The effectiveness of a percutaneous endoscopic approach in a patient with psoas and epidural abscess accompanied by pyogenic spondylitis: a case report
Psoas or epidural abscesses are often accompanied by pyogenic spondylitis and require drainage. Posterolateral percutaneous endoscopic techniques are usually used for hernia discectomy, but this approach is also useful in some cases of psoas or lumbar ventral epidural abscess. We here report a case of psoas and epidural abscesses accompanied by pyogenic spondylitis that was successfully treated by percutaneous endoscopic drainage.
Our patient was a 57-year-old Japanese woman who had been receiving chemotherapy for inflammatory breast cancer and who became unable to walk due to lower back and left leg pain. She was transported as an emergency to another hospital. Magnetic resonance imaging revealed psoas and epidural abscesses accompanied by pyogenic spondylitis, and methicillin-resistant Staphylococcus aureus was detected in a blood culture. Drainage of the psoas abscess was performed under echo guidance, but was not effective, and she was transferred to our institution. We performed percutaneous endoscopic drainage for the psoas and epidural abscesses. Immediate pain relief was achieved and the inflammatory reaction subsided after 8 weeks of antibiotic therapy with daptomycin.
Percutaneous endoscopy allowed us to approach the psoas and epidural abscesses directly, enabling the immediate drainage of the abscesses with less burden on the patient.
KeywordsPercutaneous endoscopy Psoas abscess Epidural abscess Pyogenic spondylitis Drainage
Psoas abscesses are often accompanied by pyogenic spondylitis . They can be treated with antibiotic therapy alone; however, drainage is recommended for cases involving large abscesses or when antibiotic therapy is ineffective . Surgical drainage has been the traditional treatment; however, less invasive treatments, such as drainage under computed tomography (CT) or echo guidance, have become more common . Open surgery is generally performed when percutaneous drainage is not effective. Posterolateral percutaneous endoscopic techniques are usually used for hernia discectomy ; however, this rare posterolateral approach is also useful in some cases of psoas or lumbar ventral epidural abscess. This technique enabled us to reach the abscess directly and to perform lavage and drainage less invasively in comparison to traditional open surgery. We here report a case of psoas and epidural abscesses in a patient with pyogenic spondylitis that were successfully treated by percutaneous endoscopic drainage.
The endoscopic surgical procedure
Psoas abscesses are classified as primary or secondary; pyogenic spondylitis is one of the etiologies of secondary psoas abscess. When a psoas abscess is small, antibiotic therapy alone can be selected; however, when the abscess becomes large, drainage is recommended. Percutaneous drainage under CT or echo guidance is generally used for the drainage of psoas abscesses; however, drainage fails in a considerable number of cases, especially in cases involving multiloculated abscess cavities or with thick tenacious pus . In such cases, an extraperitoneal approach has traditionally been performed. We used a posterolateral endoscopic approach to reduce the invasiveness of surgery as this patient was in a septic condition with severe undernutrition.
There are some reports on the performance of posterolateral percutaneous endoscopic surgery for the treatment of pyogenic spondylitis [6, 7]. The case series demonstrated that this approach provided acute pain relief and the early subsidence of spinal infection. It is difficult to judge the need of the surgical intervention because the cases may be treatable by percutaneous drainage under CT or echo guidance. Our case demonstrated that this percutaneous drainage technique can be adopted in the failure cases of percutaneous drainage, and showed that we could approach a psoas abscess directly by percutaneous endoscopy. The injection of Omnipaque (iohexol) into the lumbar disc before surgery proved the passage of pus between the lumbar disc and the psoas abscess; however, we decided to drain the psoas abscess directly as the abscess size was so large that setting the suction tube in the lumbar disc would probably have been insufficient for treating the psoas abscess. The approach to the psoas muscle is the same approach that is used in lumbar plexus blockade . We only used fluoroscopy because the preoperative images showed that no organs were in the way of the approach; however, echo guidance allows for the safer insertion of a needle into the psoas. Preoperative CT or MRI images can reveal when this approach would be difficult, and in which traditional open surgery would be needed. The advantage of percutaneous drainage in comparison to drainage under CT or echo guidance is that the abscess can be irrigated directly with a large amount of water and a thicker tube can be placed. This procedure is considered to contribute to immediate pain relief and an acute decrease in the size of the abscess. MRI at 1 week after surgery showed that the abscess was almost completely diminished.
Some precautions should be taken in this approach. Our patient complained of mild hypesthesia around her left knee after surgery. This may have been an after effect of the epidural and psoas abscesses, or it may have occurred due to exiting nerve root damage that was caused by the transforaminal approach for epidural abscess drainage , or because of the lumbar plexus damage that occurred during the direct approach to the psoas abscess . It was difficult to identify the cause of hypesthesia as many factors were present. Our technique of treating the psoas abscess simply involved perforating the psoas muscle and feeling the inside with a spatula; thus, the risk of damaging the lumbar plexus is considered to be low. However, it is important to keep in mind the risk of damage to the lumbar plexus when we directly approach the psoas muscle. In addition, we need to monitor the position of the cannula by fluoroscopy in order to prevent it from moving ventrally and to avoid injuring the peritoneum or urinary tract during surgery. Even though there were some technical points that needed to be remembered, the operative invasiveness was low in comparison to conventional open surgery and it was immediately effective. Moreover, while ventral epidural abscesses are difficult to drain by traditional open surgery, this unusual approach enabled us to approach the site easily. We performed this surgery under general anesthesia because three skin incisions were needed; however, the procedure is generally performed under local anesthesia to avoid exiting nerve injury. Patients with pyogenic spondylitis who have several abscesses are generally in an immunosuppressive state and the condition has the potential to be life threatening. This procedure could be a treatment option even for patients in a poor general condition and for whom general anesthesia would be considered to be associated with a high degree of risk.
Six weeks of antibiotic therapy is recommended for the treatment of pyogenic spondylitis, and more long-term antibiotic treatment is recommended for MRSA infection . Daptomycin seemed more effective than vancomycin for MRSA [12, 13]. We administered antibiotic therapy for 8 weeks after surgery, which led to a reduction in the inflammatory reaction. No marked vertebral destruction was observed, and our patient was a good candidate for endoscopic treatment. As mentioned in previous reports, some surgical instruments or anterior column reconstruction may be necessary when pyogenic spondylitis is accompanied by severe vertebral destruction .
Percutaneous endoscopy allowed us to approach the psoas and epidural abscesses directly, enabling the immediate drainage of the abscesses with less burden on the patient. It was suggested that a percutaneous endoscopic approach is one of the effective treatments for psoas and epidural abscesses.
KI wrote, edited, reviewed, and finalized the manuscript. KY, OT, KT, and KH reviewed and finalized the manuscript. All authors read and approved the final manuscript.
The authors declare that this work has not received any funding.
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Consent for publication
Written informed consent was obtained from the patient’s next of kin for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
The authors declare that they have no competing interests.
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