EBM case discussionEBM case discussion

Intern: Intern: 陳泓廷陳泓廷Supervisor: Supervisor: 劉耿彰醫師劉耿彰醫師

Basic dataBasic data

Name: Name: 何招何招ID: Q201311259 ID: Q201311259 Gender: FemaleGender: FemaleAge: 69 yearAge: 69 year--old old Admission date: 2006/08/02Admission date: 2006/08/02

Chief complaintChief complaint

Fever, and back pain from three day Fever, and back pain from three day before admissionbefore admission

Present illnessPresent illness

69 69 y/oy/o woman with woman with 1> hypertension and heart disease 1> hypertension and heart disease

for years under regular control for years under regular control 2> degenerative arthritis of knees 2> degenerative arthritis of knees

7/28 severe lower back pain went to LMD7/28 severe lower back pain went to LMDfor analgesics but in vain for analgesics but in vain

7/29 the pain radiate to lower leg with7/29 the pain radiate to lower leg withsoreness and weakness soreness and weakness

Present illnessPresent illness

7/30 7/30 highthight fever up to 40 fever up to 40 celsiuscelsius degreedegree7/31 She visited 7/31 She visited ChiayiChiayi Christian hospitalChristian hospital

and UTI was diagnosed, antibioticsand UTI was diagnosed, antibioticswas given but high fever persistedwas given but high fever persisted

8/2 went to our ER for help8/2 went to our ER for help

Social History Social History

Occupation: nilOccupation: nilLiving condition: walking aid, cared at Living condition: walking aid, cared at

homehomePersonal habits:Personal habits:

cigarette smoking (cigarette smoking (--))alcoholic drinking (alcoholic drinking (--))betel nut chewing (betel nut chewing (--) )

Physical Examination & Local Physical Examination & Local findingfinding

General appearance: bedGeneral appearance: bed--ridden, ridden, poorly nourished patientpoorly nourished patientConsciousness: alert, GCS: E4V5M6Consciousness: alert, GCS: E4V5M6Vital signs: 36.7C, 81/min, 19/min, BP 116/76mmHgVital signs: 36.7C, 81/min, 19/min, BP 116/76mmHgHEENT: HEENT: scleralscleral icterusicterus, no throat injection , no throat injection Neck: supple, no bruit, no JVENeck: supple, no bruit, no JVEChest: no chest wall deformity, clear BSChest: no chest wall deformity, clear BSHeart: regular heart beats, no murmurHeart: regular heart beats, no murmurAbdomen: distended, hypoactive bowel soundsAbdomen: distended, hypoactive bowel sounds

no no hepatomegalyhepatomegaly, no ascites, no flank pain, no ascites, no flank painExtremities: lower limb numbnessExtremities: lower limb numbnessNeuromuscular: both lower limb weaknessNeuromuscular: both lower limb weaknessSkin: no open wound Skin: no open wound

LabLab

LabLab

Clinical courseClinical course

8/2 Due to severe back pain, persisted 8/2 Due to severe back pain, persisted high fever with progressed leg high fever with progressed leg weakness, she was admitted for weakness, she was admitted for evaluation and managementevaluation and management

8/2 Abdominal 8/2 Abdominal sonographysonography------no special findingno special finding

Clinical courseClinical course

8/3 Lumbar spine MRI was arranged8/3 Lumbar spine MRI was arranged------ Degenerative changeDegenerative change of the of the thoracothoraco--

lumbar spinelumbar spine------ Enhancement around L3/4 endplatesEnhancement around L3/4 endplates

the medial the medial psoaspsoas muscles and part of muscles and part of the the paraspinalparaspinal and back muscles, but and back muscles, but without focal thick fluid collection to without focal thick fluid collection to suggestsuggestabscess formation abscess formation

ImpressionImpression

Lumbar spinal epidural abscess with Lumbar spinal epidural abscess with neurologicneurologic deficits deficits

Clinical courseClinical course

8/3 orthopedist was 8/3 orthopedist was emergent consultedemergent consulted

------PM 5:00 acute illPM 5:00 acute ill--looking, looking, bedbed--rest, severe back rest, severe back pain, hard to move her pain, hard to move her body, body, paresthesiaparesthesia below below umnilicusumnilicus, right side drop , right side drop footfoot

Muscle power

right left

Flexion 0 0

Extension 0 0

Flexion 0 0

Extension 0 0

Dorsiflexion 0 1

Plantarflexion

0 1

Flexion 1 2

Extension 1 2

Big toe

ankle

knee

hip

Clinical courseClinical course

------PM 8:00 bilateral drop foot, lower limb PM 8:00 bilateral drop foot, lower limb paralysis with urineparalysis with urineretention and stoolretention and stoolincontinenceincontinence

------PM 9:00 emergent surgical PM 9:00 emergent surgical decompressiondecompression

OPOP

Procedure: L1~L5 total Procedure: L1~L5 total laminectomylaminectomy+ bil. + bil. foraminotomyforaminotomy

Op finding:Op finding:1. 1. Turbid dischargeTurbid discharge was noted in epidural space was noted in epidural space

from L1 to L5 with from L1 to L5 with oragnizedoragnized puspus at L1/2 level.at L1/2 level.2. Severe 2. Severe spinal spinal stenosisstenosis from L1/2 to L5/S1from L1/2 to L5/S13. There was little 3. There was little pus dischargepus discharge noted in L2/3, noted in L2/3,

L3/4 or L4/5 disc space.L3/4 or L4/5 disc space.

Post opPost op

Post op day 2 mild Post op day 2 mild fever to 38.5 fever to 38.5 celsiuscelsiusPost op day 5 fever Post op day 5 fever subside , subside , paresthesiaparesthesiaimproved improved

Muscle power

right left

Flexion 1 1Extension 1 1Flexion 1 1

Extension 1 1Dorsiflexion 1 1

Plantarflexion 1 1

Flexion 2 2

Extension 2 2

Big toe

ankle

knee

hip

LabLab

QuestionQuestion

Surgical or nonSurgical or non--surgical management for surgical management for spinal epidural abscess?spinal epidural abscess?WhatWhat’’s the associated out come ?s the associated out come ?

Spinal epidural abscess: a meta-analysis of 915 patients

E. Reihsaus · H. Waldbaur · W. Seeling

Neurosurg Rev (2000) 232:175–204

MethodMethod

Review article on spinal epidural abscessReview article on spinal epidural abscessfrom 1954~1997 from 1954~1997 Total 915 patients of SEA were publishedTotal 915 patients of SEA were published

TreatmentTreatment89%--- surgical and conservative treatment were combined11%---received antibiotic treatment withoutoperative drainage of the abscess

SurgicalPosterior decompression with laminectomyIntraoperative sonography to judge the extent of abscess, especially for anterior located extensions of abscess Anterior decompression with corpectomy is necessary for SEA in the anterior segment of the epidural space

TreatmentTreatment

NonNon--surgical therapysurgical therapyPurely conservative treatment is an option for selected patients but not indicated for the majority of cases

TreatmentTreatment

NonNon--surgical therapysurgical therapyConservative therapy of SEA is only indicated when patients do not yet have severe neurologic symptoms.For patients who have been completely paralyzed for 3days or more, surgical decompression is not likely to produce significant benefits such as recovery ofneurological function---> recommend just conservativetreatmentLarge abscesses extending from the cervical to the lumbar segments may also be candidates

TreatmentTreatmentAntibiotics choice Criteria :(1) efficacy against Staphylococcus aureus, the most

common cause of SEA(2) low toxicity to enable treatment over several weeks(3) the ability to penetrate bony tissues, as also is

necessary in treating spondylodiscitisInitial treatment with combination of flucloxacillin, ampicillin, gentamicin, and metronidazoleThird-generation cephalosporin with vancomycin or nafcillin.IV antibiotics for 4~6 weeks then oral antibiotics

OutcomeOutcome

Death occurred in 16% of these patients27% retained permanent neurologicdeficits15% had either paresis or paralysis The problem with spinal epiduralabscesses is not treatment, but early diagnosis – before massive neurological symptoms occur.

OutcomeOutcomePatients without paralysis preoperativelyor whose paralysis had developed less than 36 hours before the operation had better prognoses with respect to survival and recovery of function. No patients with paralysis developing 48 hours or more beforesurgical decompression showed recovery of neurologic function.

Spinal epidural abscess: clinical presentation, management, and

outcomeWilliam T. Curry Jr., MDa, Brian L. Hoh, MDa,

Sepideh Amin-Hanjani, MDb,*,Emad N. Eskandar, MD

Surgical Neurology 63 (2005) 364–371

Neurosurgical Service, The Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114, USADepartment of Neurosurgery, Neuropsychiatric Institute, University of Illinois at Chicago, Chicago, IL 60612, USA

MethodMethod

Retrospectively reviewed the records and radiographic images of all patients between January 1995 and March 2001.30 males and 18 females were diagnosed as spinal epidural abscess25 underwent urgent surgery23 patients initially received nonoperativetherapy with antibiotics alone

ResultsResults

ConclusionConclusion

Urgent surgery was more likely to be offered to patients presenting with neurologic deficits than with pain alone.Patients treated without early surgery were significantly more likely todeteriorate and suffer poor outcomes.

Back to our patientsBack to our patients

Surgical or nonSurgical or non--surgical management for surgical management for spinal epidural abscess?spinal epidural abscess?Posterior Posterior laminectomylaminectomy was done was done immediately after lower limb paralysis immediately after lower limb paralysis WhatWhat’’s the associated outcome ?s the associated outcome ?NeurologicNeurologic deficits may improveddeficits may improved

CommentComment問的問題必須更針對病人問的問題必須更針對病人,,由於病患是有由於病患是有neurologicneurologic deficits,deficits,要針對這方面來找要針對這方面來找paperpaper問題可以針對問題可以針對epidural abscessepidural abscess要進行一階要進行一階段或兩階段治療進行討論段或兩階段治療進行討論

問題的答案過於明顯問題的答案過於明顯,,似乎可以從教科書上似乎可以從教科書上找到答案找到答案

第一篇第一篇paperpaper實際上只是實際上只是review review 證據強度不證據強度不高高

CommentComment

先將先將basic knowledge basic knowledge 唸完再來找唸完再來找paper,paper,會會較能進入主題較能進入主題

EBM case discussionBasic dataChief complaintPresent illnessPresent illnessSocial History Physical Examination & Local findingLabLabClinical courseClinical courseImpressionClinical courseClinical courseOPPost opLabQuestion�Spinal epidural abscess: a meta-analysis of 915 patients�Method�TreatmentTreatmentTreatmentTreatmentOutcome�Outcome�Spinal epidural abscess: clinical presentation, management, and outcome�MethodResultsConclusionBack to our patientsCommentComment