title: Epidural abscess as a delayed complication of spinal instrumentation in scoliosis surgery: a case of progressive neurologic dysfunction with complete recovery.
abstract: METHODS
  A case report of late-onset paraplegia from an epidural abscess in a patient years after her instrumentation and fusion for scoliosis.
  
  
  OBJECTIVE
  To present a case of delayed complication of progressive paraplegia from an epidural abscess after spinal instrumentation in scoliosis surgery and to highlight an effective surgical intervention that resulted in complete resolution of symptoms.
  
  
  BACKGROUND
  Spinal epidural abscess is a rare but devastating disorder that has previously been reported to have a mean incidence during sixth or seventh decade. It is exceedingly uncommon in the pediatric population. Deep wound infection after adolescent idiopathic scoliosis surgery is a well-known entity that has been reported in several studies; however, we could find no documented incidences of epidural abscess resulting from adolescent idiopathic scoliosis surgery in the pediatric population. To our knowledge there has been no report of a management algorithm for such a complication.
  
  
  METHODS
  A 15-year-old female with progressive thoracic and lumbar curves underwent posterior spinal fusion from T5 to L3 with instrumentation. Her postoperative course was complicated by acute wound infection that underwent irrigation and debridement with retention of implants. The patient did well for 9 months, after which she presented with recurrent back pain and elevated inflammatory markers. She had her implants removed and another course of parenteral antibiotics. After an uneventful course for 2 years, the patient presented with a 2-week history of progressive bilateral lower extremity incomplete paralysis.
  
  
  RESULTS
  After magnetic resonance imaging confirmation of a T5 to T10 epidural mass, the patient underwent debridement through her fusion mass from T5 to L1. No supplemental instrumentation was required, but the patient was placed in a thoracolumbosacral orthosis brace after surgery. She was treated with a total of 12 weeks of antibiotics. Within days of her procedure, her motor paralysis improved. By discharge, she had regained the majority of her lower extremity function. During the subsequent year, her motor and sensory function completely normalized and she has had no sequelae with over 2 years' follow-up.
  
  
  CONCLUSIONS
  This case reports a delayed spinal epidural abscess years after removal of her implants for infection. This demonstrates that our patients remain at risk for reactivation of spinal infections even though they may be healthy hosts and may have had all foreign bodies removed as part of their treatment for deep postoperative infections. This case suggests that extensive unilateral decompression and debridement through a fusion mass is a viable treatment method in patients with fused spine.
authors.affiliation: Department of Orthopaedic Surgery, University of Missouri-Columbia, Columbia, MO 65212, USA. chomat@health.missouri.edu
authors.forename: Theodore
authors.initials: T
authors.lastname: Choma
authors.forename: Matthew
authors.initials: M
authors.lastname: Burke
authors.forename: Christopher
authors.initials: C
authors.lastname: Kim
authors.forename: Raj
authors.initials: R
authors.lastname: Kakarlapudi
mesh_terms: D000293:Adolescent; D000900:Anti-Bacterial Agents / Q000008:administration & dosage; D000893:Anti-Inflammatory Agents / Q000008:administration & dosage; D003131:Combined Modality Therapy; D003646:Debridement; D020802:Epidural Abscess / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000209:etiology*; D005260:Female; D006801:Humans; D008776:Methylprednisolone Hemisuccinate / Q000008:administration & dosage; D010264:Paraplegia / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000209:etiology; D011859:Radiography; D020127:Recovery of Function; D012600:Scoliosis / Q000601:surgery*; D013123:Spinal Fusion / Q000009:adverse effects* / Q000295:instrumentation; D013530:Surgical Wound Infection / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000209:etiology*; D013997:Time Factors
chemical_list: D000900:Anti-Bacterial Agents; D000893:Anti-Inflammatory Agents; D008776:Methylprednisolone Hemisuccinate