neurosurgery
DESCRIPTION
NSTRANSCRIPT
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Neurosurgery Case Conference
2014/05/08
R1 姜冠宇
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Patient profile
٥ No. 4757887
٥ Age/gender: 57 y/o male
٥ Background:٥ denied having any systemic disease
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History
٥ 2011/5 Head injury ٥ Traumatic SAH acute SDH Herniation &
Infarct٥ Cefazolin + Gentamicin Cravit ٥ Focal seizure
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History
٥ 2011/8 continue rehabilitation program
٥ Operation : L’t FTP cranioplasty ٥ Lethargy, caused by Hydrocephalus
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History
٥ V-P shunt operation was arranged٥ Vanco + Fortum for treatment٥ Suspect V-P shunt infection
٥ 2012 VP shunt infection with wound discharge ٥ Fever, suspect V-P shunt infection٥ Tracheostomy and bedridden status٥Under Vancomicin+Rocephine
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History
٥ 2012/10/08 purulent discharge from scalp
٥ Left FTP epidural abscess ٥ Urgent Left FTP craniectomy + Debridement + CWV drain
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History
٥ 2014
1. Recurrent generalized tonic-clonic convulsion
2. Sepsis
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History
٥ 2014/02/27 Left Cranioplasty(TI-MESH)
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This time
٥ 2014/04/25 Eruption of scalp ٥ Craniectomy + Debridement
٥ remove Ti-mesh
٥ Seizure was noted at POR
٥ Antibiotics: Daptomycin
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Patient profile
٥ Age/Gender : 70 y/o female
٥ History :٥ DM under OHA control ٥ HTN under medication control
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Patient illness
٥ C.c.: Fever with chillness ٥ Accompanying with mild L’t neck and bilateral shoulder soreness٥ Arthragia and Mylgia
٥ Negative Brudnzinsky or Kernig sign
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Patient illness
٥ U/A reveaeld pyuria. ٥ Abd CT revealed suspected cholangitis or
pancreatitis. GI admission٥ Low back pain when admission٥ L spine MRI : HIVD L4-S1
٥ C spine MRI:٥ highly suspect C6-7 osteomyelitis with
epidural abscess
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Operation and Post OP
٥ C67 corpectomy+ interbody fusion with cage (zimmer, body C-cage)+ C5-T1 plate fixation+ debridment
٥ Vital sign stable٥ CRP H 3.94 mg/dL ٥ WBC 7.20 10^3/uL ٥ E.S.R. 1hr H 87 mm/hr
٥ keep penicillin G +Daptomycin use
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Epidural abscess
From Uptodate
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Epidural abscess
٥ Incidence: 2~25 per 100,000 admission
٥ Enclosed within the bony confines ٥ Compress the brain or spinal cord
٥ Spinal epidural abscess (SEA) ٥ Intracranial epidural abscess (IEA)
٥ Severe symptoms to permanent complications
٥ Prompt diagnosis: CT, MRI
٥ Proper treatment: Aspiration or Drainage
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SPINAL EPIDURAL ABSCESS —
٥ Requires prompt recognition and proper management to avoid potentially disastrous complications.
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Anatomy —
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Anatomy —
٥ Small in C region Larger in S region
٥ More common in the T-L areas٥ Infection-prone fat tissue ٥ Anterior : below L1٥ The majority : located posteriorly
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Pathogenesis —
٥ Hematogenously by direct extension from infected contiguous tissue ٥ vertebral body (pyogenic infectious discitis)٥ psoas muscle
٥ Direct inoculation into the spinal canal ٥ eg, during spinal or epidural anesthetic procedures or surgery
٥ Mechanisms ٥ Direct compression٥ Thrombosis and thrombophlebitis of nearby veins٥ Interruption of the arterial blood supply٥ Bacterial toxins and mediators of inflammation
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Pathogenesis —
٥ one level commonly extend to multiple levels. ٥ (3~5 levels)
٥ Even a small SEA can cause severe neurologic symptoms and sequelae.
٥ Abscesses Granulation tissue
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Clinical manisfiestation
٥ Back pain٥ Root pain٥ Motor weakness, sensory changes٥ Bladder or bowel dysfunction٥ Paralysis
٥ Differential diagnosis — ٥ Disc and degenerative bone disease٥ Metastatic tumors٥ Vertebral discitis and osteomyelitis٥ Meningitis٥ Herpes zoster, prior to the appearance of skin lesions
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Diagnosis
٥ No delay !٥ “Classic triad" of fever, spine pain, and neurologic
deficits
٥ Especially if the pain is worsened by percussion, should suggest the diagnosis of SEA or vertebral osteomyelitis.
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Diagnosis
٥ ESR and CRP was highly sensitive and moderately specific
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Management
٥ Follow-up MRI to confirm diminishing size or resolution of the abscess٥ Immediate surgery is warranted if neurologic deterioration occurs
٥ Empiric therapy — An empiric regimen with antibiotics active against staphylococci, streptococci, and gram-negative bacilli should be chosen.
٥ Vancomycin
٥ vancomycin could be replaced with nafcillin or oxacillin ٥ better central nervous system (CNS) penetration than vancomycin.
٥ Metronidazole
٥ Cefotaxime ceftriaxone, or ceftazidime ٥ Ceftazidime is preferable when Pseudomonas aeruginosa is considered
٥ Rehabilitation treatment
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INTRACRANIAL EPIDURAL ABSCESS —
٥ IEA are less common than SEA
٥ Less acute in evolution.
٥ Like SEAs, requiring optimal therapy to prevent complications.
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INTRACRANIAL EPIDURAL ABSCESS —
٥ Anatomy — The potential epidural space can be opened by pressure ٥ Expanding tumors, blood, inflammatory masses, or pus. ٥ Slow-growing, rounded, and well-localized.٥ Rarely spread downwards because the dura attached the
foramen magnum. ٥ granulation tissue rather than pus
٥ Epidemiology — ٥ the past, most cases associated with sinusitis, otitis, or
mastoiditis. ٥ Today, many cases arise as neurosurgical procedures.
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Management
٥ Successful treatment of an IEA requires a combination of a drainage procedure and antibiotic therapy.
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٥ Thanks!