Methicillin-Resistant Staphylococcus aureus Spinal Epidural Abscess: Local and Systemic Case Management.

Abdurrahman F Kharbat,Brendan J Mackay,Amanda Purcell,Cameron T Cox

doi:10.7759/cureus.22831

Abstract

Spinal epidural abscess (SEA) is a rare condition with complex pathophysiology and highly variable clinical presentation. While it is known to cause focal peripheral nerve symptoms such as muscle weakness, paresthesia, or pain, these are typically accompanied by complaints of back or spine pain and systemic symptoms indicative of infection. In our case, a 53-year-old male initially presented with unilateral pain and swelling in his right hand, with no fever at presentation and no complaints of back pain. Blood culture confirmed methicillin-resistant Staphylococcus aureus (MRSA)for which he was given vancomycin. The patient later endorsed back pain and diagnostic imaging revealed a spinal epidural abscess spanning the T5-T9 vertebrae. The abscess was drained, and vancomycin was placed in the subfascial and epifascial compartments. The hand was debrided in the same operation and showed no gross purulence. Two days after the procedure, intraoperative cultures remained negative, and the patient was subsequently managed with daptomycin.

Highlights

In the management of a patient with a spinal epidural abscess (SEA), case presentation must be applied against an understanding of the complexity of disease pathophysiology in order to establish the best steps for patient care
Previously thought to be a rare etiology [5], Staphylococcus aureus from oral flora was demonstrated to be the source of infection in 25% of cases in a modern prospective review, elucidating a transforming understanding of the etiology of SEA [6]
Given that the tissue was hyperemic, a round drain was placed below the fascia and layered closure was performed with additional vancomycin powder placed in the epifascial compartment

Summary

Introduction

In the management of a patient with a spinal epidural abscess (SEA), case presentation must be applied against an understanding of the complexity of disease pathophysiology in order to establish the best steps for patient care. The patient endorsed concomitant back pain and no urine output for four days Given these findings and the lack of a known causative event for pain in his right hand, MRI imaging was ordered for the lumbar spine which revealed a SEA spanning T5-T9 (Figure 2). Four days after presentation to our emergency center (two weeks after symptom onset), the patient was taken to the operating room (OR) for drainage of his spinal abscess Given that his hand pain and swelling had not improved with antibiotics, irrigation and debridement of the right hand was planned at the same time. Given that the tissue was hyperemic, a round drain was placed below the fascia and layered closure was performed with additional vancomycin powder placed in the epifascial compartment After his neurosurgical procedure, the patient was flipped supine and irrigation and debridement of his right hand was performed down to the level of bone. The patient was ambulating with a cane and progressing as expected with physical therapy

Discussion

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Disclosures