Lumbar spinal epidural abscess

• Lumbar Spondylodiscitis Caused by Clostridium perfringens: A Case Report Highlighting Diagnostic Challenges and Conservative Management
• A case of spinal epidural abscess, cauda equina syndrome, retroperitoneal abscess, aortic graft infection and aortoenteric fistula
• Unusual case of staphylococcus epidermidis-induced spinal epidural abscess in an adolescent: Clinical insights and diagnostic considerations
• The Remote Intradural Migration of Polyethylene Glycol-Based Hydrogel Sealant Following Lumbar Laminectomy: A Case Report
• Streptococcus pneumoniae-Related Infective Endocarditis Complicated by Development of Psoas and Epidural Abscesses
• Percutaneous pedicle screw fixation in the surgical treatment of monosegmental pyogenic spondylodiscitis
• Evaluation of spinal deformity and its progression in pyogenic spondylodiscitis: A retrospective MRI study of 59 cases
• Dural perforation and life-threatening central nervous system complications associated with septic arthritis of the lumbar facet joint: illustrative case

Spinal epidural abscesses usually occur in the thoracic or lumbar regions.

They can happen also as postoperative lumbar epidural abscess ¹⁾.

Facet joint septic arthritis ²⁾.

Spondylodiscitis

Compression of lumbar nerve roots may cause cauda equina syndrome, with neurologic deficits resembling those of conus medullaris syndrome (eg, leg paresis, saddle anesthesia, bladder and bowel dysfunction). Deficits progress over hours to days.

Plain x-rays are not routinely indicated but show osteomyelitis in about one third of patients. ESR is elevated, but this finding is nonspecific.

Before MRI suspicion of spinal epidural abscess should lead to immediate lumbar puncture with manometrics as well as myelography. Once the diagnosis is established surgery should be immediate. Gram stains and cultures taken at the time of lumbar puncture or at operation will dictate appropriate antibiotic therapy. The cause of infection can be fairly well determined by the location of the abscess and a knowledge of the pathogenesis. Prognosis seems directly dependent on the preoperative neurologic status of the patient ³⁾.

Lumbar puncture for CSF examination is often not performed because the diagnostic yield is low and because of the risk of introducing infection into the central nervous system if the needle goes through an affected area. In most cases, the CSF findings are limited to a nonspecific elevation of protein and pleocytosis. CSF Gram stain is usually negative, and cultures are rarely positive.

Sequestrated lumbar disc fragment mimicking ventral epidural abscess ⁴⁾.

Uchida et al reviewed 37 patients who sustained epidural abscess associated with pyogenic spondylodiscitis of the lumbar spine. Ten patients were treated conservatively, while 27 required urgent or elective surgical drainage. They studied patients with respect to symptomatology, Frankel ASIA impairment scale (ASIA) evaluation and a new proposed system of MRI staging of pyogenic spondylodiscitis (stages I–V).

Of the 37 patients with stage IV and V MRI lesions, 13 (35%) had septicemia and 8 (22%) presented with Frankel-ASIA scale C-D neurological status. All cases with ringlike enhancement on gadolinium-enhanced MRI in the epidural abscess lesions were treated surgically. Progression of local kyphosis and loss of intervertebral disk height were significantly prevented in the surgical group (P < 0.05). Improvements of neurological status and laboratory data were better in the surgical group than the conservative group (P < 0.05), with significantly short hospital stay (P < 0.05).

Epidural abscess associated with pyogenic spondylodiscitis presents with various neurological symptoms. In addition to assessment of progression by clinical symptomatology, modified neurological Frankel-ASIA scaling and the currently proposed MRI staging regimen may help to consider the timing of surgical intervention. In the acute, subacute or acute-on-chronic phase and the ringlike enhancement pattern of epidural abscess on gadolinium-enhanced MRI may be an indicator for surgery ⁵⁾.

A case of a diabetic patient who presented with a lumbar spinal epidural abscess eight days after head and neck oncologic surgery. Magnetic resonance imaging revealed an L4 spinal epidural abscess. Cultures from the spinal epidural abscess, blood, urine, and the previous neck incision grew Klebsiella pneumoniae. The patient recovered neurologic function after surgical decompression and drainage, long-term intravenous antibiotics, and physical therapy.

The development of postoperative spinal epidural abscess is rare after otolaryngology procedures but has been reported in the cervical epidural space. To authors knowledge, lumbar spinal epidural abscess has not yet been reported after head and neck oncologic surgery. Even more unique is the presence of the pathogen K. pneumoniae.

A high index of suspicion of this potential outcome is paramount as early recognition and intervention are keys to recovery of neurologic function ⁶⁾.

A 42-year-old man who presented with 3 days of low back pain and chills who rapidly decompensated with severe sepsis following admission. Magnetic resonance imaging of his lumbosacral spine revealed intramuscular abscesses of the left paraspinal musculature and iliopsoas with SEA and L4 vertebral body involvement. The patient failed maximal medical treatment, which necessitated surgical treatment as a last resort for infectious source control. He underwent a previously undescribed procedure in the setting of SEA: a single-stage, posterior-only approach for circumferential decompression and reconstruction of the L4 vertebral body with posterior segmental instrumented fixation.

After the surgery, the patient's condition gradually improved; however, he suffered a wound dehiscence necessitating a surgical exploration and deep wound debridement. Six months after the surgery, the patient underwent a revision surgery for adjacent-level pseudarthrosis. At 1-year follow-up, the patient was pain-free and off narcotic pain medication and had returned to full activity. Conclusion This patient is the first reported case of lumbar osteomyelitis with SEA treated surgically with a single-stage, posterior-only circumferential decompression and reconstruction with posterior instrumentation. Although this approach is more technically challenging, it presents another viable option for the treatment of lumbar vertebral osteomyelitis that may reduce the morbidity associated with an anterior approach ⁷⁾.

A 39-year-old male with no previous medical history presented with abdominal and low back pain. Based on clinical and radiological findings he was diagnosed with L1/L2 osteomyelitis and epidural abscess. Further history taking revealed recent use of acupuncture for treatment of mechanical back pain. The patient was treated conservatively with an extended course of antibiotics, monitored with repeat MRI scans and had a full recovery with no neurological deficit. This is the first reported case of epidural abscess formation and osteomyelitis after acupuncture in the UK. As acupuncture becomes more commonly used in western countries, it is important to be aware of this rare but serious complication ⁸⁾.

A case of tubercular spinal epidural abscess (SEA) without osseous involvement that mimicked an acute bacterial abscess. This case manifested quite unusual findings not only radiographically, but also clinically compared with previously reported cases of tubercular SEA ⁹⁾.

A 56-year-old man with alcohol-associated cirrhosis, arterial hypertension and diabetes, presented with a 1-month history of fever, lumbar back pain and lower limb weakness. MRI revealed a spinal epidural abscess extending from the cervical to the dorsolumbar spine. A methicillin-sensitive Staphylococcus aureus strain was isolated on blood cultures. Meropenem was initially started with no response, and then changed to vancomycin. During treatment, the patient's condition progressed with anasarca and renal failure with nephrotic-range proteinuria. The renal biopsy showed a membranoproliferative glomerulonephritis with IgA deposition. After completing 2 months of antibiotic therapy the patient recovered from the neurological deficits, with a complete resolution of the abscess and partial recovery of renal function and proteinuria ¹⁰⁾

A 63-year-old male, previously scheduled for Anterior Cervical Discectomy and Fusion to correct an existing cervical myelopathy at the C3-C4 spinal level, who presented to the emergency room with progressive weakness of the lower extremities and inability to ambulate for three days. Physical examination suggested a possible worsening of his cervical myelopathy but magnetic resonance imaging (MRI) findings remained unchanged from comparison studies. On the day of surgery, he became febrile and complained of excruciating back pain and we therefore initiated an infectious etiology workup and obtained a lumbar spine MRI. Results of imaging suggested a lumbar epidural abscess with effacement of the thecal sac. Emergent L4-L5 decompression led to an evacuation of a “chalky” substance, which was sent for pathology evaluation. This patient was diagnosed with tophaceous gout of the lumbar spine upon final pathological review. We aim to present the management of this case and review the literature associated with this diagnosis with the goal of improving the approach taken to diagnose and treat this pathology ¹¹⁾.

A 77-year-old patient presenting with a delayed diagnosis of a multi-regional epidural abscess with associated upper motor neurone signs. The patient was successfully treated nonoperatively with a course of antibiotics resulting in complete radiological resolution of the abscess and full neurological recovery ¹²⁾.

A case of rapidly progressive gas-containing lumbar spinal epidural abscess due to Enterococcus faecalis in a 72-year-old male patient with diabetes mellitus ¹³⁾.

Four cases of spinal epidural abscess diagnosed in Clinica Puerta de Hierro between 1982 and 1990. In three cases the localization was thoracic and in one it was lumbar. Fever and vertebral pain were the more constant clinical symptoms. Lumbar punction showed findings in Cerebro-Spinal Fluid compatible with a parameningeal inflammation focus in the three cases it was performed. Diagnosis was established with myelography or Computerized Axial Tomography. Treatment in two cases was laminectomy and systemic antibiotics: and only antibiotics in the other two cases. Evolution was favorable in the patients who underwent surgery, but the patients treated conservatively had a fatal outcome ¹⁴⁾.

Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 12-1982. Low-back pain and fever in a 71-year-old man ¹⁵⁾.

A case is reported of acute osteomyelitis of the lumbar spine presenting with a psoas abscess which extended into the epidural space mimicking an epidural abscess. The patient also had severe septicaemia and a complete cauda equina lesion. The septicaemia was controlled by draining the abscess by an anterior approach to the lumbar spine. Decompression of the cord was achieved by removing the sequestrated discs, the necrotic body of the fourth lumbar vertebra and draining the epidural abscess by opening the posterior longitudinal ligament ¹⁶⁾.

A patient aged 16 years was admitted to a neurological departement for flaccid paresis of lower extremities. Contrast radiological examination demonstrated obliteration of the vertebral canal between Th12 and L3, without coexistent changes in the bone parts of the vertebral column on plain films. During the operation a tumour situated epidurally and compressing the dural sac posteriorly and laterally from both sides at the level Th12–L3 was removed. Histological examination of the excised tumour showed presence of a chronic inflammatory process with presence of granulation tissue of probably tuberculous character. The tuberculous aetiology of the disease was confirmed by development of cold abscess in the postoperative scar 2 months after the operation. Neurological, neurosurgical and antituberculous treatment led to complete cure with return of normal neurosurgical status. The patient has been followed up for 5 years ¹⁷⁾.

Symptoms clinical course, and also statistical data are recroded for a 60-year-old man with a chronic epidural abscess in the lumbar vertebrae 3/4 following a lumbar puncture. Acute and chronic epidural intraspinal abscesses are discussed in relation to the relevant literature ¹⁸⁾

Epidural abscess of the lumbar spine: report of case ¹⁹⁾.

Epidural abscess simulating disc hernia ²⁰⁾

Epidural abscess of the spine ²¹⁾.

Epidural tuberculous abscess simulating herniated lumbar intervertebral disk; a case report ²²⁾.

Acute lumbar epidural abscess in a thirty month old child; complete recovery following surgery and antibiotic therapy ²³⁾

Acute lumbar epidural abscess; report of a case ²⁴⁾.

Lumbar spinal epidural abscess.

The patient has been experiencing left low back pain for approximately 10 days, which has progressively worsened over the past 5 days. The pain has intensified and now radiates down the posterior aspect of the left lower limb. This worsening pain has significantly impacted the patient's ability to function, prompting them to seek medical attention.

CT Scan of the Thoraco-Lumbar Spine (with IV Contrast) - Urgent. Multiplanar Reconstruction (MPR) images in various projections are attached.

In the area of the left paravertebral musculature (from L3 to L5), a low-density image with lobulated contours and peripheral enhancement consistent with inflammatory process or abscess is observed as the main diagnostic suspicion. It measures approximately 8.7 x 3 cm in maximal dimensions in the craniocaudal (CC) and anteroposterior (AP) directions. We cannot exclude its origin in the left interapophyseal joints of the mentioned levels due to its proximity and subchondral lytic changes in the left L4 interapophyseal joint. We recommend completing with contrast-enhanced MRI.

There are signs of Grade 1/2 spondylolisthesis at the L5/S1 level. A pseudoprotusion disc and bilateral spondylolysis are associated.

No clear fracture lines. Image of sclerosis affecting the vertebral body of D8, possibly related to a vertebral hemangioma.

Signs of calcified aortoiliac atherosclerosis.

No other relevant findings observed.

DIAGNOSTIC IMPRESSION:

-Image affecting the left paravertebral musculature consistent with an inflammatory process/abscess that may originate from the facet joints. Spondylolisthesis with spondylolysis at the L5/S1 level.

MRI

The imaging findings reveal a significant abscess in the posterior epidural space extending from L3 to S1, causing moderate to severe compression of the thecal sac. This abscess appears to originate from the left L3-L4 interfacet joint. Additionally, there is a large abscess in the left paravertebral musculature. Other incidental findings include a loss of normal lumbar lordosis, Schmorl's hernias, a small disc protrusion at L5-S1, and bladder distention.