Silent spinal epidural abscess due to facet joint arthritis

Abstract

Spinal epidural abscess (SEA) is an abscess that forms between the dura mater and vertebrae. SEA is characterized by back pain and neuropathy associated with fever, of which early diagnosis and treatment are necessary to avoid irreversible neurological sequelae. However, its diagnosis is often difficult because specific symptoms are rarely present in the early stages of the disease. A 25-month-old boy, healthy by nature and free of risk factors, was referred and admitted for fever symptoms only, without back pain or neurological symptoms. We focused on the residual activation of the coagulation-fibrinolytic system, which was contrary to the response to therapy, and were able to establish a diagnosis of SEA. After the initiation of antibiotics, the patient responded well to treatment and made a mild recovery without the need for surgical intervention. To date, there are no reported cases of SEA with only febrile symptoms without localized spinal cord tenderness. SEA is easily overlooked and should be considered in the differential diagnosis of pediatric fever of unknown origin. Although imaging studies have drawbacks, such as radiation exposure and sedation, they should be immediately performed if SEA is suspected.

Keywords: D-dimer; Facet joint arthritis; Fibrinogen; Magnetic resonance imaging; Pediatric; Spinal epidural abscess.

Fig. 1

Contrast enhanced computed tomography (CT) imaging and magnetic resonance imaging (MRI) performed using a 3.0 T system. (A) Axial CT image. (B) Sagittal CT image. (C) Axial fat-suppressed T2-weighted MRI image. (D) Sagittal fat-suppressed T2-weighted MRI image. A multifocal cystic structure is visible dorsally on the dura at the Th12-L3 level in the spinal canal (yellow arrowhead in A, B; orange arrowhead in C, D). Contrast effects are present on the left lateral intervertebral foramen at the L1–2 level and on the erector spinae near the L1/2 intervertebral joint (A, B). A markedly high fat-suppressed T2-weighted image signal in the left intervertebral joint at the level of L1/2 is suggestive of fluid retention (C, D). The perivertebral foramen and erector spinae show high fat-suppressed T2-weighted image signals mainly at the L2 level, indicating inflammatory spillover (C, D). No abscess formation in the psoas major muscle or bone marrow edema in the vertebral body is visible.