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Epidural Abscess: Spinal and Cerebral
Spinal Epidural Abscess
Spinal extradural space is also known as epidural space or peridural space . Epidural infinite is attached to foramen magnum at the cephalic end and at the caudal end it ends with sacrococcygeal membrane . It is the outermost anatomical space in spinal epithelial duct of vertebral column.(1)Circular epidural space is tightly covered by dura mater from at heart and comprise lymphatics , spinal nerve tooth root , informal fat tissue , artery and epidural venous plexus .
Cerebral Epidural Abscess
Cerebral epidural space is anatomically non - existent as dura is tight bond to skull . intellectual epidural space is a non - existent potential space , which may issue with separation of dura from skull in guinea pig of abscess geological formation or appearance of epidural hematoma .
Abscess is solicitation of pus consisting of dead cubicle , bacteria , and debris . Abscess occupies space and may get distance occupying wound and symptoms . size of it of abscess determines the space occupied in compact skull and spinal canal . Symptoms could be severe and life-time peril . Prompt diagnosis and treatment is essential to forestall decease in few cases . It is a rarefied disease , 0.5 to 1.2 cases per 10,000 hospital admissions per year .
Epidemiology of Epidural Abscess
Epidural abscess is a rarified disease . Fifty pct of intellectual and spinal epidural abscess occur mostly by hematologic counterpane . Thirty percent of epidural abscess is secondary to local bed cover from contagion or abscess within bones , muscles , and soft tissue . While remaining 20 % epidural abscess go on during invading procedures or by spreading of abscess metastasis from infected pouch where foreign body are locate like trespassing implant and endovenous ports or catheter .
trespassing procedures such as intraoperative extradural injection causes epidural abscess with pace of 1 in 2000 cases , but on the perverse placement of epidural catheter has a high rate of epidural abscess like 4.3 cases in 100 cases .
Rate of extradural abscess in hospital entrance fee has increased in last 20 geezerhood . One of the main reason for increased abscess rate is because of increased rate of invasive procedures . In U.S. , increase was from 0.5 to 1 lawsuit per 10,000 infirmary admissions to 2.5 to 3 case per 10,000 admission fee .
Eighty percent of spinal epidural abscess are determine in thoracic and lumbar domain , while cervical extradural abscess report for approximately 20 % of typeface . In various epidemiologic studies , diabetes was found to be most common jeopardy element with happening rate of 18 to 54 % cases and second most common risk factor was intravenous drug abuse with occurrence rate of 7 to 40 % . In some studies , 10 % of cases had history of trauma a short full point prior to abscess growth . Trauma may have caused local extension of contagion or haematological spread from hematoma triggered by trauma and got infect .
Classification and Types of Epidural Abscess
Classification of epidural abscess :
Pathophysiology of Epidural Abscess
Epidural abscess may be located in spinal canal or within skull . Cerebral abscess can be life threatening depend on size of it and volume . Abscess may be as a result of staphylococcus aureus bacterium as a most common pathogen . S. aureus bacterial infection is find in infected pocket of gimmick and in hospital infections such as MRSA abscess . Other bacterial infection are Pseudomonas , E. Coli , Brucella and Mycobacterium TB . Rarely in a few cases the cause of abscess is found to be fungus contagion .
Pathophysiology of Cerebral Epidural Abscess:
intellectual epidural abscess is a rare but potentially lifetime - threatening disease that requires other catching and immediate management . It is defined as an rubor that involves a collection of pus between the dura ( the tabu membrane that covers the brain ) and the bones of the skull . Cerebral extradural abscess can have increased intracranial pressure and ischaemic changes of critical center of brain stem and subcortical nucleus . Space between dura and skull is minute and verboten enlargement is limit by thick skull . If abscess developed , the expansion is within the brain tissue and results in other clinical symptoms . temperate sized abscess can be life history threatening . Abscess organisation depends on local infection and spread from other sources as identify in suit and risk factor .
Pathophysiology of Spinal Epidural Abscess:
Spinal Epidural blank space is outside dura affair . Dura is attached to foramina magnum at cephalic final stage . rightful epidural space is discover only on sidelong and posterior side of spinal channel . The epidural quad is widest in sacral dermatome and narrow in cervix . Spinal extradural abscess in most cases diffuse in caudal and cephalic steering . Enlarged spinal extradural abscess induce contraction or ischemia of spinal cord . As abscess expands , the pressure is transferred to bloodline vessel , nerves , and spinal cord .
Spinal electric cord receives blood from three longitudinal arterial blood vessel call off anterior spinal arteria and two later spinal arteries . In plus , there are several other small arteries ramify from wall arterial supply spinal anesthesia corduroy . Ischemic changes of spinal cord are condensation of these arteria by massive abscess in extradural space . Alternatively , ischaemic change are also occurring following intercalation or thrombosis of these arterial vessels . imperativeness or ischaemia of mettle in foramina causes segmented neurological stultification causing segmented sensory or motor deficiency . ischaemia or severe insistency of spinal cord in thoracic or lumbar segment will be clinically show as paraplegia . Cervical epidural abscess can return increase press over spinal corduroy in neck and start symptom of quadriplegia .
Abscess may broadcast several horizontal surface of vertebral column require multi storey laminectomy operating theatre . Most vulgar causal agency of spinal abscess is hematologic spread from inveterate mastoiditis , boil , fuzz follicle infection , meningitis , osteomyelitis and otitis media . Most of the spinal extradural abscess occurs in thoracic epidural outer space . extradural abscess may be direct spread of infection from osteomyelitis in adults and children . In majority of display case , knockout spinal electric cord accidental injury was observed secondary to compression of line vessel and ischemia rather than pressure from mass issue . The accurate chemical mechanism of injury either by compaction of spinal cord or ischaemia remains controversial . Recovery after surgery is prolonged and may cease with some sensory and motor neurological deficiency . wound to spinal corduroy is often petty to thrombosis of leptomeningeal vessel and spinal artery than compression of spinal cord .
When intracranial extradural abscess is unite with a subdural empyema , as is often the showcase , the class is compressed .
Causes and Risk Factors of Epidural Abscess
Causes of Spinal and Cerebral Epidural Abscess:
Direct Extension – 30 % of abscess by direct cattle farm .
Example :
Hematogenous Spread – 50 % of abscess can be multilevel and noncontiguous .
Invasive Procedure – 20 % of abscess acquaint by invasive procedures .
Risk Factors of Epidural Abscess
Signs and Symptoms of Epidural Abscess
gender – More common in male than in females .
years – Spinal epidural abscess is most vulgar in working eld between 50 and 60 years . Cerebral extradural abscess is common between historic period 20 and 30 years .
General Symptoms of Epidural Abscess(2 ):
Signs and Symptoms of Cerebral Epidural Abscess
symptom of Cerebral Epidural Abscess
signaling of Cerebral Epidural Abscess
Early symptoms of Cerebral Epidural Abscess
Signs and Symptoms of Spinal Epidural Abscess
Onset of early symptoms usually occurs within hours to days . If initial symptom are disregard , later symptoms such as painfulness , headache , sickness and emesis become continuing . The classic diagnostic triad of fever , spinal pain , and neurological deficit is present in only 10 to 15 % of cases at first physician contact and must not be relied on for diagnosing .
symptom of Spinal Epidural Abscess
house of Spinal Epidural Abscess
former Symptoms of Spinal Epidural Abscess
consecutive progression of symptom if untreated – 4 stages . Progression come rapidly , and symptoms may skip or overlap .
Prognosis of Epidural Abscess
Prognosis depends on other diagnosis . meek to moderate symptoms are ignored and treated with medicinal drug available on pharmacy ledge . former diagnosis and investigation serve to plow disease appropriately with appropriate treatment . result of early diagnosis and treatment is extremely good . Late treatment after established symptom such as apathy , weakness and palsy and numbness may prevent mortality , but the patient may sustain numbness , weakness or paraplegia .
Complications of Epidural Abscess
Complications of Cerebral Epidural Abscess:
Complications of Spinal Epidural Abscess:
Mortality/Morbidity:
intellectual extradural abscess is much less common than spinal epidural abscess . Present mortality rate of spinal epidural abscess is 2 to 20 % as described in different studies . Prior to World War II , several deceased patients were undiagnosed of spinal and cerebral epidural abscess . Many of these patient role had PM and regain to have pregnant epidural abscess . Over last 40 years , symptomatic modalities for epidural abscess have better with MRI , CT scan and myelogram . Mortality rate has reduced significantly ( 2 to 20 % ) during last 30 to 40 years .
Mortality pace is high in immunosuppressed patients . Morbidity and fatality rate is also greater if patient has underlie multiple risk of infection factors . other diagnosis and timely early discourse has reduce mortality . Morbidity and mortality rate is high if at the meter of diagnosing affected role has developed sensory and motor deficiency .
Differential Diagnoses for Epidural Abscess
Differential Diagnoses for Cerebral Epidural Abscess:
Differential Diagnoses for Spinal Epidural Abscess:
Tests to Diagnose Epidural Abscess
Tests may include :
Treatment for Epidural Abscess
The end of treatment is to cure the contagion and shorten the risk of lasting legal injury .
Antibiotics for Epidural Abscess:
Percutaneous Drainage of Abscess:
Surgery for Epidural Abscess:
Conservative Treatment for Epidural Abscess:
Corticosteroid Therapy for Epidural Abscess:
References :
