Epidural Abscess Due to Spinal Cord Stimulator Trial

Abstract

Spinal cord stimulation is increasingly utilized as a treatment to alleviate low back pain and lumbar radiculopathy, particularly in patients with failed back surgery syndrome. We present an illustrative case of early, rapidly progressive methicillin-resistant Staphylococcus aureus (MRSA) infection after a brief stimulator trial lead implantation. Operators should maintain a high level of suspicion for deep infection, including epidural abscess, even when only minor symptoms and signs are present. Because of the poor ability to clear infections in the presence of a retained foreign body, the device must be explanted immediately. Subsequent surgical intervention, however, may nevertheless still be needed. While a variety of bacteria may cause epidural abscess, methicillin sensitive Staphylococcus aureus, and increasingly, MRSA and community-associated MRSA, are the most likely etiologic organisms.A 46-year-old white man, who smoked and had a history of asthma and borderline hypertension, was being treated in our practice for failed back surgery syndrome. He was unresponsive to conservative therapy including methadone 10 mg, 6 tablets Q8hours, Oxycodone 15 mg, 4 tablets Q3hours prn, and pregabalin 75-mg capsule Q12hours, and presented for a spinal cord stimulator trial. Adhering to strict aseptic technique, the patient's thoracolumbar spine was prepped with 70% isopropyl rubbing alcohol followed by 10% povidone-iodine. The operative site was then surgically draped and the fluoroscopic image intensifier sterilely wrapped. Prophylactic systemic antibiotics were not administered. Wearing sterile gloves, mask, gown, and cap, we placed 2 percutaneous electrode leads (Advance Bionics, Sylmar, CA, U.S.A.) through separate insertion sites on a single attempt. After assuring successful stimulation coverage, the leads were secured to the back with steri-strips and Tegaderm. The procedure was uneventful and there was no break in sterility.

Epidural Abscess During a Spinal Cord Stimulator Trial: A Case Report

“…An epidural abscess is a rare occurrence, and a search of the literature yielded very few cases during an SCS trial . In our case, the patient had chronic back pain due to postlaminectomy syndrome with radiculopathy, no history of intravenous drug use, alcoholism, chronic steroid use, recent infections, or epidural steroid injections.…”

Spinal stimulator peri-electrode masses: case report

“…20,29,33,35 Common to all these entities is the need for accurate imaging of the area of concern to characterize the cause and formulate a course of treatment.…”

“…Some centers implant SCSs in interventional suites outside the rigorous sterile techniques and other procedures mandated in an operating room. 29 Additionally, a common technique when accessing the epidural space is to use approximately 5 ml of saline to dissect the plane. This is believed to reduce epidural blood vessel damage or cannulation, but it can also introduce contamination.…”

“…2,27,28,38,42 Complications associated with the procedure may include electrode migration, infection, hardware malfunction, hematoma, and, rarely, neurological deficit. 2,29,35,38 Allergic reactions with cutaneous manifestations to the components of SCS systems have been reported. 3,7,26,36 Six cases are reported in the literature of a mass forming around paddle electrodes, causing spinal cord compression and myelopathy between 14 and 22 months after implantation (Table 1).…”

Spinal Epidural Abscess as a Result of Dissemination from Gluteal Abscess Secondary to Intramuscular Analgesic Injection

“…SEA usually occurs secondary to hematogenous dissemination; it may also result from a local extension of infection from adjacent structures, as a complication of spinal surgery, particularly intervertebral discectomy, lumbar puncture or epidural injections, and through the use of epidural catheters 5–7 . The source of infection is not identified in many patients.…”