Extensive Spinal Epidural Abscess: Cord Compression with Permanent Neurological Defects

Spinal epidural abscesses (SEA) are considerably rare and tend to present over two to five vertebral segments. Occasionally, there will be two or more noncontiguous areas of pyogenic collections [1]. Minimal cases have been reported to span the entire vertebral column;a meta-analysis estimates that 1% of all SEA are holospinal [2]. The triad of presenting symptoms includes fever, back pain (often midline), and neurologic defects [1] [2] [3]. Early detection is identified as a critical aspect of improved outcomes. Cases that do not present in this manner or with other masking symptoms can lead to delayed diagnosis, thus delaying treatment. In the event of cord compression, the occurrence of neurologic defects increases. Time from the onset of clinical manifestations to the operating room is crucial in reversing symptoms [2]. This article seeks to review a case of a 65-year-old male that presented to the emergency department (ED) due to a falling second to weakness and thigh pain. On presentation, he was also noted to have rhabdomyolysis causing acute kidney injury (AKI) with tubular necrosis. The patient was admitted to the hospital with a complex history of progressive leg weakness, pain in the lower back, incontinence, and elevated white blood cell count. Days into the admission, a magnetic resonance imaging (MRI) study was performed, which revealed a continuous posterior SEA from C4 to S2 with anterior mass effect causing spinal cord compression. Emergency neurosurgery was scheduled for laminectomies in the cervical, thoracic and lumbar spine to drain the abscess. Evaluation of this complex medical course, surgical approach to drainage of an incessant spinal column abscess, and sustained neurologic defects will be discussed.

Spinal epidural abscess due to coinfection of bacteria and tuberculosis:A case report

BACKGROUND Spinal epidural abscess(SEA)is a rare condition that mostly results from infection with either bacteria or tuberculosis.However,coinfection with bacteria and tuberculosis is extremely rare,and it results in delays in diagnosis and antimicrobial treatment causing unfavorable outcomes.CASE SUMMARY A 75-year-old female visited the hospital with low back pain,and magnetic resonance imaging(MRI)revealed an SEA at the lumbosacral segment.Staphylococcus hominis and methicillin-resistant Staphylococcus epidermidis were identified from preoperative blood culture and intraoperative abscess culture,respectively.Thus,the patient underwent treatment with vancomycin medication for 9 wk after surgical drainage of the SEA.However,the low back pain recurred 2 wk after vancomycin treatment.MRI revealed an aggravated SEA in the same area in addition to erosive destruction of vertebral bodies.Second surgery was performed for SEA removal and spinal instrumentation.The microbiological study and pathological examination confirmed Mycobacterium tuberculosis as the pathogen concurrent with the bacterial SEA.The patient improved completely after 12 mo of antitubercular medication.CONCLUSION We believe that the identification of a certain pathogen in SEAs does not exclude coinfection with other pathogens.Tubercular coinfection should be suspected if an SEA does not improve despite appropriate antibiotics for the identified pathogen.

Pyogenic discitis with an epidural abscess after cervical analgesic discography:A case report

BACKGROUND Chronic neck pain is a common clinical problem.It has long been considered that degenerative cervical disc is an important source of chronic neck pain.In the clinic,cervical discography is thought to be a useful and safe method to distinguish aging discs from pathological discs,and the probability of complications caused by it is really rare.However,once complication occurs,it is likely to cause fatal consequences to patients.Therefore,accurate judgment and effective treatment are crucial.CASE SUMMARY A 45-year-old female was admitted to the department with a 5-year history of severe neck pain,dizziness,and tinnitus.In order to find the diseased disc,analgesic discography was performed on C4/5 and 6/7 discs successively.Unfortunately,Discitis with an epidural abscess was caused during the procedures.With the help of magnetic resonance imaging,an accurate diagnosis was made and an urgent anterior cervical operation was given subsequently.The patient ultimately recovered well.CONCLUSION Discitis with epidural abscess is a rare complication after cervical discography,which needs accurate diagnosis and effective antibiotic treatment.

Spinal Epidural Abscess in Patients with Sepsis Who Experienced Significant Improvements after Complete Paralysis: Two Case Reports

Spinal epidural abscess (SEA) is a rare condition, and a delay in its diagnosis causes paralysis. In this study, we report two rare cases of delayed diagnosis of SEA whose conditions improved after a state of complete paralysis. The first case was a 71-year-old diabetic man who received a corticosteroid injection for shoulder pain that caused intensified pain. Thereafter, the patient developed paralysis of both legs in stage IV according to Heusner staging. Subsequently, he was diagnosed with multiple abscesses and sepsis. He was in a poor state of health. Therefore, we treated his epidural abscess conservatively. After a month, his muscle strength had improved to Heusner stage III-A, and he was transferred to another hospital. The second case was a 64-year-old diabetic man who received an epidural corticosteroid injection for lower back pain. However, the pain intensified and was admitted to the hospital for pyelonephritis. He developed paralysis in both of his arms and legs presenting as a Heusner stage IV, caused by a cervical epidural abscess. A laminoplasty was performed and paralysis was improved. However, the patient subsequently developed a left subcortical hemorrhage. He underwent surgery. However, his right hemiplegia persisted, and on Day 21, he was transferred back to the previous hospital with a Heusner III-A. We could improve the patients’ paralysis by cooperating closely with infectious disease specialists and spine surgeons, taking intensive care, applying antibacterial agents appropriately, and operating quickly.

Compressive Myelopathy, Spinal Shock, and a Complicated Neurological Exam

The neurological examination, developed and tested since the 1800s has provided physicians with a vital tool to rapidly assess and provide clues to many of the pathological processes lurking inside the brain and spinal cord. With the advent of magnetic resonance imaging, physicians are able to visualize the precise location of the abscess before surgical intervention. In this case report, we present a 51-year-old male with an epidural abscess with multifocal compressive myelopathy, resulting in a complicated neurological examination, making localization a diagnostic challenge. With this case, we would like to stress that complicated multifocal lesions of the cord may present with a large variation in examination findings. This patient’s neurological exam was complicated secondary to a ventrally as well as dorsally located epidural abscess with superimposed spinal shock sequelae. We would like to highlight the importance of a thorough history and the neurological examination but also mention some of its limitations. It is crucial to use clinical judgement to navigate the patient’s history, presentation, and examination to accurately diagnose and treat, particularly so in cases involving compressive myelopathies of the spinal cord.

Surgical treatment of delayed cervical infection and incomplete quadriplegia with fish-bone ingestion:A case report

BACKGROUND The most commonly ingested foreign body in Asians is fish bone.The vast majority of patients have obvious symptoms and can be timely diagnosed and treated.Cases of pyogenic cervical spondylitis and diskitis with retropharyngeal and epidural abscess resulting in incomplete quadriplegia due to foreign body ingestion have been rarely reported.The absence of pharyngeal or esophageal discomfort and negative computed tomography(CT)findings of fish bone have not been reported.We report the case of an elderly female patient with delayed cervical infection and incomplete quadriplegia who had a history of fish bone ingestion.CASE SUMMARY A 73-year-old woman presented with right neck pain and weakness of four limbs for a week,and had a history of fish bone ingestion and negative findings on laryngoscopic examination one month previously.She did not complain of any pharyngeal or esophageal discomfort.Cervical magnetic resonance imaging showed C4/C5 spondylitis and diskitis along with retropharyngeal and ventral epidural abscesses.No sign of fish bone was detected on lateral cervical radiography and CT scans.The muscle strength of the patient’s right lower limb receded to grade 1 and other limbs to grade 2 suddenly on the 10th day of hospitalization.Emergency surgery was performed to drain the abscess and decompress the spinal cord by removing the anterior inflammatory necrotic tissue.Simultaneously,flexible esophagogastroduodenoscopy was carried out and a hole in the posterior pharyngeal wall was found.The motor weakness of the right lower limb improved to grade 3 and the other limbs to grade 4 within 2 d postoperatively.CONCLUSION This rare case highlights the awareness of the posterior pharyngeal or esophageal wall perforation in patients with cervical pyogenic spondylitis along with a history of fish bone ingestion,even though local discomfort symptoms are absent and the radiological examinations are negative.

Only Spondylodiscitis? A Clinical Case of Multiple Septic Embolization

Background: Spondylodiscitis and spinal epidural abscesses are rare pathologic entities, but increasing in incidence. Group G beta hemolytic Streptococcus has been recently described associated with human infections. They often present clinically in a non-specific fashion, a fact which can lead to diagnostic delay, with serious consequences for the patient. Case Report: An 80-year-old man was admitted to the hospital with complaints of fever for three days, dysuria, hematuria, and back pain. Both septic embolizations and spondylodiscitis due to Group G beta hemolytic Streptococcus were detected. The patient was successfully treated with intravenous penicillin G for eight weeks, followed by oral amoxicillin for five months. Discussion: In all patients with spondylodiscitis, infective endocarditis should be considered, particularly in patients with heart valve disease history, since spondylodiscitis may be the presenting sign of an infective endocarditis. A high level of suspicion is therefore necessary in order correctly diagnose such entities as quickly as possible. The present case illustrates the pathogenic potential of group G streptococci in spondylodiscitis and native valve endocarditis.