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Objective and Importance: We describe a case of a posterior spinal epidural abscess that was successfully treated with percutaneous, computed tomography-guided, needle aspiration and parenteral antibiotic therapy., Clinical Presentation: A 48-year-old man experienced acute pain in the paralumbar region for 1 week, followed by gait disturbance and micturition difficulty. Laboratory studies demonstrated leukocytosis and hyperglycemia. Blood cultures yielded Staphylococcus aureus. Magnetic resonance imaging scans of the thoracolumbar spine revealed a posterior spinal epidural abscess located between L2 and the lower cervical spine., Intervention: The patient's low back pain persisted despite 10 days of antibiotic therapy. Therefore, percutaneous, computed tomography-guided, needle aspiration was performed. The low back pain was relieved dramatically and immediately after the procedure. The spinal epidural abscess completely resolved after 6 weeks of antibiotic treatment., Conclusion: Surgical decompression and antibiotic therapy are the treatments of choice for patients with spinal epidural abscesses. Selected patients may be treated nonsurgically. Rarely, percutaneous drainage of the abscess has been reported to be helpful. Our case suggests that percutaneous, computed tomography-guided, needle aspiration might be a rational alternative to surgical decompression for treatment of spinal epidural abscesses.

Objective: Spinal epidural abscess is a rare infectious disorder, often with a delayed diagnosis, and associated with significant morbidity and mortality rates. We conducted a retrospective study to define its clinical characteristics and to evaluate its prognostic factors., Methods: The medical charts of 46 patients (36 men and 10 women) with spinal epidural abscess over a 10-year period (from July 1991 to May 2000) were reviewed and analyzed., Results: A high proportion of patients had underlying diseases of diabetes (46%), frequent venous puncture (35%), spinal trauma (24%), and history of spinal surgery (22%). The initial accurate diagnostic rate was 11%. Localized spinal pain (89%), paralysis (80%), fever/chills (67%), and radicular pain (57%) were the common manifestations. The erythrocyte sedimentation rate (ESR) was elevated uniformly (mean, 86.6 mm/h) when measured. Staphylococcus aureus was the most common cause of spinal epidural abscess isolated from blood (39%) and pus (50%). Low platelet counts (< 100 x 10(9)/L) (odds ratio (OR): 8.8, 95% confidence interval (CI): 1.0-77.8), extremely high ESR (> or = 110 mm/h) (OR: 4.8, 95% CI: 0.9-25.4), and cervical spine epidural abscess (OR: 5.2, 95% CI: 0.8-32.0) predicted a poor outcome., Conclusions: Localized back pain in a febrile patient with significant risk for epidural abscess warrants an immediate magnetic resonance imaging examination. The presence of thrombocytopenia, extremely elevated ESR, or evidence of spinal cord compression should prompt aggressive treatment.

An epidural abscess is a rare lesion whose consequences can cause high morbi-mortality, particularly in obstetrics, where it occurs in young, healthy patients. With increased use of regional anesthesia, the incidence of epidural abscess will increase. We therefore review the risk factors, most common etiology and clinical signs, which may be non-specific but are nevertheless suggestive. We also review available diagnostic methods. It may be difficult to distinguish epidural abscess from other causes of medullar compression, but prompt diagnosis is essential so that emergency surgical repair can proceed and neurological recovery will be as early and complete as possible. Appropriate antibiotic therapy should be aggressive. Basic aseptic measures are critical for preventing infection through epidural needles, as the presence of infection at the moment of puncture facilitates greater susceptibility to epidural abscess.

In a retrospective study, 68 patients with Spinal Epidural Abscess (SEA) were reviewed. Of these, 66% had different predisposing factors such as staphylococcal skin infections, surgical procedures, rachicentesis, trauma, spondilodiscitis. Abscess had a lumbar region location in 53% of cases. Staphylococcus aureus was the most frequent etiological agent (81%). The overall rate of mortality in SEA patients was 13.2%.

Spinal abscess due to Aspergillus is rare. A young boy with chronic granulomatous disease and aspergillosis of the rib had been treated with antifungal treatment 3 months earlier. The patient presented with a brief history of progressive paraparesis. Imaging showed D9--11 vertebral involvement and destruction of the D10 vertebral body with angulation and a large dorsally placed, multiloculated epidural abscess extending from D6 to L2. There was also extensive granulation anterior to and on either side of the vertebrae. The patient underwent extensive laminectomy and decompression of all the loculi and partial removal of the granulation tissue. Aggressive medical treatment was started. The authors recommend an aggressive surgical and medical approach in such cases of disseminated invasive aspergillosis, even though the result may not be very satisfactory. This report discusses the full clinical profile and management of Aspergillus spinal epidural abscess and emphasizes the need to follow up these cases to detect recurrence and new lesions, even if the patients are on adequate medical treatment. In spite of all efforts, high morbidity and mortality is common in such patients., (Copyright 2001 S. Karger AG, Basel)

A case report of a previously healthy adult patient with a lumbar spinal extradural abscess due to Mycobacterium chelonae is presented. His course of treatment was complicated by recurrent psoas abscesses, as well as multiantibiotic resistance, requiring multiple surgical drainage procedures and antibiotic changes over a 33-month period. Cure was achieved only after aggressive surgical debridement of the abscess.

A 67 year old man with longstanding rheumatoid disease was referred to the regional spinal surgery unit with acute onset of paraparesis due to an extensive spinal epidural abscess of the lumbar spine. Ten months previously, he had started antibiotic treatment at another hospital for an epidural abscess arising at the level of the L2-3 disc space. Despite completing seven months of medical treatment with appropriate antibiotics, he had a recrudescence of acute back pain shortly after restarting methotrexate treatment. Urgent anterior spinal decompression with excision of the necrotic vertebral bodies of L1-3 was performed. The indications for the surgical management of spinal epidural abscess are reviewed.

Introduction: Catheter-related spinal epidural abscesses are rare but increasing in incidence., Clinical Picture: An elderly gentleman received 4 days of continuous epidural analgesia following multiple traumatic rib fractures. Five days subsequently, he developed an extensive epidural abscess accompanied by backache, lower limb weakness, fever, leukocytosis and Staphylococcal bacteraemia., Treatment: He received appropriate intravenous antibiotics and underwent an emergent decompressive laminectomy., Outcome: A good outcome was achieved because of prompt diagnosis, appropriate intravenous antibiotics and timely surgical intervention., Conclusions: It is important to be vigilant and continue to maintain good clinical practice and a high index of suspicion for this procedural-related complication.

Spinal epidural abscesses account for 1 or 2 of every 10,000 hospital admissions, Staphylococcus aureus being the bacterium most frequently involved. Brucellosis is a disorder of worldwide distribution, relatively frequent in South America and in Mediterranean countries in Europe and Africa. Whilst in the USA only 200 cases are reported every year, in Spain it is the most frequent zoonosis. This systemic disease seldom produces spondylodiscitis which in a minority of cases may be complicated by spinal epidural abscesses, in general of lumbar location. The purpose of this article is to analyse 4 cases of brucellar spinal epidural abscess of cervical location and diagnosed in the Province of Teruel, Spain, an endemic area for the disease, through 10 consecutive years (1990-1999). We consider noteworthy the following facts: the first case was a technical employee who acquired the infection in our laboratory of microbiology, the second presented with an extensive purulent collection invading prevertebral and retropharyngeal regions, the third case was cured only with antibiotics without residual deficits. In the fourth case we were not able to demonstrate spondylodiscitis accompanying the epidural abscess at the C2-C6 levels. We discuss especially the epidemiological aspects of brucellosis, the existence of epidural abscess without spondylodiscitis, the clinical manifestations, the diagnosis by means of magnetic resonance imaging, specific serological tests for Brucella, antibiotic treatment and the prognosis of our cases., (Copyright 2001 S. Karger AG, Basel)

We reviewed medical records and laboratory and diagnostic evaluations for 8 pediatric patients with spinal epidural abscesses who were treated during the last 15 years at our institution. Staphylococcus aureus was isolated from 5 of 8 epidural abscesses, including 2 abscesses with methicillin-resistant S. aureus. Unusual isolates were group B Streptococcus in a patient with chronic vesicouretral reflux associated with the posterior urethral valves and Aspergillus flavus in a patient with acute myelogenous leukemia. An analysis incorporating our results and a review of the English-language literature about abscesses in children and adults revealed differences related to age. Abscesses in children were more posterior in epidural location, had greater spinal column extension, and were associated with more favorable clinical outcomes than were abscesses in adults. Magnetic resonance imaging is the diagnostic procedure of choice; however, radionuclide bone scans should be considered for associated distant osteomyelitis in children. Prompt diagnosis and combined medical and surgical treatment remain the cornerstones for the prevention of adverse outcomes.

Spinal epidural abscess (SEA) was first described in the medical literature in 1761 and represents a severe, generally pyogenic infection of the epidural space requiring emergent neurosurgical intervention to avoid permanent neurologic deficits. Spinal epidural abscess comprises 0.2 to 2 cases per 10,000 hospital admissions. This review intends to offer detailed evaluation and a comprehensive meta-analysis of the international literature on SEA between 1954 and 1997, especially of patients who developed it following anesthetic procedures in the spinal canal. In this period, 915 cases of SEA were published. This review is the most comprehensive literature analysis on SEA to date. Most cases of SEA occur in patients aged 30 to 60 years, but the youngest patient was only 10 days old and the oldest was 87. The ratio of men to women was 1:0.56. The most common risk factor was diabetes mellitus, followed by trauma, intravenous drug abuse, and alcoholism. Epidural anesthesia or analgesia had been performed in 5.5% of the patients with SEA. Skin abscesses and furuncles were the most common source of infection. Of the patients, 71% had back pain as the initial symptom and 66% had fever. The second stage of radicular irritation is followed by the third stage, with beginning neurological deficit including muscle weakness and sphincter incontinence as well as sensory deficits. Paralysis (the fourth stage) affected only 34% of the patients. The average leukocyte count was 15,700/microl (range 1,500-42,000/microl), and the average erythrocyte sedimentation rate was 77 mm in the first hour (range 2-50 mm). Spinal epidural abscess is primarily a bacterial infection, and the gram-positive Staphylococcus aureus is its most common causative agent. This is true also for patients who develop SEA following spinal anesthetics. Magnetic resonance imaging (MRI) displays the greatest diagnostic accuracy and is the method of first choice in the diagnostic process. Myelography, commonly used previously to diagnose SEA, is no longer recommended. Lumbar puncture to determine cerebrospinal fluid protein concentrations is not needed for diagnosis and entails the risk of spreading bacteria into the subarachnoid space with consequent meningitis; therefore, it should not be performed. The therapeutic method of choice is laminectomy combined with antibiotics. Conservative treatment alone is justifiable only for specific indications. Laminotomy is a therapeutic alternative for children. The mortality of SEA dropped from 34% in the period of 1954-1960 to 15% in 1991-1997. At the beginning of the twentieth century, almost all patients with SEA died. Parallel to improvements in the mortality rate, today more patients experience complete recovery from SEA. The prognosis of patients who develop SEA following epidural anesthesia or analgesia is not better than that of patients with noniatrogenic SEA, and the mortality rate is also comparable. The essential problem of SEA lies in the necessity of early diagnosis, because only timely treatment is able to avoid or reduce permanent neurologic deficits. The problem with spinal epidural abscesses is not treatment, but early diagnosis - before massive neurological symptoms occur" (Strohecker and Grobovschek 1986).

Acute sinusitis is often a mild, self-limiting disease. However, in some cases, especially among children, sinusitis may become a severe, even life-threatening, disease. To examine the nature of complications of acute sinusitis, we studied the cases of children treated at the Helsinki University ENT Hospital, because of a complication caused by acute sinusitis from January 1997 to September 1998. There were 12 children (4 girls, 8 boys), whose ages ranged from 16 months to 16 years. One child had an epidural abscess, one got meningitis and cavernous sinus thrombosis, five had orbital cellulitis, one of whom lost her vision permanently in one eye, and five had preseptal cellulitis. All the children were treated with intravenous antibiotics and all, except the youngest, were treated with a direct sinus puncture. An operation (intranasal antrostomy, orbital drainage, functional endoscopic sinus surgery or adenoidectomy) was performed on six patients. In the majority of children, acute sinusitis is a mild self-limiting disease. However, severe complications still exist. When a complication of sinusitis is suspected, it is of utmost importance that the child be sent immediately to a hospital for proper diagnosis and treatment.

Our purpose was to determine if specific MRI findings in spinal epidural abscess (SEA), at the time of diagnosis, are associated with the clinical outcome. The clinical records and MRI studies of 18 patients with SEA were reviewed and follow-up was obtained from the outpatient medical record, telephone interview, or both. The association between findings on contrast-enhanced MRI and clinical outcome (weakness, neck or back pain, and incomplete functional recovery) was evaluated. With univariate analysis, narrowing of 50% or more of the central spinal canal (P = 0.03), peripheral contrast-enhancement (P = 0.05), and abnormal spinal cord signal intensity (P = 0.05) were associated with weakness at follow-up. Persistent neck or back pain was associated with spinal canal narrowing (P = 0.02), peripheral contrast-enhancement (P = 0.02), and an abscess longer than 3 cm (P = 0.04) on MRI. Incomplete clinical recovery was associated with both abscess length (P = 0.01) and the severity of canal narrowing (P = 0.01). Abscess length, enhancement pattern, and severity of canal narrowing can be incorporated in a grading system that can be used to predict outcome.

A 42-year-old man was admitted for fever and severe low back pain radiating to both legs. On MRI, an epidural spinal abscess from S1 to D10 was seen. Treatment included laminectomy, drainage of the abscess and antibiotics. Recovery was complete without neurological damage. Increased awareness of this disease may lead to diagnosis and treatment.

Six cases of spinal epidural abscess are presented. All patients were young with no predisposing conditions. All were treated with laminectomy and intravenous antibiotics. The patients with no neurological deficit recovered completely, while patients with pre-existing neurological deficit had a poorer outcome. Emphasis is given to early detection and surgical management to prevent irreversible damage to the spinal cord.