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Case Study: Epidural Abscess 9 months after SCS implant
Ivan Samcam, MD; Ajay Antony , MD
Department of Anesthesiology, University of Florida College of Medicine, Gainesville
Spinal cord stimulator complications can range in frequency and severity. The most common complications are device related, including lead migration and pain at IPG site. Yet, Infection occurs at a lower rate with past studies illustrating rates between 3-5%. Superficial skin infections and infection involving the IPG site were found to be common. However, epidural abscesses are rare. In this case report we present an SCS patient who developed an epidural abscess, nine months after his implantation date, in the setting of cellulitis in the lower extremity.
65 year old male with a past medical history of DM, HTN, CAD, FBSS, and obesity with a spinal cord stimulator placed in 12/2016. He was in his usual state of health when he developed abdominal pain one morning 9 months later. He was woken up from his sleep with severe sharp right upper quadrant pain. CT at that times showed revealed sigmoid diverticulitis. Physical exam demonstrated a right lower leg cellulitis and Clindamycin IV, flagyl, and ciprofloxacin were started. The next morning, sepsis was suspected and antibiotics were increased to Zosyn. On day 3, the patient developed difficulty with ambulation, urinary retention and altered mental status. A, CT of his thoracic spine was ordered which showed a T5-T8 lesion with significant spinal cord compression. His neurological exam revealed decreased lower extremity strength, absent rectal tone, and absent sensation in his LE. Reflexes in the lower extremities were 1/4.
The patient was then taken to the OR by neurosurgery on day 6. A T5-T7 laminectomy, decompression of epidural space, removal of spinal cord stimulator system, and swabs for culture were performed. His confusion and lower extremity strength improved afterwards. Intraoperative cultures were positive for methicillin sensitive S. aureus.
On day of discharge, his diverticulitis had resolved, and strength was improved. MRI had revealed narrowing of the central spinal canal at the L4-5 level, which was suspicious for residual abscess. However, as he showed continued improvement in his neurological exam, surgery was deferred at the time.
One month later, after recovering from a cardiac arrest, it was noted the patient still had urinary retention at that time.
In a case series of 320 SCS patients, it was found that the rate of subcutaneous infection was 5% . Staphlococcus species have been found to be the most common pathogen in up to 18% of cases. Epidural abscesses develop from hematogenous spreads, and 1/3 are due to direct extension of local infections .
We presented a case of a 65-year-old male who developed an epidural abscess, 9 months after placement of SCS. Our patient’ risk factors included diabetes mellitus, failed back surgery syndrome, and obesity. The patient’s cellulitis seems likely to have been a source of hemateogenous spread leading to the epidural abscess. It is unlikely this infection started in the perioperative period, as one study showed median time of development of an infection to be 2 months from surgery . However, definitive conclusions can’t be made. Infections of SCS are rare and helpful guidelines continue to emerge that aid in dictating best practice for prevention and management.