1

Neurosurgery Case Conference

2014/05/08

R1 姜冠宇

2

Patient profile

٥ No. 4757887

٥ Age/gender: 57 y/o male

٥ Background:٥ denied having any systemic disease

3

History

٥ 2011/5 Head injury ٥ Traumatic SAH acute SDH Herniation &

Infarct٥ Cefazolin + Gentamicin Cravit ٥ Focal seizure

4

History

٥ 2011/8 continue rehabilitation program

٥ Operation ： L’t FTP cranioplasty ٥ Lethargy, caused by Hydrocephalus

5

History

٥ V-P shunt operation was arranged٥ Vanco + Fortum for treatment٥ Suspect V-P shunt infection

٥ 2012 VP shunt infection with wound discharge ٥ Fever, suspect V-P shunt infection٥ Tracheostomy and bedridden status٥Under Vancomicin+Rocephine

6

History

٥ 2012/10/08 purulent discharge from scalp

٥ Left FTP epidural abscess ٥ Urgent Left FTP craniectomy + Debridement + CWV drain

7

History

٥ 2014

1. Recurrent generalized tonic-clonic convulsion

2. Sepsis

8

History

٥ 2014/02/27 Left Cranioplasty(TI-MESH)

9

This time

٥ 2014/04/25 Eruption of scalp ٥ Craniectomy + Debridement

٥ remove Ti-mesh

٥ Seizure was noted at POR

٥ Antibiotics: Daptomycin

10

11

Patient profile

٥ Age/Gender : 70 y/o female

٥ History :٥ DM under OHA control ٥ HTN under medication control

12

Patient illness

٥ C.c.: Fever with chillness ٥ Accompanying with mild L’t neck and bilateral shoulder soreness٥ Arthragia and Mylgia

٥ Negative Brudnzinsky or Kernig sign

13

Patient illness

٥ U/A reveaeld pyuria. ٥ Abd CT revealed suspected cholangitis or

pancreatitis. GI admission٥ Low back pain when admission٥ L spine MRI : HIVD L4-S1

٥ C spine MRI:٥ highly suspect C6-7 osteomyelitis with

epidural abscess

14

15

16

17

18

Operation and Post OP

٥ C67 corpectomy+ interbody fusion with cage (zimmer, body C-cage)+ C5-T1 plate fixation+ debridment

٥ Vital sign stable٥ CRP H 3.94 mg/dL ٥ WBC 7.20 10^3/uL ٥ E.S.R. 1hr H 87 mm/hr

٥ keep penicillin G +Daptomycin use

19

Epidural abscess

From Uptodate

20

Epidural abscess

٥ Incidence: 2~25 per 100,000 admission

٥ Enclosed within the bony confines ٥ Compress the brain or spinal cord

٥ Spinal epidural abscess (SEA) ٥ Intracranial epidural abscess (IEA)

٥ Severe symptoms to permanent complications

٥ Prompt diagnosis: CT, MRI

٥ Proper treatment: Aspiration or Drainage

21

SPINAL EPIDURAL ABSCESS —

٥ Requires prompt recognition and proper management to avoid potentially disastrous complications.

22

Anatomy — 

24

Anatomy —

٥ Small in C region Larger in S region

٥ More common in the T-L areas٥ Infection-prone fat tissue ٥ Anterior : below L1٥ The majority : located posteriorly

25

Pathogenesis — 

٥ Hematogenously by direct extension from infected contiguous tissue ٥ vertebral body (pyogenic infectious discitis)٥ psoas muscle

٥ Direct inoculation into the spinal canal ٥ eg, during spinal or epidural anesthetic procedures or surgery

٥ Mechanisms ٥ Direct compression٥ Thrombosis and thrombophlebitis of nearby veins٥ Interruption of the arterial blood supply٥ Bacterial toxins and mediators of inflammation

26

Pathogenesis —

٥ one level commonly extend to multiple levels. ٥ (3~5 levels)

٥ Even a small SEA can cause severe neurologic symptoms and sequelae.

٥ Abscesses Granulation tissue

27

Clinical manisfiestation

٥ Back pain٥ Root pain٥ Motor weakness, sensory changes٥ Bladder or bowel dysfunction٥ Paralysis

٥ Differential diagnosis — ٥ Disc and degenerative bone disease٥ Metastatic tumors٥ Vertebral discitis and osteomyelitis٥ Meningitis٥ Herpes zoster, prior to the appearance of skin lesions

28

Diagnosis

٥ No delay !٥ “Classic triad" of fever, spine pain, and neurologic

deficits

٥ Especially if the pain is worsened by percussion, should suggest the diagnosis of SEA or vertebral osteomyelitis.

29

Diagnosis

٥  ESR and CRP was highly sensitive and moderately specific

31

Management

٥ Follow-up MRI to confirm diminishing size or resolution of the abscess٥ Immediate surgery is warranted if neurologic deterioration occurs

٥ Empiric therapy — An empiric regimen with antibiotics active against staphylococci, streptococci, and gram-negative bacilli should be chosen.

٥ Vancomycin 

٥ vancomycin could be replaced with nafcillin or oxacillin ٥ better central nervous system (CNS) penetration than vancomycin. 

٥ Metronidazole 

٥ Cefotaxime  ceftriaxone, or ceftazidime ٥ Ceftazidime is preferable when Pseudomonas aeruginosa is considered

٥ Rehabilitation treatment

32

INTRACRANIAL EPIDURAL ABSCESS —

٥ IEA are less common than SEA

٥ Less acute in evolution.

٥ Like SEAs, requiring optimal therapy to prevent complications.

33

INTRACRANIAL EPIDURAL ABSCESS —

٥ Anatomy — The potential epidural space can be opened by pressure ٥ Expanding tumors, blood, inflammatory masses, or pus. ٥ Slow-growing, rounded, and well-localized.٥ Rarely spread downwards because the dura attached the

foramen magnum. ٥ granulation tissue rather than pus

٥ Epidemiology — ٥ the past, most cases associated with sinusitis, otitis, or

mastoiditis. ٥ Today, many cases arise as neurosurgical procedures.

35

Management 

٥ Successful treatment of an IEA requires a combination of a drainage procedure and antibiotic therapy.

36

٥ Thanks!