Epidural spinal abscess following dental extraction – a rare and potentially fatal complication

Autor: D.K Dhariwal, D.W. Patton, M.C Gregory
Rok vydání: 2003
Předmět:
Zdroj: British Journal of Oral and Maxillofacial Surgery. 41:56-58
ISSN: 0266-4356
DOI: 10.1016/s0266-4356(02)00258-9
Popis: A 20-year-old woman was referred to the maxillofacial unit by her orthodontist for the extraction of four erupted first premolar teeth as a prelude to orthodontic treatment. The extractions were carried out under general anaesthesia with endotracheal intubation as a day case. There were no anaesthetic or surgical complications. All four teeth were free of caries and required uncomplicated forceps extraction. The patient returned to the unit 3 days later complaining of a stiff neck on the right side. This had started the day after the dental extractions. A constant throbbing pain had kept her awake at night. Examination showed tenderness of the right sternocleidomastoid and trapezius muscles. There were no intraoral signs of infection. A cervical collar was provided and the patient prescribed simple analgesics, rest, and home massage for musculoskeletal pain. On the fifth postoperative day the patient presented to the accident and emergency department with increasing pain in the right side of the neck. Clinical examination showed no neurological deficit and plain radiographs showed no abnormality. A diagnosis of occipital neuralgia as a result of positioning for general anaesthesia was made and physiotherapy and analgesia advised. The patient returned to the accident and emergency unit on the tenth postoperative day complaining of continuing deterioration with increasing neck pain and tingling in the right arm. There was no neurological deficit but tenderness over the cervical spine was noted. Further analgesia and physiotherapy were recommended. Three days later (the 13th postoperative day) she collapsed at home and was admitted to hospital as an emergency. She had increased pain in her neck, numbness of the right arm, and weakness of the right arm and leg. She held her neck stiffly and had bruises on the right arm and leg. She had a fever of 38.9 ◦C. Neurological examination showed reduced sensation in the right arm, greater in the ulna nerve distribution than in the radial. Power in the right arm and leg was reduced to grade 1/5 with right ankle clonus. The right pupil was constricted with little reaction to light. There was no history of urinary or faecal incontinence. She was admitted for blood tests, a lumbar puncture, and computed tomography (CT) of the head. The laboratory findings included a serum C-reactive protein concentration of 532 mg/l, erythrocyte sedimentation rate of 66 mm/in the first hour, and a white cell count of 11.5× 109/l. Cefotaxime and flucloxacillin were given intravenously for presumed bacterial meningitis. The CT showed no evidence of any intracranial lesion. The cerebrospinal fluid had 20 white cells/mm3, predominantly lymphocytes, and total protein concentration of 4.15 g/l, suggestive of severe infection. Magnetic resonance imaging (Fig. 1) was done later the same day and confirmed a large spinal epidural abscess extending from the third to the sixth cervical vertebrae predominantly on the right side. The patient was transferred to the regional neurosurgical unit and had right hemilaminectomy of C1, C2, and C3 vertebrae. A few drops of pus were noted, which yielded Streptococcus milleri on culture. There was no infective focus for metastatic spread and no history of invasive procedures that were likely to cause a transient bacteraemia other than the recent dental extractions. A further elective procedure was carried out 5 months later and C4, C5, and C6 hemilaminectomy and vertebrectomy were done with iliac crest bone grafting and buttress plate placement. Twenty-three months after the dental extractions, she presented again with a throbbing frontal headache. CT confirmed a frontal intracranial haemorrhage which was thought to have been related to her previous infection. The patient died.
Databáze: OpenAIRE
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