Topics in NeurologyThoracic Spondylodiscitis Epidural Abscess in an Afebrile Navy Veteran: A Case Report
Introduction
Back and neck pain are leading global causes of disability.1 Back pain caused by serious underlying pathology accounts for less than 3% of all back pain.2 A spinal epidural abscess (SEA) is a rare, life-threatening infection, with the incidence on the rise in recent decades. The rate of SEA in 1975 was 0.2 to 2.0 cases per 10 000.3 In a study of tertiary referral centers in 1999, 12.5 cases per 10 000 were reported.4 Early diagnosis is paramount to mitigate neurological compromise and limit morbidity. A history of diabetes mellitus (21%-38% of cases), intravenous (IV) drug use, end-stage renal disease, human immunodeficiency virus (HIV), or immunosuppressant use and iatrogenic causes, such as epidural spinal procedures, increase the risk of SEA.5, 6, 7
Cases of SEA have been documented as presenting to chiropractic offices often masquerading as non-specific neck or back pain.8, 9, 10 The classic clinical triad of back pain, fever, and neurological deficits is observed in only ~10% of cases.11 Clinical progression of SEA has been observed to comprise four phases: (1) spinal ache, (2) root pain, (3) weakness of voluntary muscles and sphincters, followed by (4) paralysis.12
Because of the pervasive nature of neck and back pain, misdiagnosis of SEA on initial presentation is noteworthy, with estimates ranging from 11% to 75%.7, 13 A SEA, on average, crosses 3.85 vertebral levels and is reported in the thoracic (15%-39.1%), lumbosacral (30%-54.7%), and cervical (9%-35.9%) regions.6, 7, 14, 15 Magnetic resonance imaging (MRI) examination with and without gadolinium of the entire spine is the gold standard, as it differentiates SEA from other space-occupying lesions and malignancy. A computed tomography (CT) myelogram should be obtained when MRI is unavailable or is contraindicated because of an implanted electrical device (eg, pacemaker, spinal stimulator).5, 11, 15 The infectious agent causing SEA is most commonly of bacterial origin and overwhelmingly either methicillin-sensitive or methicillin-resistant Staphylococcus aureus.7, 13 Once patients are diagnosed with SEA, best outcomes are achieved with rapid surgical intervention, abscess drainage, and concomitant antibiotic treatment. When monitored closely for clinical deterioration, there are select cases with limited neurological deficit that may be managed with antibiotic therapy only.11, 13
Multiple published SEA cases have suggested acupuncture to be the causative route of infection.16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31 In this report, we describe a case of SEA in a man who presented to a chiropractic office for acupuncture at a Veterans Affairs Medical Center. The purpose of this case study is to describe the differential diagnosis of a thoracic epidural abscess in a Navy veteran who presented to a chiropractic clinic for evaluation and management with acupuncture within a Veterans Affairs Medical Center.
Section snippets
Case Report
A 59-year-old man with chronic low back pain and left leg pain below the knee was referred by his primary care physician (PCP) to a chiropractor for evaluation and consideration for acupuncture. The patient developed acute, non-traumatic left-sided thoracic pain 8 days prior to his initial appointment. He reported his thoracic spine pain was significantly relieved following a bowel movement the day prior, yet remained more prominent than low back and left leg pain.
The patient had Minor’s sign
Discussion
Acupuncture is commonly used to treat back, neck, and joint pain. Since 1982, there have been at least 16 reports in the English literature of SEA secondary to acupuncture treatment.16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31 It has been proposed that poorly controlled hygiene in acupuncture practice might lead to epidural infections.17, 18, 19, 22, 25 All invasive procedures that break the skin carry the risk of infection. Appropriate clean needle technique is required to
Conclusion
A Navy veteran with acute thoracic spine and chronic low back pain appeared to initially respond to acupuncture, but failed to achieve a clinically meaningful outcome. Follow-up advanced imaging revealed a thoracic SEA, despite no elevation in temperature on multiple occasions or neurological deterioration. The spine practitioner is reminded that early diagnosis and immediate intervention are important to preserving neurological function and limiting morbidity in cases of SEA.
Funding Sources and Conflicts of Interest
This work was conducted at and supported by VA Butler Healthcare. No conflicts of interest were reported for this study.
Contributorship Information
Concept development (provided idea for the research): Z.A.C., M.T.A.
Design (planned the methods to generate the results): Z.A.C., M.T.A.
Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): Z.A.C.
Data collection/processing (responsible for experiments, patient management, organization, or reporting data): Z.A.C., T.J.S.
Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): Z.A.C.,
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2021, Complementary Therapies in Clinical PracticeAcupuncture-Induced Cranial Epidural Abscess: Case Report and Review of the Literature
2019, World NeurosurgeryCitation Excerpt :Our review yielded 1803 unique articles. After screening for inclusion/exclusion criteria, we identified 21 articles for full review (Table 1).2,31-50 Most of the indications for acupuncture were benign, including axial neck or back pain,31,33,38,41 and patients usually presented within a few weeks after single or multiple acupuncture sessions.
Mini-Reports from Veterans Administration Centers
2018, Medical Acupuncture