Epidural abscess associated with pyogenic spondylodiscitis of the lumbar spine; evaluation of a new MRI staging classification and imaging findings as indicators of surgical management: a retrospective study of 37 patients

Uchida, Kenzo; Nakajima, Hideaki; Yayama, Takafumi; Sato, Ryuichiro; Kobayashi, Shigeru; Chen, Ke-Bing; Mwaka, Erisa; Baba, H.

doi:10.1007/s00402-009-0928-3

Cited by 30 publications

(42 citation statements)

References 28 publications

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“…On radiological examinations, magnetic resonance images were classified into five categories (stage I-V) 13) . Stage I-III abscesses describe contained lesions within the posterior longitudinal ligament, while stage IV and V describe extended epidural or paravertebral lesions.…”

Section: Methodsmentioning

confidence: 99%

Predictors of conservative treatment for pyogenic spondylitis

Kugimiya

Muraki

Nagakura

et al. 2017

Spine Surg Relat Res

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Abstract:Introduction: Although initial treatments for pyogenic spondylitis include conservative approaches such as rest and antibiotics, some cases are refractory to conservative therapy. The objective of this study was to clarify the predictors for achievement of C-reactive protein (CRP) normalization in pyogenic spondylitis by conservative therapy.Methods: In the present study, we enrolled 83 patients (51 men and 32 women) with conservatively treated pyogenic spondylitis from 2006 to 2015. Multiple logistic regression analysis was used to examine the association of achievement of CRP normalization with the number of infected vertebrae, bacterial strain, blood data, and the expansion of abscess to the epidural space by using functional magnetic resonance imaging.Results: We found significant differences in the subjects with and without achievement of CRP normalization with respect to age, the number of affected vertebrae, ratio of resistant pathogenic bacteria, ratio of expansion of abscess to the epidural space, and blood data such as Hb, ALB, eGFR, Cr, and ALP levels.After adjustment for age and sex, the number of infected vertebral bodies, resistant bacteria, expansion of abscess to the epidural space, and Hb level showed significant associations with the normalization of CRP. In addition, we used multiple logistic regression analysis with age, sex, number of infected vertebral bodies, resistant bacteria, expansion of abscess to the epidural space, and serum Hb level as explanatory variables. We found that expansion of the abscess to the epidural and paravertebral spaces was significantly associated with the normalization of CRP level.Conclusions: The number of infected vertebral bodies, resistant strains of pathogenic bacteria, expansion of abscess to the epidural and paravertebral spaces, and serum Hb level predicts the prognosis of patients with pyogenic spondylitis. Particularly, expansion of abscess to the epidural and paravertebral spaces was strongly associated with the achievement of CRP normalization.

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Section: Methodsmentioning

confidence: 99%

Predictors of conservative treatment for pyogenic spondylitis

Kugimiya

Muraki

Nagakura

et al. 2017

Spine Surg Relat Res

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“…Decompressive surgery did significantly improve outcome in patients presenting with a motor deficit. Uchida et al 65 described MRI characteristics of SEA and reported that no cases with a "ring-like" enhancement pattern were successfully managed nonoperatively.…”

Section: 2950mentioning

confidence: 99%

“…In fact the medical literature includes only 28 case series, containing at least 30 subjects, and reporting on the treatment and outcome of SEA. 1,3,4,6,[11][12][13][14]16,[18][19][20]28,31,32,34,36,37,47,48,54,56,59,61,62,65,69,72 This paucity of good clinical data hampers our ability to make definitive recommendations on the optimal timing of surgery and the role for nonoperative management. This review addresses the best available evidence regarding treatment modality and timing, with an emphasis on creating a management algorithm to identify those patients who can safely be spared surgery.…”

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confidence: 99%

“…CRP > 115 mg/L, 48 WBC count > 12.5 × 10 9 cells/L, 48 ring-like enhancement on MRI, 65 or bacteremia 48 can be offered nonoperative management with close monitoring as the initial line of treatment. The patient and treating physician must be aware that even in the absence of risk factors there is no guarantee that medical management will not fail and that the patient will not go on to require surgery.…”

mentioning

confidence: 99%

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The indications and timing for operative management of spinal epidural abscess: literature review and treatment algorithm

Tuchman

Pham²,

Hsieh³

2014

FOC

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Object Delayed or inappropriate treatment of spinal epidural abscess (SEA) can lead to serious morbidity or death. It is a rare event with significant variation in its causes, anatomical locations, and rate of progression. Traditionally the treatment of choice has involved emergency surgical evacuation and a prolonged course of antibiotics tailored to the offending pathogen. Recent publications have advocated antibiotic treatment without surgical decompression in select patient populations. Clearly defining those patients who can be safely treated in this manner remains in evolution. The authors review the current literature concerning the treatment and outcome of SEA to make recommendations concerning what population can be safely triaged to nonoperative management and the optimal timing of surgery. Methods A PubMed database search was performed using a combination of search terms and Medical Subject Headings, to identify clinical studies reporting on the treatment and outcome of SEA. Results The literature review revealed 28 original case series containing at least 30 patients and reporting on treatment and outcome. All cohorts were deemed Class III evidence, and in all but two the data were obtained retrospectively. Based on the conclusions of these studies along with selected smaller studies and review articles, the authors present an evidence-based algorithm for selecting patients who may be safe candidates for nonoperative management. Conclusions Patients who are unable to undergo an operation, have a complete spinal cord injury more than 48 hours with low clinical or radiographic concern for an ascending lesion, or who are neurologically stable and lack risk factors for failure of medical management may be initially treated with antibiotics alone and close clinical monitoring. If initial medical management is to be undertaken the patient should be made aware that delayed neurological deterioration may not fully resolve even after prompt surgical treatment. Patients deemed good surgical candidates should receive their operation as soon as possible because the rate of clinical deterioration with SEA is notoriously unpredictable. Although patients tend to recover from neurological deficits after treatment of SEA, the time point when a neurological injury becomes irreversible is unknown, supporting emergency surgery in those patients with acute findings.

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“…4 The valveless Batson's venous plexus may contribute to early extension and seeding of spinal and paraspinal infections. 4,14,[22][23][24][25] The terminal branches of the same artery may supply the spinal and paraspinal area. Therefore, one site of spinal and paraspinal infections can extend locally or can disseminate hematogenously to other spinal/paraspinal areas or remote areas of the body.…”

Section: Pyogenic Infectionmentioning

confidence: 99%

Pyogenic and non-pyogenic spinal infections: emphasis on diffusion-weighted imaging for the detection of abscesses and pus collections

Moritani

Kim²,

Capizzano³

et al. 2014

BJR

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The incidence of spinal infections has increased in the past two decades, owing to the increasing number of elderly patients, immunocompromised conditions, spinal surgery and instrumentation, vascular access and intravenous drug use. Conventional MRI is the gold standard for diagnostic imaging; however, there are still a significant number of misdiagnosed cases. Diffusion-weighted imaging (DWI) with a b-value of 1000 and apparent diffusion coefficient (ADC) maps provide early and accurate detection of abscess and pus collection. Pyogenic infections are classified into four types of extension based on MRI and DWI findings: (1) epidural/paraspinal abscess with spondylodiscitis, (2) epidural/ paraspinal abscess with facet joint infection, (3) epidural/paraspinal abscess without concomitant spondylodiscitis or facet joint infection and (4) intradural abscess (subdural abscess, purulent meningitis and spinal cord abscess). DWI easily detects abscesses and demonstrates the extension, multiplicity and remote disseminated infection. DWI is often a key image in the differential diagnosis. Important differential diagnoses include epidural, subdural or subarachnoid haemorrhage, cerebrospinal fluid leak, disc herniation, synovial cyst, granulation tissue, intra-or extradural tumour and post-surgical fluid collections. DWI and the ADC values are affected by susceptibility artefacts, incomplete fat suppression and volume-averaging artefacts. Recognition of artefacts is essential when interpreting DWI of spinal and paraspinal infections. DWI is not only useful for the diagnosis but also for the treatment planning of pyogenic and nonpyogenic spinal infections.Spinal and paraspinal infections include vertebral osteomyelitis, spondylodiscitis, infectious facet arthropathy, epidural infections, meningitis, myelitis and infections of paraspinal soft tissue and musculature. Evidence of spinal infections has been discovered in the remains of prehistoric humans from 7000 BC. 1 The incidence has increased in the past two decades, owing to the rising number of elderly patients, immunocompromised conditions, spinal surgery and instrumentation, vascular access and intravenous drug use.1-4 Despite advances in medical knowledge, imaging modalities and surgical interventions, the diagnosis of this entity is still challenging since the clinical features can be subtle and misleading. MRI including post-contrast studies is the gold standard for diagnostic imaging. However, although MRI has relatively high diagnostic sensitivity, specificity and accuracy, there are still a significant number of challenging cases. In such cases, diagnostic delays and suboptimal management can result in irreversible paralysis, critical sepsis and even death.Diffusion-weighted imaging (DWI) has proven to be a useful tool for the diagnosis of a variety of intracranial infections especially in the detection of brain abscesses and pus collections, which encompass subdural and epidural empyema, purulent meningitis and ventriculitis. [5][6][7][8] Therefore, DWI ...

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Epidural abscess associated with pyogenic spondylodiscitis of the lumbar spine; evaluation of a new MRI staging classification and imaging findings as indicators of surgical management: a retrospective study of 37 patients

Cited by 30 publications

References 28 publications

Predictors of conservative treatment for pyogenic spondylitis

Predictors of conservative treatment for pyogenic spondylitis

The indications and timing for operative management of spinal epidural abscess: literature review and treatment algorithm

Pyogenic and non-pyogenic spinal infections: emphasis on diffusion-weighted imaging for the detection of abscesses and pus collections

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