Spinal Epidural Abscess SEA

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Spinal Epidural Abscess SEA
www.medkaau.com/vb

• Done by
• Dr.Walaa Gholam
• KAAU 2007
• 4th year medical student

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contents

• - Pathogenesis
• - Causative agents
• - Mechanism of injury
• - Clinical features (symptoms. Physical exam)
• - Investigation (lab. Imaging)
• - DD
• - Diagnosis
• - Treatment (surgical , medical)
• - Prognosis
• - complications

EBM
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Pathogenesis 1,2,3

• - Underlying disease
• diabetes mellitus
• alcoholism
• infection with HIV
• - A spinal abnormality or intervention
• degenerative joint
  disease
• Trauma
• Surgery
• drug injection
• placement of stimulators
  or catheters

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• - a potential local or systemic source of
  infection
• Skin and soft-tissue
  infections
• Osteomyelitis
• Pott's disease (spinal
  TB)
• UTI, URTI
• Sepsis
• Dermal sinus tract ,
  Dental abscess
• Retropharyngeal abscess
  
• Lemierres syndrome (1
  case report) !! 4
• Indwelling vascular
  access, Intravenous drug use
• Nerve acupuncture,
  Tattooing
• Epidural analgesia (in
  cancer pt) or nerve block
• hemodialysis patients
  (12 case report) 5

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(No Transcript)
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Causative agents

• S. aureus 2/3 of cases.1,4.
• (MRSA) 15 decade ago 2 (escalated rapidly up
  to 40) after spinal injection or surgery
• S. epidermidis (placement of catheters, surgery)
• Escherichia coli (subsequent to UTI)
• Pseudomonas aeruginosa (injection-drug users) 4
• Rarely anaerobic bacteria 3
• agents of actinomycosis or
  nocardiosis, mycobacteria 4
• fungi (including candida, sporothrix,
  and aspergillus species) 4
• parasites (echinococcus and
  dracunculus)
• 1- Reihsaus E, Waldbaur H, Seeling W. Spinal
  epidural abscess a meta-analysis of 915
  patients. Neurosurg Rev 2000
• 2- Rigamonti D, Liem L, Sampath P, et al. Spinal
  epidural abscess contemporary trends in
  etiology, evaluation, and management. Surg Neurol
  1999
• 3- Lechiche C, Le Moing V, Marchandin H,
  Chanques G, Atoui N, Reynes J. Spondylodiscitis
  due to Bacteroides fragilis two cases and
  review. Scand J Infect Dis 2006
• 4- Reihsaus E, Waldbaur H, Seeling W. Spinal
  epidural abscess a meta-analysis of 915
  patients. Neurosurg Rev 2000

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Bacteria gain access to the epidural space
through

• - Contiguous spread 1/3 of patients
• - Hematogenous dissemination 1/3 of patients
• - The source of infection is not identified 1/3
  of patients

infection that originates in the spinal epidural
space can extend locally or through the
bloodstream to other sites
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Mechanism of injury(principal mechanism is
uncertain)

• - Directly by mechanical compression
• (remarkable degree of neurologic improvement in
  some patients after decompressive laminectomy)
• - Indirectly as a result of vascular occlusion
  caused by septic thrombophlebitis
• (thrombosed levels are observed in few postmortem
  examinations) 1
• (infarction of the spinal cord, as reflected by
  altered cord signal MRI) result from both
• 1- Browder J, Meyers R. Pyogenic infections of
  the spinal epidural space a consideration of the
  anatomic and physiologic pathology. Surgery 1941

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• - abscesses are more likely to develop in larger
  epidural spaces that contain infection-prone fat,
  they are more common in posterior than anterior
  areas and in thoracolumbar than cervical areas 1
• - use of spinal interventions for pain management
  led to a disproportionate increase in the
  occurrence of lumbar epidural infection 2
• - generally extend over 3 to 4 vertebrae 1,3
• 1- Danner RL, Hartman BJ. Update of spinal
  epidural abscess 35 cases and review of the
  literature. Rev Infect Dis 1987
• 2- Khan SH, Hussain MS, Griebel RW, Hattingh S.
  Comparison of primary and secondary spinal
  epidural abscesses a retrospective analysis of
  29 cases. Surg Neurol 2003
• 3- Tang H-J, Lin H-J, Liu Y-C, Li C-M. Spinal
  epidural abscess -- experience with 46 patients
  and evaluation of prognostic factors. J Infect
  2002

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Paraspinal Infection

• In rare cases they involve the whole spine,
  resulting in so-called panspinal infection 1,2
• 1- Rigamonti D, Liem L, Sampath P, et al. Spinal
  epidural abscess contemporary trends in
  etiology, evaluation, and management. Surg Neurol
  1999
• 2- Solomou E, Maragkos M, Kotsarini C,
  Konstantinou D, Maraziotis T. Multiple spinal
  epidural abscesses extending to the whole spinal
  canal. Magn Reson Imaging 2004

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Clinical features

• stage 1, back pain at the level of the affected
  spine
• stage 2, nerve-root pain radiating from the
  involved spinal area
• stage 3, motor weakness, sensory deficit, and
  bladder and bowel dysfunction
• stage 4, paralysis
• Back pain in 3/4 of pt
• Fever in 1/2 pt
• Neurologic deficit in 1/3 pt
• are the three most common symptoms but in
  minority of pts 1
• 1- Reihsaus E, Waldbaur H, Seeling W. Spinal
  epidural abscess a meta-analysis of 915
  patients. Neurosurg Rev 2000

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Physical exam

• - vary with the degree of spinal cord compression
  
• - Localized tenderness to palpation at the site
  of the abscess
• - Paraspinal muscle spasm may be present
• - Signs of spinal cord dysfunction
• - Complete transverse spinal cord syndrome
  (paraplegia and sphincter dysfunction)
• - Incomplete spinal cord syndromes
• - Reflexes vary from absent to hyperreflexia with
  clonus and Babinski responses. (Areflexia may
  indicate spinal shock with transient inhibition
  of spinal reflexes)
• - Nuchal rigidity may be present, particularly
  with cervical epidural abscesses

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DDx
Other problems

• - Alcohol Related Neuropathy
• - Cervical Spondylosis
• - Epidural Hematoma
• - HIV-1 Associated Vacuolar Myelopathy
• - Leptomeningeal Carcinomatosis
• - Metastatic Disease to the Spine
• - Multiple Sclerosis
• - Spinal Cord Hemorrhage
• - Spinal Cord Infarction
• - Subdural Empyema
• - Subdural Hematoma
• - Tropical Myeloneuropathies
• - Vitamin B-12 Associated Neurological Diseases

• Cervical disk syndromes
• Lumbosacral disk syndromes
• Lumbosacral spondylosis
• Diabetes mellitus
• Intravenous drug use
• Psoas abscess
• Retropharyngeal abscess
• Transverse myelitis
• Urinary tract infection
• Vertebral osteomyelitis
• Back pain

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Diagnosis

• suspected on the basis of clinical findings
• supported by laboratory data and imaging studies
• but can be confirmed only by drainage
• Although leukocytosis detected in
  about 2/3 of pt 1,2 and inflammatory markers
  (ESR and C-reactive protein) are almost uniformly
  elevated, they are not specific
• Bacteremia causing or arising from
  spinal epidural abscess is detected in about 60
  of patients 3
• 1- Darouiche RO, Hamill RJ, Greenberg SB,
  Weathers SW, Musher DM. Bacterial spinal epidural
  abscess review of 43 cases and literature
  survey. Medicine (Baltimore) 1992
• 2- Soehle M, Wallenfang T. Spinal epidural
  abscesses clinical manifestations, prognostic
  factors, and outcomes. Neurosurgery 2002
• 3- Curry WT Jr, Hoh BL, Amin-Hanjani S, Eskandar
  EN. Spinal epidural abscess clinical
  presentation, management, and outcome. Surg
  Neurol 2005

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DiagnosisCSF

• CSF analysis shows a high level of protein
  and pleocytosis (with either a polymorphonuclear
  or a mononuclear predominance) ? parameningeal
  inflammation, but are not specific for epidural
  infection 1
• Gram staining of CSF is usually ve
• CSF cultures are ve in less than 25 of pt.
• However, blood cultures yield the
  infecting pathogen in almost all patients with a
  positive CSF culture 1
• 1- Darouiche RO, Hamill RJ, Greenberg SB,
  Weathers SW, Musher DM. Bacterial spinal epidural
  abscess review of 43 cases and literature
  survey. Medicine (Baltimore) 1992

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But !!

• although rare, there is a risk of meningitis or
  subdural infection if the needle traverses the
  epidural abscess
• Because lumbar puncture affords meager
  information and is associated with a slight
  potential risk
• it should not be done routinely
• CSF should be analyzed only if myelography is
  performed.

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Radiology

• Both MRI with intravenous administration of
  gadolinium and myelography followed by CT of the
  spine are highly sensitive (more than 90) in
  diagnosing spinal epidural abscess 1, 2
• MRI better
• longitudinal and paraspinal extension
• abscess or cancer !! 3
• 1- Rigamonti D, Liem L, Sampath P, et al. Spinal
  epidural abscess contemporary trends in
  etiology, evaluation, and management. Surg Neurol
  1999
• 2- Hlavin ML, Kaminski HJ, Ross JS, Ganz E.
  Spinal epidural abscess a ten-year perspective.
  Neurosurgery 1990
• 3- Parkinson JF, Sekhon LH. Spinal epidural
  abscess appearance on magnetic resonance imaging
  as a guide to surgical management. Neurosurg
  Focus 2004

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Radiology

• - plain roentgenograph or CT narrowing of the
  disk and bone lysis to indicate the presence of
  diskitis and osteomyelitis (which coexist with
  SEA in up to 80 of patients) 1
• - radionuclide scanning (with technetium,
  gallium, or indium) may show increased uptake
• (the findings of these tests are neither
  sensitive nor specific for SEA and should not
  take the place of MRI)
• - The presence of pulmonary infiltrates on the
  chest radiography, is evidence of
  immunodeficiency
• 1- Khan SH, Hussain MS, Griebel RW, Hattingh S.
  Comparison of primary and secondary spinal
  epidural abscesses a retrospective analysis of
  29 cases. Surg Neurol 2003

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Diagnosis cont.

• - direct smear or culture sputum positive for
  acid-fast bacilli, is suggestive of TB.

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narrowing of the L3L4 disk space (arrow) on a
plain roentgenograph of the lumbar spine of a
patient who presented with back pain and MRSA
bacteremia of unknown origin
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additional findings of bone erosion of the lower
part of L3 and, to a lesser extent, the upper
part of L4 vertebral bodies (arrows) are apparent
on CT of the spine
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a bone scan shows increased uptake of technetium
in the lower spine (arrow)
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Diagnosis in this patient was finally made with
MRI, which shows an anterior SEA at L4 (arrow)
associated with osteomyelitis of L3 and L4 and
L3L4 diskitis
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Diagnosis cont.

• - Rare condition
• - Non specific finding (fever, back pain,
  leukocytosis, ? ESR, ? C-reactive protien ?
  misdiagnosed
• particularly in neurologically intact patients
  (those in stage 1 or stage 2) 1.2
• Other diagnosis !!
• infectious conditions (osteomyelitis,
  diskitis, meningitis, UTI, sepsis, and
  endocarditis)
• noninfectious conditions
  (intervertebral-disk prolapse, degenerative joint
  disease, spinal tumor, demyelinating illness,
  transverse myelitis, and spinal hematoma)
• 1- Davis DP, Wold RM, Patel RJ, et al. The
  clinical presentation and impact of diagnostic
  delays on emergency department patients with
  spinal epidural abscess. J Emerg Med 2004
• 2- Tang H-J, Lin H-J, Liu Y-C, Li C-M. Spinal
  epidural abscess -- experience with 46 patients
  and evaluation of prognostic factors. J Infect
  2002

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Treatment

• Surgical
• Medical

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Treatment

• - prospective, randomized clinical trials to
  determine the optimal treatment (DIFFECULT)
• - But
• majority of retrospective studies provide support
  for
• surgical drainage together with systemic
  antibiotics is the treatment of choice 1, 2, 3
• - decompressive laminectomy and débridement of
  infected tissues should be done ASAP 1
• 1- Lu C-H, Chang W-N, Lui C-C, Lee P-Y, Chang HW.
  Adult spinal epidural abscess clinical features
  and prognostic factors. Clin Neurol Neurosurg
  2002
• 2- Curry WT Jr, Hoh BL, Amin-Hanjani S, Eskandar
  EN. Spinal epidural abscess clinical
  presentation, management, and outcome. Surg
  Neurol 2005
• 3- Pereira CE, Lynch JC. Spinal epidural abscess
  an analysis of 24 cases. Surg Neurol 2005

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NEJM
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- spinal instability and deformity- post
laminectomy syndrome
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• Because it is impractical to perform
  decompressive laminectomy in patients with
  panspinal epidural abscess,
• consider less extensive surgery, such as a
  limited laminectomy or laminotomy with cranial
  and caudal insertion of epidural catheters for
  drainage and irrigation

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MRI shows a posterior collection of epidural
fluid (arrow at C7) that extends from C1 to T8
and displaces the ventrally located thecal sac
(arrowhead at C7) in a patient in whom
quadriplegia developed as a result of infection
with MSSA
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MRI of the remaining spinal column from T8 to the
lumbosacral region demonstrates the caudal
extension of the same posterior spinal epidural
abscess (arrow at T11) and anterior displacement
of the spinal cord (arrowhead at T11).
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Postoprative care

• Postsurgical patients require monitoring of
  neurologic status
• Sequential compression devices (SCD), which
  decrease venous stasis in the legs (DVT)
• - If the patient has a deficit from spinal cord
  damage, nursing attention for skin care, catheter
  care, and physical therapy may be necessary
• - Outpatient
• Rehabilitation.
• Restrengthening programs and ambulation
  retraining.
• Home health care ongoing antibiotic and physical
  therapy.

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Antibiotics

• At least 6 weeks because vertebral osteomyelitis
  exists in most patients

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• S aureus is a common pathogen
• (antistaphylococcal penicillin, cephalosporin
• vancomycin to cover MRSA
• nafcillin or cefazolin for treatment of
  documented MSSA infection
• If the patient has undergone a neurosurgical
  procedure recently, the penicillin should be
  combined with a third-generation cephalosporin
  and an aminoglycoside.
• gram-negative bacilli ( with a third- or a
  fourth-generation cephalosporin, such as
  ceftazidime or cefepime, respectively),in
  suspected gram-negative bacterial infection of
  other sites, such as the urinary tract.
• Gram-stain and culture results are used to guide
  therapy

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Points

• - Neurologic function
• - signs of sepsis
• - imaging findings
• should be closely monitored after treatment
  begins (medically)
• Subsequent development of an immunocompromising
  condition or intake of immunosuppressive agents
  may result in recurrence of SEA long after the
  completion of antibiotic therapy 1
• In patients with SEA associated with an infected
  spinal cord stimulator, it is crucial to remove
  the whole stimulator system to reduce the
  likelihood of recurring implant-related epidural
  infection 2
• 1- Harrington P, Millner PA, Veale D.
  Inappropriate medical management of spinal
  epidural abscess. Ann Rheum Dis 2001
• 2- Arxer A, Busquets C, Vilaplana J, Villalonga
  A. Subacute epidural abscess after spinal cord
  stimulator implantation. Eur J Anaesthesiol 2003

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Points

• unexplained persistent or recurrent epidural
  infection may be assessed for rare sources of
  infection
• esophageal tear (in the case of cervical epidural
  abscess)
• intestinalspinal fistula (in the case of
  thoracolumbar abscess).
• Although there have been sporadic reports in
  which glucocorticoid therapy has been associated
  with an adverse outcome in patients who already
  had a severe case of spinal epidural abscess,1 it
  may help to reduce swelling in patients with
  progressive neurologic compromise who are
  awaiting surgical decompression.
• 1- Danner RL, Hartman BJ. Update of spinal
  epidural abscess 35 cases and review of the
  literature. Rev Infect Dis 1987

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Prognosis

• No studies have been done to assist in predicting
  prognosis.
• Prognosis in general is related to the duration
  of spinal cord dysfunction and the degree of cord
  impairment at the time of diagnosis

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Complications of SEA

• 1- Irreversible paralysis (4 to 22 of pt) 1,2
• 2- bladder dysfunction
• 3- decubiti (decubitus ulcer, pressure sore)
• 4- supine hypertension
• 5- recurrent sepsis
• 6- UTI
• 7- Pneumonia (in cervical abscess) 3
• 8- death 5 (uncontrolled sepsis, meningitis,
  others)
• 1- Khanna RK, Malik GM, Rock JP, Rosenblum ML.
  Spinal epidural abscess evaluation of factors
  influencing outcome. Neurosurgery 1996
• 2- Danner RL, Hartman BJ. Update of spinal
  epidural abscess 35 cases and review of the
  literature. Rev Infect Dis 1987
• 3- Soehle M, Wallenfang T. Spinal epidural
  abscesses clinical manifestations, prognostic
  factors, and outcomes. Neurosurgery 2002

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Decubitus ulcer
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Clinical Trails Done
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Delay diagnosis in ER department

• Residual motor weakness was present in 45 of
  these patients vs. only 13 of patients without
  diagnostic delays

• Department of Emergency Medicine, University of
  California, San Diego, San Diego, California USA.

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Clinical presentation in 46 pt., retrospective
study

• - DM 46
• - frequent venous puncture 35
• - spinal trauma 24
• - history of spinal surgery 22

• Section of Infection Diseases, Department of
  Internal Medicine, Chi-Mei Medical Center,
  Tainan, Taiwan.

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Presenting symptomssame study

• - Localized spinal pain 89
• - paralysis 80
• - fever/chills 67
• - radicular pain 57

• Section of Infection Diseases, Department of
  Internal Medicine, Chi-Mei Medical Center,
  Tainan, Taiwan

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Investigation75 pt. retrospective

• - Raised ESR 95
• - Peripheral leukocytosis 60
• - MRI finding 100

• Department of Neurological Surgery, Johns Hopkins
  Hospital, Baltimore, Maryland, USA

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Thank you for your time

• Dr.Wala'a Gholam
• KAAU 2007
• 4th year medical student
• www.medkaau.com/vb

Source used - The new England journal o f
medicine, review article 2006 - E-medicine
website