Pyogenic Spinal Epidural Abscess

Abstract

Letters to the EditorPyogenic Spinal Epidural Abscess Suresh K. DarganMBBS, MS(Ortho) Suresh K. Dargan Department of Orthopedics, Government General Hospital, Rafha, North Zone, Saudi Arabi Search for more papers by this author Published Online:1 Jan 2000https://doi.org/10.5144/0256-4947.2000.87aSectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionTo the Editor. I read with interest the article “Pyogenic Spinal Epidural Abscess” by Al-Othman et al.,1 reporting four cases of this rare lesion. Pyogenic spinal epidural abscess is a true surgical emergency, and its potential for permanent neurologic damage makes early diagnosis and prompt therapy of extreme importance. The rate ofmortality of adults ranges from 18% to 25%.2,3 Unfortunately, accurate diagnosis at the time of admission is the exception rather than the rule. Only 20% of epidural abscesses are recognized at the time of hospital admission. The common presenting features are backache (72%), radicular pain (47%), weakness of an extremity (35%) bladder and bowel dysfunction (30%), sensory deficit (23%), and frank paralysis (21 %).4 Atypical presentation that developed only after having moved heavy household items has also been reported in patients presenting for evaluation.5 Therefore, its possibility should always be kept in mind when evaluating a case of back pain.The authors used CT scan instead of MRI, although the latter is now considered to be the radiologic procedure of choice for the detection of epidural abscess due to its higher specificity. Gadolinium-enhanced MRI is essential for the diagnosis of abscess without frank pus formation in defining the extension of infection and in assessing the therapeutic effects.6 It has superior ability to demonstrate associated mass effect upon the cauda equina and potential signal abnormalities within the discs, vertebral bone marrow and spinal cord. The addition of an intravenous gadolinium-contrast agent better defines central necrosis suggestive of abscess rather than cellulitis. MRI offers the additional advantage of not requiring a lumbar puncture. If MRI is unavailable, CT with myelography usually provides adequate information. A normal CT alone does not exclude the diagnosis of epidural abscess. The reader would have appreciated the inclusion of photographs of CT scans in this article due to the rarity of this disorder.Surgical decompression was once thought to be mandatory in all cases. Now, early diagnosis by MRI scans allows for effective medical therapy prior to occurrence of neurologic compression. But in the case of medical management, the patient should be closely monitored by serial studies with MRI because of a potential risk of sudden neurological deterioration.7 The chances of recovery relate inversely to the amount of neurologic dysfunction at the time of diagnosis. Long-term outcome after the surgical and/or medical treatment can be predicted with the use of a simple grading system (Grades 0-III), based on patient age, degree of thecal sac compression, and duration of symptoms.8ARTICLE REFERENCES:1. Al-Othman A, Ammar A, Moussa M, El Morsy. "Pyogenic spinal epidural abscess" . Ann Saudi Med. 1999; 19:241–2. Google Scholar2. Baker AS, Ojemann RG, Swartz MN, Richardson EP. "Spinal epidural abscess" . N Engl J Med. 1975; 293:463–7. Google Scholar3. Heusner AP. "Nontuberculous spinal epidural infections" . N Engl J Med. 1948; 239:845–54. Google Scholar4. Darouiche RO, Hamill RJ, Greenberg SB, Weathers SW, Musher DM. "Bacterial spinal epidural abscess: review of 43 cases and literature survey" . Medicine. 1992; 71:369–85. Google Scholar5. Prendergast H, Jerrard D, O'Connell J. "Atypical presentations of epidural abscesses in intravenous drug users" . Am J Emerg Med. 1997; 15:158–60. Google Scholar6. Higuchi T, Imagawa A, Murahashi M, Hara H, Wakayama Y. "Spinal epidural abscess associated with epidural anesthesia: gadolinium-enhanced magnetic resonance imaging and its usefulness in diagnosis and treatment" . Intern Med. 1996; 35:902–4. Google Scholar7. Wheeler D, Keiser P, Rigamonti D, Keay S. "Medical management of spinal epidural abscess: case report and literature review" . Clin Infect Dis. 1992; 15:22–7. Google Scholar8. Khanna RR, Malik GM, Rock JP, Rosenblum ML. "Spinal epidural abscess: evaluation of factors influencing outcome" . Neurosurgery. 1996; 39:958–64. Google Scholar Previous article Next article FiguresReferencesRelatedDetails Volume 20, Issue 1January 2000 Metrics History Published online1 January 2000 InformationCopyright © 2000, Annals of Saudi MedicinePDF download