What about spinal abscess?

What about spinal abscess? Pretty uncommon, but differential diagnosis is humongous. Acute pain, paraplegia, you have to think all kinds of things. Especially the neurosurgeons in the audience. Before we get the MRI the problem may be metastases, the problem may be blood, spinal AVM. Maybe anticoagulants, obviously disc. Think of medical problems; stroke in older people. You can have pain with stroke, spinal cord stroke. Dissection, hypertension are important factors that produce spinal infarction. Lupus myelopathy, cocaine can produce vasculitis, sarcoidosis can produce acute myelopathy with pain. This is post-infection myelitis, so look for preceding infection. So the differential diagnosis of acute spinal cord syndrome is pretty big.

Shunt infection. Incidence, approximately 10% or less, higher after the first shunt. Higher in children, small children. Higher if the surgeon is less experienced. This is what the literature says. So these are the risk factors for shunt infection. They usually come within a few weeks of the first shunt insertion. Look for cells, fever, meningeal signs.

Bacterial meningitis. Strep, pneumonia, one out of four strep meningitis is now penicillin resistant. H. influenza B we don’t see anymore because of vaccination. Listeria is getting more common, especially in older people with meningitis. Strep pneumonia still carries very high morbidity and mortality. Neonates, strep pneumonia is now a number one cost. Listeria is becoming more common in the neonate. Morbidity seems to relate to cerebral edema and intracranial pressure. If you have venous thrombosis and stroke, you have higher morbidity. Many people with bacterial meningitis have vasculitis of the skull base. They get stroke. You can have subdural empyema after meningitis, you can have abscess with meningitis. So if you start out with meningitis, you treat the patient for two or three days, the patient then develops focal findings.

The differential diagnosis would be stroke, venous thrombosis, abscess forming or empyema forming. So those are the three or four complications you need to remember. This keeps coming up. If the patient is not deeply comatose, if there are no focal findings, if there is no papilledema. It’s okay to take little bit of CSF out if you suspect meningitis. Then it’s also okay to start antibiotics. One or two doses is not going to change your CSF very much. Of course typical findings in CSF is a lot of polymers, high sugar, low glucose. We all know that. You can look for bacterial antigens in just about all those situations by latex testing. Lactate in the CSF can be helpful. Lactate goes up if you are dealing with bacterial meningitis. Lactate is not increased in viral meningitis. Tumor necrosis factor is still experimental. It is increased in many people with bacterial meningitis.

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