Iliopsoas abscess accompanied by epidural abscess--a case report]

A 55-year-old man was admitted to a hospital with pain of the low back as well as the left leg, and fever. He was suspected of suffering from the lumbar disc herniation because of the presence of Lasegue's sign on the first physical examination. Abdominal computed tomography, however, revealed the swelling of the left iliopsoas muscle. Iliopsoas abscess accompanied epidural abscess was confirmed by subsequent magnetic resonance imaging (MRI). Antibiotic therapy was started for the successive 8 days. The fever resolved, but the pain persisted. The abscess extending from the iliopsoas muscle to the epidural space was still seen on the MRI 20 days after the completion of the antibiotic therapy, and he still complained of the pain of his low back and left leg. Therefore, we conducted epidural puncture under fluoroscopic guidance. Approximately 3 ml of pus was aspirated from the epidural space. Then, his complains decreased remarkably. Iliopsoas abscess should be taken into account in case of a patient with pain on the low back and leg and also inflammatory signs such as fever and leucocytosis.     

Spinal epidural hematoma progressing to Brown-Sequard syndrome: report of a case

Horton giant cell arteritis of the legs is a very rare and unusual occurrence. A very interesting case of acute ischemia of the right leg in a 51-year-old woman treated with emergency thromboendarterectomy is described. Histological findings led to the diagnosis of Horton giant cell arteritis and the patient was submitted to steroid and vascular therapy. Good results were obtained and follow-up after five years confirms the good general condition of the patient.     

Intraspinal epidural sarcoidosis: case report

OBJECTIVE AND IMPORTANCE: A rare case of lumbar intraspinal epidural sarcoidosis is identified. The rarity of this condition and its clinical presentation are stressed. CLINICAL PRESENTATION: A young Caucasian man presented with the progressive onset of cauda equina syndrome as a result of an expanding mass in the lumbar epidural space compromising the lumbar dural tube from L1 to S1. The patient presented with motor, sensory, and sphincteric dysfunction as a result of this large intraspinal epidural mass. No evidence of systemic illness was noted concomitant with the patient's onset of neurological symptomatology. The patient underwent surgical extirpation of a lumbar intraspinal epidural mass, which was identified histopathologically as sarcoid granuloma. The postoperative work-up included the identification of a mediastinal adenopathy, which was subsequently biopsied and confirmed the diagnosis of sarcoid disease. The patient was treated postoperatively with oral prednisone over a 4-month period. At 7 months postoperatively, the patient had regained gainful employment, the results of his neurological examination were normal, and he was pain-free. INTERVENTION: The patient underwent a multilevel bilateral lumbar laminectomy with facet preservation, extending from L1 to S1, allowing for a gross total removal of the epidural mass. Postoperative oral prednisone was administered as adjuvant therapy for the treatment of multisystem sarcoid disease. CONCLUSION: Aggressive surgical management involving the removal of an extensive epidural mass of the lumbar canal, which was diagnosed as sarcoid disease, coupled with the adjuvant use of oral prednisone has resulted in an excellent outcome for the patient. The results of his clinical examination are now normal, and postoperative radiological imaging reveals no evidence of recurrent or residual disease in the lumbar epidural space. In the unusual case of intraspinal epidural sarcoidosis, the surgical resection of accessible intraspinal epidural masses is recommended, as is the use of oral prednisone postoperatively.     

Spinal epidural arteriovenous fistula with intramedullary reflux. Case report

A spinal epidural arteriovenous fistula with secondary reflux into the perimedullary veins is a rare entity. The authors present such a case with a discussion of its pathophysiology and treatment. The mechanism for formation of a spinal dural arteriovenous fistula is outlined based on the anatomical substrates in this region.     

The rim sign in epidural hematoma: case report

A case of epidural hematoma of 7 days' duration showed a rim sign in the dynamic and static brain images. The significance and value of a rim sign are discussed.     

Spinal neurenteric cyst. A report of a case

A case of intradural extramedullary neurenteric cyst is reported. The embryogenesis and surgical treatment of this lesion are discussed.     

Spinal abscess of Haemophilus paraphrophilus. A case report

STUDY DESIGN: A case of paraspinal abscess formation from Haemophilus paraphrophilus is presented. OBJECTIVES: To describe a case of paraspinal abscess formation from H. paraphrophilus, a fastidious commensal organism of the mouth and pharynx. A precise bacteriologic identification can be difficult; techniques for such identification are discussed. SUMMARY OF BACKGROUND DATA: Spinal abscess caused by H. paraphrophilus is unusual and can be very difficult to diagnose. METHODS: The etiology, clinical presentation, technical examinations, and treatment are reviewed. RESULTS: Prolonged antibiotic treatment was curative, although surgery was considered. CONCLUSIONS: Bacteriologic diagnoses in these rare infections are difficult. Antibiotic therapy was curative in the patient described.     

Spinal epidural abscess. Optimizing patient care

The medical literature regarding spinal epidural abscess has two common threads: reports of poor prognosis and appeals for rapid treatment. Spinal epidural abscess is a difficult diagnosis to make because of its rarity--many physicians will never see a case during their careers. Among all patients admitted to hospitals, the incidence is approximately one to two cases per 10,000. Only increased awareness and swift management of spinal epidural abscess will improve outcome. Our goal through this report is to enhance the recognition and treatment of spinal epidural abscess. We present 28 new cases of spinal epidural abscess, giving special attention to the peculiarities of the disease; we compile and analyze comprehensive data from cases from literature; and finally, we present the results of 16 retrospective personal interviews of infected patients.     

Lumbar disk herniation combined with epidural hematoma. A case report

We examined the protective effect of nicotine against neuronal cell death in the model system of serum- and nerve growth factor (NGF)-free cultures of PC12 cells. Serum deprivation induced massive death of undifferentiated PC12 cells, which was inhibited by the addition of NGF, but not by the addition nicotine (100 microM). Even after PC12 cells had been differentiated by the treatment with NGF, serum and NGF deprivation induced rapid and massive death of these cells. The addition of nicotine (1-100 microM) to the deprivation system prevented such cell death almost completely. The protective effect of nicotine was abolished by hexamethonium or mecamylamine, inhibitors of nicotinic acetylcholine (nACh) receptors. Treatment with reserpine to deplete intracellular catecholamines did not influence the effect. The results suggest that the protective effect of nicotine against neuronal cell death is exerted through nACh receptors.     

Spinal tumour due to primary hyperparathyroidism causing sciatica: case report

We report a unilateral intraspinal cyst-like lesion adjacent to the lamina and facet joint at the L4-L5 level producing sciatica. Histological examination revealed multinucleate giant cells suggesting a brown tumour. Further studies disclosed primary hyperparathyroidism, whose first manifestation was the lumbar nerve root compression. Previous cases of compression of neural structures by spinal brown tumours are reviewed and a radiological differential diagnosis is presented.     

Extensive epidural hemangioma with skin and bone involvement. A case report

STUDY DESIGN: This is a case report. OBJECTIVE: To report and to examine the clinical findings and management of epidural cavernous hemangioma. SUMMARY OF BACKGROUND DATA: Spinal epidural cavernous hemangiomatous malformation is a very rare entity. Only 20 cases of this disease have been reported in the literature. METHODS: The case of a 20-year-old woman with spinal epidural cavernous hemangioma was reviewed. RESULTS: The clinical presentation, diagnosis, and therapy of this disease are discussed. CONCLUSION: The treatment of epidural hemangioma consists of total or subtotal excision of the lesion, depending on the relation of the lesion to the spinal cord.     

Diagnostic scintigraphic sign in epidural hematoma at the vertex: case report

Brain scintigraphy was described in a case of vertical (biparasagittal) epidural hematoma confirmed by contrast angiography. The anterior dynamic and static studies showed inferior displacement of the superior sagittal sinus, diagnostic of an epidural collection. Delayed static anterior and lateral images showed an increased vertical uptake with a crescentic and straight inner contour, respectively. A transaxial computed tomographic scan was negative.     

Diagnosis and epidural hematoma by brain scan and perfusion study: case report

By using the arterial and venous phases of an anterior cerebral perfusion study, which showed downward displacement of the sagittal sinus, and the finding of a "rim" on the delayed scans, the specific diagnosis of epidural hematoma was established.     

Pneumocephalus and respiratory depression after accidental dural puncture during epidural analgesia--a case report

BACKGROUND: Adenomatous colonic polyps are accepted as premalignant lesions. There is controversy regarding the significance of the hyperplastic polyp. The aim of this study was to determine the incidence of further polyps in patients with only hyperplastic polyps on a first colonoscopy in comparison with patients without polyps and with adenomatous polyps. METHODS: Ninety patients had only hyperplastic polyps (group I). These patients were paired according to age and sex with subjects having no polyps (group II) and with patients having adenomas (group III). RESULTS: Fifty-six patients in group I had at least one follow-up examination. New polyps were found in 46.4% in group I versus 15.5% in group II (p < 0.001) and 50% in group III (NS). In group I, 30.7% of new polyps were hyperplastic and 69.3% were adenomas. In fact, 32.2% of group I patients developed further adenomas (mean 1.5 +/- 0.8 adenomas). These adenomas occurred 1 to 4 years after the first polypectomy (mean 2.4 +/- 0.8 years). Most of these adenomas were small and tubular, but 16.6% were villous or had severe dysplasia. CONCLUSION: Patients with hyperplastic polyps were 2.4 times more likely to have further adenomas than were those without polyps.     

Spinal epidural abscess: evaluation of factors influencing outcome

OBJECTIVE: The goal of this study was to critically evaluate the predictive efficacy of various clinical factors in spinal epidural abscess influencing outcome after surgical and/or medical treatment. METHODS: A retrospective analysis of 41 cases of spinal epidural abscess treated at Henry Ford Hospital between 1984 and 1992 was performed. RESULTS: Thirty patients underwent open surgery and received antibiotic therapy, and 11 patients received medical treatment alone. After a mean follow-up period of 20.9 months (range, 4-45 mo), 24 patients (58.5%) had no or minimal deficits, 9 patients (22%) had severe paresis or plegia and/or bowel/bladder dysfunction, and 8 patients (19.5%) died. Univariate analysis revealed patient age, degree of thecal sac compression, spinal location, surgical findings, and septic presentation to be significantly associated with outcome. In multiple logistic regression analysis, increasing age and degree of thecal sac compression were the only factors with significant independent association with poor outcome (P = 0.01 for both). A simple grading system (Grades 0-III) was developed, with patient age, degree of thecal sac compression, and duration of symptoms as the determining criteria. The incidence of poor outcome for patients with Grade 0 was 0%, compared to 85.7% for patients with Grade III. CONCLUSION: We conclude that long-term outcome after treatment of spinal epidural abscess can be predicted with the use of the proposed grading scheme. Surgical drainage plus parenterally administered antibiotics remains the recommended treatment, although medical treatment alone can also be used for certain patients.     

Spinal cord compression secondary to epidural extramedullary hematopoiesis in thalassemia: a clinical case and review of literature

INTRODUCTION: Extramedullary hematopoiesis generally occurs in a variety of hematological disorders where the normal functioning of the blood forming organs is disturbed. It is a common manifestation in thalassemia where it occurs as a compensatory phenomenon in order to combat long standing anemia. Spinal cord compression as a consequence of extramedullary hematopoiesis in the intraspinal epidural space is an extremely rare complication, though this complication has been reported more commonly in thalassemia. CLINICAL CASE: A case of spinal cord compression due to extramedullary hematopoiesis in a patient with thalassemia is reported. The patient was successfully treated with radiation therapy and blood transfusions and he made a complete clinical recovery. Development. The literature is reviewed and the efficacy of several treatments such as surgery, radiotherapy and blood transfusion therapy is discussed. Until recently surgical decompression followed by radiation therapy remained the recommended treatment. Hematopoietic tissue is particularly sensitive to the ionizing radiation and low-dose radiotherapy is enough to relieve the spinal cord compression. Blood transfusion therapy may be diagnostically and therapeutically useful in the management of this entity. CONCLUSIONS: A prompt recognition of the syndrome and early treatment with radiotherapy and blood transfusion therapy is recommended to prevent irreversible damage to the spinal cord. Surgery may be only considered in the event of progressive neurological deficit despite of radiotherapy or blood transfusion therapy.     

Spinal cord compression by catheter granulomas in high-dose intrathecal morphine therapy: case report

OBJECTIVE AND IMPORTANCE: The use of chronic intrathecal morphine for the treatment of intractable, nonmalignant pain is becoming more prevalent. A rare but devastating complication of this therapy is the development of spinal cord compression secondary to the formation of intrathecal granulomas. CLINICAL PRESENTATION: We report three cases of intrathecal granuloma formation in the thoracic subarachnoid space, associated with intrathecal morphine pumps. These three patients were receiving high doses of morphine to control their pain (25 mg/d, 28 mg/d, and 45 mg/d, respectively) when they presented with signs and symptoms of thoracic spinal cord compression. Myelography and postmyelographic computed tomography of the spine revealed masses causing spinal cord compression. INTERVENTION: Two patients underwent thoracic laminectomies for resection of these masses, and the other patient had the intrathecal catheter removed. A pathological examination revealed sterile granulomas in the resected masses. CONCLUSION: Intrathecal granulomas are likely to occur with increasing frequency as the use of chronic intrathecal morphine delivery increases in patients with nonmalignant pain. The cause of intrathecal granulomas is unknown, although it is likely that morphine plays a major role in their formation. We think that those patients receiving high doses of morphine are at greater risk for developing this complication.     

Spontaneous spinal epidural hematoma with spinal cord compression complicating plasma cell myeloma. A case report

STUDY DESIGN: A case is reported in which a patient had acute paraplegia with sensory loss caused by a spontaneous epidural hematoma that was ascribed to bleeding of pre-existing myeloma lesions of the thoracic vertebrae. OBJECTIVES: To highlight the causes of secondary epidural hematomas with special attention to pre-existing vertebral or epidural lesions. SUMMARY OF BACKGROUND DATA: There are no apparent previous reports of epidural spinal hematomas ascribed to underlying malignant diseases. Benign dysplasia, such as hemangioma or Paget's disease, has been implicated in a few cases. METHODS: A case of spontaneous dorsal epidural hematoma is reported in a patient followed up for plasma cell myeloma with osteolytic lesions in the lower thoracic spine. There was no history of major trauma or coagulation disorders. Complete loss of motor and sensory function in both lower limbs was noted, with sphincter dysfunction. Magnetic resonance imaging of the thoracic spine showed a large posterolateral epidural hematoma responsible for spinal cord compression. RESULTS: The patient failed to improve despite surgical decompression within 6 hours of symptom onset. He died 13 days later of refractory bacterial pneumonia. A large epidural hematoma adjacent to myelomatous lesions of the thoracic vertebrae was found at autopsy. CONCLUSIONS: This is the first reported case of spontaneous epidural hematoma ascribed to underlying malignant disease, with confirmation of the diagnosis by postmortem examination. Possible mechanisms include tumor-related epidural inflammation and fragility of epidural venous plexuses.