Extensive Spinal Epidural Abscess Resulting in Complete Paraplegia Treated by Selective Laminectomies and Irrigation

Abstract

Background: Spinal epidural abscess (SEA) is an uncommon clinical entity that is often subject to delayed diagnosis and suboptimal treatment. Untreated disease leads to compression of the spinal cord, resulting in devastating complications.

Case presentation: A 56-year-old man visited our hospital for progressive lower back and lower extremity pain of several days' duration. Significant pyrexia (39.5°C) and elevated C-reactive protein (89.2 mg/L) were detected during admission, but no positive neurological examination findings were observed. Magnetic resonance imaging revealed pyogenic discitis at L3-4. Despite the administration of directed antibiotic therapy, the patient's condition rapidly deteriorated, culminating in complete paraplegia secondary to an extensive SEA from L4 to C7. Emergency spinal decompression surgery was canceled due to his poor clinical condition and refusal of informed consent. After further deterioration, he consented to two-level selective laminectomies and irrigation.

Conclusions: In contrast with prior case reports, this case illustrates the natural history of an extensive SEA during conservative and late surgical treatment. Early diagnosis and timely surgical decompression are of great importance for extensive SEA.

Keywords: irrigation; laminectomies; neurological infection; paraplegia; spinal epidural abscess.

Fig. 1

(A) Sagittal and (B) axial T2‐weighted magnetic resonance images show pyogenic discitis at L3–4 and abscesses (white arrows) disseminated in the anterior, right lateral, and epidural space of L3–4. (C) T2‐weighted sagittal magnetic resonance image of the whole spine shows progressing epidural abscess predominating anteriorly continuous from L4 to T1. The white dotted line indicates T1–2 and the blue dotted line indicates L3–4, at which levels axial images are shown in (D) and (E), respectively. T2‐weighted axial image at (D) T1–2 and (E) L3–4 levels show the huge epidural abscess (white arrows) is located in the ventral part of the spinal canal, critically compressing the spinal cord toward the posterior side

Fig. 2

Anatomical exposure after laminectomies is performed. (A) Yellowish‐white pus is noted (white arrow). (B) Normal saline is slowly injected through the catheter to irrigate the epidural abscess. (C) The two catheters meet at approximately the level of T8–9. The intraspinal length of the catheters is approximately the length of the spine from T2 to L2. (D) Blue arrows indicate flush tubes, and black arrows indicate drainage tubes

Fig. 3

Preoperative magnetic resonance images: postcontrast T1‐weighted magnetic resonance image (MRI) of the spine showing extensive epidural abscess (A, red arrow) continuous from L4 to C7, with enhancement of the margins of the abscess (B, white arrow). Postoperative magnetic resonance images: (C) T2‐weighted sagittal MRI of the whole spine shows the complete disappearance of the epidural abscess. The white dotted line indicates T1–2 and the blue dotted line indicates L3–4, at which levels axial images are shown in (D) and (E), respectively. (D) An abnormal high signal (white arrow) is detected on T2‐weighted axial MRI of T1–2. (E) Spinal epidural abscess and pyogenic discitis disappear on T2‐weighted axial MRI of L3–4