Absceso epidural espinal: nuesta experiencia en un año

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Abstract

Objetivo. Describir y analizar el tratamiento de tres pacientes con absceso epidural espinal (AEE). Descripción. Caso 1: varón de 58 años, con antecedentes de artritis séptica de rodilla izquierda y dolor lumbar de 2 meses de evolución que presentó una paraparesia progresiva 48 horas antes de la consulta. IRM: espondilodiscitis D8-D10 y colección epidural. Caso 2: mujer de 68 años, con antecedentes de tratamiento percutáneo por lumbalgia secundaria a canal estrecho; ingresó por shock séptico, presentando dolor y parestesias en miembros inferiores. IRM: espondilodiscitis L4-L5, colección epidural y abscesos de ambos psoas. Caso 3: varón de 56 años, con antecedentes de tratamiento crónico con corticoides y AINES por lumbociatalgia; ingresó por shock séptico asociado a cuadriparesia. IRM: colección anterior cervicodorsolumbar epidural. Intervención. En los casos 1 y 2 se realizaron sendas laminectomías con evacuación de colección purulenta. En el caso 3, el tratamiento fue conservador (antibioticoterapia) con resolución de la colección. En los 3 casos se rescató un Staphylococcus aureus. El caso 1 evolucionó a la paraplejía y los casos 2 y 3 se recuperaron completamente. Conclusión. El AEE es una urgencia tanto neuroquirúrgica como infectológica. En los pacientes con déficit neurológico, la cirugía es el tratamiento de elección, sumado a la antibioticoterapia; mientras que en pacientes sin compromiso neurológico, de alto riesgo quirúrgico o con una extensa lesión a lo largo del canal espinal, el tratamiento conservador sería el indicado.

Translated abstract

Objetive. To describe and analyze the treatment of 3 patients with a spinal epidural abscess (SEA). Description. Case 1 (male, 58 years old): with a history of left knee's septic arthritis, and a two-month history of lumbar pain, who refered a progresssive paraparesis. MRI: D8-D10 discitis and SEA. Case 2 (female, 68 years old): with a history of previous percutaneous treatment; for lumbar pain was admitted with a septic shock, parestesias and pain in both legs. MRI: L4-L5 discitis, SEA and bilateral psoas abscess. Case 3 (male, 56 years old): with a history of previous long-term steroid treatment for lumbar pain; was admitted with a septic shock and tetraparesis. MRI: anterior cervicothoracolumbar SEA. Intervention. In both cases 1 and 2, laminectomy and drainage were performed. In the third case, the favorable outcome was due to antibiotic treatment. Conclusion. Surgery plus antibiotic treatment were the gold standard for patients who showed neurological deficit. For patients without neurological deficit and an extensive lesion along the spinal cord or an increased surgical risk, antibiotic treatment was suggested.

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Most cited references 11

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Spinal epidural abscess: contemporary trends in etiology, evaluation, and management.

Daniele Rigamonti, Leon K Liem, Prakash Sampath … (1999)

Despite advances in neuroimaging and neurosurgical treatment, spinal epidural abscess remains a challenging problem; early diagnosis is often difficult and treatment is delayed. Optimal management is unclear, and morbidity and mortality are significant. To define contemporary trends in etiology and management, and establish diagnostic and therapeutic guidelines, we reviewed our 10-year experience with spinal epidural abscess. We examined medical records, laboratory data, radiological (CT and MRI) studies, and operative reports from 75 cases of spinal epidural abscess between 1983 and 1992. Demographic characteristics, frequency, clinical features, pathogens, risk factors, surgical and medical treatment, and outcome were analyzed. We found a significant increase in the frequency of spinal epidural abscess over the 10-year period (p-value = 0.0195). Intravenous drug abuse was present in 28 patients (33%), diabetes mellitus in 22 patients (27%), and prior spinal surgery in 11 patients (17%). Back pain, progressive neurologic deficit, and low grade fever remained the distinguishing diagnostic features. Erythrocyte sedimentation rate was elevated in 48 of 50 patients (95%); peripheral leukocyte count was elevated in 45 patients (60%). MRI was the most effective technique for diagnosing spinal epidural abscess, revealing or suggesting the diagnosis in all 59 patients (100%) studied. Sites of spinal epidural abscess were equally distributed along the spinal axis. Staphylococcus aureus was the predominant organism (67% of patients, with 15% having a methicillin-resistant strain); 8% of patients had Streptococcal species. Most patients had open surgical drainage followed by prolonged antibiotic treatment; 22 patients were managed with antibiotics alone; 50 patients (66%) had a good clinical outcome after treatment. Multiple medical problems, prior spinal surgery, and methicillin-resistant Staphylococci were correlated with a significantly worse outcome. The frequency of diagnosis of spinal epidural abscess is increasing. To prevent serious morbidity and mortality, early diagnosis is essential. Patients with localized back pain who are at risk for developing such abscesses or who have an increased erythrocyte sedimentation rate and/or neurologic deficit should have an immediate MRI scan with contrast enhancement. Surgical drainage and prolonged antibiotic use are the cornerstones of treatment, although selected patients may be treated conservatively.

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Spinal epidural abscess: the importance of early diagnosis and treatment.

Chad Laing, PETER SMITH, Ian Mackenzie … (1998)

To remind clinicians of the dangers of delayed diagnosis and the importance of early treatment of spinal epidural abscess. A review of the literature on spinal epidural abscess and a comparison of the published literature with local experience. Imaging with MRI or CT enables early diagnosis of spinal epidural abcess and optimal therapy is surgical evacuation combined with 6-12 weeks (median 8 weeks) of antimicrobial chemotherapy. Clinical features are fever, pain, and focal neurological signs and may be associated with preceding and pre-existing bone or joint disease. The commonest aetiological organism is S aureus. Early diagnosis and appropriate early antimicrobial chemotherapy with surgery is associated with an excellent prognosis.

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Spinal epidural abscess: evaluation of factors influencing outcome.

L Rosenblum, Matthew Rock, Safarina G Malik … (1996)

The goal of this study was to critically evaluate the predictive efficacy of various clinical factors in spinal epidural abscess influencing outcome after surgical and/or medical treatment. A retrospective analysis of 41 cases of spinal epidural abscess treated at Henry Ford Hospital between 1984 and 1992 was performed. Thirty patients underwent open surgery and received antibiotic therapy, and 11 patients received medical treatment alone. After a mean follow-up period of 20.9 months (range, 4-45 mo), 24 patients (58.5%) had no or minimal deficits, 9 patients (22%) had severe paresis or plegia and/or bowel/bladder dysfunction, and 8 patients (19.5%) died. Univariate analysis revealed patient age, degree of thecal sac compression, spinal location, surgical findings, and septic presentation to be significantly associated with outcome. In multiple logistic regression analysis, increasing age and degree of thecal sac compression were the only factors with significant independent association with poor outcome (P = 0.01 for both). A simple grading system (Grades 0-III) was developed, with patient age, degree of thecal sac compression, and duration of symptoms as the determining criteria. The incidence of poor outcome for patients with Grade 0 was 0%, compared to 85.7% for patients with Grade III. We conclude that long-term outcome after treatment of spinal epidural abscess can be predicted with the use of the proposed grading scheme. Surgical drainage plus parenterally administered antibiotics remains the recommended treatment, although medical treatment alone can also be used for certain patients.