Spinal epidural abscess associated with epidural catheterization: report of a case and a review of the literature.
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We describe a 53-year-old man who developed a catheter-related epidural abscess 8 days after left upper lobectomy for lung cancer. Methicillin-resistant Staphylococcus aureus (MRSA) was detected in a culture of the epidural pus. Magnetic resonance imaging was essential for the diagnosis of epidural abscess and for determining the extent of spread. The patient was treated by laminectomy and administration of appropriate antibiotics, with almost complete recovery, except for urinary retention. A literature search yielded 29 additional cases of catheter-related epidural abscess. The median duration of catheterization was 4 days and the median time to onset of the clinical symptoms after catheter placement was 8 days. Eleven of the 30 patients had some underlying disorders, including malignancy or herpes zoster, or were receiving steroids. Nine of the 10 patients with thoracic epidural abscess had persistent neurological deficits, whereas 12 of the 15 patients with lumbar epidural abscess showed a full recovery after treatment. Surgical decompression was not required in six patients without significant neurological deficits, who recovered following antibiotic treatment (four patients) or percutaneous drainage (two patients). Thoracic catheters are associated with a disproportionately high incidence of epidural abscess and persistent neurological sequelae following treatment. (+info)
A five-year assessment of controlled trials of in-patient and out-patient treatment and of plaster-of-Paris jackets for tuberculosis of the spine in children on standard chemotherapy. Studies in Masan and Pusan, Korea. Fifth report of the Medical Research Council Working Party on tuberculosis of the spine.
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In two centres in Korea 350 patients with a diagnosis of tuberculosis of the thoracic and/or lumbar spine were allocated at random: in Masan to in-patient rest in bed (IP) for six months followed by out-patient treatment or to ambulatory out-patient treatment (OP) from the start; in Pusan to out-patient treatment with a plaster-of-Paris jacket (J) for nine months or to ambulatory treatment without any support (No J). All patients recieved chemotherapy with PAS with isoniazid for eighteen months, either supplemented with streptomycin for the first three months (SPH) or without this supplement (PH), by random allocation. The main analysis of this report concerns 299 patients (eighty-three IP, eighty-three OP, sixty-three J, seventy No J; 143 SPH, 156 PH). Pre-treatment factors were similar in both centres except that the patients in Pusan had, on average, less extensive lesions although in a greater proportion the disease was radiographically active. One patient (J/SPH) died with active spinal disease and three (all No J/SPH) with paraplegia. A fifth patient (IP/PH) who died from cardio respiratory failure also had pulmonary tuberculosis. Twenty-three patients required operation and/or additional chemotherapy for the spinal lesion. A sinus or clinically evident abscess was either present initially or developed during treatment in 41 per cent of patients. Residual lesions persisted in ten patients (four IP, two OP, one J, three No J; six SPH, four PH) at five years. Thirty-two patients had paraparesis on admission or developing later. Complete resolution occurred in twenty on the allocated regimen and in eight after operation or additional chemotherapy or both. Of the remaining four atients, all of whom had operation and additional chemotherapy, three died and one still had paraparesis at five years. Of 295 patients assessed at five years 89 per cent had a favourable status. The proportions of the patients responding favourably were similar in the IP (91 per cent) and OP (89 per cent) series, in the J (90 per cent) and No J (84 per cent) series and in the SPH (86 per cent) and PH (92 per cent) series. (+info)
Extradural inflammation associated with annular tears: demonstration with gadolinium-enhanced lumbar spine MRI.
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Annular tears are manifest on MRI as the high-intensity zone (HIZ) or as annular enhancement. Patients with annular tears may experience low back pain with radiation into the lower limb in the absence of nerve root compression. Inflammation of nerve roots from leak of degenerative nuclear material through full-thickness annular tears is a proposed mechanism for such leg pain. The aim of this study is to illustrate the appearance of extradural enhancement adjacent to annular tears in patients being investigated for low back pain with radiation into the lower limb(s). Sagittal T1- and T2-weighted spin echo and axial T1-weighted spin echo sequences were obtained in eight patients being investigated for low back and leg pain. In all patients, the T1-weighted sequences were repeated following intravenous gadopentetate dimeglumine (Gd-DTPA). Annular tears were identified at 12 sites in eight patients. Extradural inflammation appeared as a region of intermediate signal intensity replacing the fat between the posterior disc margin and the theca, which enhanced following Gd-DTPA. The inflammatory change was always associated with an annular tear, and in four cases directly involved the nerve root. Enhancement of the nerve root was seen in two cases. The findings may be relevant in the diagnosis of chemical radiculopathy secondary to inflammation at the site of an annular leak from a degenerating disc. (+info)
Can autologous bone culture predict spinal fusion capacity?
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The capacity of the individual patient to initiate osteoblast proliferation as a predictor for successful lumbar spinal fusion has not yet been reported. The objectives of this study were, first, to analyze the relationship between in vitro osteoblast proliferation and clinical bony fusion in the individual patient in order to predict the fusion outcome and, second, to measure the effect of preoperative tobacco smoking on osteoblast proliferation. Sixty-one patients (mean age 46 years) underwent posterolateral lumbar fusion in the period 1994-1995. Thirty-eight patients received CD pedicle screw implants and 23 received posterolateral fusions alone. During surgery, autogenous iliac bone was harvested and 1 g of trabecular bone without blood or bone marrow was then isolated for cell culturing. The cultures were classified as excellent (confluence within 4 weeks), good (confluence between 4 and 6 weeks) and poor (no or poor growth). Spine fusion was evaluated by two independent observers from plain anterior-posterior, lateral, and flexion/extension radiographs taken 1 year postoperatively, and the functional outcome was measured by the Dallas Pain Questionnaire (DPQ). Twenty-three patients had excellent, 19 good, and 19 poor in vitro osteoblast proliferation. Bony fusion was obtained in 77% of patients: 83% in the CD instrumentation group and 70% in the non-instrumentation group (NS). There was no significant correlation between osteoblast proliferation and spinal fusion or functional outcomes when analyzing the CD instrumentation and non-instrumentation groups together or separately. Elderly patients had a significantly poorer osteoblast proliferation than younger patients (P < 0.008). Preoperative tobacco consumption had no discernible effect on osteoblast proliferation, and no correlation between smoking and fusion was found. Further refinement of autologous osteoblast culturing may provide a biological tool for selection of patients who require biological enhancement of their bone fusion capacity. The poorer osteoblast proliferation related to advanced age supports the important negative biological influence of age on bony fusion. However, with more sensitive testing and better discrimination, other results are possible - or can in any event not be excluded. (+info)
Pulmonary embolism caused by acrylic cement: a rare complication of percutaneous vertebroplasty.
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A pulmonary embolus of acrylic cement was present in a 41-year-old woman with Langerhans' cell vertebral histiocytosis (LCH) after percutaneous vertebroplasty. Chest radiograph and CT confirmed pulmonary infarction and the presence of cement in the pulmonary arteries. She was treated with anticoagulants, and responded favorably. This rare complication occurred because perivertebral venous migration was not recognized during vertebroplasty. Adequate preparation of cement and biplane fluoroscopy are recommended for vertebroplasty. (+info)
Fungal spinal osteomyelitis in the immunocompromised patient: MR findings in three cases.
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The MR imaging findings of fungal spinal osteomyelitis in three recipients of organ transplants showed hypointensity of the vertebral bodies on T1-weighted sequences in all cases. Signal changes and enhancement extended into the posterior elements in two cases. Multiple-level disease was present in two cases (with a total of five intervertebral disks involved in three cases). All cases lacked hyperintensity within the disks on T2-weighted images. In addition, the intranuclear cleft was preserved in four of five affected disks at initial MR imaging. MR features in Candida and Aspergillus spondylitis that are distinct from pyogenic osteomyelitis include absence of disk hyperintensity and preservation of the intranuclear cleft on T2-weighted images. Prompt recognition of these findings may avoid delay in establishing a diagnosis and instituting treatment of opportunistic osteomyelitis in the immunocompromised patient. (+info)
Segmental spinal dysgenesis: neuroradiologic findings with clinical and embryologic correlation.
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BACKGROUND AND PURPOSE: Segmental spinal dysgenesis (SSD) is a rare congenital abnormality in which a segment of the spine and spinal cord fails to develop properly. Our goal was to investigate the neuroradiologic features of this condition in order to correlate our findings with the degree of residual spinal cord function, and to provide insight into the embryologic origin of this disorder. We also aimed to clarify the relationship between SSD and other entities, such as multiple vertebral segmentation defects, congenital vertebral displacement, and caudal regression syndrome (CRS). METHODS: The records of patients treated at our institutions for congenital spinal anomalies were reviewed, and 10 cases were found to satisfy the inclusion criteria for SSD. Plain radiographs were available for review in all cases. MR imaging was performed in eight patients, one of whom also underwent conventional myelography. Two other patients underwent only conventional myelography. RESULTS: Segmental vertebral anomalies involved the thoracolumbar, lumbar, or lumbosacral spine. The spinal cord at the level of the abnormality was thinned or even indiscernible, and a bulky, low-lying cord segment was present caudad to the focal abnormality in most cases. Closed spinal dysraphisms were associated in five cases, and partial sacrococcygeal agenesis in three. Renal anomalies were detected in four cases, and dextrocardia in one; all patients had a neurogenic bladder. CONCLUSION: SSD is an autonomous entity with characteristic clinical and neuroradiologic features; however, SSD and CRS probably represent two faces of a single spectrum of segmental malformations of the spine and spinal cord. The neuroradiologic picture depends on the severity of the malformation and on its segmental level along the longitudinal embryonic axis. The severity of the morphologic derangement correlates with residual spinal cord function and with severity of the clinical deficit. (+info)
Epidurography and therapeutic epidural injections: technical considerations and experience with 5334 cases.
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BACKGROUND AND PURPOSE: Even in experienced hands, blind epidural steroid injections result in inaccurate needle placement in up to 30% of cases. The use of fluoroscopy and radiologic contrast material provides confirmation of accurate needle placement within the epidural space. We describe our technique and experience with contrast epidurography and therapeutic epidural steroid injections, and review the frequency of systemic and neurologic complications. METHODS: Epidural steroid injections were performed in 5489 consecutive outpatients over a period of 5 1/2 years by three procedural neuroradiologists. In 155 cases (2.8%), the injections were done without contrast material owing to either confirmed or suspected allergy. The remaining 5334 injections were performed after epidurography through the same needle. Patients and referring clinicians were instructed to contact us first regarding complications or any problem potentially related to the injection. In addition, the referring clinicians' offices were instructed to contact us regarding any conceivable procedure-related complications. RESULTS: Only 10 patients in the entire series required either oral (n = 5) or intravenous (n = 5) sedation. Four complications (0.07%) required either transport to an emergency room (n = 2) or hospitalization (n = 2). None of the complications required surgical intervention, and all were self-limited with regard to symptoms and imaging manifestations. Fluoroscopic needle placement and epidurography provided visual confirmation of accurate needle placement, distribution of the injectate, and depiction of epidural space disease. CONCLUSION: Epidurography in conjunction with epidural steroid injections provides for safe and accurate therapeutic injection and is associated with an exceedingly low frequency of untoward sequelae. It can be performed safely on an outpatient basis and does not require sedation or special monitoring. (+info)