Discitis, osteomyelitis, and epidural abscess after kypho

[gdub25]

Have a pretty bad situation with a patient that had kypho at T4 and T5. She did great after the procedure which was on 1/30. Post-op on 2/18 she was feeling great and in my notes I even put in parentheses “Pain is gone 100%, I feel amazing”. Haven’t seen her since. Then yesterday I get a call from a radiologist and he tells me he’s reading an MRI for her and she has an epidural abscess at T4/5 level. She apparently developed severe back pain and went to PCP who ordered it since I had last seen her. I had her go to the ER, called the neurosurgeon on call and explained the situation and offered to help any way I could. Never heard back from him the rest of the night. Will be going by the hospital today to check on her.

Thoughts from the group on what I do from here, both in regards to her treatment and dealing with the surgeon? I don’t know him well and would have felt better had he called back or text after seeing her. Sometimes I see you guys throw out ideas that wouldn’t think of so open to suggestions.

---

Members don't see this ad.

 

[lobelsteve]

I punt above T7, but nothing to do with this.
ESR/CRP, see if CT was also done.
Cement kills everything and I cannot see how this is possibly an infection unless infection was there before kyphoplasty.
2G Ancef pre-kypho?

She gets decompressed and PICC with 6 weeks+ ABX. As long as caught early then not a big deal.
We have a local pain doc and SCS went bad. CTL hematoma with entire spine decompression from NS.
ShT happens. Keep us posted.

 

[BobBarker]

Vote to move to private forum if OP approved.

 

[paindoc007]

I think it’s out of your hands at this point to be honest. Hopefully things turn out okay. Good reminder to all of us of the risk in everything we do.

 

[SSdoc33]

seems unlikely -- but not impossible -- that you caused the infection. check out pre-kypho films and look for any evidence of infection at that time. if you did this just with an xray and no MRI pre-procedure, then thats a problem

agree with moving to the private forum

 

[au bon pain]

I'm a current fellow trying to join the private forum to follow this. Trying to follow the directions on the sticky but there's no option for "join usergroup" when I hover over my username. Is there a new way to do this?

 

[Wkrdoc]

Vote to move to private forum if OP approved.

How do you get approved for the private forum and where is it?

 

[SommeRiver]

What is this secret society?

 

[clubdeac]

I had a case I almost did a kypho on. Fortunately I waited and while I did, the edematous fracture seeded an infection from a UTI. Had I not waited I would've been blamed for the osteomyelitis.

In your case, I'm not sure how a kypo could cause an epidural abscess without first causing an osteomyelitis.

 

[deleted993114]

Have a pretty bad situation with a patient that had kypho at T4 and T5. She did great after the procedure which was on 1/30. Post-op on 2/18 she was feeling great and in my notes I even put in parentheses “Pain is gone 100%, I feel amazing”. Haven’t seen her since. Then yesterday I get a call from a radiologist and he tells me he’s reading an MRI for her and she has an epidural abscess at T4/5 level. She apparently developed severe back pain and went to PCP who ordered it since I had last seen her. I had her go to the ER, called the neurosurgeon on call and explained the situation and offered to help any way I could. Never heard back from him the rest of the night. Will be going by the hospital today to check on her.

Thoughts from the group on what I do from here, both in regards to her treatment and dealing with the surgeon? I don’t know him well and would have felt better had he called back or text after seeing her. Sometimes I see you guys throw out ideas that wouldn’t think of so open to suggestions.

Crap happens. Infection is a risk of any procedure and most epidural abscesses are spontaneous, not procedural related. This could have very well happened in the absence of the procedure. Do you think bacteria can live through methyl methacrylate? Obviously you did not place cement in the epidural space, yet she has an abscess there. My bet is that this was happening prior to/during your procedure. You probably killed the bacteria in the vertebral body.

Not much you can do.
1. Consult ID
2. Consult neurosurg to see if needs surgery
3. follow with CBC with diff and sed rates, as well as neuro exams and pain responses.
4. Go see the patient. However, any treatment at this point is out of your hands. The patient will appreciate your following up and your concern.
5. What you did is not malpractice- infection is a known complication of procedures. It was diagnoses and now it is being treated. You did not deviate from the standard of care. Also, lets say you did (you did not). Damages for somebody over 65 are usually fairly low and not worth even a greedy lawyer taking to try to shake you down to settle.

DON'T BEAT YOURSELF UP OVER THIS. Everyone has suffered complications at some point in their practice and one must not get emotionally worn down- it will kill you. Learn from the experience and understand that your practice will have similar events over the course of your career.

 

[10KHertz]

Catching this early with an MRI was key. Should resolve once organism is identified.

I am pretty OCD and open/draw up medications for most epidural, disc, or high spine cases. I once caught an OR staffer contaminating my field by accident. Never trusted anybody thereafter...

 

[lobelsteve]

I set up my own trays in office for kypho and SCS trials. It takes 3 months of working with me to set up RF, ESI trays.

 

[painfree23]

Don’t most of you order trays?

 

[Ferrismonk]

Don’t most of you order trays?

I don't.