Spinal epidural abscess: a meta-analysis of 915 patients View Full Text


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Article Info

DATE

2000-12

AUTHORS

E. Reihsaus, H. Waldbaur, W. Seeling

ABSTRACT

Spinal epidural abscess (SEA) was first described in the medical literature in 1761 and represents a severe, generally pyogenic infection of the epidural space requiring emergent neurosurgical intervention to avoid permanent neurologic deficits. Spinal epidural abscess comprises 0.2 to 2 cases per 10,000 hospital admissions. This review intends to offer detailed evaluation and a comprehensive meta-analysis of the international literature on SEA between 1954 and 1997, especially of patients who developed it following anesthetic procedures in the spinal canal. In this period, 915 cases of SEA were published. This review is the most comprehensive literature analysis on SEA to date. Most cases of SEA occur in patients aged 30 to 60 years, but the youngest patient was only 10 days old and the oldest was 87. The ratio of men to women was 1:0.56. The most common risk factor was diabetes mellitus, followed by trauma, intravenous drug abuse, and alcoholism. Epidural anesthesia or analgesia had been performed in 5.5% of the patients with SEA. Skin abscesses and furuncles were the most common source of infection. Of the patients, 71% had back pain as the initial symptom and 66% had fever. The second stage of radicular irritation is followed by the third stage, with beginning neurological deficit including muscle weakness and sphincter incontinence as well as sensory deficits. Paralysis (the fourth stage) affected only 34% of the patients. The average leukocyte count was 15,700/µl (range 1,500–42,000/µl), and the average erythrocyte sedimentation rate was 77 mm in the first hour (range 2–50 mm). Spinal epidural abscess is primarily a bacterial infection, and the gram-positive Staphylococcus aureus is its most common causative agent. This is true also for patients who develop SEA following spinal anesthetics. Magnetic resonance imaging (MRI) displays the greatest diagnostic accuracy and is the method of first choice in the diagnostic process. Myelography, commonly used previously to diagnose SEA, is no longer recommended. Lumbar puncture to determine cerebrospinal fluid protein concentrations is not needed for diagnosis and entails the risk of spreading bacteria into the subarachnoid space with consequent meningitis; therefore, it should not be performed. The therapeutic method of choice is laminectomy combined with antibiotics. Conservative treatment alone is justifiable only for specific indications. Laminotomy is a therapeutic alternative for children. The mortality of SEA dropped from 34% in the period of 1954–1960 to 15% in 1991–1997. At the beginning of the twentieth century, almost all patients with SEA died. Parallel to improvements in the mortality rate, today more patients experience complete recovery from SEA. The prognosis of patients who develop SEA following epidural anesthesia or analgesia is not better than that of patients with noniatrogenic SEA, and the mortality rate is also comparable. The essential problem of SEA lies in the necessity of early diagnosis, because only timely treatment is able to avoid or reduce permanent neurologic deficits. More... »

PAGES

175-204

References to SciGraph publications

  • 1984-07. Spinal epidural abscess: An unusual complication of bacterial endocarditis in INFECTION
  • 1997-09. Risiken und Komplikationsmöglichkeiten der Periduralanästhesie in DIE ANAESTHESIOLOGIE
  • 1979-09. Spinal epidural abscess in patients on maintenance haemodialysis (a presentation of two cases) in INTERNATIONAL UROLOGY AND NEPHROLOGY
  • 1986-09. New perspectives in acute spinal epidural abscess in ACTA NEUROCHIRURGICA
  • 1991-11. Diagnosis of anterior cervical spinal epidural abscess by US and MRI in a newborn in PEDIATRIC RADIOLOGY
  • 1996-06. Spinal epidural abscess: an unusual cause of sciatica in EUROPEAN SPINE JOURNAL
  • 1990. Spinal Epidural Abscess in INFECTIONS OF THE NERVOUS SYSTEM
  • 1978. Neurochirurgische Operationen, Weiterbildung in NONE
  • 1991-11. Non-granulomatous spinal epidural abscess: a rehabilitation perspective in SPINAL CORD
  • 1997-03. Epidural abscess after combined spinal-epidural block in JOURNAL CANADIEN D'ANESTHÉSIE
  • 1986-12. Epidural abscess causing tetraparesis: case report in SPINAL CORD
  • 1994-11-05. Metastatic paraspinal abscess and paraplegia secondary to dental extraction in BRITISH DENTAL JOURNAL
  • 1993-01. Plain film clues to the diagnosis of spinal epidural neoplasm and infection in NEURORADIOLOGY
  • 1997-06. Rückenmarknahe Regionalanästhesien bei Bakteriämie in DIE ANAESTHESIOLOGIE
  • 1985-03. Acute spinal epidural empyema in ACTA NEUROCHIRURGICA
  • 1985-03. CT of pyogenic spine infection in NEURORADIOLOGY
  • 1988-05. Infections and the parturient: anaesthetic considerations in JOURNAL CANADIEN D'ANESTHÉSIE
  • 1990-05. Adverse Effects of Spinal and Epidural Anaesthesia in DRUG SAFETY
  • 1994-01. Spinal epidural abscess with gadolinium-enhanced MRI: serial follow-up studies and clinical correlations in NEURORADIOLOGY
  • 1925-07. Über akute Pachymeningitis spinalis externa in VIRCHOWS ARCHIV
  • 1920-09. Kasuistischer Beitrag zur Pathologie der RückenmarkshÄute (Pachymeningitis externa) in JOURNAL OF NEUROLOGY
  • 1985-01. Acute spinal epidural abscess in JOURNAL OF NEUROLOGY
  • 1996-05. Spinal epidural abscess — review of 10 cases in ACTA NEUROCHIRURGICA
  • 1980. Bakteriologische Studien bei Katheter-Periduralanästhesien in 25 JAHRE DGAI
  • 1993-03. Diagnosis and results of different treatment regimes in patients with spinal abscesses in ACTA NEUROCHIRURGICA
  • 1995-05. Spinal epidural abscess complicating tuberculous spondylitis in NEUROLOGICAL SCIENCES
  • 1993-10. Iatrogenic epidural spinal abscess in JOURNAL OF MOLECULAR MEDICINE
  • 1979-09. Acute spinal epidural abscess in SPINAL CORD
  • 1973-02. A study of 49 patients with acute spinal extradural abscess in SPINAL CORD
  • Identifiers

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    http://scigraph.springernature.com/pub.10.1007/pl00011954

    DOI

    http://dx.doi.org/10.1007/pl00011954

    DIMENSIONS

    https://app.dimensions.ai/details/publication/pub.1002440756

    PUBMED

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