Neurol Sci DOI 10.1007/s10072-014-1972-5
LETTER TO THE EDITOR
Cervical epidural abscess of odontogenic origin Stefanos Korfias • George A. Alexiou • Efstathios Vlachakis • Damianos E. Sakas
Received: 28 July 2014 / Accepted: 24 September 2014 Ó Springer-Verlag Italia 2014
Keywords Spine Cervical Epidural abscess Odontogenic Dear Editor, Spinal epidural abscess is a rare disorder accounting for 0.2–2 cases per 10,000 hospital admissions [1]. The majority of patients with spinal epidural abscess have one or more predisposing conditions such as compromised immune system, due to diabetes mellitus, AIDS, chronic renal failure, alcoholism, or cancer, recent spinal surgery, trauma or soft tissue infections [2]. To date only ten cases of cervical epidural abscesses of odontogenic origin have been reported. Herewith, we report on case of a previously healthy 57-year-old man that presented in our institute because of progressive weakness of both hands and legs, often with urinary retention or overflow incontinence. Four days before admission the patient had experienced neck pain that was not resolved with non-steroidal anti-inflammatory medications. At presentation the patient had no mental status alteration; there was neck pain, tetraparesis and hypoesthesia below the C5–C6 level. There was positive Hoffmann sign bilaterally. Reflexes were increased in lower limbs and the Babinski sign was bilaterally positive. Few hours later the patient developed fever. Laboratory data showed the elevation of inflammatory markers (C-reactive protein, 28.8 mg/dL; white blood cells, 14.8 9 103/lL). The differential diagnosis included mainly meningitis, osteomyelitis, discitis and transverse myelitis, thus after performing a brain CT, a lumbar
S. Korfias G. A. Alexiou (&) E. Vlachakis D. E. Sakas Department of Neurosurgery, Evangelismos General Hospital, University of Athens, Athens, Greece e-mail: [email protected]; [email protected]
puncture was carried out. Analysis of CSF showed a pleocytosis of 80 cells/mm3, mainly lymphocytes, and a protein concentration of 51 mg/dL, whereas the glucose content was 40 mg/dL (blood 83 mg/dL). Based on the above findings an inflammatory disease of the spinal canal or spinal cord was suspected and vancomycin (1 g 9 2) and meropenem (2 g 9 3) were administered. For further evaluation, an MRI was performed and revealed the presence of an epidural abscess along the cervical posterior longitudinal ligament between C1 and C5, with significant cord compression mainly at the C4–C5 level (Fig. 1a). The patient was operated upon via an anterior approach. After skin incision pus was coming out during muscle retraction (Fig. 2). A C4–C5 discectomy was performed and the abscess located epidurally was drained. Then, debridement of necrotic tissues was performed. No interbody material was used and the spinal stability was ensured via cervical collar. The patient was transferred to ICU. The pathogens isolated from the pus culture were Staphylococcus aureus and the patient received the proper antibiotic treatment. Detailed patient’s history revealed that 10 days before the patient had complained for odontogenic pain but no dental examination was performed. Thus, we performed a dental CT, which revealed a dental abscess and two teeth were removed (31 and 32 according to the universal numbering system). Postoperatively, the patient’s tetraparesis gradually resolved, and 2 months later he started to walk independently. The follow-up MRI at 2 months after surgery revealed vertebral body fusion (Fig. 1b). Spinal epidural abscess may develop as a spread from a neighboring structure or as a hematogenous spread from distant sites. Nevertheless, in nearly one-third of cases no apparent cause can be found. Diagnostic delay may lead to adverse neurological outcomes and surgical decompression is the mainstay of treatment. Cervical epidural abscess
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Neurol Sci Fig. 1 a Sagittal T1-weighted MRI after gadolinium administration revealing a C1– C5 extending epidural collection ventrally compressing the spinal cord mainly at the C4–C5 level with peripheral enhancement. b Postoperative sagittal T2weighted MRI 2 months later revealing complete fusion
although rare disorder, should be suspected in patients with cervical pain, fever and neurological deficits even without any predisposing factor [3]. Prompt diagnosis and early surgical intervention, in cases with progressive neurological deficit, are associated with favorable outcome.
References 1. Reihsaus E, Waldbaur H, Seeling W (2000) Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev 23:175–204 2. Darouiche RO (2006) Spinal epidural abscess. N Engl J Med 355:2012–2020 3. Muzii VF, Mariottini A, Zalaffi A, Carangelo BR, Palma L (2006) Cervical spine epidural abscess: experience with microsurgical treatment in eight cases. J Neurosurg Spine 5:392–397
Fig. 2 Intraoperative photograph demonstrating the pus after muscle retraction
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LETTER TO THE EDITOR
Cervical epidural abscess of odontogenic origin Stefanos Korfias • George A. Alexiou • Efstathios Vlachakis • Damianos E. Sakas
Received: 28 July 2014 / Accepted: 24 September 2014 Ó Springer-Verlag Italia 2014
Keywords Spine Cervical Epidural abscess Odontogenic Dear Editor, Spinal epidural abscess is a rare disorder accounting for 0.2–2 cases per 10,000 hospital admissions [1]. The majority of patients with spinal epidural abscess have one or more predisposing conditions such as compromised immune system, due to diabetes mellitus, AIDS, chronic renal failure, alcoholism, or cancer, recent spinal surgery, trauma or soft tissue infections [2]. To date only ten cases of cervical epidural abscesses of odontogenic origin have been reported. Herewith, we report on case of a previously healthy 57-year-old man that presented in our institute because of progressive weakness of both hands and legs, often with urinary retention or overflow incontinence. Four days before admission the patient had experienced neck pain that was not resolved with non-steroidal anti-inflammatory medications. At presentation the patient had no mental status alteration; there was neck pain, tetraparesis and hypoesthesia below the C5–C6 level. There was positive Hoffmann sign bilaterally. Reflexes were increased in lower limbs and the Babinski sign was bilaterally positive. Few hours later the patient developed fever. Laboratory data showed the elevation of inflammatory markers (C-reactive protein, 28.8 mg/dL; white blood cells, 14.8 9 103/lL). The differential diagnosis included mainly meningitis, osteomyelitis, discitis and transverse myelitis, thus after performing a brain CT, a lumbar
S. Korfias G. A. Alexiou (&) E. Vlachakis D. E. Sakas Department of Neurosurgery, Evangelismos General Hospital, University of Athens, Athens, Greece e-mail: [email protected]; [email protected]
puncture was carried out. Analysis of CSF showed a pleocytosis of 80 cells/mm3, mainly lymphocytes, and a protein concentration of 51 mg/dL, whereas the glucose content was 40 mg/dL (blood 83 mg/dL). Based on the above findings an inflammatory disease of the spinal canal or spinal cord was suspected and vancomycin (1 g 9 2) and meropenem (2 g 9 3) were administered. For further evaluation, an MRI was performed and revealed the presence of an epidural abscess along the cervical posterior longitudinal ligament between C1 and C5, with significant cord compression mainly at the C4–C5 level (Fig. 1a). The patient was operated upon via an anterior approach. After skin incision pus was coming out during muscle retraction (Fig. 2). A C4–C5 discectomy was performed and the abscess located epidurally was drained. Then, debridement of necrotic tissues was performed. No interbody material was used and the spinal stability was ensured via cervical collar. The patient was transferred to ICU. The pathogens isolated from the pus culture were Staphylococcus aureus and the patient received the proper antibiotic treatment. Detailed patient’s history revealed that 10 days before the patient had complained for odontogenic pain but no dental examination was performed. Thus, we performed a dental CT, which revealed a dental abscess and two teeth were removed (31 and 32 according to the universal numbering system). Postoperatively, the patient’s tetraparesis gradually resolved, and 2 months later he started to walk independently. The follow-up MRI at 2 months after surgery revealed vertebral body fusion (Fig. 1b). Spinal epidural abscess may develop as a spread from a neighboring structure or as a hematogenous spread from distant sites. Nevertheless, in nearly one-third of cases no apparent cause can be found. Diagnostic delay may lead to adverse neurological outcomes and surgical decompression is the mainstay of treatment. Cervical epidural abscess
123
Neurol Sci Fig. 1 a Sagittal T1-weighted MRI after gadolinium administration revealing a C1– C5 extending epidural collection ventrally compressing the spinal cord mainly at the C4–C5 level with peripheral enhancement. b Postoperative sagittal T2weighted MRI 2 months later revealing complete fusion
although rare disorder, should be suspected in patients with cervical pain, fever and neurological deficits even without any predisposing factor [3]. Prompt diagnosis and early surgical intervention, in cases with progressive neurological deficit, are associated with favorable outcome.
References 1. Reihsaus E, Waldbaur H, Seeling W (2000) Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev 23:175–204 2. Darouiche RO (2006) Spinal epidural abscess. N Engl J Med 355:2012–2020 3. Muzii VF, Mariottini A, Zalaffi A, Carangelo BR, Palma L (2006) Cervical spine epidural abscess: experience with microsurgical treatment in eight cases. J Neurosurg Spine 5:392–397
Fig. 2 Intraoperative photograph demonstrating the pus after muscle retraction
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