脊髓硬膜外脓肿

Sonia Teufack
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引用次数: 0

摘要

尽管神经外科疾病的诊断和治疗取得了进展,脊髓硬膜外脓肿(SEA)仍然具有挑战性。诊断是复杂的,治疗是有争议的,潜在的不良后果是显著的。每10 000名住院病人中就有2人患有东南亚性贫血,这一发病率在过去20年里翻了一番。造成这种情况的原因可能包括人口老龄化、静脉注射药物使用增加以及血管和脊柱手术数量的增加。SEA可能由潜在的医疗状况引起,如糖尿病、酗酒、慢性阻塞性肺疾病(COPD)或艾滋病毒感染。SEA的基因座可由其他脊柱异常或先前的侵入性脊柱手术形成,包括硬膜外、神经阻滞或类固醇注射。全身性感染的来源可能包括血管导管、静脉用药或慢性尿路感染。脊髓硬膜外感染的50%为血源性,30%来自皮肤或结缔组织,20%未分类。常见的病原体包括金黄色葡萄球菌和铜绿假单胞菌。15%至40%的SEA可能是由MRSA引起的。在脊柱外伤或脊柱手术的病例中,表皮葡萄球菌也可能是一种病原体。79%的SEA出现在脊髓背侧。对这一发现的一种可能的解释是硬膜外空间的最大范围位于神经根的后方。21%出现在前方,常伴有椎间盘炎和/或骨髓炎。在SEA病例中获得正确诊断可能具有挑战性。50%的硬膜外脊髓脓肿最初被误诊。最常见的症状是背部疼痛,高达85%的患者出现背痛。高达50%的人出现发烧。较不常见的症状是感觉异常、感觉缺陷、神经根性疼痛或运动缺陷。SEA可在合并症增加的患者中自发发生。在术后患者中,SEA可能需要数天至数周才能出现。背侧SEA是由背侧硬膜外脂肪的自发播散引起的。随着脓肿的扩大,可能出现神经压迫。相反,腹侧SEA可能是由于腹侧硬膜外脂肪的自发播散或椎间盘间隙的播散,并继发延伸到腹侧硬膜外间隙。腹侧SEA在出现神经功能缺陷之前更有可能出现全身性症状(如发热、败血症)。诊断SEA的最佳方法是在怀疑的情况下接近高危患者。在某些病例中,神经学检查可能有助于确定脊髓受累程度。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Spinal Epidural Abscesses
Despite advances in the diagnosis and treatment of neurosurgical diseases, spinal epidural abscesses (SEA) remain challenging. The diagnosis is complex, treatments are controversial, and the potential for adverse outcomes is significant. SEA accounts for 2 of every 10,000 of hospital admissions, an incidence which has doubled in the past twenty years. Reasons which may account for this include an aging population, increased IV drug use, and increase in number of vascular and spinal procedures. SEA can arise from an underlying medical condition, such as diabetes mellitus, alcoholism, chronic obstructive pulmonary disease (COPD), or HIV infection. Loci for SEA can be formed by other spinal abnormalities or by prior invasive spinal procedures, including epidurals, nerve blocks, or steroid injections. Sources for systemic infection may include vascular access catheters, IV drug use, or chronic UTI. 50% of spinal epidural infections have hematogenous origin, 30% arise from the skin or connective tissue, and 20% are unclassified. Common pathogens include S. aureus and P. aeruginosa. From 15% to 40% of SEA may be due to MRSA. In cases of spine trauma or spinal surgery, S. epidermidis may also be a pathogen. 79% of SEA appear dorsal to the spinal cord. A possible explanation for this finding is that the largest extent of the epidural space lies posterior to the nerve roots. The 21% that appear anterior are often associated with vertebral discitis and/ or osteomyelitis. Achieving correct diagnosis in cases of SEA may be challenging. 50% of epidural spinal abscesses are initially misdiagnosed. The most common presenting symptom is back pain, present in up to 85% of patients. Fever is present in up to 50%. Less common symptoms are paresthesias, sensory deficits, radicular pain, or motor deficits. SEA can occur spontaneously in patients with increased co-morbidi-ties. In post-operative patients, SEA may take days to weeks to appear. A dorsal SEA results from the spontaneous seeding of the dorsal epidural fat. As the abscess enlarges, neural compression may occur. Conversely, a ventral SEA may result from either spontaneous seed-ing of the ventral epidural fat or seeding of the disc space with secondary extension into the ventral epidural space. A ventral SEA is more likely to present with systemic symptoms (i.e., fevers, septicemia) prior to presentation of neurological deficits. The best way to diagnose SEA is to approach high-risk patients with suspicion. The neuro-logical exam may aid in localizing the level of spinal involvement in cases …
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