Epidural abscess in children
Introduction
Introduction to children with epidural abscess Spinal epidural abscess (spinalepiduralabscess) is a localized suppurative inflammation of the spinal epidural space, often manifested as spinal cord compression or nerve root irritation. Due to the wide thoracic epidural space, rich in fat and connective tissue, and more venous plexus, adipose tissue has poor anti-infective ability and venous plexus blood flow, so there are more chances of infection, chest segment The occurrence of dural abscess accounted for about 50% of the total number of patients, followed by the lumbosacral segment, accounting for about 35% of the total, and the neck segment was less common, accounting for about 15% of the total. Abscesses are mostly located behind the spinal ganglia (82%) and are rare in the anterior ganglia (18%). basic knowledge The proportion of illness: 0.001% Susceptible people: children Mode of infection: non-infectious Complications: sepsis
Cause
Causes of pediatric epidural abscess
(1) Causes of the disease
Infection pathway
(1) Blood-derived: It is the most common infection route for abscesses (26% to 50%). It is more common in purulent infections around the skin, such as bloated skin (15%), intravenous or intramuscular injection, bacteria. Endocarditis, respiratory infections and local abscesses in the pharyngeal cavity are also common sources of infection.
(2) direct diffusion: hemorrhoids in the lumbosacral region, psoas abscess caused by vertebral tuberculosis, open trauma in the abdomen and neck, inflammation of the oropharynx, mediastinal inflammation, perirenal abscess can lead to infection The spinal cord segment directly spreads into the epidural space, forming an abscess.
(3) iatrogenicity: spinal surgery, epidural anesthesia and lumbar puncture and other medical operations are not standardized may bring pathogenic bacteria into the epidural space, causing abscess.
(4) Traumatic: Open injury of the lower back and penetrating injury of the spine is also a common cause of epidural abscess formation, accounting for about 30%.
(5) cryptogenic: about 50% of patients may not find a clear source of infection, but most cryptogenic infections are also blood-borne infections, just because the body's resistance is strong or the application of a large number of antibiotics, so that the primary lesions The performance is not obvious.
2. Etiology: The culture of pus helps to clarify the type of pathogenic bacteria. When the patient has been treated with a large number of antibiotics, the culture may also be negative. The bacteria can not find bacteria in the culture, accounting for 29% to 50% of the total. The most common pathogens are Staphylococcus aureus (50%); followed by Streptococcus; Pseudomonas aeruginosa, Enterobacter and Salmonella are also common pathogens, for chronic epidural abscesses, More secondary to vertebral tuberculosis, so tuberculosis is the most common pathogenic bacteria, accounting for about 25% of the total number of patients, cryptococcal bacterium, Aspergillus, Clostridium and anaerobic bacteria are occasionally reported in chronic abscesses, Mixed infections of various pathogens accounted for about 10% of the total number of positive bacterial cultures, and anaerobic infections accounted for about 8%.
(two) pathogenesis
Most are acute epidural abscesses, a few are subacute or chronic.
1. Acute epidural abscess: manifested as hyperhepatic tissue congestion, exudation, a large number of leukocyte infiltration, and then adipose tissue necrosis liquefaction, the formation of pus accumulation.
2. Subacute epidural abscess: There are pus and inflammatory granulation tissue in the epidural space, and some may have incomplete capsule.
3. Chronic epidural abscess: the epidural space is dominated by granulation and connective tissue hyperplasia, and the abscess envelops to form an abscess. Subacute or chronic patients often have localized thickening of the meninges, which has a compressive effect on the spinal nerves. The theory suggests that spinal cord dysfunction is attributed to the oppressive effects of abscesses. Recent studies have shown that abnormal venous return plays a major role in neurological dysfunction. Pathology confirms that no arterial involvement of the spinal ganglia is evident, but vein compression and embolism, Edema of the spinal ganglia, infarction of the epidural venous plexus, and formation of embolic phlebitis are common, and the spinal ganglia itself may also exhibit an inflammatory response due to direct spread of infection.
Prevention
Prevention of epidural abscess in children
1. Prevention of iatrogenic infections: various treatments, strict and sterile regulations.
2. Prevent all kinds of trauma: prevent all kinds of trauma from causing open injury to the kidneys.
Complication
Pediatric epidural abscess complications Complications sepsis
Symptoms of infection poisoning or sepsis, spinal cord transverse damage occurs as numbness of both lower extremities, complete soft palate, retention of stool and so on.
Symptom
Pediatric epidural abscess symptoms Common symptoms Children crying disturbed abdominal pain Compulsive posture sphincter dysfunction Chronic nerve root stimulation
Typical performance can be divided into three phases:
1. Spinal and nerve root pain: more than 1 to 3 days after the onset of symptoms of fever, chills, body aches and other infections, the nerve root stimulation symptoms of the corresponding spinal segments appear, which is difficult to tolerate pain, when slamming the spine There may be sniper pain in the affected segment. When the child cannot express the symptoms, it often shows crying and restlessness. The scoliosis takes the forced position to relieve the pain. The abscess may have severe abdominal pain or lower limb pain in the thoracolumbar region. Clinical It is easy to misdiagnose "acute appendicitis in children". In this stage, the symptoms of systemic infection are heavier, and the peripheral blood shows obvious increase of white blood cells.
2. Spinal cord dysfunction: Symptoms of transverse spinal cord injury often occur within hours or days of root pain, manifested as numbness of both lower extremities, rapid progression of muscle strength and sphincter dysfunction.
3. Complete sputum: From the second phase, the limbs will be completely softened, and all reflexes will disappear and the stool will remain.
Examine
Examination of children with epidural abscess
1. Peripheral blood: white blood cell count and neutrophil increase, nuclear left shift and toxic particles can occur.
2. Lumbar puncture examination: lumbar puncture and pus extraction is a direct evidence of diagnosis, but lumbar puncture has the risk of causing infection in the subarachnoid space. Care should be taken to gradually insert the needle. After acupuncture of the ligamentum flavum, whether it should be sucked back or not Pus, such as once the pus can be pulled out; when the lumbar puncture needle does not pull out the pus and enter the subarachnoid space, there is clear cerebrospinal fluid outflow, the test shows that the white blood cell count and protein amount increase, the dynamic test can be seen obstruction which performed.
3. Spinal X-ray film: unless the osteomyelitis of adjacent vertebral bodies is combined, abnormal findings are found, which are manifested as osteolysis and destruction of the vertebral body.
4. The typical manifestations of MRI are: T1 is low or equal signal, T2 is a high signal epidural space, cancellous bone can be seen in vertebral osteomyelitis, and the soft tissue signal of the affected disc and paravertebral is reduced, enhanced scanning At the same time, the annular thin-walled reinforcement of the pus wall can be seen, and when a large amount of granulation tissue is formed, it is characterized by irregular mass-like strengthening.
Diagnosis
Diagnosis and diagnosis of children with epidural abscess
A typical medical history, tenderness or snoring of the spine in the lesion, combined with laboratory and auxiliary examinations, is not difficult to diagnose the disease.
Need to distinguish from acute transverse myelitis, spinal ganglion tumor and disc herniation, when the thoracolumbar abscess causes severe abdominal pain, pay attention to distinguish acute appendicitis.
