Epidural abscess surgery: Difference between revisions
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'''Video | '''Video courtesy of Peyman Pakzaban ''' | ||
==References== | ==References== | ||
Revision as of 14:37, 2 April 2014
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Epidural abscess Microchapters |
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Epidural abscess surgery On the Web |
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American Roentgen Ray Society Images of Epidural abscess surgery |
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Risk calculators and risk factors for Epidural abscess surgery |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]
Overview
An epidural abscess is a rare suppurative infection of the central nervous system, a collection of pus localised in the epidural space, lying outside the dura mater, which accounts for less than 2% of focal CNS infections. [1] It may occur in two different places: intracranially or in the spinal canal. Due to the fact that the initial symptoms and clinical characteristics are not always identical and are similar to other diseases, along with the fact that they are both rare conditions, the final diagnosis might be delayed in time. This late diagnosis comes at great cost to the patient, since it is usually accompanied by a bad prognosis and severe complications, with a potential fatal outcome. According to the location of the collection, the abscess may have different origins, different organisms involved, symptoms, evolutions, complications and therapeutical techniques. [2] The treatment of epidural abscess focuses in two main aspects: reduction of the inflammatory mass and eradication of the responsible organism. These goals can be reached through a combination of medical and surgical approaches. An early surgical decompression and drainage, along with an aggressive antibiotic treatment is the ideal procedure to increase the chances of a better outcome.
Surgery
Several studies have reached the conclusion that the best approach to therapy of epidural abscess, either intracranial or spinal, is a combination of surgical drainage along with prolonged systemic antibiotics (6-12 weeks, IV followed by PO). [3] Due to the importance of preoperative neurologic status, along with the unpredictable progression of neurologic impairment, for the neurological outcome of the patient, decompressive laminectomy and debridement of infected tissues, in the case of SEA, and burr hole placement or craniotomy, in the case of IEA, should take place as early as possible. [4][5]
Intracranial Epidural Abscess
The standard treatment of intracranial epidural abscess consists in surgical drainage, followed by antibiotic therapy. The surgical drainage of the infected material in the cranial epidural space may be performed by several techniques, namely: craniotomy or craniectomy, which are the preferred approaches, or by burr hole placement or aspiration through the scalp.[6]
- Burr hole placement
In the burr hole placement technique, a previous imaging study accurately localizes the collection of pus to be evacuated. It is indicated in the evacuation of the empyema in patients in septic shock or parafalcine empyemas, or 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 the craniotomy procedure and may also lead to secondary injury of the cortex, which might exacerbate the infection. [7][8]
- Craniotomy
A wide craniotomy with irrigation is the surgical procedure of choice, since it allows a wide exposure of the area, adequate exploration, better evacuation of the infected material and decompression of the underlying cerebral hemisphere, thereby improving the outcome. [9][10] Craniotomy is also the indicated surgical procedure in the presence of large or multiloculated infections and empyemas refractory to drainage by burr hole or stereotactic aspiration. [10] A possible complication of craniotomy is the higher probability of damage to the bridging veins during the procedure.
Spinal Epidural Abscess
Patients presenting with spinal epidural abscess, complicated with neurologic deficits, require prompt surgical drainage and decompression, to avoid long-term neurologic damage. Depending on the location and extent of the abscess, the surgical procedure might be: laminectomy, hemilaminectomy or interlaminar fenestration. One approach to the abscess is surgery with decompression of most affected area of the spinal cord, with removal of the pus or granulation tissue. [11]
- Laminectomy
Surgical technique in which the lamina of the vertebra is removed, to widen the spinal canal, thereby creating more space for the spinal nerves. It can be used to treat spinal stenosis, by relieving pressure on the spinal cord, or for the drainage of epidural abscesses compressing the cord.
- Hemilaminectomy
Surgical technique in which part of the vertebral lamina is removed, thereby allowing for decompression of nerve roots, as well as access to the epidural space. This also allows the drainage of abscesses in this space.
- Interlaminar Fenestration
Surgical technique in which a "window" or "fenestra" is opened between laminae in order to gain access to the epidural space. This will allow the drainage of abscesses in this space.
Below is a video demonstrating L4 laminotomy for surgical evacuation of ventral epidural abscess
{{#ev:youtube|Vw2KF9wn6aM}}
Video courtesy of Peyman Pakzaban
References
- ↑ Longo, Dan L. (Dan Louis) (2012). Harrison's principles of internal medici. New York: McGraw-Hill. ISBN 978-0-07-174889-6.
- ↑ Danner, R. L.; Hartman, B. J. (1987). "Update of Spinal Epidural Abscess: 35 Cases and Review of the Literature". Clinical Infectious Diseases. 9 (2): 265–274. doi:10.1093/clinids/9.2.265. ISSN 1058-4838.
- ↑ Grewal, S. (2006). "Epidural abscesses". British Journal of Anaesthesia. 96 (3): 292–302. doi:10.1093/bja/ael006. ISSN 0007-0912.
- ↑ Darouiche, Rabih O. (2006). "Spinal Epidural Abscess". New England Journal of Medicine. 355 (19): 2012–2020. doi:10.1056/NEJMra055111. ISSN 0028-4793.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 10.0 10.1 Greenlee JE (2003). "Subdural Empyema". Curr Treat Options Neurol. 5 (1): 13–22. PMID 12521560.
- ↑ 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.