This document discusses four cases of vertebral osteomyelitis complicated by epidural abscesses. It describes the patients' symptoms, diagnostic findings including MRI and lab results, and treatments which involved surgical drainage and decompression followed by long-term IV and oral antibiotics. The author concludes that early surgical treatment along with antibiotics can allow for full neurologic recovery, but delays in surgery are associated with higher morbidity and mortality.

1. Vertebral Osteomyelitis
complicated with
Epidural Absceses
GEORGE SAPKAS
PROFESSOR AT ORTHOPAEDICS
Metropolitan Hospital
Athens Greece

2. Cases

3. 1st case
J. Chr.
M 69 – Retired Civil servant
Symptoms
 Neurologic deficit
 Cervical Pain
 Low fever
Laboratory
 Neutroph. ↑
 SR 40

4. MRI
Unknown origin

6. Treatment

7. Transoral
Pus evacuation

8. Post op.
CT scan

9. Post op.
MRI

10. Occipito-cervical
stabilization

12. 2nd Post op.
CT scan

13. 2nd Post op.
MRI (6mts)

14. Post op.
3D scan (3yrs)

15. Follow up
Culture
 staphylococous aureous
Antibiotics
i-v for 2 mts
orally for 4 mts
Full neurologic recovery

16. 2nd case
Ma. Pal.
F 56 – Lawyer
Symptoms
 Neurologic deficit
 Cervical Pain
 Low fever
Laboratory
 Neutroph. ↑
 SR 50

17. 56
X-rays
Unknown origin

18. MRI
3
3

19. MRI

20. Anterior procedure
Vertebrectomy - PUS evacuation + Stabilization

22. Posterior stabilization

24. 2nd Post op.
MRI

25. Follow up
Pus culture
(staphylococous aureous)
Antibiotics
 i-v for 2 mts
 orally for 6 mts
Complete neurologic recovery

26. 3rd case
EV. PY.
M 56 – Industrial labor
Symptoms
 Neurologic deficit
 Thoracic Pain
 Low fever
Laboratory
 Neutroph. ↑
 SR 45

27. Unknown Origin

34. Follow up
Pus culture
(staphylococous aureous)
Antibiotics
 i-v for 2 mts
 orally for 6 mts
Complete neurologic recovery

36. 4th case
D.N.
M 61– Cardiologist
Symptoms
 Severe Neurologic deficit
 Intensive Thoracic-lumbar Pain
 High fever
Laboratory
 Neutroph. ↑
 SR 60
PMH
 Heavy smoker
 Diabetes melitus
 Recent Elbow Furuncle (untreated)

37. Elbow furuncle

38. 3
3
4 4
04/06/2007

39. 04/06/2007

40. 04/06/2007

41. 13/06/2007
3
4
3
4

42. 13/06/2007

43. Anterior
PUS evacuation
Bilaterally

44. Laminectomies
PUS evacuation

45. Post posterior PUS
evacuation

47. Follow up
Pus culture
(staphylococous aureous)
Antibiotics
 i-v for 2 mts
 orally for 7 mts
Complete neurologic recovery

48. Conclusions

49. Epidural abscesses
Of the spinal column is
a rare but potentially
devastating disease.
When recognized early
and treated
appropriately the
outcome can be
excellent
However the mortality
is as high as 20% even
in modern series

50. Surgical therapy
Decompression of the neural elements
and
drainage of purulent material or
debridement of granulation tissue
is recognized as the best method to
prevent neurologic deficits
and if performed quickly after the onset
of deficits, may allow full recovery.

51. Delay in surgical
drainage and
decompression
has repeatedly been
associated with high
morbidity and mortality.
Given the life-
threatening nature of
subdural empyema,
decompression of
epidural abscess is
uniformly considered an
emergency.

52. SPINAL EPIDURAL,
AND
SUBDURAL - INTRAMEDULAR
ABSCESSES
GEORGE SAPKAS
PROFESSOR AT ORHTOPAEDICS
Metropolitan Hospital
Athens Greece

53. Epidural abscesses

54. Subdural
abscesses

55. Intramedullar
abscesses

56. Historical review
1761 Morgagni
first to allude pyogenic infection in the spinal
epidural space
(Feldenzer et al. Neurosurgery 1987)
1820 Bergamaschi
first description
(Hlavin et al. Neurosurgery 1990)
1892 (Unknown)
first surgical drainage
1901 Barth
first successful drainage
(Hlavin et al. Neurosurgery 1990)

57. Epidemiology
2 cases per 10.000
hospital admissions per year
(Hlavin et al. Neurosurgery 1990)
The peak age incidence is in the sixth
and seventh decade of life
(Danner et al. Rev infection disease 1987)
(Wheeler et al. Clin Infect, disease 1992)
Rare in the pediatric population
(Rubin et al. Pediatric infect disease 1993)

58. Comorbid conditions
Diabetes mellitus
Intravenous drug use
Chronic renal failure
Alcoholism
Cancer
(Redekop et al. Can J. Neurol. Sci 1992)

60. Source of infection
Skin and soft tissue 25%
Previous spinal surgery
Osteomyelitis
Spinal trauma
Urinary tracts
Respiratory tracts
(Redekop et al. Can J. Neurol. Sci 1992)
Unknown and not indentified 16% - 40%
(Hlavin et al. Neurosurgery 1990)
(Redekop et al. Can J. Neurol. Sci 1992)

61. Etiologic agent
(Hlavin et al. Neurosurgery 1990)
(Redekop et al. Can J. Neurol. Sci 1992)

62. Pathophysiology
The spinal epidural
space is a metameric
segmental structure in
which some areas are
filled with fat and veins
and other areas the
dura is in direct contact
with bone or ligament
In addition individual
metameres are septated
preventing free
communication between
the anterior and
posterior epidural space (Redekop et al. Can J. Neurol. Sci 1992)

63. The majority of
epidural abscesses
are from
hematogenous
spread and are
localized posteriorly
(Redekop et al. Can J. Neurol. Sci 1992)

64. Cases associated with:
 Discitis
 Vertebral osteomyelitis
typically involve the
anterior epidural space
and
cont.

65. In few cases that
are commonly
post-surgical, the
abscess may be
circumferential
because of
disruption of the
normal anatomic
septations

66. The extend of the
abscess is usually
limited with an average
of 3 to 4 vertebral
segments
(Del Curling et al. Neurosurgery 1990)
(Hlavin et al. Neurosurgery 1990)

67. Location
Cervical 15%
Thoracic 50%
Lumbar 34%
Posterior 80%
Anterior 20%

69. The precise pathophysiologic cause of
the neurological impairment is not
known
 Rapid and irreversible deterioration
prompted several authors to postulate an
ischemic mechanism either from arterial
occlusion or venous stasis
(Baker et al. N. Engl J Med 1975)

70. Recent studies indicate
that the progressive
neurologic deficits were
secondary to
compression
(Feldenzer et al. Neurosurgery 1987)
(Feldenzer et al. Neurosurgery 1988)
It is most likely that the
cause of neurological
deficit is multi factorial
with compression been
the major component

71. Diagnosis
Onset of symptoms usually occurs
within hours to days
but may be more chronic in nature,
presenting with weeks to months
of symptoms.
The microbiology often dictates the
pace of progression.

72. If left untreated, the progression of
symptoms is usually sequential:
 back pain (70-100%),
 radicular irritation (50%),
 motor weakness (30-40%)
 sphincter incontinence (30-40%)
 sensory changes (12%),
 then paralysis (6-48%)
 fever is frequently present especially in acute
phases
(Redekop et al. Can J. Neurol. Sci 1992)
(Maslen et al. Arch inten Med 1993)

73. Tuberculous abscesses
The clinical presentation is slightly
different
 Back pain ~ 100%
 The prodrome is longer
 Leukocytosis frequently absent
 Fever - // -
 The patients are usually younger than
patients with bacterial abscesses

74. Differential diagnosis
Spondylosis or disk syndromes
Epidural Hematoma
Leptomeningeal Carcinomatosis
Metastatic Disease to the Spine
Spinal Cord Hemorrhage or Infarction
Subdural Hematoma or Empyema
HIV-1 Associated Vacuolar Myelopathy
Tropical Myeloneuropathies
Vitamin B-12 Associated Neurological Diseases
Alcohol (Ethanol) Related Neuropathy

75. Laboratory studies
Leukocytosis,
(left shift),
anemia.
In one retrospective analysis,
leukocytosis was present in only
60% of patients.
Blood cultures positive in 60%.
ESR and CRP elevated.
Lumbar puncture relatively contraindicated
(risk of spreading the bacteria into the
subarachnoid space).
Usually reveals inflammation, cultures positive
in 25% of cases.

76. Imaging studies
Plain radiographs occasionally demonstrate
osteomyelitis but are of almost no utility.
Spinal MRI is the procedure of choice
(sensitivity 95%, specificity 92%).
Gadolinium enhancement increases sensitivity
and enables better differentiation between
abscess and surrounding neurological
structures.
CT-guided needle aspiration may be used to
obtain material for analysis.

77. Plain radiographs

78. MRI

79. Treatment

80. Medical therapy
Medical management
with appropriate
antibiotics has been
successful in several
reports
Potential candidates :
 Lumbar epidural
abscess
with no
neurologic deficit
and bacteriologic
agent has been
cultured
(Wheller et al. Clin Inf Des. 1992)

81. Proposed criteria for exclusive medical
treatment in spinal epidural abscesses
Poor surgical candidates because of sever
concomitant medical problems
Cases in which the abscess involves a
considerable length of spinal canal and who
have epiduritis from the cervical to the lumbar
level
Patients not suffering from severe loss of spinal
cord or cauda equina function
Patients with complete paralysis for more 3
days

82. The length of suggested medical
therapy is at least 8 to 12 weeks
of intravenous antibiotics
followed by oral agents
(Leys et al. Ann Neurol. 1985)

83. Management
Initiate empirical therapy; must continue for 3 – 4 weeks
Ceftriaxone (ROCEPHIN) 2g x 2
Ceftazidime (SOLVETAN) 2g x 3
Cefazolin (BIOZOLIN) 2g x3
+
Meropenem (MERONEM) 1g x 3 (antipseudomonal)
±
Metronidazole (FLAGYL) 500mg x 3
±
Gentamycin (GARAMYCIN) 80mg x3 in D/W 5%
(if post – op or IV drug user or endocarditis)
±
Vancomycin (VONCON) 1g x 2 (MRSA)

84. Operative treatment

86. Posterior decompression

87. Posterior decompression
and stabilization

88. Anterior decompression
± stabilization