Spinal epidural abscess

Spinal epidural abscess

Spinal infection in the epidural space.

Epidemiology

Spinal epidural abscess epidemiology.

Classification

It is possible to distinguish two types of SEA: primary SEA due to pathogen hematogenous dissemination and secondary SEA resulting from direct inoculation of pathogen. This entity, very uncommon, shows a prevalence peak between the 5th and the 7th decade of life with predominance in males 1).

see Cervical spinal epidural abscess.

see Lumbar spinal epidural abscess.

Etiology

Spinal epidural abscess etiology.

Pathophysiology

Spinal epidural abscess pathophysiology.

Clinical features

Spinal epidural abscess clinical features.

Diagnosis

Spinal epidural abscess diagnosis.

Differential diagnosis

Spinal epidural abscess differential diagnosis.

Treatment

Spinal epidural abscess treatment.

Outcome

Spinal epidural abscess outcome.

Case series

Spinal epidural abscess case series.

Case reports

Spinal epidural abscess case reports.

1)

Maiese A, Volonnino G, Viola RV, Nelson Cavallari E, Fazio V, Arcangeli M, La Russa R. A rare case of Spinal Epidural Abscess following mesotherapy: a challenging diagnosis and the importance of clinical risk management. Considerations concerning uncommon risk factor for development of Spinal Epidural Abscess and its prevention. Clin Ter. 2020 Jan-Feb;170(1):e15-e18. doi: 10.7417/CT.2020.2183. PubMed PMID: 31850479.

Intraoperative ultrasound for intradural spinal tumor

Intraoperative ultrasound for intradural spinal tumor

Intraoperative ultrasound is a valuable tool to detect spinal tumors, evaluate the surgical approach and plan the surgical strategy considering the position and relationships of the lesion with bony, neural and vascular structures 1).

Surgeons should consider the use of intraoperative ultrasound when approaching intradural spinal tumor or when addressing pathology ventral to the thecal sac via a posterior approach 2).

Three-dimensional intraoperative ultrasound for intradural spinal tumor

see Three-dimensional intraoperative ultrasound for intradural spinal tumor


In 69 intradural spinal tumors, operated on between 2012 and 2016. A 5-8 MHz probe of IOUSG was used, before and after durotomy to perform the exact durotomy and myelotomy, and after tumor resection, to detect a residual tumor. A retrospective review of parameters including demographic data, localization, and histopathology of the tumor, IOUSG findings, and the amount of tumor resection was made.

In a total of 69 intradural spinal tumors (42 extramedullary, and 27 intramedullary tumors) IOUSG was used during surgery. Total excision was performed in 68 cases, and subtotal excision in one case. Pre-durotomy IOUSG showed sufficient laminectomy in 62 cases. In 7 cases, as the IOUSG failed to show all borders of the tumor, laminectomy was extended.

IOUSG is an important tool, which contributes to intradural spine surgery. This modality shows the tumor appearance before durotomy and is therefore helpful in deciding the amount of laminectomy and durotomy in addition to the exact location of myelotomy. It also provides the surgeon with information about residual tumor after excision, thereby increasing the safety and success of the surgical procedure 3).


From January to July 2016, Stefini et al. performed 10 navigated procedures for intradural spinal tumors by merging MRI and 3-D fluoro images. Nine patients had an intradural extramedullary tumor, 6 had neurinomas, and 3 had meningiomas; 1 patient had an intramedullary spinal cord metastasis. : The surgically demonstrated benefits of spinal navigation for the removal of intradural tumors include the decreased risk of surgery at the wrong spinal level, a minimal length of skin incision and muscle strip, and a reduction in bone removal extension. Furthermore, this technique offers the advantage of opening the dura as much as is necessary and, in the case of intrinsic spinal cord tumors, it allows the tumor to be centered. Otherwise, this would not be visible, thus enabling the precise level and the posterior midline sulcus to be determined when performing a mielotomy 4).


A total number of 158 intradural spinal lesions were operated on using iUS. Of these, 107 lesions (68%) were intradural extramedullary and 51 (32%) were intramedullary. All lesions were clearly visible using the ultrasound probe. The high-frequency linear probes (10-12 MHz) provided a better image quality compared with lower-frequency probes. Color and power-angiography modes were helpful in assessing the vascularization of the tumors and location of the major vessels in the vascular lesions.

Ivanov et al. documented how iUS was used to facilitate safe and efficient spinal tumor resection at each stage of the operation. iUS was beneficial in confirmation of tumor location and extension, planning myelotomy, and estimation of degree of resection of the intramedullary tumors. It was particularly helpful in guiding the approach in redo surgeries for recurrent spinal cord tumors.

iUS has a fast learning curve and offers additional intraoperative information that can help improve surgical accuracy and therefore may reduce procedure-related morbidity 5).


Twenty-six patients with intradural spinal cord tumors were surgically treated under intraoperative ultrasonographic guidance between January 2007 and May 2011. Guidance with IOUSG was used in 26 patients, of which 14 fourteen had extramedullary and 12 had intramedullary tumors. Intraoperative ultrasound assistance was used to localize each tumor exactly before opening the dura. The extent of tumor resection was verified using axial and sagittal sonographic views. The extent of tumor resection achieved with IOUSG guidance was assessed on postoperative early control MRI sections.

Total tumor resection was achieved in 22 (84%) of 26 cases. All of the residual tumors were typically intramedullary and infiltrative. The sensitivity of IOUSG for the determination of the extent of resection was found to be 92%. Ultrasonography was found to be effective in identification of tumor boundaries and protection of spinal cord vessels. The average time spent for IOUSG assessment was 7 minutes.

Intraoperative ultrasonography is practical, reliable and highly sensitive for spinal cord surgery. It not only enhances surgical orientation, but also reduces morbidity and helps to resect the tumor completely 6).


Between January 2006 and July 2007, 30 patients with suspected intradural spinal tumours underwent surgery with the aid of IOUS. There were 13 patients with intramedullary tumours (ependymoma=2, astrocytoma=5, hemangioblastoma=2 and metastasis=4); and 14 patients with extramedullary tumours (meningioma=6, neurinoma=6, filum terminale ependymoma=1 and lipoma=1). In 3 patients histopathology did not reveal any neoplasm despite an MRI suggesting tumour. Their sonographic features are analyzed and the advantages of IOUS are discussed.

The shape and expansion of intradural tumours could be visualized on IOUS. The sonographic visualization allowed adapting the approach to an appropriate location and size before dura opening. Certain sonographic features can be used for a differential diagnosis of different intradural tumours. In addition, IOUS can inform neurosurgeons about the location of the neoplastic tissue, its relation to the spinal cord and the size of residual tumour following excision.

IOUS is a sensitive intraoperative tool. When appropriately applied to assist surgical procedures, it offers additional intraoperative information that helps to improve surgical precision and therefore might reduce the procedure related morbidity 7).


From 1997 to 9/2002 32 patients with the diagnosis of an ependymoma (n = 9), astrocytoma (n = 5), haemangioblastoma (n = 5), neurinoma (n = 4), meningeoma (n = 4) and filum terminale ependymoma (n = 5) were investigated by intraoperative transdural sonography. The sonographic results were correlated to the preoperative MRI-findings and histopathological work-up.

Intramedullary tumours characteristically present with a heterogenous morphology, sometimes carrying intralesional or perilesional cysts. The tumour margins are frequently poorly defined, and there is a perifocal oedema. Extramedullary tumours frequently display a homogenous signal intensity, well defined tumour margins and the abscence of perifocal oedema. Haemangioblastomas turned out to be a specific sonographic entity among intramedullary tumours, as they most often contain only a cystic part with a small tumour nodule. IOUS influenced the surgical approach as laminotomy has to be extended in 7/32 cases to reach the tips of the tumour.

The precision of surgical exposure of intradural spinal lesions can be optimised by IOUS which shows a high correlation with MRI characterizing extra- and intramedullary tumours. Using IOUS, the exact position of the laminectomy/laminotomy can be adapted to the true extent of the tumour, thus avoiding the necessity of further bone work in the case of the frequently oedematous spinal cord protruding through the opening in the dura. Overall, IOUS guidance can help to reduce postoperative morbidity in surgery for all spinal intradural lesions 8).

References

1)

Prada F, Vetrano IG, Filippini A, Del Bene M, Perin A, Casali C, Legnani F, Saini M, DiMeco F. Intraoperative ultrasound in spinal tumor surgery. J Ultrasound. 2014 Jun 7;17(3):195-202. doi: 10.1007/s40477-014-0102-9. eCollection 2014 Sep. PubMed PMID: 25177392; PubMed Central PMCID: PMC4142127.
2)

Vasudeva VS, Abd-El-Barr M, Pompeu YA, Karhade A, Groff MW, Lu Y. Use of Intraoperative Ultrasound During Spinal Surgery. Global Spine J. 2017 Oct;7(7):648-656. doi: 10.1177/2192568217700100. Epub 2017 May 31. PubMed PMID: 28989844; PubMed Central PMCID: PMC5624373.
3)

Haciyakupoglu E, Yuvruk E, Onen MR, Naderi S. The Use of Intraoperative Ultrasonography in Intradural Spinal Tumor Surgery. Turk Neurosurg. 2019;29(2):237-241. doi: 10.5137/1019-5149.JTN.23296-18.3. PubMed PMID: 30649794.
4)

Stefini R, Peron S, Mandelli J, Bianchini E, Roccucci P. Intraoperative Spinal Navigation for the Removal of Intradural Tumors: Technical Notes. Oper Neurosurg (Hagerstown). 2018 Jul 1;15(1):54-59. doi: 10.1093/ons/opx179. PubMed PMID: 28962027.
5)

Ivanov M, Budu A, Sims-Williams H, Poeata I. Using Intraoperative Ultrasonography for Spinal Cord Tumor Surgery. World Neurosurg. 2017 Jan;97:104-111. doi: 10.1016/j.wneu.2016.09.097. Epub 2016 Oct 3. PubMed PMID: 27713065.
6)

Toktas ZO, Sahin S, Koban O, Sorar M, Konya D. Is intraoperative ultrasound required in cervical spinal tumors? A prospective study. Turk Neurosurg. 2013;23(5):600-6. doi: 10.5137/1019-5149.JTN.7199-12.1. PubMed PMID: 24101306.
7)

Zhou H, Miller D, Schulte DM, Benes L, Bozinov O, Sure U, Bertalanffy H. Intraoperative ultrasound assistance in treatment of intradural spinal tumours. Clin Neurol Neurosurg. 2011 Sep;113(7):531-7. doi: 10.1016/j.clineuro.2011.03.006. Epub 2011 Apr 20. PubMed PMID: 21507563.
8)

Regelsberger J, Langer N, Fritzsche E, Westphal M. [Intraoperative ultrasound of intra- and extramedullary tumours]. Ultraschall Med. 2003 Dec;24(6):399-403. German. PubMed PMID: 14658083.

Spinal angiography

Spinal angiography

Similar to angiography of the brain, where a catheter is placed into an artery supplying the brain parenchyma, such as internal carotid or vertebral artery, and contrast material injected to directly visualize brain arteriovenous system, — spinal angiography accomplishes the same goal for arteries which supply the spine and paraspinal regions.

There are usually 31 vertebrae in the body, and most have 1 or 2 individual arteries feeding them. Which means that spinal angiography can be a long procedure, if the entire spine vasculature needs to be visualized.

That is not always the case. However, because of the length of procedure, and because the arteries and veins of the spine tend to me much smaller than of the brain, spinal angiography is usually done under anesthesia. This minimizes movement of the patient, which degrades imaging, and allows for control of breathing and peristalsis (movement of the bowel). The less movement, the better. The procedure is as follows: the patient is placed under anesthesia, a catheter is introduced into the aorta, usually via the artery in the groin called femoral artery, and various catheters are used to individually catheterize spinal arteries, one by one, taking x-ray pictures of each. Depending on the disease process, several or dosens need to be viewed. Once angiography is completed, the catheter is withdrawn, groin access site closed by compression or deployment of special closure devices, and patient woken up. Sometimes, both angiography and actual treatment of the condition in question can be carried out at the same time.

Spinal angiography is more specialized than even brain angiography. Many places which are comfortable with brain angiography may not be as versed in spinal procedures, depending on disease 1).


Contrast-enhanced MR angiography (MRA) has been increasingly used in the evaluation of spinal vascular malformations. Even though MR spinal angiography has several advantages over catheter spinal angiography (DSA), however, spinal DSA must never be omitted before operation, even if the vascular malformation is nicely demonstrated by MR angiography.

Sharma et al. report a case of spinal vascular malformation in which MR angiography provided great images which almost convinced everyone about the type and site of malformation/fistula. The images were so convincing that it was almost decided to skip catheter based angiography, citing reason of disadvantages of catheter based angiography over MR angiography. However, spinal DSA was luckily done which completely changed the type and site of malformation and helped in avoiding failed surgery. They conclude that even though catheter based spinal angiography has disadvantages over MRA, it should never be omitted from the diagnostic protocol 2).

Indications

Spinal angiography: rarely indicated for intramedullary spinal cord tumors, except in spinal cord hemangioblastoma (maybe suspected on myelography or MRI by linear serpiginous structures). MRI often obviates this test.

Spinal Angiography for Spinal Vascular Malformation

Spinal Angiography for vertebral hemangioma

Contraindications

Thoracic aortic aneurysm (relative)

References

2)

Sharma AK, Westesson PL. Preoperative evaluation of spinal vascular malformation by MR angiography: how reliable is the technique: case report and review of literature. Clin Neurol Neurosurg. 2008 May;110(5):521-4. doi: 10.1016/j.clineuro.2008.02.005. Epub 2008 Mar 21. Review. PubMed PMID: 18358597.

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