Sir,
Spinal epidural abscess is a dreaded complication of epidural analgesia.[1] Early diagnosis and prompt treatment is crucial.
A 29-year-old male patient diagnosed with periampullary carcinoma was planned for laparotomy. An Epidural catheter was inserted preoperatively in the D6–D7 space, with strict asepsis. Postoperatively, epidural analgesia was continued using elastomeric pump (0.1% bupivacaine and 10 μg/mL morphine sulphate) at 8 mL/h. The preparation of anaesthetic solution for the disposable balloon pump was done using aseptic precautions. On day 3, a temperature of 100°F was noted. As a hospital policy, all catheters are removed on day 4. As pain, tenderness and minimal pus were present at the catheter site, a swab was collected from around the insertion site at removal. Injection amoxicillin-clavulanate 1.2 g was administered intravenously every 8 h. As fever continued, injection meropenem 1 g intravenously 8 hourly was started. Computerised tomography of the abdomen did not show any infection. The epidural site remained tender, erythematous [Figure 1] and incision and drainage was done on 7th postoperative day. Minimal pus was drained, the infection was adjudged to be superficial. The patient had backache with no radicular or meningeal signs, which settled in 24 h. Over the next 72 h, the patient was afebrile with persistent leucocytosis [Table 1]. Skin swab culture grew methicillin-resistant Staphylococcus aureus. In view of clinical improvement, the patient was discharged home on day 10. As per protocol, the patient was educated about the early signs of epidural abscess and given an information leaflet with an emergency contact number.
Figure 1.
Infection at epidural catheter site as seen on postoperative day 4 and day 7
Table 1.
Serial white blood cell counts at various time intervals
On day 11, the acute pain service was contacted by a relative reporting that the patient had developed acute-onset weakness of lower limbs, with urinary retention. The patient reported back to the hospital. Physical examination revealed bilateral sensory and motor loss below L1. Magnetic resonance imaging of the spine showed an epidural abscess causing cord compression from D2 to D6, [Figure 2]. Emergency decompression was performed within 6 h and the patient was started on injection dexamethasone 4 mg intravenously 8 hourly for 48 h, and injection vancomycin 500 mg 12 hourly for 14 days. The patient made a good neurological recovery in 72 h and was eventually discharged. On follow-up, he had no residual motor weakness or bladder/bowel dysfunction.
Figure 2.
Magnetic resonance imaging plate of patient showing extradural lesion from 2nd to 6th thoracic spine (A - anterior, P - posterior)
Epidural space infection may occur during catheter insertion or subsequently due to skin contamination, haematological or intraluminal routes.[2] In this case, skin contamination and spread to the epidural space was the probable cause. As a hospital policy, in all cases along with the skin swab, the epidural catheter tip is also sent for culture. This was missed in this case. However, a positive epidural catheter tip culture alone is not a reliable predictor of epidural space infection,[3] and the role of empirical extended antibiotic course to treat colonisation is unclear.[4] Our patient had fever and backache with no accompanying radicular signs, which subsided with symptomatic management. Six days later, he presented with paraparesis and urinary symptoms. The lesson learnt is that symptomatic improvement of backache, in the presence of catheter site infection, does not rule out spread of infection to deeper structures. Epidural abscesses usually present late and the signs and symptoms may not appear until after discharge.[2,5] It is, therefore, crucial to ensure that patients are informed and understand the early signs of epidural infection and report immediately. An information card explaining early signs of infection, instructions and emergency contact telephone numbers should be issued. The favourable neurological outcome in this case was linked to prompt reporting and timely intervention. We conclude that patient information regarding early symptoms of epidural abscess is essential and must be a part of pain protocols in institutes offering epidural analgesia.
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Conflicts of interest
There are no conflicts of interest.
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