nonspecific pyogenic spinal epidural abscess ( sea ) is an uncommon entity , especially in cervical region , but its clinical importance overshadows its rarity ( 1 - 6 ) . the overall frequency has been reported to be between 0.2 and 2 per 10,000 hospitalized patients ( 5 , 7 - 10 ) . because of the indistinct symptoms , it causes the patient to become neurologically worse in short span of time ( 2 , 6 , 8 , 11 - 13 ) . a successful treatment is possible with early recognition and beginning appropriate treatment immediately ( 5 - 7 , 9 , 10 , 14 ) . in the presence of the predisposing factors , such as iv drug abuse , senility , diabetes , mellitus , alcoholism , immunosuppression , liver diseases , renal failure or surgical attempts such as spinal / central venous catheterization , indistinct symptoms of the patient such as dorsal - lumbar - neck pain or subfebril fever must be examined seriously ( 5 , 8 , 10 , 11 , 13 ) . we report two cases of cervical epidural abscesses in haemodialysis patients and discuss clinical features , role of neuroimaging techniques for rapid diagnosis and guidelines for their medical and surgical management . a 66-yr - old male patient was in haemodialysis program for 1 yr due to end - stage renal insufficiency . after a central venous catheterization had been applied three weeks ago in another hospital , he had been referred to our clinic with severe neck pain , high fever and rapid progressive quadriparesis . in the physical examination , he was febril ( 37.2 ) but no neck stiffness was present . in the neurological examination , he was quadriparetic ( motor strength was proximally 3/5 , distally 1/5 in upper extremities , 1/5 in lower extremities ) . babinski , hofmann , and clonus reflexes were bilaterally positive and he was hypoesthetic below c4 dermatome . postgadolinium magnetic resonance ( mr ) revealed an epidural abscess at c4 - 5 level ( fig . 1 ) . at surgery , via a posterior midline approach , we performed hemilaminectomy to c4 and c5 levels and partial facetectomy and debridement of infective tissues . postoperative period of the patient was uneventful and he transferred to infection diseases clinic to have the antimicrobial therapy ( vancomycin 2 gr / day and ceftriaxone 2 gr / day ) . in follow - ups , his spasticity and quadriparesis recovered gradually to 3/5 in upper extremities and 2/5 in lower limbs . a 45-yr - old male patient was in haemodialysis program for 3 yr due to end - stage renal insufficiency . he had a history of two operations for peritonitis because of performing peritoneal dialysis before . after a central venous catheterization had been applied one month ago , he had been referred to our clinic with severe neck pain , high fever and acute progressive quadriparesis . in his neurological examination , he was quadriparetic ( motor strength was promixally 3 - 4/5 , distally 1 - 2/5 in upper extremities and 3/5 in the lower extremities ) . babinski , hofmann , and clonus reflexes were bilaterally positive . the peripheral white blood cell ( wbc ) count was 13.810/l , erythrocyte sedimentation rate ( esr ) was 136 mm / hr and creactive protein ( crp ) level was 52.5 mg / dl , and the other laboratory findings were normal . mr images revealed an epidural abscess , spondylodiscitis and anterior kyphotic deformity with cord compression in c5 to c7 levels ( fig . 2 ) . at surgery , via anterior approach , total corpectomies to c5 , c6 , and c7 , and partial corpectomies to c4 and t1 bodies were performed . after drainage of the abscess located epidurally and debridement of necrotic tissues , plate fusion procedure was performed by the autograft taken from the patient 's fibula to the corpectomy area . the pathogens isolated from the pus culture were staphylococcus aureus and pseudomonas aeruginosa which were resistant to methicillin and he transferred to infection diseases clinic to have the antimicrobial therapy ( tazocin 7.5 gr / day , targocid 400 mg/72 hr ) . postoperative period was uneventful and after 3 weeks he mobilized with somi corset . in follow - ups , his spasticity and quadriparesis recovered gradually to 3 - 4/5 in upper extremity and 3/5 in the lower extremity . a 66-yr - old male patient was in haemodialysis program for 1 yr due to end - stage renal insufficiency . after a central venous catheterization had been applied three weeks ago in another hospital , he had been referred to our clinic with severe neck pain , high fever and rapid progressive quadriparesis . in the physical examination , he was febril ( 37.2 ) but no neck stiffness was present . in the neurological examination , he was quadriparetic ( motor strength was proximally 3/5 , distally 1/5 in upper extremities , 1/5 in lower extremities ) . babinski , hofmann , and clonus reflexes were bilaterally positive and he was hypoesthetic below c4 dermatome . postgadolinium magnetic resonance ( mr ) revealed an epidural abscess at c4 - 5 level ( fig . 1 ) . at surgery , via a posterior midline approach , we performed hemilaminectomy to c4 and c5 levels and partial facetectomy and debridement of infective tissues . postoperative period of the patient was uneventful and he transferred to infection diseases clinic to have the antimicrobial therapy ( vancomycin 2 gr / day and ceftriaxone 2 gr / day ) . in follow - ups , his spasticity and quadriparesis recovered gradually to 3/5 in upper extremities and 2/5 in lower limbs . a 45-yr - old male patient was in haemodialysis program for 3 yr due to end - stage renal insufficiency . he had a history of two operations for peritonitis because of performing peritoneal dialysis before . after a central venous catheterization had been applied one month ago , he had been referred to our clinic with severe neck pain , high fever and acute progressive quadriparesis . in his neurological examination , he was quadriparetic ( motor strength was promixally 3 - 4/5 , distally 1 - 2/5 in upper extremities and 3/5 in the lower extremities ) . babinski , hofmann , and clonus reflexes were bilaterally positive . the peripheral white blood cell ( wbc ) count was 13.810/l , erythrocyte sedimentation rate ( esr ) was 136 mm / hr and creactive protein ( crp ) level was 52.5 mg / dl , and the other laboratory findings were normal . mr images revealed an epidural abscess , spondylodiscitis and anterior kyphotic deformity with cord compression in c5 to c7 levels ( fig . 2 ) . at surgery , via anterior approach , total corpectomies to c5 , c6 , and c7 , and partial corpectomies to c4 and t1 bodies were performed . after drainage of the abscess located epidurally and debridement of necrotic tissues , plate fusion procedure was performed by the autograft taken from the patient 's fibula to the corpectomy area . the pathogens isolated from the pus culture were staphylococcus aureus and pseudomonas aeruginosa which were resistant to methicillin and he transferred to infection diseases clinic to have the antimicrobial therapy ( tazocin 7.5 gr / day , targocid 400 mg/72 hr ) . in follow - ups , his spasticity and quadriparesis recovered gradually to 3 - 4/5 in upper extremity and 3/5 in the lower extremity . sea occurs primarily in individuals over 30 yr of age . however , published series with more than ten patients report differing average ages for affected patients ( 4 , 6 , 8 , 10 , 13 ) . the colonization of the spinal epidural space by micro - organisms may occur hematologenously or by contiguous spread from neighboring structures . infection due to hematogenous spread may originate from all types of extraspinal infection leading to a persistent or temporary bacteremia . all invasive procedures can lead to the introduction of bacteria into the blood stream with resultant sea . in addition , many patients have risk factors that may favor the development of sea ( 4 , 6 , 8 , 10 , 13 ) . it is also reported after central venous catheterization in patients on maintenance haemodialysis ( 6 , 10 , 13 - 16 ) . the preferential thoracic or lumbar localization of sea is likely related to the greater extension of the epidural space in the thoraco - lumbar segment of the vertebral column and to the well - developed extradural venous plexus in this region ( 3 , 4 , 17 - 20 ) . in the present cases , the reason of cervical localization might be the using of internal jugular veins . in the clinical symptoms , following the initial stage of severe pain associated with local tenderness in the area of the spinal column , these manifestations include laseque 's , kernig 's and lhermitte 's signs , brudzinski 's reflex and neck stiffness ( 5 ) . in the third stage , initial neurologic deficits are observed such as weakness of the voluntary musculature or fecal or urinary incontinence . importantly , the transition to the terminal stage with paralysis can occur very quickly ( 5 ) . in addition to neurological findings , patients with sea may also develop fever in the initial stage due to inflammation associated with the abscess . this is accompanied by an elevated esr and leukocytosis ( 3 - 5 , 8 , 11 ) . radiological investigations have been the mainstay of diagnosis for patients with sea . however , the most important step in diagnosing sea is consideration of the entity . so , delay in the diagnosis of this entity , some manifest neurological deficits are seen on approximately 60% of the patients , like as in our cases ( 2 - 4 , 7 , 11 , 12 , 20 ) . before the era of computerized tomography ( ct ) and magnetic resonance imaging ( mri ) , the only imaging modalities of use in diagnosis were conventional radiographs and myelography . however , conventional radiography of the vertebral column is not necessarily reliable for sea . only after erosion or sclerotic changes of bony structures and these changes are to be expected only after several weeks of chronic sea ( 8) . in contrast to ct , mri is able to form multiplanar images with high contrast among soft - tissue structures and without bone artifacts . in a study , it was reported a sensitivity of 95% in mri for the definitive diagnosis of sea ( 17 ) . it reveals low signal intensity in vertebra corpus in t-1 weighted images and destruction in cortex and high signal intensity at effected corpus in t-2 weighted images ( 4 , 17 ) ( fig . 1 , 2 ) . the use of gadolinium in mri allows better delineation of sea from contiguous structures . a wide range of microorganisms can cause sea , and isolation of the aetiologic agent , particularly from blood culture , bone biopsies , or aspirates from bone or paravertebral abscess , the easiest and the least invasive method to obtain the agent is from blood and its isolation rate is reported as 68% in cultures of blood ( 13 ) . another method is fine - needle biopsy guided with ct or fluoroscope which success rate varies from 35% to 63% ( 13 ) . neverthless , the most successful route in obtaining the pathogen is via open surgery ( 3 , 4 , 8 , 11 ) . sea is primarily a bacterial infection ( 1 , 4 - 6 , 8 , 10 - 13 , 18 ) . the few reported cases of fungal infections were seen mainly in immunocompromised patients and individual cases of sea due to parasites have been reported from certain geographic regions . staphylococcus aureus was described as the principle etiologic agent of sea in the international literature . gram negative bacteria may be more common in cases of sea in drug users . although conservative treatment modalities have occasionally been reported to be successful , in our opinion , surgical intervention is the method of choice and is generally performed with pre- and postoperative administration of antibiotics . conservative method is only possible for cases without any neurological deficits in early periods and together with their close neurological follow ups ( 1 , 8 , 19 ) . the most commonly used operative procedure was laminectomy , via posterior approach . intraoperative sonography is especially useful in the surveillance of surgical decompression of anteriorly located extensions of the abscess . anterior decompression is necessary for sea in the anterior segment of the epidural space and this operation is usually combined with anterior corpectomy . the choice of surgical approach in the cases which have manifest neurological deficit , as in our both cases , provides decompression of spinal cord , debridement of infected / necrotic material , drainage of abscess and correction of spinal deformity in one session . although the issue of appropriate surgical approach - anterior versus posterior - in sea is controversial , we think it should be individualized according to location of the abscess and its own features . the second main problem is application of a foreign material into the infected area and this is also controversial . however , in some conditions , as in our second case , because of extensive bone resections , foreign material implantation and reconstruction will be compulsory and today wide spectrum antibacterials can make it possible ( 3 , 4 , 8 , 19 ) . 1 ) efficacy against staphylococcus aureus , the most common cause of sea , 2 ) low toxicity to enable treatment over several weeks , and 3 ) the ability to penetrate bony tissues , as also is necessary in treating spondylodiscitis . the choice of antibiotics is based on the preferences of the clinician and the institution , resistance testing , and the country of treatment . the duration of antibiotic administration is up to 12 weeks but usually 4 to 6 weeks . antibiotics should be initially given intravenously but may be continued with oral formulations . in conclusion , it is known that optimal management is unclear in sea , and morbidity and mortality are still significant in spite of modern diagnostic and treatment opportunities . we present two adult haemodialysis patients who developed cervical epidural abscess with end - stage renal insufficiency following central venous catheter placement . early surgical intervention is mandatory in cases those have progressive neurological deficit and spinal deformity , and this is also increases the success rate of medical therapy .
despite advances in neuroimaging and neurosurgical treatment modalities , spinal epidural abscess remains a challenging problem . 
 early diagnosis is often difficult and treatment is always delayed . 
 spinal epidural abscess usually develops in patients with predisposing factors such as iv drug abuse , senillity , diabetes mellitus , spinal attempts , alcoholism , immunosuppression , liver diseases and catheterizations . 
 it is rarely seen in cervical region . 
 a successful treatment is only possible with early diagnosis and accurate surgical and medical treatment . 
 optimal management is unclear and morbidity and mortality are significant . 
 we present two adult haemodialysis patients with end - stage renal insufficiency who developed cervical epidural abscess following central venous catheter placement . 
 early surgical intervention is mandatory in cases those have progressive neurological deficit and spinal deformity , and this is also increases the success rate of medical therapy .