Management of Acute Spinal Epidural Abscess: 2 Cases Report

急性脊椎硬膜外膿瘍之處理：二例報告

區朗生(Long-Sang Au) ； 鄧復旦(Fuk-Tan Tang) ； 黃美涓(May-Kuen Wong)

《中華民國復健醫學會雜誌》 18期 (1990/12) Pp. 201-207

摘要

在台灣地區，細菌感染後引起的脊椎病變，以肺結核桿菌為最常見的菌種。但其它病菌種所引起的急性脊椎病變，亦時有發現。其臨床症狀與肺結核脊椎(TB Spine)並不太相同，而且處理方法亦有差異。本文提出二例細菌性急性脊椎硬膜外膿瘍報告，以供參考。並與有關文獻作一相對的比較。
本報告收集之二病例，男女性各一名。男病者所感染之菌種為大腸桿菌(E. coli)，而女病者則是金黃色葡萄球菌(Staph. aureus)。至於脊椎硬膜外膿瘍病灶處：男病患位於腰椎第三至第五節；女病患為胸椎第九至第十一節。
兩病人發病時只有突發性高燒(spiking fever)及發冷為其主要表徵，而背痛情形卻並不嚴重。這與文獻上所報告的發病過程並不一致。但其神經性病變 (兩下肢癱瘓及小便瀦留等)出現及進行均非常迅速。在病況最初出現後四天左右就達到完全性兩下肢癱瘓。
至於在血液檢查方面，兩病例均有多形核白血球增生情形；血液細菌培養亦均呈陽性。在兩病例的生化檢查中，鹼性燐酸鹽?(Alk-Pase)及總瞻紅素(total bilirubin)值都有明顯上升，但腹部超音波掃瞄檢查，並無發現這兩病患有任何膽道及肝臟方面的異常。故推論為一急性期間過渡性之升高。
腦脊髓液生化檢查中，兩病患的樣本內總蛋白質(toral protein)和乳酸鹽(lactate)量亦有明顯的升高。這與各文獻所報告資料相同。所有病人因病情進行快速，而予緊急脊椎攝影術(myelography)及電腦斷層掃瞄(computerized tomography)檢查，都發現在脊椎硬膜外有明顯的病灶。目前在此方面的檢查，磁振造影(magnetic resonance imaging)亦被應用。希望以它高度的解析能力，來作為診斷早期脊椎硬膜外膿瘍的一種方法。但因報告病例仍佔少數，故此造影方法需更進一步探計。
在治療方面，所有病人在診斷確定後便予椎板切除術(laminectomy)及膿瘍洩液法(drainage of abscess)治療。手術後並加以適當的抗生素注射，為期約四週。兩病患在接受手術後，其神經性異常的情況都有迅速的改善。
因此，積極性的檢查對診斷細菌性脊椎病變有很大的幫助，而儘早施行手術治療，方能讓病人獲得良好的預後。

並列摘要

Within a period of 8 months, we encountered 2 cases of spinal epidural abscess. The site of abscess and causative organism were lumbar spine with E. coli and thoracic spine with S. aureus respectively. The clinical courses of both cases did not follow the four phases described in literature for an epidural abscess. Spiking fever and chillness were the only prominent signs observed initially and back pain was not the chief complaint. However, neurological deterioration with urinary retention and paraplegia progressed rapidly. The time interval between onset of symptoms and appearance of paraplegia was 4 and 7 days for case 1 and 2 respectively.
Our data of peripheral blood and cerebrospinal fluid were similar to those reported. Due to the rapid progression of the clinical condition,myelography and computerized tomography were performed in both cases. The results showed good visualization of the site of the epidural compression by the abscess.
Therapeutically,emergent laminectomy and drainage of abscess were performed after the diagnosis was certain. Postoperatively both patients recovered satisfactorily.
Our purpose to report here is to remind readers of the existence of this potentially crippling,but treatable disease. We further plead for early diagnosis and prompt surgical management in order to achieve a better outcome for the patient.

並列關鍵字

spinal epidural abscess ； paraplegia ； CT-scan ； myelography