Racz's minimal invasive epidural catheter procedure, known as "epidural neuroplasty", is not utilized exclusively in patients suffering from failed back surgery syndrome, but is also increasingly applied to non-surgical back pain patients, to prevent chronification or deterioration, even in the neurosurgical field. Its hypothesized principle of action is local epidural lysis of adhesions, neurolysis of spinal nerve roots and local lavage of proinflammatory mediators, by repeated injection of local anesthetics, corticosteroids, hyaluronidase and hypertonic saline solution
7,10,12). However, adverse events are well known to occur in epidural neuroplasty. Thus, complications of epidural neuroplasty are due to the procedure itself or due to specific drug-related side effects. Unintended dural puncture, administration of the drugs to the subarachnoid or subdural space, catheter shearing, infection and severe hemodynamic instability during application are the most commonly observed adverse events
11). Among them, epidural infection or abscess formation may be due to either hematogenous spread or extension of superficial skin infections. Immuncompromised patients, diabetic patients, steroid-dependant patients, and patients with malignancies are at higher risk for infection
6). Epidural abscess formation may not be recognized at the beginning, since it is localized. In addition, fever, pain and increased white blood cell count may not always accompany this serious infection, although, in time, fever will rise as the abscess develops and meningismus signs may be observed. MRI evaluation is necessary to verify the extent of the problem, but it may not always reveal specific findings, especially in the beginning of abscess formation. In this patient, a high fever of 39℃ developed on the sixth day of the procedure. The patient developed signs of meningitis with neck stiffness, headache, and confusion; though the brain CT did not reveal any abnormal findings of meningitis. Nagra et al.
8) reported the vast majority of CT scans being performed in patients with meningitis have normal findings. Cerebral vasculopathy is one of the major complications of bacterial meningitis. Large-size arteries at the base of the brain, medium-sized arteries, small pial and intraparenchymal arteries, as well as sinus and cortical veins might be affected. Alteration of the cerebral blood flow in the large-size vessels at the base of the brain has been previously shown, by means of ultrasound, in patient with bacterial meningitis
1,2). Brain infarction has been reported in bacterial meningitis caused by streptococcus pneumonia, Neisseria meningitides, Haemophilus influenza, Staphylococcus aureus, and other pathogens
3,4). However, the exact mechanism of vascular occlusion is still not clear. Probably most ischemic lesions can be explained by distal vasculitis and impaired cerebral blood flow. Occlusion of the great cerebral vessels has been reported to be caused by not only vasospasm but also by thrombosis. Usually, ischemic lesions affect the cerebral cortex, whereas cerebellum is rarely affected. The prognosis of bacterial meningitis with cerebrovascular complications is poor. In the study of Pfister et al.
9) only two of 13 patients recovered. Cerebral ischemia may lead to poor outcome, as a result of direct focal cerebral damage, as well as increased intracranial pressure due to cytotoxic edema.