Epidural Abscess

Spinal epidural abscess (SEA) is an uncommon but serious condition with significant morbidity and mortality. The prognosis of SEA is highly dependent on the timeliness of its diagnosis before neurological deficits develop. Unfortunately, often due to its nonspecific presentation, such as back pain, the diagnosis of SEA may be delayed in up to 75% of cases. Although many risk factors for SEA can be found in the published literature, their utility is limited by their frequent lack of objective evidence, numerousness, and absence in a significant proportion of cases. In this review, we call for a more discriminate evidence-based use of the term "risk factor" when discussing SEA and explore several approaches to its earlier diagnosis, including a simple algorithm based on its pathophysiology and serum C-reactive protein or erythrocyte sedimentation rate.

BackgroundBacteria in the Streptococcus milleri group (S. anginosus, S. constellatus, and S. intermedius) are associated with bacteremia and abscess formation. While most reports of Streptococcus milleri group (SMG) infection occur in patients with underlying medical conditions, SMG infections during pregnancy have been documented. However, SMG infections in pregnant women are associated with either neonatal or maternal puerperal sepsis. Albeit rare, S. milleri spinal-epidural abscess in pregnancy has been reported, always as a complication of spinal-epidural anesthesia. We report a case of spinal-epidural abscess caused by SMG in a young, pregnant woman without an antecedent history of spinal epidural anesthesia and without any underlying risk factors for invasive streptococcal disease.Case presentationA 25 year old pregnant woman developed neurological symptoms consistent with spinal cord compression at 20 weeks gestation. She underwent emergency laminectomy for decompression and was treated with ceftriaxone 2 gm IV daily for 28 days. She was ambulatory at the time of discharge from the inpatient rehabilitation unit with residual lower extremity weakness.ConclusionTo our knowledge, this is the first reported case of a Streptococcus milleri epidural abscess in a healthy, pregnant woman with no history of epidural anesthesia or invasive procedures. This report adds to the body of literature on SMG invasive infections. Treatment of SMG spinal-epidural abscess with neurologic manifestations should include prompt and aggressive surgical decompression coupled with targeted anti-infective therapy.

BackgroundSpinal fungal infections, especially spinal Aspergillus infections, are rare in the clinic. Here, we introduce the clinical features, diagnosis, treatment, and prognoses of 6 cases of Aspergillus spondylitis.MethodsWe retrospectively analysed the complete clinical data of patients with Aspergillus spondylitis treated in our hospital from January 2013 to January 2020.ResultsAspergillus fumigatus was isolated in 4 cases, and Aspergillus spp. and Aspergillus niger were isolated in 1 case each. All six patients reported varying degrees of focal spinal pain; one patient reported radiating pain, one patient experienced bowel dysfunction and numbness in both lower limbs, and three patients had fever symptoms. One case involved the thoracic spine, one case involved the thoracolumbar junction, and 4 cases involved the lumbar spine. Three patients were already in an immunosuppressed state, and three patients entered an immunosuppressed state after spinal surgery. All six patients were successfully cured, and five required surgery. Of the 5 patients who underwent surgical treatment, 2 had spinal cord compression symptoms, and 3 had spinal instability. At the end of follow-up, 1 patient reported left back pain and 1 patient reported left limb numbness.ConclusionThe clinical manifestations of Aspergillus spondylitis are non-specific, and the diagnosis depends on typical imaging findings and microbiological and histopathological examination results. When there is no spinal instability, spinal nerve compression symptoms, or progressive deterioration, antifungal therapy alone may be considered. If spinal instability, spinal nerve compression, or epidural abscess formation is present, surgery combined with antifungal therapy is recommended.

IntroductionSpinal epidural abscess (SEA) is a rare surgical emergency of the spine that can result in permanent neurological injury if not diagnosed and treated in a timely manner. Because early presentation can appear similar to benign back or neck pain, delays in diagnosis may be relatively common. We sought an improved understanding of the characteristics associated with SEA and frequency of delays in SEA diagnosis.MethodsWe conducted a retrospective cohort study of adult patients with new magnetic resonance imaging-confirmed SEA from January 1, 2016-December 31, 2019 in an integrated healthcare system. We applied electronic data abstraction and focused manual chart review to describe potentially SEA-related ambulatory and emergency visits in the 30 days prior to SEA diagnosis, and patient characteristics including comorbidities, potential risk factors, and presenting signs and symptoms. We described the frequency of potential delays in diagnosis and of previously described clinical characteristics and risk factors for SEA.ResultsSpinal epidural abscess was diagnosed in 457 patients during the study period, 178 (39%) of whom were female, with median age 63 years (interquartile range 45-81 years). More than two-thirds of patients had at least one visit prior to diagnosis (323, 71%), and SEA location was most commonly the lumbar spine (235, 51%). Although over 90% of patients presented with back or neck pain or tenderness, the classic triad of back pain, fever, and neurologic symptoms was present in only 10% of patients. Diabetes mellitus and infection in the prior 90 days were common, while injection drug use, chronic steroid use, HIV infection, and solid organ transplant were rare.ConclusionIn an integrated healthcare system, 71% of patients with spinal epidural abscess had potentially related ambulatory care or emergency visits in the 30 days prior to diagnosis. Diagnosis of SEA remains challenging, with multiple visits common before the diagnosis is clear.