Spinal Epidural Abscess Early Detection With Gadolinium Magnetic
Resonance
Imaging
Allen J. Teman, MD
emphasize the importance of timely diagnosis of spiepidural abscess, thirteen patients admitted to a single general hospital are presented. In 10 patients, diagnosis was not appreciated at the time of presentation. After treatment, four remained paraparetic and three died. Nine patients had predisposing factors, including seven with infections at sites other than the spinal canal. Staphylococcus aureus was the predominant organism. Outcome was equally devastating for the seven patients with acute and the six patients with chronic infections. Gadolinium-enhanced magnetic resonance imaging was the most useful diagnostic test, and we recommend that it be performed promptly in any patient with clinical features suggesting spinal epidural abscess since early surgical drainage and appropriate antibiotics \s=b\
To
nal
may
yield a favorable outcome.
(Arch Neurol. 1992;49:743-746)
diagnosis of spinal epidural abscess (SEA) is Prompt imperative because delays in may result in irreversible To treatment
em¬ neurologic impairment or death. this and to illustrate the value of gadoliniumenhanced magnetic resonance imaging (MRI) in early diagnosis, 13 patients with acute or chronic SEA are presented. In 10 patients, the diagnosis of SEA was not entertained at presentation. Three died and four re¬ mained paraparetic.
phasize
SUBJECTS AND METHODS A
computer search of records of a tertiary care suburban general hospital identified 13 patients who were discharged with a diagnosis of SEA between lanuary 1981 and lune 1989. Inquiries of attending neurologists, neurosurgeons, and review of surgical pathology records identified no additional cases. The records and roentgenograms of all patients were re¬ viewed. Surviving patients and family members were inter¬ viewed when possible. I was directly involved with the care of two patients (cases 1 and 13). Findings in the 13 cases are summarized in Tables 1 and 2, plus two illustrative cases are described in greater detail. Accepted for publication February 10, 1992. From the Department of Neurology, North Shore University Hospital\p=m-\ Cornell University Medical College, Manhasset, NY. Dr Teman is now with the Coral Springs Medical Center, Carol Springs, Fla. Reprint requests to 9750 NW 33 St, Suite 207, Coral Springs, FL 33065 (Dr Teman).
REPORT OF CASES CASE 1.—A
previously healthy 52-year-old man visited the hospital's emergency department complaining of fever, consti¬ pation, and midthoracic pain for 2 days. Other than low-grade fever, examination
was
unremarkable. After
an
abdominal flat
plate revealed large amounts of stool within the colon, he received an enema and was released. He returned 2 days later with sim¬ ilar complaints. Examination revealed right lower quadrant abdominal tenderness and a white blood cell count of 14 10 L. Laparotomy was performed, revealing a normal appendix. On the third postoperative day he developed urinary retention. By the fourth day he had a grade 1 /5 paraparesis with impaired sensa¬ tion below the midthoracic level. Gadolinium MRI that day revealed persistence of high signal in the dorsal thoracic epidural space on progressive T2-weighted images with compression of the spinal cord at the level of the eighth thoracic vertebrae (Figs 1 and 2). Purulent material was removed during a decompressive laminectomy that yielded Staphylcoccus aureus. He was given cefoxitin, nafcillin, and dexamethasone and power in his legs improved to 4/5. He died of a pulmonary embolism 5 days after
spine surgery. CASE 2.—A 64-year-old woman was hospitalized for neck pain, confusion, and lethargy. She was known to have metastatic breast
history of alcohol abuse. One month previously she treated for 10 days with oral trimethoprim-sulfamethoxazole for an Escherichia coli urinary tract infection. After a single dose of ceftazidime administered intravenously, a lumbar puncture was performed to rule out meningitis. Cerebrospinal fluid (CSF) contained 99 X 106/L white blood cells (0.98 polymorphonuclear cells), a glucose level of 1.5 mmol/L (serum glucose, 3.9 mmol/ L), and a protein level of 0.96 g/L. The cerebrospinal fluid culture was negative. She then reported weakness of the arms; examina¬ tion revealed hypoactive upper extremity reflexes and electro¬ myography confirmed a cervical radiculopathy. Cervical spine MRI revealed evidence of epidural inflammation with compres¬ sion of the spinal cord at the C4 through C6 levels (Fig 3). Because of coexisting coagulopathy, decompressive surgery was not per¬ formed. She was given intravenous ceftazidine, ampicillin, ceftri¬ axone, clindamycin, and gentamicin over 7 weeks, followed by dexamethasone. Her findings resolved and cervical spine MRI at the completion of treatment revealed no evidence of inflamma¬ tion (Fig 4). Two months later she was readmitted with sepsis and a perforated bowel. Within 24 hours she became acutely quadraplegic and died. An autopsy was not performed. cancer, and a was
RESULTS Patient ages were men
factors
ranged
and six
were
from 44 to 75 years. Seven
were women
(Table 1).
patients
Predisposing
present in nine. On initial presentation all
Downloaded From: http://archneur.jamanetwork.com/ by a University of Manitoba User on 06/21/2015
Table 1 .—Patient Data Patient/
Presenting
Predisposing
Age, y/Sex
Symptoms
1/5 2/M 2/64/F 3/70/F 4/44/F 5/63/M 6/59/M 7/68/M 8/74/F 9/65/M
Back pain, constipation Neck pain, confusion Sciatica, incontinence Neck pain, arm weakness Sciatica Back pain, leg weakness Back pain, paraparesis Neck pain Back, chest, and leg
Factors
pain, constipation 10/75/M Back pain 11/58/F Draining surgical wound 12/52/F Back pain, paraparesis 1 3/65/M Back pain, paraparesis *This patient presented 10 days after lumbar disk
None
None Intravenous
2 3 28 14
None
14 2 mo 2 mo 7 7
Alcohol abuse Disk surgery Tuberculosis None
3 mo 10* 5 mo 4
Alcohol abuse
drug abuse Diabetes Alcohol abuse Diabetes Nadir from chemotherapy
No.
9 10
From
Presentation, Until Surgery, d No surgery 25 13 8 7
Resonance
Imaging
Allen J. Teman, MD
emphasize the importance of timely diagnosis of spiepidural abscess, thirteen patients admitted to a single general hospital are presented. In 10 patients, diagnosis was not appreciated at the time of presentation. After treatment, four remained paraparetic and three died. Nine patients had predisposing factors, including seven with infections at sites other than the spinal canal. Staphylococcus aureus was the predominant organism. Outcome was equally devastating for the seven patients with acute and the six patients with chronic infections. Gadolinium-enhanced magnetic resonance imaging was the most useful diagnostic test, and we recommend that it be performed promptly in any patient with clinical features suggesting spinal epidural abscess since early surgical drainage and appropriate antibiotics \s=b\
To
nal
may
yield a favorable outcome.
(Arch Neurol. 1992;49:743-746)
diagnosis of spinal epidural abscess (SEA) is Prompt imperative because delays in may result in irreversible To treatment
em¬ neurologic impairment or death. this and to illustrate the value of gadoliniumenhanced magnetic resonance imaging (MRI) in early diagnosis, 13 patients with acute or chronic SEA are presented. In 10 patients, the diagnosis of SEA was not entertained at presentation. Three died and four re¬ mained paraparetic.
phasize
SUBJECTS AND METHODS A
computer search of records of a tertiary care suburban general hospital identified 13 patients who were discharged with a diagnosis of SEA between lanuary 1981 and lune 1989. Inquiries of attending neurologists, neurosurgeons, and review of surgical pathology records identified no additional cases. The records and roentgenograms of all patients were re¬ viewed. Surviving patients and family members were inter¬ viewed when possible. I was directly involved with the care of two patients (cases 1 and 13). Findings in the 13 cases are summarized in Tables 1 and 2, plus two illustrative cases are described in greater detail. Accepted for publication February 10, 1992. From the Department of Neurology, North Shore University Hospital\p=m-\ Cornell University Medical College, Manhasset, NY. Dr Teman is now with the Coral Springs Medical Center, Carol Springs, Fla. Reprint requests to 9750 NW 33 St, Suite 207, Coral Springs, FL 33065 (Dr Teman).
REPORT OF CASES CASE 1.—A
previously healthy 52-year-old man visited the hospital's emergency department complaining of fever, consti¬ pation, and midthoracic pain for 2 days. Other than low-grade fever, examination
was
unremarkable. After
an
abdominal flat
plate revealed large amounts of stool within the colon, he received an enema and was released. He returned 2 days later with sim¬ ilar complaints. Examination revealed right lower quadrant abdominal tenderness and a white blood cell count of 14 10 L. Laparotomy was performed, revealing a normal appendix. On the third postoperative day he developed urinary retention. By the fourth day he had a grade 1 /5 paraparesis with impaired sensa¬ tion below the midthoracic level. Gadolinium MRI that day revealed persistence of high signal in the dorsal thoracic epidural space on progressive T2-weighted images with compression of the spinal cord at the level of the eighth thoracic vertebrae (Figs 1 and 2). Purulent material was removed during a decompressive laminectomy that yielded Staphylcoccus aureus. He was given cefoxitin, nafcillin, and dexamethasone and power in his legs improved to 4/5. He died of a pulmonary embolism 5 days after
spine surgery. CASE 2.—A 64-year-old woman was hospitalized for neck pain, confusion, and lethargy. She was known to have metastatic breast
history of alcohol abuse. One month previously she treated for 10 days with oral trimethoprim-sulfamethoxazole for an Escherichia coli urinary tract infection. After a single dose of ceftazidime administered intravenously, a lumbar puncture was performed to rule out meningitis. Cerebrospinal fluid (CSF) contained 99 X 106/L white blood cells (0.98 polymorphonuclear cells), a glucose level of 1.5 mmol/L (serum glucose, 3.9 mmol/ L), and a protein level of 0.96 g/L. The cerebrospinal fluid culture was negative. She then reported weakness of the arms; examina¬ tion revealed hypoactive upper extremity reflexes and electro¬ myography confirmed a cervical radiculopathy. Cervical spine MRI revealed evidence of epidural inflammation with compres¬ sion of the spinal cord at the C4 through C6 levels (Fig 3). Because of coexisting coagulopathy, decompressive surgery was not per¬ formed. She was given intravenous ceftazidine, ampicillin, ceftri¬ axone, clindamycin, and gentamicin over 7 weeks, followed by dexamethasone. Her findings resolved and cervical spine MRI at the completion of treatment revealed no evidence of inflamma¬ tion (Fig 4). Two months later she was readmitted with sepsis and a perforated bowel. Within 24 hours she became acutely quadraplegic and died. An autopsy was not performed. cancer, and a was
RESULTS Patient ages were men
factors
ranged
and six
were
from 44 to 75 years. Seven
were women
(Table 1).
patients
Predisposing
present in nine. On initial presentation all
Downloaded From: http://archneur.jamanetwork.com/ by a University of Manitoba User on 06/21/2015
Table 1 .—Patient Data Patient/
Presenting
Predisposing
Age, y/Sex
Symptoms
1/5 2/M 2/64/F 3/70/F 4/44/F 5/63/M 6/59/M 7/68/M 8/74/F 9/65/M
Back pain, constipation Neck pain, confusion Sciatica, incontinence Neck pain, arm weakness Sciatica Back pain, leg weakness Back pain, paraparesis Neck pain Back, chest, and leg
Factors
pain, constipation 10/75/M Back pain 11/58/F Draining surgical wound 12/52/F Back pain, paraparesis 1 3/65/M Back pain, paraparesis *This patient presented 10 days after lumbar disk
None
None Intravenous
2 3 28 14
None
14 2 mo 2 mo 7 7
Alcohol abuse Disk surgery Tuberculosis None
3 mo 10* 5 mo 4
Alcohol abuse
drug abuse Diabetes Alcohol abuse Diabetes Nadir from chemotherapy
No.
9 10
From
Presentation, Until Surgery, d No surgery 25 13 8 7
