Epidural abscess surgery: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Epidural abscess}} | {{Epidural abscess}} | ||
{{CMG}} | {{CMG}} {{AE}} {{JS}}; {{AG}} | ||
==Overview== | ==Overview== | ||
A combination of surgical drainage and prolonged systemic [[antibiotics]] (6-12 weeks, IV followed by PO) is the mainstay of therapy for both intracranial and spinal epidural abscess.<ref name="Grewal2006">{{cite journal|last1=Grewal|first1=S.|title=Epidural abscesses|journal=British Journal of Anaesthesia|volume=96|issue=3|year=2006|pages=292–302|issn=0007-0912|doi=10.1093/bja/ael006}}</ref> Due to the importance of preoperative neurologic status, along with the unpredictable progression of neurologic impairment, for the neurological outcome of the patient, surgical therapy varies depending on the location of the abscess. In intracranial epidural abscess cases, [[burr hole]] placement or [[craniotomy]] should occur as early as possible. In spinal epidural abscess cases, decompressive [[laminectomy]] and [[debridement]] of [[infected]] tissues should occur as early as possible.<ref name="Darouiche2006">{{cite journal|last1=Darouiche|first1=Rabih O.|title=Spinal Epidural Abscess|journal=New England Journal of Medicine|volume=355|issue=19|year=2006|pages=2012–2020|issn=0028-4793|doi=10.1056/NEJMra055111}}</ref><ref name="pmid1359381">{{cite journal| author=Darouiche RO, Hamill RJ, Greenberg SB, Weathers SW, Musher DM| title=Bacterial spinal epidural abscess. Review of 43 cases and literature survey. | journal=Medicine (Baltimore) | year= 1992 | volume= 71 | issue= 6 | pages= 369-85 | pmid=1359381 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1359381 }} </ref> | |||
==Surgery== | ==Surgery== | ||
A combination of surgical drainage and prolonged systemic [[antibiotics]] (6-12 weeks, IV followed by PO) is the mainstay of therapy for either intracranial or spinal epidural abscess.<ref name="Grewal2006">{{cite journal|last1=Grewal|first1=S.|title=Epidural abscesses|journal=British Journal of Anaesthesia|volume=96|issue=3|year=2006|pages=292–302|issn=0007-0912|doi=10.1093/bja/ael006}}</ref> Due to the importance of preoperative neurologic status, along with the unpredictable progression of neurologic impairment, for the neurological outcome of the patient, surgical therapy varies depending on the location of the abscess. In intracranial epidural abscess cases, [[burr hole]] placement or [[craniotomy]] should occur as early as possible. In spinal epidural abscess cases, decompressive [[laminectomy]] and [[debridement]] of [[infected]] tissues should occur as early as possible.<ref name="Darouiche2006">{{cite journal|last1=Darouiche|first1=Rabih O.|title=Spinal Epidural Abscess|journal=New England Journal of Medicine|volume=355|issue=19|year=2006|pages=2012–2020|issn=0028-4793|doi=10.1056/NEJMra055111}}</ref><ref name="pmid1359381">{{cite journal| author=Darouiche RO, Hamill RJ, Greenberg SB, Weathers SW, Musher DM| title=Bacterial spinal epidural abscess. Review of 43 cases and literature survey. | journal=Medicine (Baltimore) | year= 1992 | volume= 71 | issue= 6 | pages= 369-85 | pmid=1359381 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1359381 }} </ref> | |||
===Intracranial Epidural Abscess=== | ===Intracranial Epidural Abscess=== | ||
In intracranial epidural abscess cases, either [[craniotomy]] or [[burr hole]] placement should occur as early as possible, followed by [[antibiotic]] therapy. [[Craniotomy]] is the preferred approach to [[surgical]] drainage of the [[infected]] material from the cranial [[epidural space]]. Alternatively, [[burr hole]] placement or [[aspiration]] through the scalp may be used to access the abscess.<ref name=Mandell>{{Cite book | last1 = Mandell | first1 = Gerald L. | last2 = Bennett | first2 = John E. (John Eugene) | last3 = Dolin | first3 = Raphael. | title = Mandell, Douglas, and Bennett's principles and practice of infectious disease | date = 2010 | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | isbn = 0-443-06839-9 | pages = }}</ref> | |||
*''' | |||
*'''[[Craniotomy]]''' | |||
*''' | A wide [[craniotomy]] with irrigation is the [[surgical]] mainstay for intracranial epidural abscess, as it allows a wide exposure of the area, adequate exploration, better evacuation of the [[infected]] material and decompression of the underlying [[cerebral hemisphere]], increasing chances of improved [[outcome]].<ref name="AgrawalTimothy2007">{{cite journal|last1=Agrawal|first1=Amit|last2=Timothy|first2=Jake|last3=Pandit|first3=Lekha|last4=Shetty|first4=Lathika|last5=Shetty|first5=J.P.|title=A Review of Subdural Empyema and Its Management|journal=Infectious Diseases in Clinical Practice|volume=15|issue=3|year=2007|pages=149–153|issn=1056-9103|doi=10.1097/01.idc.0000269905.67284.c7}}</ref><ref name="pmid12521560">{{cite journal| author=Greenlee JE| title=Subdural Empyema. | journal=Curr Treat Options Neurol | year= 2003 | volume= 5 | issue= 1 | pages= 13-22 | pmid=12521560 | doi= | pmc=|url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12521560 }} </ref> | ||
A possible [[complication]] of [[craniotomy]] is the higher probability of damage to the [[bridging veins]] during the procedure. | |||
*'''[[Burr hole]] placement''' | |||
In [[burr hole]] placement, a previous imaging study accurately localizes the collection of [[pus]] to be evacuated. [[Burr hole]] placement is generally performed for intracranial epidural abscess when the patient is considered too frail to undergo [[craniotomy]].<ref name="Hendaus2013">{{cite journal|last1=Hendaus|first1=Mohammed A.|title=Subdural Empyema in Children|journal=Global Journal of Health Science|volume=5|issue=6|year=2013|issn=1916-9744|doi=10.5539/gjhs.v5n6p54}}</ref> It is associated with a higher rate of recurrence of the [[empyema]], compared to [[craniotomy]]. Burr hole placement may also lead to secondary injury of the [[cortex]], possibly exacerbating the [[infection]].<ref name="Hendaus2013">{{cite journal|last1=Hendaus|first1=Mohammed A.|title=Subdural Empyema in Children|journal=Global Journal of Health Science|volume=5|issue=6|year=2013|issn=1916-9744|doi=10.5539/gjhs.v5n6p54}}</ref><ref name="pmid11564248">{{cite journal| author=Nathoo N, Nadvi SS, Gouws E, van Dellen JR| title=Craniotomy improves outcomes for cranial subdural empyemas: computed tomography-era experience with 699 patients. | journal=Neurosurgery | year= 2001 | volume= 49 | issue= 4 | pages= 872-7; discussion 877-8 | pmid=11564248 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11564248 }} </ref> | |||
===Spinal Epidural Abscess=== | ===Spinal Epidural Abscess=== | ||
In spinal epidural abscess cases, [[laminectomy]], [[laminotomy]], [[hemilaminectomy]], or interlaminar fenestration should occur as early as possible, followed by [[antibiotic]] therapy. Patients presenting with spinal epidural abscess require prompt [[surgical]] drainage and decompression to avoid long-term neurologic damage. The mainstay of therapy is dependent on the location of the abscess.<ref name=Mandell>{{Cite book | last1 = Mandell | first1 = Gerald L. | last2 = Bennett | first2 = John E. (John Eugene) | last3 = Dolin | first3 = Raphael. | title = Mandell, Douglas, and Bennett's principles and practice of infectious disease | date = 2010 | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | isbn = 0-443-06839-9 | pages = }}</ref> | |||
*'''Laminectomy''' | *'''[[Laminectomy]]''' | ||
Surgical technique in which the [[lamina]] of the [[vertebra]] is removed | [[Surgical]] technique in which the [[lamina]] of the [[vertebra]] is removed or trimmed to widen the [[spinal canal]], creating more space for the [[spinal nerves]]. | ||
*''' | *'''[[Laminotomy ]]''' | ||
Surgical technique in which part of the | [[Surgical]] technique in which the part of a lamina of the vertebral arch is removed in order to decompress the corresponding [[spinal cord]] and spinal [[nerve root]]s. | ||
The following video demonstrates L4 [[laminotomy]] for surgical evacuation of ventral [[epidural abscess]]:<ref name=SEALaminotomy> Video courtesy of YouTube, Dr. Peyman Pakzaban. https://www.youtube.com/watch?v=Vw2KF9wn6aM Accessed on November 20, 2015</ref> | |||
{{#ev:youtube|Vw2KF9wn6aM}} | {{#ev:youtube|Vw2KF9wn6aM}} | ||
''' | *'''[[Hemilaminectomy]]''' | ||
[[Surgical]] technique in which part of the [[vertebral]] [[lamina]] is removed, allowing for decompression of [[nerve root|nerve roots]], as well as access to the [[epidural space]]. This technique also allows the drainage of [[abscesses]] in this space. | |||
*'''Interlaminar Fenestration''' | |||
[[Surgical]] technique in which a gap is opened between [[laminae]] in order to gain access to the [[epidural space]]. This technique allows for the drainage of [[abscesses]]. | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
[[Category:Disease]] | [[Category:Disease]] | ||
[[Category:Neurology]] | [[Category:Neurology]] | ||
Latest revision as of 21:36, 29 July 2020
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]; Anthony Gallo, B.S. [3]
Overview
A combination of surgical drainage and prolonged systemic antibiotics (6-12 weeks, IV followed by PO) is the mainstay of therapy for both intracranial and spinal epidural abscess.[1] Due to the importance of preoperative neurologic status, along with the unpredictable progression of neurologic impairment, for the neurological outcome of the patient, surgical therapy varies depending on the location of the abscess. In intracranial epidural abscess cases, burr hole placement or craniotomy should occur as early as possible. In spinal epidural abscess cases, decompressive laminectomy and debridement of infected tissues should occur as early as possible.[2][3]
Surgery
A combination of surgical drainage and prolonged systemic antibiotics (6-12 weeks, IV followed by PO) is the mainstay of therapy for either intracranial or spinal epidural abscess.[1] Due to the importance of preoperative neurologic status, along with the unpredictable progression of neurologic impairment, for the neurological outcome of the patient, surgical therapy varies depending on the location of the abscess. In intracranial epidural abscess cases, burr hole placement or craniotomy should occur as early as possible. In spinal epidural abscess cases, decompressive laminectomy and debridement of infected tissues should occur as early as possible.[2][3]
Intracranial Epidural Abscess
In intracranial epidural abscess cases, either craniotomy or burr hole placement should occur as early as possible, followed by antibiotic therapy. Craniotomy is the preferred approach to surgical drainage of the infected material from the cranial epidural space. Alternatively, burr hole placement or aspiration through the scalp may be used to access the abscess.[4]
A wide craniotomy with irrigation is the surgical mainstay for intracranial epidural abscess, as it allows a wide exposure of the area, adequate exploration, better evacuation of the infected material and decompression of the underlying cerebral hemisphere, increasing chances of improved outcome.[5][6] A possible complication of craniotomy is the higher probability of damage to the bridging veins during the procedure.
- Burr hole placement
In burr hole placement, a previous imaging study accurately localizes the collection of pus to be evacuated. Burr hole placement is generally performed for intracranial epidural abscess when the patient is considered too frail to undergo craniotomy.[7] It is associated with a higher rate of recurrence of the empyema, compared to craniotomy. Burr hole placement may also lead to secondary injury of the cortex, possibly exacerbating the infection.[7][8]
Spinal Epidural Abscess
In spinal epidural abscess cases, laminectomy, laminotomy, hemilaminectomy, or interlaminar fenestration should occur as early as possible, followed by antibiotic therapy. Patients presenting with spinal epidural abscess require prompt surgical drainage and decompression to avoid long-term neurologic damage. The mainstay of therapy is dependent on the location of the abscess.[4]
Surgical technique in which the lamina of the vertebra is removed or trimmed to widen the spinal canal, creating more space for the spinal nerves.
Surgical technique in which the part of a lamina of the vertebral arch is removed in order to decompress the corresponding spinal cord and spinal nerve roots.
The following video demonstrates L4 laminotomy for surgical evacuation of ventral epidural abscess:[9]
{{#ev:youtube|Vw2KF9wn6aM}}
Surgical technique in which part of the vertebral lamina is removed, allowing for decompression of nerve roots, as well as access to the epidural space. This technique also allows the drainage of abscesses in this space.
- Interlaminar Fenestration
Surgical technique in which a gap is opened between laminae in order to gain access to the epidural space. This technique allows for the drainage of abscesses.
References
- ↑ 1.0 1.1 Grewal, S. (2006). "Epidural abscesses". British Journal of Anaesthesia. 96 (3): 292–302. doi:10.1093/bja/ael006. ISSN 0007-0912.
- ↑ 2.0 2.1 Darouiche, Rabih O. (2006). "Spinal Epidural Abscess". New England Journal of Medicine. 355 (19): 2012–2020. doi:10.1056/NEJMra055111. ISSN 0028-4793.
- ↑ 3.0 3.1 Darouiche RO, Hamill RJ, Greenberg SB, Weathers SW, Musher DM (1992). "Bacterial spinal epidural abscess. Review of 43 cases and literature survey". Medicine (Baltimore). 71 (6): 369–85. PMID 1359381.
- ↑ 4.0 4.1 Mandell, Gerald L.; Bennett, John E. (John Eugene); Dolin, Raphael. (2010). Mandell, Douglas, and Bennett's principles and practice of infectious disease. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0-443-06839-9.
- ↑ Agrawal, Amit; Timothy, Jake; Pandit, Lekha; Shetty, Lathika; Shetty, J.P. (2007). "A Review of Subdural Empyema and Its Management". Infectious Diseases in Clinical Practice. 15 (3): 149–153. doi:10.1097/01.idc.0000269905.67284.c7. ISSN 1056-9103.
- ↑ Greenlee JE (2003). "Subdural Empyema". Curr Treat Options Neurol. 5 (1): 13–22. PMID 12521560.
- ↑ 7.0 7.1 Hendaus, Mohammed A. (2013). "Subdural Empyema in Children". Global Journal of Health Science. 5 (6). doi:10.5539/gjhs.v5n6p54. ISSN 1916-9744.
- ↑ Nathoo N, Nadvi SS, Gouws E, van Dellen JR (2001). "Craniotomy improves outcomes for cranial subdural empyemas: computed tomography-era experience with 699 patients". Neurosurgery. 49 (4): 872–7, discussion 877-8. PMID 11564248.
- ↑ Video courtesy of YouTube, Dr. Peyman Pakzaban. https://www.youtube.com/watch?v=Vw2KF9wn6aM Accessed on November 20, 2015