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Epidural Abscess Associated With Intravenous Drug Abuse in a Pregnant Patient
Case Report Epidural Abscess Associated With Intravenous Drug Abuse in a Pregnant Patient
JO T. VAN WINTER, M.D., SKOTT N. J. NIELSEN, M.D.,* PAUL L. OGBURN, Jr., M.D., Department of Obstetrics and Gynecology
The association between intravenous drug abuse and epidural abscess is well known; however, this association has not previously been reported in a pregnant patient. The classic manifestation of epidural abscess is a febrile patient with back pain that progresses rapidly to radicular pain, spinal cord dysfunction, weakness, and then complete paralysis•. Although this condition is rare during pregnancy, these serious complications necessitate prompt diagnosis and intervention. If spinal infection is suspected, magnetic resonance imaging should be performed immediately. After epidural abscess is diagnosed, emergent decompressive laminectomy and appropriate antibiotic coverage are necessary. Herein we describe a 27-year-old pregnant patient with epidural abscess probably related to use of contaminated needles for intravenous administration of drugs and subsequent hematologic spread of staphylococci to the epidural space. The differential diagnosis of epidural abscess can be difficult, and management options must consider the well-being of both the mother and the fetus.
Escalating abuse of illicit drugs during pregnancy has resulted in increased adverse maternal and perinatal outcomes. I Although the association between intravenous drug abuse and epidural abscess is well known," to our knowledge such an association during pregnancy has not previously been reported. Herein we describe such a case and emphasize the need for immediate decompressive laminectomy and concomitant antibiotic treatment. Without this intervention, substantial morbidity or mortality can occur. In addition, if a severe neurologic deficit is present, recovery of spinal cord function is unpredictable.v'
REPORT OF CASE A 27-year-old woman, a known intravenous polydrug abuser, came to our emergency department at approximately 22 weeks' gestation; she had fever, chest and abdominal pain, and bilateral leg weakness. Results of a urine drug *Current address: Duluth Clinic, Duluth, Minnesota, Address reprint requests to Dr. J. T, Van Winter, Department of Obstetrics and Gynecology, MayoClinic,Rochester, MN 55905. Mayo Clin Proc 66:1036-1039,1991
screen were positive for acetaminophen and opiates. The patient left our emergency department against medical advice only to return to her local emergency department 48 hours later because of flaccid paraplegia and urinary retention. After a spinal puncture revealed epidural pus, she was transferred to our institution. On arrival, the patient immediately underwent magnetic resonance imaging studies of the spine, which showed a large epidural abscess. This abscess was located posterior to the left side of the spinal cord and extended from T-1 to T-6 (Fig. 1). A decompressive laminectomy (from T-l to T-6) was performed as an emergency procedure, along with dissection of a large amount of granulation tissue from the nearby dura mater. In addition, the abscess was drained and cultures were obtained, blood was withdrawn for cultures, and therapy with a penicillinase-resistant penicillin (nafcillin) was begun pending results of the cultures. Staphylococcus aureus sensitive to cefazolin was isolated from all cultures, and parenteral coverage with this antibiotic was continued for 6 weeks. Postoperatively, a neurologic examination showed no improvement in the flaccid paralysis of the patient. She was
1036
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EPIDURAL ABSCESS DURING PREGNANCY
1037
the aid of leg braces and arm supports. Her infant had evidence of narcotic withdrawal and was closely monitored in the high-risk nursery for 2 weeks. He was then placed in protective foster care pending a court decision about a permanent home. DISCUSSION Spinal epidural abscess has an estimated incidence of 0.2 to 1.2 per 10,000 hospital admissions annually.' It has been reported during pregnancy as a result of vertebral osteomyelitist and in the puerperium as a spontaneous occurrence.' In addition, it has been described during the postpartum period in association with use of a lumbar epidural anesthetic agent during labor." Epidural abscess, however, has not been reported in a peripartum state in conjunction with intravenous drug abuse. In our patient, the probable source of infection was contaminated needles used for intravenous administration of drugs and the subsequent hematologic Fig. 1. Magnetic resonance image of spine of 27-year-old pregnant spread of staphylococci to the epidural space. The increased woman, showing epidural abscess from T-I to T-6 (bracketed area) vascularity of the epidural space during pregnancy would associated with intravenous drug abuse. promote such a blood-borne infection. No evidence of any other infectious source, including vertebral osteomyelitis, assessed daily in physical therapy, occupational therapy, and and no history of antecedent back trauma were noted." The classic manifestation of epidural abscess is a febrile psychiatry; postpartum goals were independent care and successful treatment of the chemical dependence. Metha- patient with back pain that progresses to radicular pain, done maintenance was part of her therapy, and serial drug spinal cord dysfunction, and weakness and then rapidly screening studies of the urine confirmed compliance with eventuates in complete paralysis. 3,5,8,9 This progression of symptoms usually occurs in 48 to 72 hours and is thought to this treatment. The patient's postoperative course was complicated by result from cord compression due to the expanding inflamthe onset of preterm labor at 24 weeks' gestation. Successful matory mass, destruction of neural tissue, and thrombosis of tocolysis was obtained initially with magnesium sulfate small spinal arteries and veins. Although this condition is administered intravenously, followed by terbutaline sulfate extremely rare during pregnancy, these complications are so administered orally until 37 weeks' gestation. As a result of serious that prompt diagnosis and immediate intervention the patient's inability to detect contractions (attributed to are necessary. Major considerations in the differential diagnosis of acute sensory loss), physical disabilities, and treatment for drug dependence, hospitalization for the rest of the pregnancy was epidural abscess are osteomyelitis, disk prolapse, meningitis, acute transverse myelopathy, spontaneous epidural henecessary. Fetal surveillance with use of alternate-day heart tracings matoma or other vascular lesions, and intraspinal tumors.v' and serial ultrasonography was initiated at 24 weeks' gesta- Although a patient who has osteomyelitis may have focal or tion and was continued until onset of labor (37 517 weeks' diffuse back pain, results of analysis of the cerebrospinal gestation). During labor and delivery, analgesia and anes- fluid are usually negative. Therefore, a differential diagnosis thesia were achieved with meperidine hydrochloride admin- may be difficult. In a study by Bergman and associates," 20 istered parenterally and paracervical and pudendal blocks. to 50% of patients with spinal epidural abscess had contiguEpidural anesthesia was not used, and no autonomic hyper- ous osteomyelitis based on radiographic criteria.v'? Prolapse reflexia was noted. The patient was delivered of a 2,960-g or extrusion of a disk may cause symptoms similar to those male infant (Apgar scores of 8 at I minute and 9 at 5 of epidural abscess, but this condition is rarely associated minutes) with the aid of low forceps because of intermittent with fever or changes in cerebrospinal fluid. In patients with meningitis, diffuse back pain and headache are the major bradycardia and ineffectual attempts at pushing. During the postpartum period, tapering of the dose of complaints at initial examination. Paralysis associated with methadone was initiated, and the patient was transferred to a acute transverse myelopathy occurs within 72 hours, and long-term drug and physical rehabilitation facility. While back pain may be absent.t-'! Paralysis associated with interthere, she learned to function independently and to walk with ruption of the vascular supply of the spinal cord is usually
1038 EPIDURAL ABSCESS DURING PREGNANCY
instantaneous. 12,13 In contrast, an intraspinal tumor would usually be associated with' a more protracted course, similar to that of chronic epidural abscess." If spinal infection is suspected, magnetic resonance imaging should be done immediately. For diagnosis, this procedure is preferred to either spinal puncture or myelography because spinal puncture has been associated with bacterial inoculation into the subarachnoid space" and neurologic deterioration has been reported after myelography. 16 If an epidural mass is found on magnetic resonance imaging, laminectomy should be performed, and antibiotic treatment should be initiated after specimens have been obtained for culture. Patients with epidural abscess require treatment with parenterally administered antibiotics, usually with a penicillinase-resistant penicillin for at least 3 to 4 weeks. During pregnancy, the well-being of the fetus also is of concern. Unfortunately, drug dependence often begins in utero. As a result of a history of intravenous narcotic use, our patient (and her fetus) were placed on a methadone maintenance program in conjunction with careful fetal surveillance. Methadone maintenance is preferred to methadone detoxification during pregnancy because of fetal stress or even fetal death associated with narcotic withdrawal, particularly in the third trimester.'? Because the methadone maintenance program may still be associated with fetal death, low birth weight, and premature onset of labor, frequent antenatal testing and serial ultrasonography for evaluation of growth are necessary to assess fetal well-being. In addition, the long-term effects of intrauterine exposure to methadone are generally unknown. Tocolysis was also necessary because of preterm labor, which may have occurred as a result of the infective process, narcotic use, or surgical intervention. Frequent intermittent or continuous electronic monitoring for uterine contractions was necessary because our patient could not perceive uterine contractions. Intermittent manual palpation was inadequate screening for preterm labor in this case. Labor and delivery have been associated with autonomic hyperreflexia in patients with paraplegia, especially those with spinal cord injury at or above the level of T-6. Fortunately, this life-threatening complication, which can lead to sudden, severe hypertension and subsequent subarachnoid hemorrhage and death, did not develop in our patient. Epidural anesthesia is recommended to prevent autonomic hyperreflexia in paralyzed parturients; however, use of this type of regional anesthesia was impossible in our patient because of the recent epidural abscess. Obstetricians should be aware that when hypertension develops in a patient with paraplegia who is in labor, autonomic hyperreflexia should be strongly considered in the absence of other signs of preeclampsia. If hypertension occurs suddenly despite the use of a regional anesthetic agent, the patient should immedi-
Mayo Clio Proc, October 1991, Vol 66
ately be placed in a sitting position. If this maneuver fails to control the blood pressure, a ganglionic blocking agent or direct vasodilator should be administered by intravenous drip, and the blood pressure should be constantly monitored. If these measures fail to control the hypertension, an emergency cesarean section should be considered because symptoms of autonomic hyperreflexia usually resolve after delivery of the infant and placenta. 18.19 Nonetheless, because of potential wide fluctuations in blood pressure that can be associated with anesthesia for cesarean section (that is, hypertension associated with general anesthesia and hypotension associated with regional blocks), extreme care must be exercised by a skilled team in order to avoid mortality or morbidity for the mother and fetus when cesarean section is chosen.
CONCLUSION Although mild to moderate back discomfort is common during pregnancy, severe back pain may indicate a serious problem and merits immediate assessment, especially if the patient is a known or suspected substance abuser. If epidural abscess is diagnosed, emergency decompressive laminectomy and appropriate antibiotic coverage are necessary. Early recognition and treatment are essential; if the neurologic deficit is extensive (as in our patient), the potential for functional neurolo,gic recovery is limited.
REFERENCES
I.
Little BB, GilstrapLC III, Cunningham FG: Socialand illicit substance use during pregnancy. In Williams Obstetrics. Eighteenthedition, Suppl 7. Edited by FG Cunningham, PC MacDonald, NF Gant. East Norwalk, Connecticut, Appleton & Lange, August/September 1990 2. KoppelBS, Tuchman AJ, Mangiardi JR, Daras M, Weitzner I: Epidural spinal infection in intravenous drug abusers. Arch Neurol 45:1331-1337,1988
3. Baker AS, Ojemann RG, Swartz MN, Richardson EP Jr: Spinal epidural abscess. N Engl J Moo 293:463-468, 1975 4. Hunter JC, Ryan MD, Taylor TKF, Pennington IC: Spinal epiduralabscessin pregnancy. Aust N Z J Surg 47:672-674, 1977
5. Crawford JS: Pathology in the extradural space. Br J Anaesth 47:412-414, 1975 6. Male CG, MartinR: Puerperal spinalepiduralabscess (letter to the editor). Lancet 1:608-609, 1973 7. Hulme A: Spinal epiduralabscess. Br Med J 1:64-68, 1954 8. Bergman I, Wald ER, Meyer ID, Painter MJ: Epidural abscess and vertebral osteomyelitis following serial lumbar punctures. Pediatrics 72:476-480,1983 9. Hancock DO: A study of 49 patients with acute spinal extradural abscess. Paraplegia 10:285-288, 1973 10. Kaufman DM, Kaplan JG, Litman N: Infectious agents in spinal epiduralabscesses. Neurology 30:844-850, 1980 II. Altrocchi PH: Acute transverse myelopathy. Arch Neurol 9:111-119,1963
Mayo Clio Proc, October 1991, Vol 66
12.
Markham JW, Lynge HN, Stahlman GEB: The syndrome of spontaneous spinal epidural hematoma: .report of three cases. J Neurosurg 26:334-342,1967 13. Herrick MK, Mills PE Jr: Infarction of spinal cord: two cases of selective gray matter involvement secondary to asymptomatic aortic disease. Arch Neurol 24:228-241,1971 14. Mullins GM, Flynn JPG, EI-Mahdi AM, McQueen JD, Owens AH Jr: Malignant lymphoma of the spinal epidural space. Ann Intern Med 74:416-423,1971 15. Dripps RD, Vandam LD: Hazards of lumbar puncture. JAMA 147:1118-1121,1951
EPIDURAL ABSCESS DURING PREGNANCY
16.
1039
Willis BK, Benzel EC: Acute postmyelographic neurological deterioration (letter to the editor). J Neurosurg 69:148-149, 1988 17. Blinick G, Wallach RC, Jerez E, Ackerman BD: Drug addiction in pregnancy and the neonate. Am J Obstet Gynecol 125:135-142,1976 18. Committee on Obstetrics: Maternal and Fetal Medicine: Management of labor and delivery for patients with spinal cord injury. ACOG Committee Opinion, No. 83, May 1990 19. Robertson DNS: Pregnancy and labour in the paraplegic. Paraplegia 10:209-212, 1972
JO T. VAN WINTER, M.D., SKOTT N. J. NIELSEN, M.D.,* PAUL L. OGBURN, Jr., M.D., Department of Obstetrics and Gynecology
The association between intravenous drug abuse and epidural abscess is well known; however, this association has not previously been reported in a pregnant patient. The classic manifestation of epidural abscess is a febrile patient with back pain that progresses rapidly to radicular pain, spinal cord dysfunction, weakness, and then complete paralysis•. Although this condition is rare during pregnancy, these serious complications necessitate prompt diagnosis and intervention. If spinal infection is suspected, magnetic resonance imaging should be performed immediately. After epidural abscess is diagnosed, emergent decompressive laminectomy and appropriate antibiotic coverage are necessary. Herein we describe a 27-year-old pregnant patient with epidural abscess probably related to use of contaminated needles for intravenous administration of drugs and subsequent hematologic spread of staphylococci to the epidural space. The differential diagnosis of epidural abscess can be difficult, and management options must consider the well-being of both the mother and the fetus.
Escalating abuse of illicit drugs during pregnancy has resulted in increased adverse maternal and perinatal outcomes. I Although the association between intravenous drug abuse and epidural abscess is well known," to our knowledge such an association during pregnancy has not previously been reported. Herein we describe such a case and emphasize the need for immediate decompressive laminectomy and concomitant antibiotic treatment. Without this intervention, substantial morbidity or mortality can occur. In addition, if a severe neurologic deficit is present, recovery of spinal cord function is unpredictable.v'
REPORT OF CASE A 27-year-old woman, a known intravenous polydrug abuser, came to our emergency department at approximately 22 weeks' gestation; she had fever, chest and abdominal pain, and bilateral leg weakness. Results of a urine drug *Current address: Duluth Clinic, Duluth, Minnesota, Address reprint requests to Dr. J. T, Van Winter, Department of Obstetrics and Gynecology, MayoClinic,Rochester, MN 55905. Mayo Clin Proc 66:1036-1039,1991
screen were positive for acetaminophen and opiates. The patient left our emergency department against medical advice only to return to her local emergency department 48 hours later because of flaccid paraplegia and urinary retention. After a spinal puncture revealed epidural pus, she was transferred to our institution. On arrival, the patient immediately underwent magnetic resonance imaging studies of the spine, which showed a large epidural abscess. This abscess was located posterior to the left side of the spinal cord and extended from T-1 to T-6 (Fig. 1). A decompressive laminectomy (from T-l to T-6) was performed as an emergency procedure, along with dissection of a large amount of granulation tissue from the nearby dura mater. In addition, the abscess was drained and cultures were obtained, blood was withdrawn for cultures, and therapy with a penicillinase-resistant penicillin (nafcillin) was begun pending results of the cultures. Staphylococcus aureus sensitive to cefazolin was isolated from all cultures, and parenteral coverage with this antibiotic was continued for 6 weeks. Postoperatively, a neurologic examination showed no improvement in the flaccid paralysis of the patient. She was
1036
Mayo Clin Proc, October 1991, Vol 66
EPIDURAL ABSCESS DURING PREGNANCY
1037
the aid of leg braces and arm supports. Her infant had evidence of narcotic withdrawal and was closely monitored in the high-risk nursery for 2 weeks. He was then placed in protective foster care pending a court decision about a permanent home. DISCUSSION Spinal epidural abscess has an estimated incidence of 0.2 to 1.2 per 10,000 hospital admissions annually.' It has been reported during pregnancy as a result of vertebral osteomyelitist and in the puerperium as a spontaneous occurrence.' In addition, it has been described during the postpartum period in association with use of a lumbar epidural anesthetic agent during labor." Epidural abscess, however, has not been reported in a peripartum state in conjunction with intravenous drug abuse. In our patient, the probable source of infection was contaminated needles used for intravenous administration of drugs and the subsequent hematologic Fig. 1. Magnetic resonance image of spine of 27-year-old pregnant spread of staphylococci to the epidural space. The increased woman, showing epidural abscess from T-I to T-6 (bracketed area) vascularity of the epidural space during pregnancy would associated with intravenous drug abuse. promote such a blood-borne infection. No evidence of any other infectious source, including vertebral osteomyelitis, assessed daily in physical therapy, occupational therapy, and and no history of antecedent back trauma were noted." The classic manifestation of epidural abscess is a febrile psychiatry; postpartum goals were independent care and successful treatment of the chemical dependence. Metha- patient with back pain that progresses to radicular pain, done maintenance was part of her therapy, and serial drug spinal cord dysfunction, and weakness and then rapidly screening studies of the urine confirmed compliance with eventuates in complete paralysis. 3,5,8,9 This progression of symptoms usually occurs in 48 to 72 hours and is thought to this treatment. The patient's postoperative course was complicated by result from cord compression due to the expanding inflamthe onset of preterm labor at 24 weeks' gestation. Successful matory mass, destruction of neural tissue, and thrombosis of tocolysis was obtained initially with magnesium sulfate small spinal arteries and veins. Although this condition is administered intravenously, followed by terbutaline sulfate extremely rare during pregnancy, these complications are so administered orally until 37 weeks' gestation. As a result of serious that prompt diagnosis and immediate intervention the patient's inability to detect contractions (attributed to are necessary. Major considerations in the differential diagnosis of acute sensory loss), physical disabilities, and treatment for drug dependence, hospitalization for the rest of the pregnancy was epidural abscess are osteomyelitis, disk prolapse, meningitis, acute transverse myelopathy, spontaneous epidural henecessary. Fetal surveillance with use of alternate-day heart tracings matoma or other vascular lesions, and intraspinal tumors.v' and serial ultrasonography was initiated at 24 weeks' gesta- Although a patient who has osteomyelitis may have focal or tion and was continued until onset of labor (37 517 weeks' diffuse back pain, results of analysis of the cerebrospinal gestation). During labor and delivery, analgesia and anes- fluid are usually negative. Therefore, a differential diagnosis thesia were achieved with meperidine hydrochloride admin- may be difficult. In a study by Bergman and associates," 20 istered parenterally and paracervical and pudendal blocks. to 50% of patients with spinal epidural abscess had contiguEpidural anesthesia was not used, and no autonomic hyper- ous osteomyelitis based on radiographic criteria.v'? Prolapse reflexia was noted. The patient was delivered of a 2,960-g or extrusion of a disk may cause symptoms similar to those male infant (Apgar scores of 8 at I minute and 9 at 5 of epidural abscess, but this condition is rarely associated minutes) with the aid of low forceps because of intermittent with fever or changes in cerebrospinal fluid. In patients with meningitis, diffuse back pain and headache are the major bradycardia and ineffectual attempts at pushing. During the postpartum period, tapering of the dose of complaints at initial examination. Paralysis associated with methadone was initiated, and the patient was transferred to a acute transverse myelopathy occurs within 72 hours, and long-term drug and physical rehabilitation facility. While back pain may be absent.t-'! Paralysis associated with interthere, she learned to function independently and to walk with ruption of the vascular supply of the spinal cord is usually
1038 EPIDURAL ABSCESS DURING PREGNANCY
instantaneous. 12,13 In contrast, an intraspinal tumor would usually be associated with' a more protracted course, similar to that of chronic epidural abscess." If spinal infection is suspected, magnetic resonance imaging should be done immediately. For diagnosis, this procedure is preferred to either spinal puncture or myelography because spinal puncture has been associated with bacterial inoculation into the subarachnoid space" and neurologic deterioration has been reported after myelography. 16 If an epidural mass is found on magnetic resonance imaging, laminectomy should be performed, and antibiotic treatment should be initiated after specimens have been obtained for culture. Patients with epidural abscess require treatment with parenterally administered antibiotics, usually with a penicillinase-resistant penicillin for at least 3 to 4 weeks. During pregnancy, the well-being of the fetus also is of concern. Unfortunately, drug dependence often begins in utero. As a result of a history of intravenous narcotic use, our patient (and her fetus) were placed on a methadone maintenance program in conjunction with careful fetal surveillance. Methadone maintenance is preferred to methadone detoxification during pregnancy because of fetal stress or even fetal death associated with narcotic withdrawal, particularly in the third trimester.'? Because the methadone maintenance program may still be associated with fetal death, low birth weight, and premature onset of labor, frequent antenatal testing and serial ultrasonography for evaluation of growth are necessary to assess fetal well-being. In addition, the long-term effects of intrauterine exposure to methadone are generally unknown. Tocolysis was also necessary because of preterm labor, which may have occurred as a result of the infective process, narcotic use, or surgical intervention. Frequent intermittent or continuous electronic monitoring for uterine contractions was necessary because our patient could not perceive uterine contractions. Intermittent manual palpation was inadequate screening for preterm labor in this case. Labor and delivery have been associated with autonomic hyperreflexia in patients with paraplegia, especially those with spinal cord injury at or above the level of T-6. Fortunately, this life-threatening complication, which can lead to sudden, severe hypertension and subsequent subarachnoid hemorrhage and death, did not develop in our patient. Epidural anesthesia is recommended to prevent autonomic hyperreflexia in paralyzed parturients; however, use of this type of regional anesthesia was impossible in our patient because of the recent epidural abscess. Obstetricians should be aware that when hypertension develops in a patient with paraplegia who is in labor, autonomic hyperreflexia should be strongly considered in the absence of other signs of preeclampsia. If hypertension occurs suddenly despite the use of a regional anesthetic agent, the patient should immedi-
Mayo Clio Proc, October 1991, Vol 66
ately be placed in a sitting position. If this maneuver fails to control the blood pressure, a ganglionic blocking agent or direct vasodilator should be administered by intravenous drip, and the blood pressure should be constantly monitored. If these measures fail to control the hypertension, an emergency cesarean section should be considered because symptoms of autonomic hyperreflexia usually resolve after delivery of the infant and placenta. 18.19 Nonetheless, because of potential wide fluctuations in blood pressure that can be associated with anesthesia for cesarean section (that is, hypertension associated with general anesthesia and hypotension associated with regional blocks), extreme care must be exercised by a skilled team in order to avoid mortality or morbidity for the mother and fetus when cesarean section is chosen.
CONCLUSION Although mild to moderate back discomfort is common during pregnancy, severe back pain may indicate a serious problem and merits immediate assessment, especially if the patient is a known or suspected substance abuser. If epidural abscess is diagnosed, emergency decompressive laminectomy and appropriate antibiotic coverage are necessary. Early recognition and treatment are essential; if the neurologic deficit is extensive (as in our patient), the potential for functional neurolo,gic recovery is limited.
REFERENCES
I.
Little BB, GilstrapLC III, Cunningham FG: Socialand illicit substance use during pregnancy. In Williams Obstetrics. Eighteenthedition, Suppl 7. Edited by FG Cunningham, PC MacDonald, NF Gant. East Norwalk, Connecticut, Appleton & Lange, August/September 1990 2. KoppelBS, Tuchman AJ, Mangiardi JR, Daras M, Weitzner I: Epidural spinal infection in intravenous drug abusers. Arch Neurol 45:1331-1337,1988
3. Baker AS, Ojemann RG, Swartz MN, Richardson EP Jr: Spinal epidural abscess. N Engl J Moo 293:463-468, 1975 4. Hunter JC, Ryan MD, Taylor TKF, Pennington IC: Spinal epiduralabscessin pregnancy. Aust N Z J Surg 47:672-674, 1977
5. Crawford JS: Pathology in the extradural space. Br J Anaesth 47:412-414, 1975 6. Male CG, MartinR: Puerperal spinalepiduralabscess (letter to the editor). Lancet 1:608-609, 1973 7. Hulme A: Spinal epiduralabscess. Br Med J 1:64-68, 1954 8. Bergman I, Wald ER, Meyer ID, Painter MJ: Epidural abscess and vertebral osteomyelitis following serial lumbar punctures. Pediatrics 72:476-480,1983 9. Hancock DO: A study of 49 patients with acute spinal extradural abscess. Paraplegia 10:285-288, 1973 10. Kaufman DM, Kaplan JG, Litman N: Infectious agents in spinal epiduralabscesses. Neurology 30:844-850, 1980 II. Altrocchi PH: Acute transverse myelopathy. Arch Neurol 9:111-119,1963
Mayo Clio Proc, October 1991, Vol 66
12.
Markham JW, Lynge HN, Stahlman GEB: The syndrome of spontaneous spinal epidural hematoma: .report of three cases. J Neurosurg 26:334-342,1967 13. Herrick MK, Mills PE Jr: Infarction of spinal cord: two cases of selective gray matter involvement secondary to asymptomatic aortic disease. Arch Neurol 24:228-241,1971 14. Mullins GM, Flynn JPG, EI-Mahdi AM, McQueen JD, Owens AH Jr: Malignant lymphoma of the spinal epidural space. Ann Intern Med 74:416-423,1971 15. Dripps RD, Vandam LD: Hazards of lumbar puncture. JAMA 147:1118-1121,1951
EPIDURAL ABSCESS DURING PREGNANCY
16.
1039
Willis BK, Benzel EC: Acute postmyelographic neurological deterioration (letter to the editor). J Neurosurg 69:148-149, 1988 17. Blinick G, Wallach RC, Jerez E, Ackerman BD: Drug addiction in pregnancy and the neonate. Am J Obstet Gynecol 125:135-142,1976 18. Committee on Obstetrics: Maternal and Fetal Medicine: Management of labor and delivery for patients with spinal cord injury. ACOG Committee Opinion, No. 83, May 1990 19. Robertson DNS: Pregnancy and labour in the paraplegic. Paraplegia 10:209-212, 1972