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Year : 2000  |  Volume : 48  |  Issue : 2  |  Page : 181-3

Spinal extradural abscess following local steroid injection.


Department of Neurology, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad, 500082, India.

Correspondence Address:
Department of Neurology, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad, 500082, India.

  »  Abstract

A case of spinal extradural abscess following local steroid injection for back ache, in a 26 years old male is described. The abscess presented as a swelling externally. MRI localised the lesion to L2-S1 segments. Mechanism of such an infection has been discussed.

How to cite this article:
Kaul S, Meena A K, Sundaram C, Reddy J M, Naik R T, Murthy J M. Spinal extradural abscess following local steroid injection. Neurol India 2000;48:181


How to cite this URL:
Kaul S, Meena A K, Sundaram C, Reddy J M, Naik R T, Murthy J M. Spinal extradural abscess following local steroid injection. Neurol India [serial online] 2000 [cited 2020 Oct 29];48:181. Available from: https://www.neurologyindia.com/text.asp?2000/48/2/181/1548



A 26 year old man presented with complaints of headache, vomiting and increasing low backache of one week duration. One week before the onset of his present symptoms, he had received local injection of hydrocortisone in the lumbar region for chronic low backache. On examination he was febrile, pulse-100/mt and blood pressure-140/90 mmHg. Chest, cardiovascular and abdominal examination was normal. Neurological examination was unremarkable. He had positive meningeal signs. Plain skiagram of the lumbosacral spine was normal. Cerebrospinal fluid examination showed 20 cells/cumm, predominantly lymphocytes. CSF biochemistry was normal. No organism was grown. During the hospital stay his backache became more severe, local tenderness increased and small swelling appeared at the site of pain. Aspiration of the swelling revealed frank pus but no organisms could be grown. Magnetic resonance imaging (MRI) of the lumbar spine showed a lesion extending from L3 to S1 segment which was isointense in T1 weighted and hyperintense in T2 weighted, images [Figure.1]. Patient was subjected to L2-S1 laminectomy. The facet joints of L4/L5 level were found to be lax. The spinous process and lamina of L4 were removed. There was granulation tissue in the extradural plane and also few cavities filled with pus. Pus was evacuated and granulation tissue was excised. The histological examination of the material showed fragments of ligament, skeletal muscle, bony lamellae with marrow elements infiltrated with few neutrophils, eosinophils, lymphonuclear cells and foamy histocytes. All these features were consistent with a pyogenic abscess. Postoperatively patient was put on third generation cephalosporins and he made an uneventful recovery.
Extradural abscess following local injection of steroids is very rare.[7] Early diagnosis is important because of the need for urgent and aggressive management. Presentation of extradural abscess is highly variable and four stages are described: spinal pain; nerve root pain; weakness; and paralysis. Associated findings may include fever leukocytosis, increased sedimentation rate, alteration in reflexes, neck stiffness and headache.[8] Neurological deficit and fever may not be seen in all the cases but local pain is the most important symptom and is invariably present. Regarding the mechanism of formation of abscess, it has been proposed that following a needle insertion, a small haematoma may develop which acts as a site for bacterial growth. The infection may be transported from skin due to failure to observe asepsis during procedure. The injected substance may itself be contaminated. Spread may occur from an adjacent locally infected area such as rib, vertebral body or paraspinal muscle.[2] The most common organism cultured is Staphylococcus aureus but the spectrum of causative organisms is broadening.[9] At times, the organism may not be identified.[10] Associated immunosuppressive states like diabetes mellitus may contribute to the spread of infection.[11] Another hypothesis proposed in patients who receive local steroids is that the extradurally injected steroids can suppress the hypothalamic - pituitary - adrenocortical axis which may lead to immunosuppression predisposing to infection.[7] The mainstay of diagnosis is neuroimaging. Several reports have shown the superiority of magnetic resonance imaging (MRI) over myelography.[12] CT scan has proved useful when combined with myelography; more so to demonstrate associated osteomyelitis of the vertebrae.
Extradural abscess is a potentially treatable complication of a local injection particularly steroids, into the spine. It is a neuro surgical emergency but can masquerade as many other conditions. High degree of suspicion in appropriate clinical setting is essential to diagnose and treat this condition, before irreversible neurological deficit sets in.
 

  »   References Top

1.Baker AS, Ojemann RG, Swartz MN et al: Spinal epidural abscess. N Engl J Med 1975; 293: 463-468.   Back to cited text no. 1    
2.Walton J: Compression of spinal cord. Walton J (ed). In: Brain's diseases of nervous system. 9th edition. Great Britain. Oxford University Press 1985; 398-412.   Back to cited text no. 2    
3.Edward EB, Hingson RA: Present status of continuous caudal anaesthesia for obstetrics. Bull NY Acad Med 1943; 19: 507-518.   Back to cited text no. 3    
4.Fine PG, Hare BD, Zahniser JC: Epidural abscess following epidural catheterization in a chronic pain patient: A diagnostic dilemma. Anesthesiology 1988; 69: 422-424.   Back to cited text no. 4    
5.Loarie DS,Fairlie HB: Epidural abscess following spinal anesthesia. Anesth and Analg 1978; 57: 351-353.   Back to cited text no. 5    
6.Rustin MHA, Flynn MD, Coomes EN: Acute sacral epidural abscess. Postgrad Med J 1983; 59: 399-400.   Back to cited text no. 6    
7.Goucke CR, Graziotti P: Extradural abscess following local anaesthetic and steroid injection for chronic low back pain. Br J Anaesth 1990; 65: 427-429.   Back to cited text no. 7    
8.Verner EF, Musher DM: Spinal epidural abscess. Med Clin North Am 1985; 69: 375-384.   Back to cited text no. 8    
9.Curling OD jr, Gower DJ, McWhorter JM: Changing concepts in spinal epidural abscess. A report of 29 cases. Neurosurgery 1990; 27: 185-192   Back to cited text no. 9    
10.catheterization: A rare event? Report of two cases with markedly delayed presentation. Anesthesiology 1991; 74: 943-946.   Back to cited text no. 10    
11.Danner RL, Hartmann BS: Update of spinal epidural abscess: 35 cases and review of literature. Rev Inf Dis 1987; 9: 265-274.   Back to cited text no. 11    
12.Angtuaco EJC, McConnel JR, Chadduck WM et al: MR imaging of spinal epidural sepsis. AJNR 1987; 8: 879.   Back to cited text no. 12    

 

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