Infectious Complications of Central Neuraxial Block

Case Synopsis

A 58-year-old man with a history of insulin-dependent diabetes mellitus, rheumatoid arthritis, and bladder cancer status postneoadjuvant chemotherapy underwent a radical cystectomy and diversion. A lumbar epidural catheter was placed for perioperative analgesia, and the patient received an epidural infusion of ropivacaine and fentanyl for 3 days postoperatively. At the time of epidural catheter removal, the insertion site was surrounded by a small area of erythema, with a scant amount of serosanguineous drainage. The patient was followed by Acute Pain Service for an additional 2 days, at which time he reported progressively worsening thoracolumbar back pain, low-grade fever, and subjective lower extremity weakness. Examination of his back on postoperative day 5 revealed a dime-sized erythematous area at the previous epidural catheter insertion site with a small amount of purulent drainage when expressed. His neurologic examination was unremarkable. Laboratory studies demonstrated leukocytosis. A magnetic resonance imaging (MRI) scan with and without gadolinium contrast was obtained of the thoracic, lumbar, and sacral spine. MRI demonstrated an extensive posterior spinal epidural abscess from T12 to L4. The patient underwent an open laminotomy for drainage of the abscess and culture-directed antibiotic therapy for Staphylococcus aureus. The remainder of his hospital recovery was uneventful, and he was discharged home on postoperative day 8 without neurologic sequelae.