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Spinal epidural abscess and meningitis following an epidural catheterisation
Acute Pain (2007) 9, 35—38
SHORT COMMUNICATION
Spinal epidural abscess and meningitis following an epidural catheterisation夽 Vijay B. Bandikatla a,∗, B. Rizwan b, A. Skalimis b, H. Patel b a
Accident & Emergency, Wishaw General Hospital, North Lanarkshire NHS Trust, Wishaw, Scotland ML2 7PD, UK b Critical Care Directorate, Darent Valley Hospital, Dartford and Gravesham NHS Trust, Dartford, Kent DA2 8DA, UK Received 16 August 2006 ; received in revised form 5 October 2006; accepted 13 October 2006 Available online 22 December 2006 KEYWORDS Epidural abscess; Epidural catheterisation; Post-operative pain
Summary We present a case of spinal epidural abscess (SEA) following a short-term epidural catheterisation for post-operative pain relief. Preoperative investigations showed no derangement in coagulation as well as full blood counts. The diagnosis of SEA was made within three days of accidental dislodgement of the catheter. By the fifth post-operative day, signs of meningitis and methicillin resistant Staphylococcus aureus (MRSA) in the blood and from the epidural catheterisation site were identified. The microbiologist, neurologist and neurosurgeon were involved from the beginning. An early magnetic resonance image (MRI) scan, initiation of appropriate management, repeat MRI scans and regular follow-up prevented further morbidity. © 2006 Elsevier B.V. All rights reserved.
1. Introduction Spinal epidural space is a narrow potential space filled mostly with the loose aereolar tissue (fat), the blood vessels and the nerve roots. An epidural haematoma may occur, when the blood vessels are damaged while threading or removing the catheter, 夽
The following case was reported in the Darent Valley Hospital, Dartford, Kent DA2 8DA, UK. ∗ Corresponding author. Tel.: +44 1698372637. E-mail addresses: vijaybhaskar [email protected], [email protected], [email protected] (V.B. Bandikatla).
more often in anticoagulated patients. Infection can reach this spinal epidural space by different mechanisms, leading to an abscess, which has a poor prognosis with 13—16% mortality [1,2]. Though the incidence is low [1,3,4], this collection could lead to meningitis, paraplegia, spinal cord syndrome etc and can leave permanent neurological deficits [5]. Early diagnosis and treatment is the key to avoid these complications. We report a case of SEA, which presented as septicaemia and meningitis. Further complications were avoided after diagnosis because of the awareness of this condition and subsequent quick action. We also discuss its aetiology, diagnosis, treatment and prevention.
1366-0071/$ — see front matter © 2006 Elsevier B.V. All rights reserved. doi:10.1016/j.acpain.2006.10.002
36
V.B. Bandikatla et al.
2. Case history A 61-year old gentleman was admitted with adenocarcinoma of prostate, with bone scan showing some uptake in his ribs (possible metastasis). He had no significant medical problems except for colitis. He was an ex-smoker with two uneventful general anaesthetics in the past. After optimal preoperative investigations, he was posted for radical prostatectomy. A thoracic (T) epidural catheter was inserted at T10—11 spinal level after administering general anaesthesia. No blood or clear fluid was in the catheter on aspiration. Intra operative period was uneventful. Two units of blood were given towards the end of the surgery. An epidural test dose was given before extubation. With stable vital parameters for 2 h, recovery period was uneventful. The central line was removed and epidural infusion started at rate of 10 ml/h using sterile closed loop system with bacterial filter. A rise in temperature was noted on the first post-operative day. Blood investigation revealed leucocytosis and raised C-reactive protein (CRP). Cultures were sent as septicaemia was suspected. Blood culture at this stage did not grow any organism. On the fourth post-operative day, the epidural catheter fell out and there was inflammation and tenderness at the site. The patient had already been on Co-amoxiclav as part of post-operative cover. Anaesthetist was not contacted when this was noted. Temperature spiked (39 ◦ C) on the fifth postoperative day and he developed signs of meningitislike severe headache, neck rigidity and opisthotonus with hyperpyrexia. Urology senior house officer ordered an urgent computed tomographic scan of the brain, which was inconclusive. When contacted, the acute pain team found minimal discharge from the epidural catheterisation site. The blood cultures and the discharge from catheterisation site grew methicillin resistant Staphylococcus aureus (MRSA). On advice from the microbiologist he was started on intra-venous antibiotics Tazobactam and Piperacillin. An SEA was suspected and its possibility explained to the patient by the acute pain team along with the Anaesthetist involved in siting the epidural catheter. An urgent magnetic resonance image (MRI) scan of the thoraco-lumbar spine (Fig. 1) demonstrated mass effect with moderate degree of spinal canal stenosis at T10 level, an epidural thickening and development of granulation tissue in the posterior epidural space at T8—11 levels. The acute concern was due to two small loculi at T8 and T10 levels with
Fig. 1 Axial T1 weighted post-gadolinium T10 level MR image showing, mass effect upon the thecal sac, with central spinal canal stenosis and antero-posterior compression.
focal inflammation over T11, which was consistent with the epidural tract (Fig. 2). Neurological referral advised conservative management, as there were no sign of neurological deficits. Patient was advised to stay in hospital for further management and continued on antibiotics. He was closely monitored and a repeat MRI scan performed after a week showed remarkable improvement with little compression of the cord. He was discharged with a 3-week course of Linezolid, explaining the need for urgent consultation if any signs of incontinence, numbness and or weakness in lower limbs develop. The third MRI scan after a month showed that the cord was no longer compressed with minimal epidural thickening. He did not develop any neurological signs. The fourth MRI scan, after 2 months showed complete resolution of the epidural mass without any stenosis. Follow-up stopped at this point.
3. Discussion The superior quality of pain relief provided by epidural analgesia has a positive impact on mobilisation, bowel function, and intake of food with long lasting effects on exercise capacity and healthrelated quality of life [6]. The recent evidence also suggests there is overall reduction in mortality by a third with reduced incidence of deep vein thrombosis, pulmonary embolism, myocardial infarction,
Spinal epidural abscess and meningitis
Fig. 2 Sagittal T2 weighted section showing epidural mass extending from T8 to T11, with dural thickening and granulation tissue and two small loculi at T8 and T10 levels.
renal failure and reduction in transfusion requirements [7]. Despite the evidence showing proven benefits, being an invasive technique it is associated with risks of developing post-dural puncture headache, nerve and spinal cord damage, epidural haematoma and SEA [8] which according to the recent anecdotal reports seem to be on the rise [9,10]. Epidural abscess is an inflammation that includes a collection of infected material (pus) located between the coverings of the brain and the spinal cord (dura) and the bone of the skull and the spine [8]. The incidence of SEA is quoted between 0.2 and 2.0 cases per 10,000 hospital admissions [3]. We assume many cases are missing as diagnostic delay
37 account for 75% of cases [11] and the initial diagnosis rate was only 11% [12]. About 5.5% of all cases were due to epidural analgesia [3], most of these were from long-term catheterisation. Overall estimates range from as low as 5.5 cases per million [4] to as high as one in 600 [9] epidural procedures. Epidural haematoma can be produced during catheter insertion or removal particularly in anti coagulated patients. The predisposing factors like diabetes mellitus, trauma, IV drug abuse, and alcoholism, produces a ‘weak zone’ in the epidural space [13] which helps formation of an abscess. Though skin abscesses and furuncles are the common sources, many cases were due to haematogenous spread and a third of cases have no identifiable source [3]. In our case, it is inconclusive whether the communication of the needle/catheter created between the skin and epidural space introduced colonised MRSA from the skin to the epidural space or simply the track created let the pus out, as the patient initially developed signs of systemic infection rather than local. The risk of haematogenous spread from the pelvic surgery cannot be completely ruled out. Symptoms include localised back pain and fever during the first stage. The radicular irritation occurs in the second stage. The neurological deficits like muscle weakness, sensory deficits as well sphincter weakness occur in the more severe third stage while paralysis occurs in fourth stage [3]. Staphylococcus aureus is the most common (60%) organism isolated [3]. Though Pseudomonas aeruginosa, Escherichia coli, Mycobacterium tuberculosis [5] and enterococcal species were also commonly found [14], nearly 15% of cases remain culture negative [15,16]. Our case was rather rare in growing methicillin resistant Staphylococcus aureus (MRSA), which is on the rise [13]. Therefore contemplating epidural catheterisation requires proper assessment of risks and benefits. Safe practice requires avoiding contraindications and performing the procedure under strict aseptic precautions in a clean suitable environment, with thorough scrubbing, wearing head, mask, sterile gown and gloves. Double spraying of the skin with chlorhexidine is the disinfectant of choice [17]. Proper identification of landmarks limits multiple attempts. In our case, a facemask was not used and betadine rather than chlorhexidine was used. Daily inspection of the epidural site with a high index of suspicion for any signs of infection or discharge and proper documentation of any backache, radiculopathy, fever, etc., is necessary. Close monitoring for markers of infection like rising leucocyte count, C-reactive protein and erythrocyte sedimen-
38 tation rate helps. An acute pain nurse helps in the follow-up and the support needed for these patients on the wards. The standard practice in many institutes is to remove the post-operative epidural catheters after approximately 3 days [18] unless it is strongly indicated. If there is development of any suspicious neurological signs or symptoms, perform an urgent MRI scan without waiting for the neurological deficits to develop. Early involvement of the microbiologist is vital, as these organisms (MRSA) are resistant to routine antibiotics and can progress quickly leading to permanent disability. These early decisions play a crucial role in reducing morbidity and deciding on the course of management, i.e. either conservative or surgical decompression for the drainage of the abscess. Neurosurgical intervention may be needed in patients with neurological deficits, but most cases resolve with conservative therapy. General practitioners and health care professionals should be alerted of the possibility of this potential catastrophe.
References [1] Hlavin M, Kaminski HJ, Ross JS, Ganz E. Spinal epidural abscess: a 10-year perspective. Neurosurgery 1990;27:177—84. [2] Khanna RK, Malik GM, Rock JP, Rosenblum ML. Spinal epidural abscess: evaluation of risk factors influencing outcome. Neurosurgery 1996;39:958—64. [3] Reihsaus E, Waldbaur H, Seeling W. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev 2000;23(4):175—204. [4] Chadwick HS, Bonica JJ. Complications of regional anaesthesia. In: Bonica JJ, McDonald JS, editors. Principles and practice of obstetric analgesia and anaesthesia. 2nd ed. Baltimore: Williams & Wilkins; 1995. p. 538—72.
V.B. Bandikatla et al. [5] J Stephen Huff, M.D. Spinal epidural Abscess. http://www. emedicine.com/neuro/topic349.htm (date July 22, 2004). [6] Carli F, Mayo N, Klubien K, Schricker T, Trudel J, Belliveau P. Epidural analgesia enhances functional exercise capacity and health related quality of life after colonic surgery. Anaesthesiology 2002;97:540—9. [7] Rodger A, Walker N, Schug S, Mckee A, Kehlet H, Van zundert A, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. Br Med J 2000;321:1493—7. [8] Daniel Levy, M.D., Ph.D. Epidural abscess. http://www.nlm. nih/medlineplus/print/ency/article/001416.htm (date: February 20, 2006). [9] Grewal S, Hocking G, Wildsmith JAW. Epidural abscess. Br J Anaesthesia 2006;96:292—302. [10] Rigamonti D, Liem L, Sampath P, Knoller N, Namaguchi Y, Schreibman DL, et al. Spinal epidural abscess: contemporary trends in etiology, evaluation, and management. Surg Neurol 1999;52(2):189—96 [discussion 197]. [11] Davis DP, Wold RM, Patel RJ, Tran AJ, Tokhi RN, Chan TC, et al. The clinical presentation and impact of diagnostic delays on emergency department patients with spinal epidural abscess. J Emerg Med 2004;26(3):285—91. [12] Tang HJ, Lin HJ, Liu YC, Li CM. Spinal epidural abscess—– experience with 46 patients and evaluation of prognostic factors. J Infect 2002;45(2):76—81. [13] Yuste M, Canet J, Garcia M, Gill MA, Vidal F. Epidural abscess due to resistant staphylococcus aureus following epidural catheterisation. Anaesthesia 1997;52:150—68. [14] Burgess M, Wolverson AS, Dale MT. Cervical epidural abscess: a rare complication of venous cannulation. Anaesthesia 2005;60:605—8. [15] Danner R, Hartmann B. Update of spinal epidural abscess 35 cases and review of literature. Rev Infect Dis 1987;9: 265—74. [16] Tang HJ, Lin HJ, Lin YC, Li CM. Spinal epidural abscess experience with 46 patients and evaluation of prognostic factors. J Infect 2002;45:76—81. [17] Benhamou D, Mercier FJ, Dounas M. Hospital policy for prevention of infection after neuraxial blocks in obstetrics. Int J Obstetric Anaesthesia 2002;11:265—9. [18] Tsui SL, Yong BH, Ng KFJ, Yuen TST, Li CCF, Chui KY. Delayed epidural catheter removal: the impact of postoperative coagulopathy. Anaesthesia Intensive Care 2004;32(5):630—6.
SHORT COMMUNICATION
Spinal epidural abscess and meningitis following an epidural catheterisation夽 Vijay B. Bandikatla a,∗, B. Rizwan b, A. Skalimis b, H. Patel b a
Accident & Emergency, Wishaw General Hospital, North Lanarkshire NHS Trust, Wishaw, Scotland ML2 7PD, UK b Critical Care Directorate, Darent Valley Hospital, Dartford and Gravesham NHS Trust, Dartford, Kent DA2 8DA, UK Received 16 August 2006 ; received in revised form 5 October 2006; accepted 13 October 2006 Available online 22 December 2006 KEYWORDS Epidural abscess; Epidural catheterisation; Post-operative pain
Summary We present a case of spinal epidural abscess (SEA) following a short-term epidural catheterisation for post-operative pain relief. Preoperative investigations showed no derangement in coagulation as well as full blood counts. The diagnosis of SEA was made within three days of accidental dislodgement of the catheter. By the fifth post-operative day, signs of meningitis and methicillin resistant Staphylococcus aureus (MRSA) in the blood and from the epidural catheterisation site were identified. The microbiologist, neurologist and neurosurgeon were involved from the beginning. An early magnetic resonance image (MRI) scan, initiation of appropriate management, repeat MRI scans and regular follow-up prevented further morbidity. © 2006 Elsevier B.V. All rights reserved.
1. Introduction Spinal epidural space is a narrow potential space filled mostly with the loose aereolar tissue (fat), the blood vessels and the nerve roots. An epidural haematoma may occur, when the blood vessels are damaged while threading or removing the catheter, 夽
The following case was reported in the Darent Valley Hospital, Dartford, Kent DA2 8DA, UK. ∗ Corresponding author. Tel.: +44 1698372637. E-mail addresses: vijaybhaskar [email protected], [email protected], [email protected] (V.B. Bandikatla).
more often in anticoagulated patients. Infection can reach this spinal epidural space by different mechanisms, leading to an abscess, which has a poor prognosis with 13—16% mortality [1,2]. Though the incidence is low [1,3,4], this collection could lead to meningitis, paraplegia, spinal cord syndrome etc and can leave permanent neurological deficits [5]. Early diagnosis and treatment is the key to avoid these complications. We report a case of SEA, which presented as septicaemia and meningitis. Further complications were avoided after diagnosis because of the awareness of this condition and subsequent quick action. We also discuss its aetiology, diagnosis, treatment and prevention.
1366-0071/$ — see front matter © 2006 Elsevier B.V. All rights reserved. doi:10.1016/j.acpain.2006.10.002
36
V.B. Bandikatla et al.
2. Case history A 61-year old gentleman was admitted with adenocarcinoma of prostate, with bone scan showing some uptake in his ribs (possible metastasis). He had no significant medical problems except for colitis. He was an ex-smoker with two uneventful general anaesthetics in the past. After optimal preoperative investigations, he was posted for radical prostatectomy. A thoracic (T) epidural catheter was inserted at T10—11 spinal level after administering general anaesthesia. No blood or clear fluid was in the catheter on aspiration. Intra operative period was uneventful. Two units of blood were given towards the end of the surgery. An epidural test dose was given before extubation. With stable vital parameters for 2 h, recovery period was uneventful. The central line was removed and epidural infusion started at rate of 10 ml/h using sterile closed loop system with bacterial filter. A rise in temperature was noted on the first post-operative day. Blood investigation revealed leucocytosis and raised C-reactive protein (CRP). Cultures were sent as septicaemia was suspected. Blood culture at this stage did not grow any organism. On the fourth post-operative day, the epidural catheter fell out and there was inflammation and tenderness at the site. The patient had already been on Co-amoxiclav as part of post-operative cover. Anaesthetist was not contacted when this was noted. Temperature spiked (39 ◦ C) on the fifth postoperative day and he developed signs of meningitislike severe headache, neck rigidity and opisthotonus with hyperpyrexia. Urology senior house officer ordered an urgent computed tomographic scan of the brain, which was inconclusive. When contacted, the acute pain team found minimal discharge from the epidural catheterisation site. The blood cultures and the discharge from catheterisation site grew methicillin resistant Staphylococcus aureus (MRSA). On advice from the microbiologist he was started on intra-venous antibiotics Tazobactam and Piperacillin. An SEA was suspected and its possibility explained to the patient by the acute pain team along with the Anaesthetist involved in siting the epidural catheter. An urgent magnetic resonance image (MRI) scan of the thoraco-lumbar spine (Fig. 1) demonstrated mass effect with moderate degree of spinal canal stenosis at T10 level, an epidural thickening and development of granulation tissue in the posterior epidural space at T8—11 levels. The acute concern was due to two small loculi at T8 and T10 levels with
Fig. 1 Axial T1 weighted post-gadolinium T10 level MR image showing, mass effect upon the thecal sac, with central spinal canal stenosis and antero-posterior compression.
focal inflammation over T11, which was consistent with the epidural tract (Fig. 2). Neurological referral advised conservative management, as there were no sign of neurological deficits. Patient was advised to stay in hospital for further management and continued on antibiotics. He was closely monitored and a repeat MRI scan performed after a week showed remarkable improvement with little compression of the cord. He was discharged with a 3-week course of Linezolid, explaining the need for urgent consultation if any signs of incontinence, numbness and or weakness in lower limbs develop. The third MRI scan after a month showed that the cord was no longer compressed with minimal epidural thickening. He did not develop any neurological signs. The fourth MRI scan, after 2 months showed complete resolution of the epidural mass without any stenosis. Follow-up stopped at this point.
3. Discussion The superior quality of pain relief provided by epidural analgesia has a positive impact on mobilisation, bowel function, and intake of food with long lasting effects on exercise capacity and healthrelated quality of life [6]. The recent evidence also suggests there is overall reduction in mortality by a third with reduced incidence of deep vein thrombosis, pulmonary embolism, myocardial infarction,
Spinal epidural abscess and meningitis
Fig. 2 Sagittal T2 weighted section showing epidural mass extending from T8 to T11, with dural thickening and granulation tissue and two small loculi at T8 and T10 levels.
renal failure and reduction in transfusion requirements [7]. Despite the evidence showing proven benefits, being an invasive technique it is associated with risks of developing post-dural puncture headache, nerve and spinal cord damage, epidural haematoma and SEA [8] which according to the recent anecdotal reports seem to be on the rise [9,10]. Epidural abscess is an inflammation that includes a collection of infected material (pus) located between the coverings of the brain and the spinal cord (dura) and the bone of the skull and the spine [8]. The incidence of SEA is quoted between 0.2 and 2.0 cases per 10,000 hospital admissions [3]. We assume many cases are missing as diagnostic delay
37 account for 75% of cases [11] and the initial diagnosis rate was only 11% [12]. About 5.5% of all cases were due to epidural analgesia [3], most of these were from long-term catheterisation. Overall estimates range from as low as 5.5 cases per million [4] to as high as one in 600 [9] epidural procedures. Epidural haematoma can be produced during catheter insertion or removal particularly in anti coagulated patients. The predisposing factors like diabetes mellitus, trauma, IV drug abuse, and alcoholism, produces a ‘weak zone’ in the epidural space [13] which helps formation of an abscess. Though skin abscesses and furuncles are the common sources, many cases were due to haematogenous spread and a third of cases have no identifiable source [3]. In our case, it is inconclusive whether the communication of the needle/catheter created between the skin and epidural space introduced colonised MRSA from the skin to the epidural space or simply the track created let the pus out, as the patient initially developed signs of systemic infection rather than local. The risk of haematogenous spread from the pelvic surgery cannot be completely ruled out. Symptoms include localised back pain and fever during the first stage. The radicular irritation occurs in the second stage. The neurological deficits like muscle weakness, sensory deficits as well sphincter weakness occur in the more severe third stage while paralysis occurs in fourth stage [3]. Staphylococcus aureus is the most common (60%) organism isolated [3]. Though Pseudomonas aeruginosa, Escherichia coli, Mycobacterium tuberculosis [5] and enterococcal species were also commonly found [14], nearly 15% of cases remain culture negative [15,16]. Our case was rather rare in growing methicillin resistant Staphylococcus aureus (MRSA), which is on the rise [13]. Therefore contemplating epidural catheterisation requires proper assessment of risks and benefits. Safe practice requires avoiding contraindications and performing the procedure under strict aseptic precautions in a clean suitable environment, with thorough scrubbing, wearing head, mask, sterile gown and gloves. Double spraying of the skin with chlorhexidine is the disinfectant of choice [17]. Proper identification of landmarks limits multiple attempts. In our case, a facemask was not used and betadine rather than chlorhexidine was used. Daily inspection of the epidural site with a high index of suspicion for any signs of infection or discharge and proper documentation of any backache, radiculopathy, fever, etc., is necessary. Close monitoring for markers of infection like rising leucocyte count, C-reactive protein and erythrocyte sedimen-
38 tation rate helps. An acute pain nurse helps in the follow-up and the support needed for these patients on the wards. The standard practice in many institutes is to remove the post-operative epidural catheters after approximately 3 days [18] unless it is strongly indicated. If there is development of any suspicious neurological signs or symptoms, perform an urgent MRI scan without waiting for the neurological deficits to develop. Early involvement of the microbiologist is vital, as these organisms (MRSA) are resistant to routine antibiotics and can progress quickly leading to permanent disability. These early decisions play a crucial role in reducing morbidity and deciding on the course of management, i.e. either conservative or surgical decompression for the drainage of the abscess. Neurosurgical intervention may be needed in patients with neurological deficits, but most cases resolve with conservative therapy. General practitioners and health care professionals should be alerted of the possibility of this potential catastrophe.
References [1] Hlavin M, Kaminski HJ, Ross JS, Ganz E. Spinal epidural abscess: a 10-year perspective. Neurosurgery 1990;27:177—84. [2] Khanna RK, Malik GM, Rock JP, Rosenblum ML. Spinal epidural abscess: evaluation of risk factors influencing outcome. Neurosurgery 1996;39:958—64. [3] Reihsaus E, Waldbaur H, Seeling W. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev 2000;23(4):175—204. [4] Chadwick HS, Bonica JJ. Complications of regional anaesthesia. In: Bonica JJ, McDonald JS, editors. Principles and practice of obstetric analgesia and anaesthesia. 2nd ed. Baltimore: Williams & Wilkins; 1995. p. 538—72.
V.B. Bandikatla et al. [5] J Stephen Huff, M.D. Spinal epidural Abscess. http://www. emedicine.com/neuro/topic349.htm (date July 22, 2004). [6] Carli F, Mayo N, Klubien K, Schricker T, Trudel J, Belliveau P. Epidural analgesia enhances functional exercise capacity and health related quality of life after colonic surgery. Anaesthesiology 2002;97:540—9. [7] Rodger A, Walker N, Schug S, Mckee A, Kehlet H, Van zundert A, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. Br Med J 2000;321:1493—7. [8] Daniel Levy, M.D., Ph.D. Epidural abscess. http://www.nlm. nih/medlineplus/print/ency/article/001416.htm (date: February 20, 2006). [9] Grewal S, Hocking G, Wildsmith JAW. Epidural abscess. Br J Anaesthesia 2006;96:292—302. [10] Rigamonti D, Liem L, Sampath P, Knoller N, Namaguchi Y, Schreibman DL, et al. Spinal epidural abscess: contemporary trends in etiology, evaluation, and management. Surg Neurol 1999;52(2):189—96 [discussion 197]. [11] Davis DP, Wold RM, Patel RJ, Tran AJ, Tokhi RN, Chan TC, et al. The clinical presentation and impact of diagnostic delays on emergency department patients with spinal epidural abscess. J Emerg Med 2004;26(3):285—91. [12] Tang HJ, Lin HJ, Liu YC, Li CM. Spinal epidural abscess—– experience with 46 patients and evaluation of prognostic factors. J Infect 2002;45(2):76—81. [13] Yuste M, Canet J, Garcia M, Gill MA, Vidal F. Epidural abscess due to resistant staphylococcus aureus following epidural catheterisation. Anaesthesia 1997;52:150—68. [14] Burgess M, Wolverson AS, Dale MT. Cervical epidural abscess: a rare complication of venous cannulation. Anaesthesia 2005;60:605—8. [15] Danner R, Hartmann B. Update of spinal epidural abscess 35 cases and review of literature. Rev Infect Dis 1987;9: 265—74. [16] Tang HJ, Lin HJ, Lin YC, Li CM. Spinal epidural abscess experience with 46 patients and evaluation of prognostic factors. J Infect 2002;45:76—81. [17] Benhamou D, Mercier FJ, Dounas M. Hospital policy for prevention of infection after neuraxial blocks in obstetrics. Int J Obstetric Anaesthesia 2002;11:265—9. [18] Tsui SL, Yong BH, Ng KFJ, Yuen TST, Li CCF, Chui KY. Delayed epidural catheter removal: the impact of postoperative coagulopathy. Anaesthesia Intensive Care 2004;32(5):630—6.