Infection in SCS pt?

[Timeoutofmind]

Guy I did a permanent on is three weeks out.

He said in the last two days he is having weakness fatigue, headaches, vomiting, neck stiffness, the shakes etc.

He does not have a fever in the office today.

The sites are good, although there is some tenderness around the battery site. The smallest bit of redness pretty typical post op around the sites but no fluctuance or fluid or anything. Neuro exam non-focal. I did not do a proper Kernig's and Brudzinski's in office as I just wasnt thinking meningitis initially, but then got worried thinking about the neck pain/headaches.

I am sending him for a stat CT thoracic and lumbar with contrast. They are pending for later today.

WBC is up from 10.8 preop to 11.5 with neutrophils up from 8.4 to 9.2. ESR and CRP are normal.

He is not that reliable generally, has been a drinker at times, and is being weaned from opioids from someone else. No big changes recently but I wonder if some of it is subtle withdrawal type symptoms? Or just a flu?

What do you think? Seems aggressive just take it out at this point...LP? Send to ER? Call a spine surgeon to try and get him in STAT?

Have you ever seen a deeper type infection this early even though the sites looked good?

Thanks for your help in advance.

---

Members don't see this ad.

 

[deleted472101]

CT with IV contrast or MRI with contrast

 

[paintrain]

CT with IV contrast or MRI with contrast

If lucky (or unlucky), you'll see a large collection and stranding that may indicate an infectious process. But most likely, I'd expect post-surgical changes with some post-surgical fluid collection around both incisions. Neither CT/MRI would be able to discern if this is normal post-surgical or infectious/purulent.

Would anyone consider treating empirically for gram positives and watch/wait?

 

[deleted472101]

The pocket was visualized by 'timeoutofmind' which looked 'ok'.
I would be more concerned about the epidural space. there shouldn't be that much post surgical changes there.
You can always place a sterile needle into the pocket if you were concerned of an infection. I have never done this but multiple neurosurgeons stated this in past.

 

[lobelsteve]

Weaning too fast, withdrawal.
Esr normal, no infection.
Would be better if one doc was caring for the entire patient.

 

[NJPAIN]

The scary part of doing implants. Very useful discussion.


Sent from my iPhone using SDN mobile app

 

[unchockey21]

I agree with probable withdrawal given those labs and presentation. I would've got the scan too to cover my butt. I think anything else would be too aggressive unless imaging shows something unexpected.

 

[244913]

Guy I did a permanent on is three weeks out.

He said in the last two days he is having weakness fatigue, headaches, vomiting, neck stiffness, the shakes etc.

He does not have a fever in the office today.

The sites are good, although there is some tenderness around the battery site. The smallest bit of redness pretty typical post op around the sites but no fluctuance or fluid or anything. Neuro exam non-focal. I did not do a proper Kernig's and Brudzinski's in office as I just wasnt thinking meningitis initially, but then got worried thinking about the neck pain/headaches.

I am sending him for a stat CT thoracic and lumbar with contrast. They are pending for later today.

WBC is up from 10.8 preop to 11.5 with neutrophils up from 8.4 to 9.2. ESR and CRP are normal.

He is not that reliable generally, has been a drinker at times, and is being weaned from opioids from someone else. No big changes recently but I wonder if some of it is subtle withdrawal type symptoms? Or just a flu?

What do you think? Seems aggressive just take it out at this point...LP? Send to ER? Call a spine surgeon to try and get him in STAT?

Have you ever seen a deeper type infection this early even though the sites looked good?

Thanks for your help in advance.

Very much doubt infection with no induration or fluctuance at the site three weeks out and normal ESR and CRP

If no focal neurological signs I'd watch and wait, maybe keep on po abx as a precaution

All a CT would show would be a postoperative seroma

We do a ton of stim implants where I train, about 100 per fellow. Postoperative wound complications seem to peak at day 10 with another bump at 4-5 weeks, so I'd bring him back in another week and give follow up precautions

- ex 61N

 

[clubdeac]

Agree... likely not bacterial with normal inflammatory labs. Probably withdrawal

 

[NJPAIN]

I suppose that a Percocet would solve the mystery. That would support the fact that Percocet makes life livable


Sent from my iPhone using SDN mobile app

 

[Timeoutofmind]

Update:

Decided not to mess around with that slight WBC count rise.

Sent to ER for LP and blood cultures
- which were neg.

No fever documented in ER.

CT scans were normal too.

The ER doc thought he was drug seeking, did not look toxic or meningeal, etc.

Kind of a good case for the fellows and shows how many layers there are to these pain patients and why nothing is ever striaghtforward lol.

I suspect he was self-escalating opioids at home (even though he denied this when I asked) due to intolerance of the wean psychologically and ran out early but did not want to admit this because the doctor weaning him has an addictionology background and would likely just dc opioids immediately if this was documented. I dont think he even bothered to ask me about opioids, just went right to the ER, as he knew my answer already.

Either that or just got panicky/freaked himself out seemed to be a component too.

Thank you everyone for all your feedback, very helpful.

I will trend labs if he complains of the same symptoms in the coming days here.

 

[deleted472101]

Always better to be safe than sorry. Glad nothing was wrong

 

[bedrock]

moral of the story is to never do an SCS implant in the middle of an opioid wean. Plenty of time to do a wean after the SCS implant wounds have healed so there is no confusion.

 

[Orin]

Are you guys using that antibiotic envelope? The literature from the cardiac pacemaker side is amazing.

Any one ever order a PET scan or tagged WBC scan to eval infection?