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Epidural Abscess Associated With Intravenous Drug Abuse in a Pregnant Patient

1991; Elsevier BV; Volume: 66; Issue: 10 Linguagem: Inglês

10.1016/s0025-6196(12)61727-3

1942-5546

Jo T. Van Winter, Skott N.J. Nielsen, Paul L. Ogburn,

Spinal Hematomas and Complications

The association between intravenous drug abuse and epidural abscess is well known; however, this association has not previously been reported in a pregnant patient. The classic manifestation of epidural abscess is a febrile patient with back pain that progresses rapidly to radicular pain, spinal cord dysfunction, weakness, and then complete paralysis. Although this condition is rare during pregnancy, these serious complications necessitate prompt diagnosis and intervention. If spinal infection is suspected, magnetic resonance imaging should be performed immediately. After epidural abscess is diagnosed, emergent decompressive laminectomy and appropriate antibiotic coverage are necessary. Herein we describe a 27-year-old pregnant patient with epidural abscess probably related to use of contaminated needles for intravenous administration of drugs and subsequent hematologic spread of staphylococci to the epidural space. The differential diagnosis of epidural abscess can be difficult, and management options must consider the well-being of both the mother and the fetus. The association between intravenous drug abuse and epidural abscess is well known; however, this association has not previously been reported in a pregnant patient. The classic manifestation of epidural abscess is a febrile patient with back pain that progresses rapidly to radicular pain, spinal cord dysfunction, weakness, and then complete paralysis. Although this condition is rare during pregnancy, these serious complications necessitate prompt diagnosis and intervention. If spinal infection is suspected, magnetic resonance imaging should be performed immediately. After epidural abscess is diagnosed, emergent decompressive laminectomy and appropriate antibiotic coverage are necessary. Herein we describe a 27-year-old pregnant patient with epidural abscess probably related to use of contaminated needles for intravenous administration of drugs and subsequent hematologic spread of staphylococci to the epidural space. The differential diagnosis of epidural abscess can be difficult, and management options must consider the well-being of both the mother and the fetus. Escalating abuse of illicit drugs during pregnancy has resulted in increased adverse maternal and perinatal outcomes.1Little BB Gilstrap III, LC Cunningham FG Social and illicit substance use during pregnancy.in: Cunningham FG MacDonald PC Gant NF Williams Obstetrics. Eighteenth edition, Suppl 7. Appleton & Lange, East Norwalk, ConnecticutAugust/September 1990Google Scholar Although the association between intravenous drug abuse and epidural abscess is well known,2Koppel BS Tuchman AJ Mangiardi JR Daras M Weitzner I Epidural spinal infection in intravenous drug abusers.Arch Neurol. 1988; 45: 1331-1337Crossref PubMed Scopus (93) Google Scholar to our knowledge such an association during pregnancy has not previously been reported. Herein we describe such a case and emphasize the need for immediate decompressive laminectomy and concomitant antibiotic treatment. Without this intervention, substantial morbidity or mortality can occur. In addition, if a severe neurologic deficit is present, recovery of spinal cord function is unpredictable.3Baker AS Ojemann RG Swartz MN Richardson Jr, EP Spinal epidural abscess.N Engl J Med. 1975; 293: 463-468Crossref PubMed Scopus (555) Google Scholar, 4Hunter JC Ryan MD Taylor TKF Pennington JC Spinal epidural abscess in pregnancy.Aust N Z J Surg. 1977; 47: 672-674Crossref PubMed Scopus (12) Google Scholar A 27-year-old woman, a known intravenous polydrug abuser, came to our emergency department at approximately 22 weeks' gestation; she had fever, chest and abdominal pain, and bilateral leg weakness. Results of a urine drug screen were positive for acetaminophen and opiates. The patient left our emergency department against medical advice only to return to her local emergency department 48 hours later because of flaccid paraplegia and urinary retention. After a spinal puncture revealed epidural pus, she was transferred to our institution. On arrival, the patient immediately underwent magnetic resonance imaging studies of the spine, which showed a large epidural abscess. This abscess was located posterior to the left side of the spinal cord and extended from T-1 to T-6 (Fig. 1). A decompressive laminectomy (from T-1 to T-6) was performed as an emergency procedure, along with dissection of a large amount of granulation tissue from the nearby dura mater. In addition, the abscess was drained and cultures were obtained, blood was withdrawn for cultures, and therapy with a penicillinase-resistant penicillin (nafcillin) was begun pending results of the cultures. Staphylococcus aureus sensitive to cefazolin was isolated from all cultures, and parenteral coverage with this antibiotic was continued for 6 weeks. Postoperatively, a neurologic examination showed no improvement in the flaccid paralysis of the patient. She was assessed daily in physical therapy, occupational therapy, and psychiatry; postpartum goals were independent care and successful treatment of the chemical dependence. Methadone maintenance was part of her therapy, and serial drug screening studies of the urine confirmed compliance with this treatment. The patient's postoperative course was complicated by the onset of preterm labor at 24 weeks' gestation. Successful tocolysis was obtained initially with magnesium sulfate administered intravenously, followed by terbutaline sulfate administered orally until 37 weeks' gestation. As a result of the patient's inability to detect contractions (attributed to sensory loss), physical disabilities, and treatment for drug dependence, hospitalization for the rest of the pregnancy was necessary. Fetal surveillance with use of alternate-day heart tracings and serial ultrasonography was initiated at 24 weeks' gestation and was continued until onset of labor (37 5/7 weeks' gestation). During labor and delivery, analgesia and anesthesia were achieved with meperidine hydrochloride administered parenterally and paracervical and pudendal blocks. Epidural anesthesia was not used, and no autonomic hyperreflexia was noted. The patient was delivered of a 2,960-g male infant (Apgar scores of 8 at 1 minute and 9 at 5 minutes) with the aid of low forceps because of intermittent bradycardia and ineffectual attempts at pushing. During the postpartum period, tapering of the dose of methadone was initiated, and the patient was transferred to a long-term drug and physical rehabilitation facility. While there, she learned to function independently and to walk with the aid of leg braces and arm supports. Her infant had evidence of narcotic withdrawal and was closely monitored in the high-risk nursery for 2 weeks. He was then placed in protective foster care pending a court decision about a permanent home. Spinal epidural abscess has an estimated incidence of 0.2 to 1.2 per 10,000 hospital admissions annually.3Baker AS Ojemann RG Swartz MN Richardson Jr, EP Spinal epidural abscess.N Engl J Med. 1975; 293: 463-468Crossref PubMed Scopus (555) Google Scholar It has been reported during pregnancy as a result of vertebral osteomyelitis4Hunter JC Ryan MD Taylor TKF Pennington JC Spinal epidural abscess in pregnancy.Aust N Z J Surg. 1977; 47: 672-674Crossref PubMed Scopus (12) Google Scholar and in the puerperium as a spontaneous occurrence.5Crawford JS Pathology in the extradural space.Br J Anaesth. 1975; 47: 412-414Crossref PubMed Scopus (39) Google Scholar In addition, it has been described during the postpartum period in association with use of a lumbar epidural anesthetic agent during labor.6Male CG Martin R Puerperal spinal epidural abscess (letter to the editor).Lancet. 1973; 1: 608-609Abstract PubMed Scopus (21) Google Scholar Epidural abscess, however, has not been reported in a peripartum state in conjunction with intravenous drug abuse. In our patient, the probable source of infection was contaminated needles used for intravenous administration of drugs and the subsequent hematologic spread of staphylococci to the epidural space. The increased vascularity of the epidural space during pregnancy would promote such a blood-borne infection. No evidence of any other infectious source, including vertebral osteomyelitis, and no history of antecedent back trauma were noted.7Hulme A Spinal epidural abscess.Br Med J. 1954; 1: 64-68Crossref PubMed Scopus (60) Google Scholar The classic manifestation of epidural abscess is a febrile patient with back pain that progresses to radicular pain, spinal cord dysfunction, and weakness and then rapidly eventuates in complete paralysis.3Baker AS Ojemann RG Swartz MN Richardson Jr, EP Spinal epidural abscess.N Engl J Med. 1975; 293: 463-468Crossref PubMed Scopus (555) Google Scholar, 5Crawford JS Pathology in the extradural space.Br J Anaesth. 1975; 47: 412-414Crossref PubMed Scopus (39) Google Scholar, 8Bergman I Wald ER Meyer JD Painter MJ Epidural abscess and vertebral osteomyelitis following serial lumbar punctures.Pediatrics. 1983; 72: 476-480PubMed Google Scholar, 9Hancock DO A study of 49 patients with acute spinal extradural abscess.Paraplegia. 1973; 10: 285-288Crossref PubMed Scopus (75) Google Scholar This progression of symptoms usually occurs in 48 to 72 hours and is thought to result from cord compression due to the expanding inflammatory mass, destruction of neural tissue, and thrombosis of small spinal arteries and veins. Although this condition is extremely rare during pregnancy, these complications are so serious that prompt diagnosis and immediate intervention are necessary. Major considerations in the differential diagnosis of acute epidural abscess are osteomyelitis, disk prolapse, meningitis, acute transverse myelopathy, spontaneous epidural hematoma or other vascular lesions, and intraspinal tumors.3Baker AS Ojemann RG Swartz MN Richardson Jr, EP Spinal epidural abscess.N Engl J Med. 1975; 293: 463-468Crossref PubMed Scopus (555) Google Scholar, 4Hunter JC Ryan MD Taylor TKF Pennington JC Spinal epidural abscess in pregnancy.Aust N Z J Surg. 1977; 47: 672-674Crossref PubMed Scopus (12) Google Scholar Although a patient who has osteomyelitis may have focal or diffuse back pain, results of analysis of the cerebrospinal fluid are usually negative. Therefore, a differential diagnosis may be difficult. In a study by Bergman and associates,8Bergman I Wald ER Meyer JD Painter MJ Epidural abscess and vertebral osteomyelitis following serial lumbar punctures.Pediatrics. 1983; 72: 476-480PubMed Google Scholar 20 to 50% of patients with spinal epidural abscess had contiguous osteomyelitis based on radiographic criteria.9Hancock DO A study of 49 patients with acute spinal extradural abscess.Paraplegia. 1973; 10: 285-288Crossref PubMed Scopus (75) Google Scholar, 10Kaufman DM Kaplan JG Litman N Infectious agents in spinal epidural abscesses.Neurology. 1980; 30: 844-850Crossref PubMed Google Scholar Prolapse or extrusion of a disk may cause symptoms similar to those of epidural abscess, but this condition is rarely associated with fever or changes in cerebrospinal fluid. In patients with meningitis, diffuse back pain and headache are the major complaints at initial examination. Paralysis associated with acute transverse myelopathy occurs within 72 hours, and back pain may be absent.4Hunter JC Ryan MD Taylor TKF Pennington JC Spinal epidural abscess in pregnancy.Aust N Z J Surg. 1977; 47: 672-674Crossref PubMed Scopus (12) Google Scholar, 11Altrocchi PH Acute transverse myelopathy.Arch Neurol. 1963; 9: 111-119Crossref PubMed Scopus (131) Google Scholar Paralysis associated with interruption of the vascular supply of the spinal cord is usually instantaneous.12Markham JW Lynge HN Stahlman GEB The syndrome of spontaneous spinal epidural hematoma: report of three cases.J Neurosurg. 1967; 26: 334-342Crossref PubMed Scopus (126) Google Scholar, 13Herrick MK Mills Jr, PE Infarction of spinal cord: two cases of selective gray matter involvement secondary to asymptomatic aortic disease.Arch Neurol. 1971; 24: 228-241Crossref PubMed Scopus (76) Google Scholar In contrast, an intraspinal tumor would usually be associated with a more protracted course, similar to that of chronic epidural abscess.14Mullins GM Flynn JPG El-Mahdi AM McQueen JD Owens Jr, AH Malignant lymphoma of the spinal epidural space.Ann Intern Med. 1971; 74: 416-423Crossref PubMed Scopus (74) Google Scholar If spinal infection is suspected, magnetic resonance imaging should be done immediately. For diagnosis, this procedure is preferred to either spinal puncture or myelography because spinal puncture has been associated with bacterial inoculation into the subarachnoid space15Dripps RD Vandam LD Hazards of lumbar puncture.JAMA. 1951; 147: 1118-1121Crossref PubMed Scopus (55) Google Scholar and neurologic deterioration has been reported after myelography.16Willis BK Benzel EC Acute postmyelographic neurological deterioration (letter to the editor).J Neurosurg. 1988; 69: 148-149PubMed Google Scholar If an epidural mass is found on magnetic resonance imaging, laminectomy should be performed, and antibiotic treatment should be initiated after specimens have been obtained for culture. Patients with epidural abscess require treatment with parenterally administered antibiotics, usually with a penicillinase-resistant penicillin for at least 3 to 4 weeks. During pregnancy, the well-being of the fetus also is of concern. Unfortunately, drug dependence often begins in utero. As a result of a history of intravenous narcotic use, our patient (and her fetus) were placed on a methadone maintenance program in conjunction with careful fetal surveillance. Methadone maintenance is preferred to methadone detoxification during pregnancy because of fetal stress or even fetal death associated with narcotic withdrawal, particularly in the third trimester.17Blinick G Wallach RC Jerez E Ackerman BD Drug addiction in pregnancy and the neonate.Am J Obstet Gynecol. 1976; 125: 135-142Abstract Full Text PDF PubMed Scopus (75) Google Scholar Because the methadone maintenance program may still be associated with fetal death, low birth weight, and premature onset of labor, frequent antenatal testing and serial ultrasonography for evaluation of growth are necessary to assess fetal well-being. In addition, the long-term effects of intrauterine exposure to methadone are generally unknown. Tocolysis was also necessary because of preterm labor, which may have occurred as a result of the infective process, narcotic use, or surgical intervention. Frequent intermittent or continuous electronic monitoring for uterine contractions was necessary because our patient could not perceive uterine contractions. Intermittent manual palpation was inadequate screening for preterm labor in this case. Labor and delivery have been associated with autonomic hyperreflexia in patients with paraplegia, especially those with spinal cord injury at or above the level of T-6. Fortunately, this life-threatening complication, which can lead to sudden, severe hypertension and subsequent subarachnoid hemorrhage and death, did not develop in our patient. Epidural anesthesia is recommended to prevent autonomic hyperreflexia in paralyzed parturients; however, use of this type of regional anesthesia was impossible in our patient because of the recent epidural abscess. Obstetricians should be aware that when hypertension develops in a patient with paraplegia who is in labor, autonomic hyperreflexia should be strongly considered in the absence of other signs of preeclampsia. If hypertension occurs suddenly despite the use of a regional anesthetic agent, the patient should immediately be placed in a sitting position. If this maneuver fails to control the blood pressure, a ganglionic blocking agent or direct vasodilator should be administered by intravenous drip, and the blood pressure should be constantly monitored. If these measures fail to control the hypertension, an emergency cesarean section should be considered because symptoms of autonomic hyperreflexia usually resolve after delivery of the infant and placenta.18Committee on Obstetrics: Maternal and Fetal Medicine: Management of labor and delivery for patients with spinal cord injury. ACOG Committee Opinion, No. 83, May 1990Google Scholar, 19Robertson DNS Pregnancy and labour in the paraplegic.Paraplegia. 1972; 10: 209-212Crossref PubMed Scopus (57) Google Scholar Nonetheless, because of potential wide fluctuations in blood pressure that can be associated with anesthesia for cesarean section (that is, hypertension associated with general anesthesia and hypotension associated with regional blocks), extreme care must be exercised by a skilled team in order to avoid mortality or morbidity for the mother and fetus when cesarean section is chosen. Although mild to moderate back discomfort is common during pregnancy, severe back pain may indicate a serious problem and merits immediate assessment, especially if the patient is a known or suspected substance abuser. If epidural abscess is diagnosed, emergency decompressive laminectomy and appropriate antibiotic coverage are necessary. Early recognition and treatment are essential; if the neurologic deficit is extensive (as in our patient), the potential for functional neurologic recovery is limited.