Intraspinal Infection Research Articles

Infected congenital cervical dermal sinuses leading to spinal cord abscess: two case reports and a review of the literature

PurposeCongenital dermal sinuses are a rare form of spinal dysraphism. The developmental defects are located along the midline neuroaxis, with sinuses in the cervical region being the least common. Congenital dermal sinuses can be associated with intraspinal infection as they act as a direct route from the skin and subcutaneous tissues into the spinal cord.MethodsThe authors present two cases of cervical dermal sinuses complicated by intramedullary abscess. Both children presented with neurological decline and febrile illness. MRI showed intraspinal abscess. Both underwent prompt surgical excision of the sinus tract, exploration of the cord and intravenous antibiotics.ResultsBoth patients demonstrated excellent neurological recovery.ConclusionsComplete surgical excision of the sinus and tract in addition to long-term antimicrobials can yield excellent neurological outcomes. At surgery, do not expect to find pus when exploring the intramedullary component. Long-term follow-up is advocated due to potential late recurrence.

Complicated congenital dermal sinus: Diagnosis and management

ObjectiveCongenital dermal sinus tracts of the spine are a rare form of spinal dysraphism, and should be considered in the differential diagnosis of lumbar subcutaneous abscesses, The CDS tracts can be associated with several pathological findings, including inclusion tumors (for example, epidermoid, dermoid, and teratoma), split-cord malformations, and tethered spinal cords. Excision of the sinus and its track with untethering of the cord should be done as early as possible to avoid intraspinal infection and abscess formation. Our study aims to find out the value of early diagnosis & rapid management of complicated CDS, to re-establish neurological function. Patients and methodsTen cases (2 females and 8 males), with age range (13 months −4 years) presented with acute paraparesis and one case of quadriparesis, MRI spine showed spinal abscess, operative drainage was done with excision of the dermal sinus and track. ResultsNeurological deficits improved in all cases, but 4 cases showed residual deficits, while the other 6 cases got complete recovery. ConclusionEstablishing diagnosis and rapid management of abscess complicating a congenital dermal sinus, is crucial to restore neurological function.

Comparison of Theiler's Murine Encephalomyelitis Virus Induced Spinal Cord and Peripheral Nerve Lesions Following Intracerebral and Intraspinal Infection.

Hallmarks of Theiler’s murine encephalomyelitis virus (TMEV)-induced demyelinating disease (TMEV-IDD) include spinal cord (SC) inflammation, demyelination and axonal damage occurring approximately 5–8 weeks after classical intracerebral (i.c.) infection. The aim of this study was to elucidate the consequences of intraspinal (i.s.) TMEV infection and a direct comparison of classical i.c. and intraspinal infection. Swiss Jim Lambert (SJL)-mice were i.s. infected with the BeAn strain of TMEV. Clinical investigations including a scoring system and rotarod analysis were performed on a regular basis. Necropsies were performed at 3, 7, 14, 28 and 63 days post infection (dpi) following i.s. and at 4, 7, 14, 28, 56, 98, 147 and 196 dpi following i.c. infection. Serial sections of formalin-fixed, paraffin-embedded SC and peripheral nerves (PN) were investigated using hematoxylin and eosin (HE) and immunohistochemistry. I.s. infected mice developed clinical signs and a deterioration of motor coordination approximately 12 weeks earlier than i.c. infected animals. SC inflammation, demyelination and axonal damage occurred approximately 6 weeks earlier in i.s. infected animals. Interestingly, i.s. infected mice developed PN lesions, characterized by vacuolation, inflammation, demyelination and axonal damage, which was not seen following i.c. infection. The i.s. infection model offers the advantage of a significantly earlier onset of clinical signs, inflammatory and demyelinating SC lesions and additionally enables the investigation of virus-mediated PN lesions.

Posterior Approach Combined with Thoracic Intervertebral Foramen Posterior Wall Opening and Spinal Reconstruction for Complex Thoracic Intervertebral Foramen Lesions: a Single-Centre Experience

Background: Thoracic intervertebral foramen (TIF) lesions were really difficult to expose through posterior or transforaminal approaches. There was no effective treatment strategy, especially for complex ones. Methods: Between 2013 and 2015, 22 patients presenting with complex TIF lesions underwent posterior approach combined with TIF posterior wall opening and spinal reconstruction were retrospectively reviewed. After ascertaining the precise location of complex TIF lesions, incisions should allow for exposure of the lesion’s adjacent vertebral pedicle screw entry point. The adjacent pair of vertebral lamina and spinous processes is typically removed in a single piece, such that the intra-spinal section can be fully exposed. The posterior wall of the TIF is subsequently opened, allowing the intra-TIF and extra-spinal sections to be sufficiently exposed. Subsequently, spinal reconstruction at the appropriate level is required. When the ventral spinal column is intact, dorsal reconstruction is typically performed using the screw and rod fixation technique (SRFT). After the dorsal surface of the spine has been burnished, the removed vertebral lamina and spinous process are rendered granular to allow reconstruction of the TIF and fusion of adjacent vertebrae. Results: All patients presenting with complex TIF lesions were successfully treated with this approach. No patient had experienced any complications arising from SRFT use. No patient suffered intraspinal infection, incision splits, or CSF leakage in the short-term (between 1 and 3 months) or fixation loosening or spinal instability in the long-term (6–24 months). Imaging studies confirmed that the TIF and spinal reconstruction outcomes were favorable. Conclusion: A posterior approach combined with TIF posterior wall opening and spinal reconstruction is a rapid, effective, and reliable method in the treatment of complex TIF lesions. This technique can provide total lesion resection while reconstructing spinal stability. Keywords: posterior approach; thoracic intervertebral foramen (TIF); intervertebral articular process (IAP); spinal reconstruction; screw and rod fixation technique (SRFT)

Multi-Stage Pyocyanic Spondylodiscitis: A Case Report

Spondylodiscitis is an intraspinal infection that affects the intervertebral disk and adjacent vertebral bodies. Neurological signs represent urgency and a criterion of gravity. Magnetic resonance imaging (MRI) is the baseline assessment to make the diagnosis. Pyocyanic bacillus represents less than 5% of bacterial causes. We report the case of a 79-year-old woman who progressively presented paresthesia of the four limbs with flaccid tetraparesis. MRI showed multi-stage cervico-dorsal involvement. Based on that, computed tomography-guided disco vertebral biopsy was performed and permitted to isolate a pyocyanic agent. The treatment consisted of a double antibiotherapy with resuscitation measures. The evolution was favorable, and the entry gate remained mysterious.

Infection Rate in 1033 Elective Neurosurgical Procedures at a University Hospital in South China.

Objective Infection following surgery is a serious complication, especially in neurosurgery. The aim of the study is to report the change of incidence rates of infection in patients undergoing elective neurosurgical procedures at a university hospital in South China as well as the risk factors. Material and Methods The medical records and postoperative courses for patients undergoing 1,033 neurosurgical procedures from 2008 to 2014 were reviewed retrospectively to determine the incidence of neurosurgical infection, the identity of the offending organisms, and the factors associated with infection. Results A total of 33 patients (40 cases) experienced postoperative infection representing 3.19% of the study population. Twenty cases were incision infections (1.94%), and 20 were cranial/spinal infections (1.94%) including 15 intracranial infections and 5 intraspinal infections. The 2.4-fold greater incidence of postoperative infection in 2008 to 2010 was compared with that in 2011 to 2014 with perioperative antibiotic prophylaxis (p <0.01). The neurosurgical procedure associated with the highest rate of infection was cranioplasty (6.85%); the lowest rate of infection was associated with functional neurosurgery (1.08%). The most common offending organism was Staphylococcus aureus (27.5%). Foreign body implantation, operative time > 4 hours, and cerebrospinal fluid (CSF) leak (13 infections in 158 patients; p <0.001) were risk factors for infections (p <0.05). Conclusion The neurosurgical infection rate is usually low with perioperative antibiotic prophylaxis even in developing countries. Less foreign body implantation, shorter operative times, and controlling CSF leak could reduce infection rates.

333: Screening Strategies for Early Identification of Spine Infections in Patients Presenting to Emergency Departments With Severe Back or Neck Pain

Spinal epidural abscess (SEA) is an intraspinal infection that is typically not detected by physicians until the classic triad of symptoms is evident; however, this is only present in 8-13% of cases. Numerous studies have quantified how poor physician judgment alone is at detecting SEA (0-26% sensitivity). Delay in recognition of SEA occurs frequently, resulting in disease progression which may subsequently lead to permanent paralysis, sepsis, meningitis and death in a tragic number of these cases.

Methicillin-resistant Staphylococcus aureus retropharyngeal abscess complicated by a cervical spinal subdural empyema

Methicillin-resistant Staphylococcus aureus (MRSA) cervical spinal subdural empyema as a result of a retropharyngeal abscess has not been reported previously. We present a 65-year-old male intravenous drug user who developed spinal subdural empyema after an operation for a retropharyngeal abscess. Although imaging diagnosis and follow-up surgery were performed quickly, the neurological outcome was poor. We review the literature on retropharyngeal abscess with intraspinal infection.

Pyogenic infections of the central nervous system secondary to dental affections—a report of six cases

Pyogenic infections of the central nervous system of dental origin are quite uncommon in industrialized countries. We report six cases with intracerebral (n = 4) and intraspinal (n = 2) infections treated in our hospital. The microbial pathogen was successfully isolated in all patients. Fusobacterium nucleatum as well as Streptococcus species were found in three cases. Bacillus species were identified in two patients. Actinomyces was the etiologic agent in one case. All patients suffered from dental pathologies, so that after clinical and radiological exclusion of other sources an oral focus was presumed. Therapeutic management consisted of an operative procedure in order to obtain decompression, as well as evacuation of the pus on the one hand, followed by targeted antibiotics on the other. Clinical improvement was achieved in all patients, with one patient lost to follow-up. On magnetic resonance tomography, the inflammatory changes also disappeared in all cases. We recommend that oral infection with recurrent bacteraemia should always be considered in the pathogenesis of the so-called "cryptic" intracerebral and intraspinal infections.

Extended-Release Epidural Morphine (DepoDur™)

D a EPIDURAL MORPHINE HAS been administered by single and intermittent bolus doses, continuous infusion, and patient-controlled analgesia (PCA) for the management of postoperative pain for many years. All of these methods have proven to be safe and effective in controlling pain, but each also has its limitations. A single epidural injection of conventional morphine (Astramorph; AstraZeneca LP, Wilmington, DE) produces pain relief for as long as 24 hours, which may not be long enough for some patients after major surgery. Although continuous epidural infusion and patient-controlled epidural analgesia (PCEA) techniques provide prolonged relief, they require an indwelling catheter, which can impede mobility and carries the risk of intraspinal infection. In addition, guidelines for insertion and removal of indwelling epidural catheters must be carefully followed in patients receiving prophylactic anticoagulant therapy to prevent the occurrence of an epidural hematoma. However, the US Food and Drug Administration (FDA) has recently approved a unique formulation of epidural morphine called extended-release epidural morphine (EREM) (DepoDur; Endo Pharmaceuticals, Chadds Ford, PA) that may provide a better choice for pain control after some surgical procedures. A single epidural bolus of EREM is capable of providing pain relief for as long as 48 hours, which represents an exciting new postoperative pain management option for many patients undergoing major surgery.

A reply

Despite the bacteriostatic effect of local anaesthetics, an epidural catheter causes bacterial contamination/infection, and we cannot therefore rely solely on this bacteriostatic effect. During continuous epidural analgesia, most bacteria appear to enter from a skin surface into the epidural space along the outside of an epidural catheter, since Staphylococcus epidermidis and S. aureus, which constitute epidermal bacterial flora, are frequently found in positive cultures of epidural catheter tips [1]. Therefore, bacterial culture of the outside, but not inside, of the catheter tip is important. In a tunnelled catheter with a subcutaneously implanted reservoir, however, the catheter system is isolated from a skin surface [2]. Furthermore, they described intraspinal infection, whereas we mentioned one case of catheter-tip contamination without infection. Therefore, these two results cannot be compared. Cefazolin is administered clinically at a dose of 1–4 g in an intravenous infusion, and the blood or tissue concentration may reach a similar or higher level to the epidural solution, 18 µg.ml−1. Therefore, the epidural cefazolin should not be neurotoxic. Of course, we do not think that epidural infection is entirely prevented by the cefazolin, and the skin was sterilised every other day. Usually, broad-spectrum antibiotics, including cephazolin, are beneficial for prophylaxis of contamination/infection, and can be administered by both the epidural and the intravenous routes. An epidural antibiotic is low cost as compared with an intravenous antibiotic.

Pathogenesis of scrapie is faster when infection is intraspinal instead of intracerebral

Previous studies of mice infected peripherally with 139A scrapie showed that scrapie agent initially replicates outside the CNS and that invasion of the CNS occurs several weeks later by neural spread of infection along visceral autonomic fibres to the mid-thoracic cord, and thence to brain. Direct intracerebral infection of brain bypasses the need for extraneural replication and gives shorter incubation periods than peripheral routes. However, it was also found that the duration of the scrapie replication phase in brain, before clinical disease develops, is actually shorter with peripheral routes than with the intracerebral route. We have now investigated this surprising observation using the intraspinal route to reproduce just the neural phase of scrapie pathogenesis seen after peripheral infection. In studies of three strains of scrapie (263K, 139A and ME7) in either hamsters or mice, we have fulfilled the prediction that incubation periods should be shorter after intraspinal infection than after intracerebral infection. Detailed studies of 139A scrapie showed that the shorter incubation period by the intraspinal route could be accounted for by the shorter duration of the scrapie replication phase in brain before clinical disease developed. As a consequence, the severity of the vacuolar lesions in brain at the clinical stage of all three scrapie models was less after intraspinal infection than after intracerebral infection but the severities of vacuolation after intraspinal and intraperitoneal infection were remarkably similar. We speculate that (a) the site of injection (or of invasion) of the central nervous system determines which neural pathways become accessible for the spread of scrapie infection, and that (b) the duration of the neural phase of scrapie pathogenesis is related to the complexity of the pathways between the site of invasion and the clinical target areas in which, it is suggested, scrapie must replicate for disease to develop.

Spinal Subdural Empyema

Abstract Spinal subdural empyema (SSE) is a rare variety of intraspinal infection. SSE should be suspected in patients presenting with fever, back pain, and signs of cord or nerve root compression. Two patients with SSE are presented. The first patient complained of fever and back pain. She had no neurological deficit but was found to have SSE. The second patient, who presented with intracerebral hemorrhage in the fifth month of pregnancy and spontaneous abortion, was found to have SSE at lumbar puncture. The clinical manifestations and management are discussed.

Spinal Subdural Empyema

Spinal subdural empyema (SSE) is a rare variety of intraspinal infection. SSE should be suspected in patients presenting with fever, back pain, and signs of cord or nerve root compression. Two patients with SSE are presented. The first patient complained of fever and back pain. She had no neurological deficit but was found to have SSE. The second patient, who presented with intracerebral hemorrhage in the fifth month of pregnancy and spontaneous abortion, was found to have SSE at lumbar puncture. The clinical manifestations and management are discussed.

Antimicrobial effect of abalone juice.

Commercial canned abalone juice given to Swiss mice orally possessed sparing effect against intraspinal infection of type I and III poliovirus and intracerebral infection of type II poliovirus. Crude fresh abalone juice also possessed marked inhibitory effect against Staphylococcus aureus.