.29). In contrast, juries were more likely to rule in favor of plaintiffs who became paraplegic or quadriplegic (p = 0.03) compared with plaintiffs who suffered pain or isolated weakness. Monetary awards for paraplegic or quadriplegic patients were also significantly higher (p = 0.003). Plaintiffs were more likely to win if there was a delay in diagnosis (p = 0.04) or delay in treatment (p = 0.006), although there was no difference in monetary awards (p > 0.57). Internists were the most commonly sued physician (named in 13 suits [23.2%]), followed by emergency medicine physicians (named in 8 [14.3%]), and orthopedic surgeons (named in 3 [5.4%]). CONCLUSIONS This investigation is the largest examination of legal claims due to spinal epidural abscess to date. The proportion of plaintiff verdicts was significantly higher in cases in which the patient became paraplegic or quadriplegic and in cases in which there was delay in diagnosis or treatment. Additionally, paralysis is linked to large sums awarded to the plaintiff. Nonsurgeon physicians, who are often responsible for initial diagnosis, were more likely to be sued than were surgeons.

Parvimonas micra (P. micra) infections causing spinal cord compression are extremely rare. We report an occult oesophageal pleural fistula presenting with spinal epidural and brain abscesses resulting in severe neurological deficits caused by P. micra. Molecular detection proved to be instrumental in identifying the causative pathogen. Essential management with decompression, drainage, antibiotics and fistula repair lead to a good outcome., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objectives/hypothesis: To describe the presentation and management of acute complicated mastoiditis in children., Study Design: Retrospective case series., Methods: An analysis of pediatric patients with acute complicated mastoiditis treated at an urban, tertiary care children's hospital from 2007 to 2014 was performed., Results: Forty-eight patients presented with a total of 67 complications of acute mastoiditis. Mean age at presentation was 4.8 years (range = 0.1-15.3 years). The most common complications were subperiosteal abscess (n = 22, 45.8%), epidural abscess (n = 16, 33.3%), and sigmoid sinus thrombosis (n = 14, 29.2%). The most common pathogens isolated included Streptococcus pneumoniae (n = 14, 29.2%) and group A streptococcus (n = 10, 20.8%). Multidrug resistance was not associated with complication type. Surgical management included myringotomy ± tympanostomy tube placement in 46 (95.8%) patients (the only surgery in 10), drainage of subperiosteal abscess without mastoidectomy in 18 (37.5%) patients, and mastoidectomy in 21 (43.8%) total patients. Patients presenting with intracranial complications were the most likely to undergo a mastoidectomy. Anticoagulation was used in the management of nine of 14 (64.3%) patients presenting with sigmoid sinus thrombosis. Neurosurgical interventions (n = 7, 14.6% patients) were primarily performed to manage increased intracranial pressure., Conclusions: Subperiosteal abscess was the most common complication of acute mastoiditis, and when occurring as the sole complication was successfully managed with antibiotics and surgical intervention that did not include mastoidectomy. Epidural abscess and sigmoid sinus thrombosis were more prevalent than reported in prior series and were managed more aggressively. These patients were more likely to need neurosurgical interventions., Level of Evidence: 4. Laryngoscope, 127:2321-2327, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Spinal epidural abscess (SEA) is a serious infection requiring prompt treatment and potential neurosurgical intervention. Although contrast-enhanced spine MRI is the mainstay for diagnosis of SEA, unenhanced MRI is typically performed for patients with nonspecific symptoms or insufficient clinical information. We evaluated the sensitivity and specificity of imaging features suggestive of SEA at unenhanced spine MRI., Materials and Methods: We searched our database for contrast-enhanced lumbar spine MRI examinations from January 1, 2000, through August 1, 2014, with "epidural abscess" in the report. We included 68 patients older than 18 years with an enhancing epidural collection at MRI and surgical (60%), microbiologic (15%), or clinical (25%) confirmation of SEA. Sixty-eight age- and sex-matched control subjects without SEA were also selected. Three readers scored unenhanced MR images on the degree of psoas and paraspinal muscle edema, extent of bone marrow edema, and abnormal disk signal., Results: Paraspinal edema was highly sensitive (97%) for SEA, with lower sensitivities for psoas (54%), bone marrow (65%), and disk edema (66%). Each of these markers was highly significant in univariate analysis (p < 0.001). A multivariate logistic regression model adjusting for age and sex found that paraspinal (p < 0.001) and bone marrow edema (p = 0.006) were significant independent predictors of SEA (odds ratio, 58; p < 0.001), with a trend toward significance for psoas edema and abnormal disk signal. Psoas muscle edema was the most specific (96%) finding for the presence of SEA., Conclusion: Paraspinal edema is highly sensitive for SEA. Familiarity with the findings for SEA at unenhanced MRI could help expedite further definitive evaluation when contrast agent is not administered.

Objective: Recent studies have shown that in carefully selected patients, conservative treatment alone can be an option in the management of spinal epidural abscess (SEA). The aim of this study was to identify prognostic factors of outcome in patients with spontaneous SEA treated conservatively., Patients and Methods: A retrospective cohort study of all patients with spontaneous SEA treated with antibiotics alone from January 2012 to December 2015 was conducted in a 1200-bed tertiary referral center. Demographic, clinical, microbiological, and radiological characteristics were analyzed. Failure of medical treatment was defined as the need for delayed surgical intervention, no neurological improvement or deterioration, death due to the infection, or relapse after hospital discharge., Results: We identified 21 patients diagnosed with spontaneous SEA treated conservatively. Median age was 72 years and 10 patients were male. Eleven patients presented with radicular weakness and/or radicular sensory deficit, or incomplete cord injury. Inflammatory markers were markedly elevated in all patients. Thirteen patients were successfully treated with conservative treatment, while among 8 patients with treatment failure, 1 died due to the infection. Presence of serious neurological deficits and infection due to methicillin-resistant S. aureus (MRSA) were associated with failure of conservative treatment. Notably, neither the extension nor the location of the abscess on magnetic resonance imaging (MRI) was associated with failed medical management., Conclusions: A significant proportion of patients with spontaneous SEA can respond to antibiotic treatment alone. However, in patients with infection due to MRSA or with severe neurological impairment, conservative management has an increased risk of failure., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Intraspinal abscesses (ISAs) are rare lesions that are often neurologically devastating. Current treatment paradigms vary widely including early surgical decompression, drainage, and systemic antibiotics, delayed surgery, and sole medical management. The National Inpatient Sample (NIS) database was queried for cases of ISA from 2003 to 2012. Early and late surgery were defined as occurring before or after 48h of admission. Outcome measures included mortality, incidence of major complications, length of stay (LOS), and inpatient costs. A total of 10,150 patients were included (6281 early surgery, 3167 delayed surgery, 702 medical management). Paralysis, the main comorbidity, was most associated with early surgery (p<0.0001). In multivariate analysis, the rates of postoperative infection and paraplegia were highest with early surgery (p<0.0001), but the incidence of sepsis was higher with delayed surgery (p<0.0001). Early surgery was least associated with in-hospital mortality (p=0.0212), sepsis (p<0.001), and had the shortest LOS (p<0.001). Charges were highest with delayed surgery, and least with medical management (p<0.001). Medical management was associated with lower rates of complications (p<0.001). This is the largest study of patients with ISAs ever performed. Our results suggest that patients with ISAs undergoing surgical management have better outcomes and lower costs when operated on within 48h of admission, emphasizing the importance of accurate and early diagnosis of ISA., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Lemierre disease is a rare postanginal sepsis caused by the anaerobe Fusobacterium necrophorum. It is associated with a pharyngitis that progresses quickly to thrombophlebitis of the internal jugular vein and metastatic abscesses to pulmonary, soft tissue, articular, and organ systems. It is rarely associated with spinal epidural abscesses. Because of the increasing antibiotic resistance, its incidence is on the rise., Methods: A single-patient case report of an adolescent male who initially presented to our institution for bacteremia and febrile episodes. Over a 1-week course, he developed severe back pain and progressive lower extremity weakness. Advanced imaging revealed an epidural abscess spanning T2-L3 level with extension into the psoas and the paraspinal musculature. Acute management consisted of broad-spectrum intravenous (IV) antibiotics and hemilaminectomy decompression from T2 to L3. The patient completed a 6-week course of IV antibiotics and was followed for a 1-year time period with close clinical follow-up., Results: Blood cultures identified the infecting organism as F. necrophorum. The combination of IV antibiotics and acute hemilaminectomy decompression resulted in successful clearance of the infecting organism with normalization of inflammatory markers and cultures. The patient noted immediate and sustained neurological improvement, with return of full motor and sensory function. At the 1-year timepoint, the patient was able to return to sports and no sagittal/coronal imbalance was noted on radiographs., Conclusions: An aggressive case of Lemierre disease with extensive epidural abscess formation and neurological weakness was successfully managed with the combination of IV antibiotics and extensive hemilaminectomies for decompression. The patient exhibited no long-term sequela as a result of either the epidural abscess or of its treatment., Level of Evidence: Level V.

An epidural abscess represents a rare acute medical emergency, with a reported incidence of 2.5/10 000 hospital admissions annually. The clinical features include fever, spinal pain, radiating nerve root pain and leg weakness. When sepsis is present, prompt recognition is required to initiate appropriate antimicrobial therapy and surgical decompression. We present the case of a man aged 68 years presenting to the emergency department with a 3-day history of fever, low back, right hip and leg pain. He was hypoxic, tachycardic and hypotensive. He required intubation and ventilation. An MRI spine confirmed a posterior epidural abscess from T12 to L4. Blood cultures revealed Staphylococcus aureus He started treatment with linezolid and underwent incision and drainage. He remained septic and 8 days later, a repeat MRI spine showed a peripherally enhancing posterior epidural collection from L2/L3 to L4/L5, consistent with a recurrent epidural abscess. Further drainage was performed. He developed bilateral knee pain requiring washout. His right knee synovial biopsy cultured S. aureus He continued treatment with linezolid for 6 weeks until his C reactive protein was 0.8 ng/L. He started neurorehabilitation. 10 weeks later, he became feverish with lumbar spine tenderness. An MRI spine showed discitis of the L5/S1 endplate. A CT-guided biopsy confirmed discitis and osteomyelitis. Histology was positive for S. aureus and he started treatment with oral linezolid. After 19 days, he was discharged with 1 week of oral linezolid 600 mg 2 times per day, followed by 1 further week of oral clindamycin 600 mg 4 times daily. This case report reinforces the importance of maintaining a high clinical suspicion, with a prompt diagnosis and combined medical and surgical treatment to prevent adverse outcomes in this patient cohort. With spinal surgical services centralised, physicians may not encounter this clinical diagnosis more often in day-to-day hospital medical practice. The unique aspect of this case is the persistence and then the recurrence (despite 6 weeks of antimicrobial therapy and a second debridement) of S. aureus infection. Furthermore, the paucity of clinical recommendations and the controversy regarding the adequate duration of antimicrobial therapy are notable features of this case., Competing Interests: Conflicts of Interest: None declared., (2016 BMJ Publishing Group Ltd.)