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A 31-year-old female from the United States who is an active IV drug abuser presents with worsening gait instability for the last four days. She has no history of prior international travel. Physical exam shows diffuse weakness in her upper and lower extremities. A sagittal MRI is shown in Figure A. What is the next most appropriate step in management?
Anterior decompression and fusion
Posterior decompression and fusion
Methylprednisone loaded at 30 mg/kg followed by drip at 5.4 mg/kg/hr drip for 23 hrs
Broad spectrum IV antibiotics and bracing
CT guided biopsy
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This patient’s clinical presentation is most consistent with spondylodiscitis with an associated epidural abscess in the cervical spine with compression of the thecal sac. The most appropriate next step would be anterior decompression and fusion of the cervical spine as the patient has a neurologic deficit prompting surgical decompression In this case, the epidural abscess is anterior, so an anterior decompression would be most effective. A partial corpectomy will be required so a fusion will be indicated.
The most common pathogen seen in epidural abcesses is staph aureus. Prophylactic antibiotics should be initiated until intra-operative cultures are reported. Duration of antibiotics usually ranges from 2-4 weeks if no bony involvement of infection or 6 week with bony involvement. 33% of patients with an epidural abscess will have neurologic symptoms and a large proportion will have permanent paralysis.
Hadjipavlou et al. retrospective reviewed 101 cases of pyogenic spinal infection. Infection elsewhere was the most common predisposing factor. Leukocyte counts were elevated in 42.6% of spondylodiscitis cases. The erythrocyte sedimentation rate was elevated in all cases. Spondylodiscitis is more prone to develop epidural abscesses in the cervical spine (90%) than the thoracic (33.3%) or lumbar (23.6%) areas.
Tay et al. review spinal infections. The most common types of spinal infections are hematogenous bacterial or fungal infections, pediatric diskitis, epidural abscess, and postoperative infections. Persistent pain and fever are the most common presenting symptoms prior to neurological deficit.
Figure A shows as sagittal T1 MRI of the spine. There is a large anterior epidural abscess at the level of C3/4.
Answer 2: The epidural abscess is anterior, so an anterior decompression would be most effective.
Answer 3: There is no literature to support delaying surgical decompression for IV steroids.
Answer 4: Broad spectrum IV antibiotics and bracing would be indicated for small abscess with minimal compression on neural elements and no neurologic deficits.
Answer 5: Biopsy would not be indicated when there are acute neurological deficits.
Hadjipavlou AG, Mader JT, Necessary JT, Muffoletto AJ
Spine. 2000 Jul;25(13):1668-79. PMID: 10870142 (Link to Abstract)
Hadjipavlou, SPINE 2000
Tay BK, Deckey J, Hu SS.
J Am Acad Orthop Surg. 2002 May-Jun;10(3):188-97. PMID: 12041940 (Link to Abstract)
Tay, JAAOS 2002
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A 64-year-old female accountant from Oregon is diagnosed with endocarditis 6 months ago underwent a course of IV antibiotic treatment. She now reports 3 months of severe low back pain and progressive lower extremity weakness and paresthesias for the past week. Her leukocyte count is normal and she is afebrile. The ESR and CRP are elevated. Radiographs and MRI scans are shown in Figures A and B, respectively. What is the most appropriate next step in management?
Intrathecal catheter placement with antibiotic administration for 6 weeks
Irrigation and debridement, corpectomy, and fusion
Oral prednisone regimen for 4 weeks
Irrigation and debridement via posterior approach
Initiation of multiagent antibiotic regimen for tuberculosis for 6 months
The clinical history, physical examination, and imaging is consistent with extensive destruction of the lumbar spine extending over three vertebral segments with associated epidural abcess necessitating surgical decompression and fusion. An epidural abscess may present rapidly with neurological compromise. Prognosis improves with prompt decompression, but only 18% of patients with frank abscess and 23% of patients with paralysis completely recover after decompression.
Hadjipavlou et al report in their Level 4 study that leukocyte counts were elevated in 42.6% of spondylodiscitis cases. The erythrocyte sedimentation rate was elevated in all cases of epidural abscess.
The article by Harrington et al states that the surgical indications for an epidural abcess include: unsuccessful antibiotic treatment after 6 weeks, vertebral deformity or instability, neurological deficit, MRI showing >50% compression of thecal sac, and depressed host immune response.
Illustration A shows radiographs following anterior debridement, corpectomy, fibular strut grafting, and Kaneda instrumentation.
Harrington P, Millner PA, Veale D.
Ann Rheum Dis. 2001 Mar;60(3):218-22. PMID: 11171681 (Link to Abstract)
Harrington, ANRD 2001
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