Spinal purulent epiduritis (external pachymeningitis)

Spinal purulent epiduritis (external pachymeningitis, spinal epidural abscess, purulent peripachymeningitis) is a rapidly developing purulent inflammation of the epidural tissue of the spinal cord. The disease is of a secondary nature and occurs due to the penetration of a bacterial infection from the focus of purulent inflammation into the epidural space. The nature of the disease can be diffuse (spread out) or limited (in the form of separate foci of varying sizes).

Epidural abscesses most often develop in the posterior epidural space, which is due to the presence of a dense network of lymphatic slits in it and the absence of epidural tissue in the anterior section. The localization of purulent inflammation in most cases is observed in the middle and lower thoracic spine. The pia mater and spinal cord, as a rule, are not involved in the pathological process, however, degenerative-destructive and secondary inflammatory reactive changes can develop in them (as a result of the development of edema, intoxication, compression, disturbances in lympho- and hemodynamics).

Causes of spinal purulent epiduritis (external pachymeningitis)

There are several main reasons that provoke the development of spinal purulent epiduritis:

• direct transition of the infectious pathogen into the epidural space during tuberculous and osteomyelitic processes in the spine;
• spread of predominantly staphylococcal infection by hematogenous or lymphogenous route from purulent or infectious foci in the body (furuncle, abscess, etc.);
• direct penetration of infection into the epidural space during punctures (in isolated cases).

Etiology and pathogenesis

Epidurit of the spinal canal is almost always a secondary disease against the background of existing foci of bacterial or fungal infection. About 80% of cases of the formation of purulent spinal abscess are associated with infection with staphylococcus - non-motile, spherical gram-positive bacteria. Staphylococcus is a representative of the opportunistic human flora and can be found in large quantities (in latent form) on the skin and mucous membranes, including the epithelial membranes of internal organs. Staphylococcus is widespread in medical institutions, so primary prevention of staphylococcal infection is aimed at destroying this pathogen in hospitals and maternity hospitals through regular disinfection of premises and surfaces.

Epidurit of the spinal canal

Experts believe that chronic foci of infection can cause inflammation of the epidural tissue. Infectious pathologies that occur in an acute form do not cause such severe consequences provided proper and timely treatment, since the main route of infection of the brain and spinal cord is hematogenous, that is, through the blood. The table below lists the main groups of diseases that most often cause secondary infection of the spinal space.

Disc herniation, epiduritis

Table. What diseases can cause epiduritis?

The risk of epiduritis is 22.9% higher in patients with injuries and degenerative-dystrophic diseases of the spine, intervertebral hernia, chronic mediastinitis (inflammation of the mediastinum - the anatomical space of the middle part of the chest, limited by the vertebrae and sternum). Some doctors believe that patients with autoimmune disorders, such as cystic fibrosis, multiple sclerosis, and allergies, are also at risk.

Types of epiduritis

Important! In approximately 4.7% of women, spinal epiduritis occurs in the first days after childbirth. The cause of inflammation in this case is infection with the catheter, which is inserted into the epidural space for local anesthesia (epidural anesthesia). Insufficient sterility of the materials used or improper treatment of the puncture site with antiseptics can lead to the penetration of bacteria into the spinal canal.

In women, the disease often appears after childbirth

Bandages for pregnant women

Symptoms of spinal purulent epiduritis (external pachymeningitis)

Spinal purulent epiduritis usually develops acutely, with fever (up to 40 °C), chills, general malaise and headaches. The chronic course is characterized by a gradual onset of the disease with less pronounced clinical symptoms.

Due to damage to the dorsal roots, hypoesthesia or segmental anesthesia, a pain syndrome of varying intensity develops with possible irradiation along the entire spine, and compression of the spinal cord occurs. When the inflammatory process spreads to the back muscles, swelling may occur.

During the first days, the pain is accompanied by increasing weakness in the limbs (mainly in the legs), as well as partial or complete dysfunction of the pelvic organs (with severe myelitic syndrome). As a result of compression of the spinal cord below the lesion, a decrease in sensitivity of the radicular or conduction type occurs, paresis and paralysis occur (mainly of the lower extremities), and bedsores form.

The transition of acute purulent epiduritis to a chronic condition is characterized by stabilization or some weakening of the compression syndrome:

• reduction of radicular pain;
• relative restoration of the functions of the pelvic organs;
• relative restoration of motor functions of the affected limbs;
• decrease in body temperature.

In the chronic course of the disease, there is a change in phases of exacerbation and attenuation of the pathological process.

Spinal epiduritis

Spinal epiduritis (epiduritis; synonym: spinal epidural abscess, external purulent pachymeningitis, purulent peripachymeningitis) is an inflammatory acute or chronic process in the epidural space and on the outer surface of the dura mater of the spinal cord [4].

Classification.

Classically, as in any other inflammatory disease, acute and chronic forms are distinguished. The vertebrae of the lower thoracic and lumbar spine are most often affected.

Depending on the location of the disease, epiduritis is distinguished:

1) limited - the affected area is limited only by the hernial protrusion;

2) unlimited – the inflammatory process is observed in the descending and ascending segments;

3) common unilateral - inflammation is observed only on one side;

4) widespread bilateral - the process of inflammation affects both sides [3];

5) cicatricial adhesions - may occur after surgery to remove a hernia or other intervention. At the same time, fibrous growths appear at the site of the manipulations, which cause inflammation.

6) There are internal and external epiduritis of the spinal cord. The first variety is rare. More often there is an external appearance in which the inflammatory process always spreads to the fatty tissue of the epidural space. Even more often, the process begins with the epidural tissue and then spreads to the outer layers of the dura mater. [2]

In addition, there are two forms of the disease:

1) Purulent: The most severe form of the disease, characterized by the presence of a purulent focus in the epidural space.

2) Non-purulent (serous, serous-fibrous, hyperplastic): often has a hidden course. During the development of the disease, no neurological disorders are observed. Sluggish processes can lead to changes in the epidural tissue, as well as disrupt the integrity of the dura mater. Often the fibrous tissue grows, and the inflammation spreads to the soft membranes of the spinal cord. The circulation of liquor is disrupted, the vessels are compressed. The result of this effect is ischemic changes in the spinal cord [3].

2. Etiology and pathogenesis.

Purulent epiduritis usually develops as a complication of purulent processes near the epidural space: spinal osteomyelitis, posterior mediastinitis, paravertebral abscess, lung abscess, etc., or a general purulent infection: sepsis (usually staphylococcal, less often streptococcal, pneumococcal), purulent tonsillitis, erysipelas, pyelitis , infected abortion, furunculosis. The pathogen enters the epidural space per continuitatem or hematogenously. The process is most often localized in the lower thoracic region. The abscess usually spreads over 3-4 vertebrae. The pathogen does not penetrate the dura mater, so the soft membranes and spinal cord are usually not directly involved in the inflammatory process. But they can, of course, suffer from pressure, exposure to toxins, circulatory and lymph circulation disorders and other pathogenic factors [1, 3]. Non-purulent epiduritis, according to researchers, often occurs latently. Epidural fiber is highly reactive and is involved in the process of many local and general infections, especially allergic reactions. Acute non-purulent epiduritis is usually completely benign and does not cause permanent neurological disorders. Along with this, chronically ongoing non-purulent pachymeningitis and epiduritis occur, causing massive changes in the epidural tissue and dura mater. Adipose tissue is replaced by granulation tissue, and fibrous tissue grows in the membrane. Over time, inflammatory changes can spread to the soft meninges. Dense fibrous tissue, like a ring surrounding the spinal cord, disrupts liquor circulation, compresses blood vessels and causes ischemic changes in the spinal cord and its membranes [1, 3].

Similar hyperplastic forms of pachymeningitis and epiduritis, in which the dura mater can become 5-10 times thicker than normal, fused with the periosteum of the vertebrae, on the one hand, and with the soft membranes, on the other, gradually progressing, give the clinical picture of a spinal cord tumor. This is hypertrophic pachymeningitis, according to the terminology of old authors [2].

Chronic epiduritis is a secondary disease complicating tuberculosis, syphilis (rarely), brucellosis. It can be detected in connection with a spinal injury suffered many years before the onset of symptoms of epiduritis, with the presence of a foreign body or tumor in the spinal canal, with a cold. Chronic diseases of the spine of an inflammatory and degenerative nature can also be complicated by chronic epiduritis. Epidurit can manifest as a single lesion, several separate lesions, or diffusely affect the entire epidural space. Affects mainly the thoracic or simultaneously the thoracic and lumbar regions. Hypertrophic cervical pachymeningitis, described by older authors, is much less common. Cicatricial changes and inflammatory layers are more pronounced along the posterior surface of the dural sac; less often, their more or less identical development is observed in the form of a muff along the entire circumference of the dura mater. [2]

3. Clinical picture

Purulent epiduritis.

The disease begins acutely, less often subacutely. Symptoms of severe acute infection appear: weakness, malaise, headaches, lack of appetite, hectic fever, septic blood changes (accelerated ESR, neutrophil shift). Against this background, radicular pain, symptoms of tension, paresthesia, and dysfunction of the pelvic organs develop. Later, paralysis occurs, most often in the form of lower paraparesis (paraplegia) of a spastic nature. With damage at the cervical level, tetraparesis of varying severity develops to plegia. Radicular symptoms of prolapse are often observed: lethargy of individual reflexes, hypoesthesia, muscle loss [1, 2]

Non-purulent _ epiduritis. The process begins mostly subacutely with severe radicular pain and pain in the spine, accompanied by reflex tension of the back muscles. Sometimes an attack resembling lumbago occurs. The localization of local radicular pain depends on the topic of the process. Remission often occurs (characterized by a decrease in radicular pain, relative restoration of the functions of the pelvic organs and movements in the affected limbs, a decrease in temperature to subfebrile), after which the pain resumes. In addition, pelvic disorders of varying degrees occur. Examination of the cerebrospinal fluid usually reveals protein-cell dissociation or even complete Fruen-Nonne syndrome. All neurological symptoms increase over time. Along with this, patients complain of pain in the spine in the absence of changes in the bones on the radiograph, movements of the spine at the level of the lesion are limited, tapping on one or more spinous processes is painful. Body temperature may be normal or may fluctuate slightly. The blood is also mostly unchanged. During periods of exacerbation of the process, the ESR is increased, and a neutrophil shift is detected [1, 2].

4. Diagnostics

To recognize spinal epiduritis, the following triad was proposed (D. Kuimov):

— acute radicular pain against the background of high fever and meningeal phenomena;

- syndrome of increasing compression of the spinal cord - acute compression syndrome;

- presence of a purulent or infectious focus in the body (according to MRI). In addition, first of all, laboratory diagnostics are carried out (Leukocytosis with a shift to the left, increased ESR, CRP). It is also possible to use cytological examination during surgical treatment. In addition, it is important to carry out differential diagnosis with spondylodiscitis, spondylitis, paravertebral abscesses, meningitis, myelitis, and tumor lesions [1].

Diagnosis of acute purulent epiduritis does not present much difficulty. Chronic epiduritis is detected either during surgery for other spinal cord lesions or during section [5].

5. Treatment

Conservative and surgical treatment are classically distinguished. In the case of the described disease, both types of treatment cannot be avoided.

When a purulent etiology of epiduritis is established, urgent laminectomy and emptying of the epidural space from purulent exudate are indicated, followed by vigorous treatment with antibiotics. The dura mater should not be opened during surgery. Broad-spectrum antibiotics are used (usually penicillins) [2].

In the case of non-purulent epiduritis, treatment is also primarily surgical. Antibiotics are prescribed before and after surgery [2].

Subsequently, rehabilitation treatment of varying duration (depending on the severity of the neurological deficit), including therapeutic exercises and physiotherapy, is indicated. In addition, with prolonged immobilization of the patient, one must not forget about the risk of pulmonary embolism and carry out anticoagulant therapy and other types of symptomatic treatment.

6. Forecast

The prognosis largely depends on how early the patient consults a specialist. Early diagnosis allows you to begin timely treatment and reduce the negative consequences of the disease. Of course, it is necessary to promptly identify the causative agent of the infection process and carry out competent surgical intervention and antibacterial therapy. If treatment was started untimely, then epiduritis may end in recovery or become chronic. Among the consequences in this case are impaired motor abilities in the form of paresis, plegia, sensitivity disorders, as well as disorders of the pelvic organs (urinary incontinence or chronic retention). In addition, with prolonged immobilization of the patient, bedsores, pulmonary embolism, and various urogenital infections may form. If treatment is untimely or incomplete, the patient may remain permanently disabled.

Bibliography:

1. Clinical guidelines for the diagnosis and treatment of inflammatory diseases of the spine and spinal cord, 2015
2. http://surgeryzone. net/nevrologia/epidurit-spinnogo-mozga. html
3. http: //neurodoc. ru/bolezni/spinnoy-mozg/epidurit. html
4. http://www. medical-enc. ru/m/26/epidurit. shtml
5. https: //ortocure. ru/pozvonochnik/prochee/epidurit. html

Diagnosis of spinal purulent epiduritis (external pachymeningitis)

The diagnosis is established after identifying typical clinical symptoms, studying the nature of the course of the disease and differentiation with transverse myelitis and other diseases that cause compression of the spinal cord (tumors, injuries).

Laboratory research:

• confirmation of the inflammatory process in the body (increased ESR, neutrophilia, shift in the leukocyte formula to the left);
• obtaining pus by puncture of the epidural space at the level of the lesion;
• lumbar puncture (to detect blockage of the subarachnoid space).

Of the instrumental diagnostic methods, MRI and CT provide the most complete information.

How does the disease manifest?

Symptoms of epiduritis depend on the form in which the disease occurs. In the vast majority of patients, the inflammatory process can be detected in an acute form, since an acute spinal-epidural abscess occurs with pronounced symptoms and often leads not only to limited mobility, but also to paralysis of the limbs. The main symptom of purulent epiduritis is radiculopathy (radicular syndrome) . Radicular syndrome is a complex of neuralgic symptoms that occur due to compression of the spinal roots, at the end of which there are a large number of nerve receptors. Radicular syndrome with epiduritis includes the following symptoms:

• intense pain and lumbago , which can occur in any part of the spinal column and intensifies with heavy lifting, sudden movements, coughing and other types of stress;
• impaired sensitivity of nerves in the area of ​​inflammation (if a needle is poked into a nerve, the patient will not feel anything);
• atrophy and weakness of the muscular corset that supports the spine;
• disruption of the functioning of organs located in the pelvic cavity;
• numbness of the upper and lower extremities.

Radicular syndrome

The acute form of epiduritis is accompanied by severe intoxication: the patient's temperature rises (up to 39-40°C), drowsiness, weakness, and intense headaches occur. Some patients experience severe nausea, lack of appetite, and possible repeated vomiting.

Note! If the pathological process involves the meninges, the patient is diagnosed with “external pachymeningitis.” In this case, the patient will exhibit all the symptoms of bacterial meningitis: photophobia, increased sensitivity to loud sounds and other irritants, decreased elasticity of the muscle tissue located in the back of the head.

External pachymeningitis

Treatment of spinal purulent epiduritis (external pachymeningitis)

Conservative treatment methods include intensive use of sulfonamide drugs and broad-spectrum antibiotics. If there is no effect, urgent surgical intervention is required - laminectomy (opening the spinal canal by removing the vertebral arches), removal of the abscess and drainage of the epidural space. After the operation, massive antibiotic therapy and rehabilitation therapy are prescribed. With timely treatment and the absence of dissemination of abscesses in the epidural space, the prognosis is favorable. At later stages of the disease, as a rule, the prognosis is unfavorable.

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Recommendations for the regimen

During treatment, the patient should limit physical activity as much as possible. During this period, patients are recommended bed rest, increased nutrition with a high content of vitamins and foods rich in calcium and phosphorus (fish, eggs, cottage cheese, cheese). It is useful to include in the menu dishes that contain gelatin (jelly, jellied meat, pudding): it strengthens cartilage and reduces the risk of dystrophy and degeneration of the vertebrae.

Therapeutic gymnastics in a seawater pool

After completion of therapy, the patient is recommended to undergo restorative sanatorium treatment using physiotherapy, mud therapy and treatment with mineral waters. To maintain and restore normal blood circulation in the vessels of the spine, it is recommended to regularly perform exercise therapy exercises selected by your doctor. You can start exercising 2-4 weeks after the end of treatment.

Causes

The disease occurs in the epidural part of the spinal cord. During development, inflammation covers the dura mater of the brain.

At the moment there is no consensus on the causes of the disease. Some scientists are of the opinion that the primary cause is infectious, others believe that the disease is an autoimmune reaction of the body due to other infectious diseases.

Factors causing epiduritis:

• Spine pathologies;
• Having had surgery on the spine or a puncture taken from it, as a result of which the infection damages the epidural spinal area and the patient feels constant fatigue.

Spine pathologies

Previous surgery

Epidurit in children

In childhood, this disease is rare. It mainly occurs in older people and those who already have some problems with the spine. The disease occurs in children if it is inherited. In childhood, the prognosis is more favorable, epiduritis is more treatable, and deaths are unknown. At the end of treatment, the child will not be any different from his peers.

For prevention, it is necessary to avoid hypothermia, especially the legs.

Diagnostics

Due to the nonspecificity of symptoms, it is often not possible to diagnose epiduritis at the initial stage. The analyzes also do not reveal any differences from the indicators characteristic of many other ailments. After the doctor examines the patient, the doctor refers the patient to additional diagnostic procedures. This may include radiography, spinal cord puncture, or MRI.

Lumbar puncture is also often prescribed to detect the local spinal form of epiduritis. In case of a complex form of the disease, an MRI is necessary, which gives an idea of ​​the course of the disease. After this, the patient is prescribed complex therapy.

Symptoms

Diagnosis presents certain difficulties, since the symptoms of spinal epiduritis are similar to the symptoms of other ailments. As a result, a diagnostic error is often made. The main manifestations of spinal epiduritis:

1. Temperature increase;
2. General weakness;
3. Frequently recurring attacks of headache, dizziness;
4. Partial or complete loss of their functions by the pelvic organs;
5. Pain in arms and legs;
6. Involuntary muscle contractions (this symptom is also a characteristic sign of radiculitis).

Treatment

Once the diagnosis is determined, a comprehensive treatment regimen is prescribed. Self-medication for this disease is unacceptable.

The main method of treatment is surgery. A laminectomy (an operation that involves opening the vertebral arches) or an operation to eliminate a herniated disc is performed. Antibiotics are prescribed to suppress the infection. The choice of specific drugs is determined by the site of infection.

If the disease proceeds with the formation of pus, the only effective treatment is laminectomy. This operation allows you to minimize the impact on the area affected by the disease. For spasms, muscle relaxants are prescribed.

To reduce pain, drugs from the glucocorticosteroid group are used.

Only an integrated approach to therapy makes it effective. Chondroprotective drugs can improve the condition of the spine.

In addition, vitamin preparations and hormonal preparations are prescribed. All methods of alternative treatment for epiduritis are ineffective. Changes in diet also do not make sense.

Forecast

The prognosis for epiduritis is determined by the time of diagnosis of the disease. With the purulent form of the disease, diagnosis is a relatively simple task. In the chronic form, epiduritis is often detected only during surgery.

In general, the prognosis depends
on 4 factors: timeliness of diagnosis; cause of the disease; coverage of the disease in various parts of the body; timeliness and quality of the operation. Timely surgical intervention leads to a positive outcome. But with chronic epiduritis, even after successful treatment, the patient becomes disabled, and a possible negative result is the death of the patient from complications.