Spinal subdural abscess: A rare cause of low back pain

Spontaneous lumbar intraspinal subdural abscess: a case report

BACKGROUND

Subdural spinous abscess is a rare pathology that carries significant morbidity if not diagnosed and treated early; of the cases reported in the literature, very few are genuinely spontaneous in nature.

CASE PRESENTATION

Here we demonstrate the case of an otherwise entirely fit and well 56-year-old White, British female presenting with low back pain, bilateral sciatica and sensate urinary retention; lumbar subdural spinous abscess was diagnosed on urgent magnetic resonance imaging and the patient was successfully managed with surgical evacuation and prolonged antibiotic therapy. The patient made a full neurological recovery and was followed-up in the outpatient setting 12 weeks following her initial surgery; she was pain free with normal inflammatory markers and a normal neurological examination. There have been no further consultations and a telephone call at 20 weeks confirmed that she remains well.

CONCLUSIONS

This is the second case reported in the literature of a genuinely spontaneous subdural spinous abscess, which was successfully managed with surgical evacuation following prompt diagnosis. This highlights the need to ensure infective pathologies are kept at the back of one's mind even in the most unlikely circumstances, and that excellent outcomes can be achieved with early surgical intervention.

Intradural Extramedullary Pyogenic Abscess: Incidence, Management, and Clinical Outcomes in 45 Patients With a Mean Follow Up of 2 Years

STUDY DESIGN

Retrospective review.

OBJECTIVES

Spinal intradural extramedullary abscess (SIEA) is a rare disease with an unknown incidence. In this study, we systematically described the clinical course of SIEA in a large cohort with acute onset of neurological illness, assessed the morbidity and mortality rates, and determined the potential risk factors for mortality.

METHODS

Electronic medical records of patients diagnosed with SIEA at a single institution for the period between September 2005 and December 2020 were retrieved.

RESULTS

Over a period of 15 years, 881 patients with spinal infections were treated either conservatively or surgically at our center, of whom 45 patients (45/881, 5.1%) had SIEA. The overall mean age was 69.6 ± 5.6 years of patients diagnosed with SIEA and all of them underwent posterior decompression via laminectomy. The mean Charlson Comorbidity Index (CCI) was 6.9 ± 2.5, indicating a poor baseline reserve. Progressive neurological decline was observed in all patients (mean motor score, 88.6 ± 9.7). The in-hospital rate and 90-day mortality were 4.4% and 10%, respectively. Mortality was not surgery related. Most importantly, the patients' motor deficits and blood infection parameters significantly improved after surgery. Risk factors for mortality were increased age, comorbidities as measured by CCI, and preoperative motor weakness (MS).

CONCLUSIONS

Immediate surgical decompression via laminectomy, with antiseptic irrigation and drainage of the subdural space, followed by antibiotic therapy, appears to be the key to ensuring beneficial clinical outcomes to treatment of rare diseases such as SIEA.

Surgical Outcome of Spinal Subdural Abscesses: A Report of Four Consecutive Patients and Brief Review of the Literature

BACKGROUND AND STUDY AIMS

 Spinal subdural abscesses (SSAs) are rare and have a poor prognosis, especially when they are diagnosed late. In the literature, most cases of SSAs have been reported as case reports and small case series. In this study, we aimed to evaluate the surgical outcomes of four consecutive SSA patients.

MATERIAL AND METHODS

 In this retrospective study, we reviewed the medical charts of four SSA patients who underwent surgical intervention at two neurosurgical centers from September 2012 to September 2019.

RESULTS

 Our series comprised four patients (three females and one male) with SSA (intradural-extramedullary) who were treated surgically. Holocord SSA was observed in two patients. The mean age was 15.1 ± 17.1 years. Unsteady gait and weakness of legs was the presenting symptom in all patients. The mean preoperative course was 5.3 ± 3.4 weeks. The causative pathogens were methicillin-resistant Staphylococcus aureus (MRSA), Escherichia coli, and Mycobacterium tuberculosis. In the fourth case, the pathogen was non-M. tuberculosis. In the 44th postoperative month, the patient underwent surgery for an intramedullary abscess. The causative pathogen was E. coli. Except for one adolescent male who was paraplegic at presentation, improvement was observed in all patients at their last follow-up after 54.0 ± 35.9 months after surgery.

CONCLUSION

 Early diagnosis and urgent surgical intervention are essential for a good prognosis in SSA cases. We recommend drainage followed by appropriate antibiotics.

Pediatric Spinal Subdural Abscesses: A Report of Three Consecutive Patients

BACKGROUND

Despite technological advances in medical treatment, the prognosis of the rarely reported spinal subdural abscesses (SSAs) has remained a serious entity largely unaffected, especially when they are diagnosed late. In this study, the authors aimed to present the surgical outcomes of 3 consecutive pediatric patients with SSA.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of pediatric patients with spinal lesions who underwent surgery at 2 neurosurgical centers spanning 7 years, from 2012 to 2019. All pediatric patients who were diagnosed with SSA (n = 3) were selected as the core sample for this study.

RESULTS

Three pediatric patients (2 females and 1 male) with SSA were surgically treated. Holocord SSA was observed in 1 patient. The mean age was 7.1 ± 7.7 years. The most common presenting symptoms were gait disturbance and weakness of lower extremities (100%). The mean preoperative course was 5.7 ± 4.0 weeks. The causative pathogens were Escherichia coli (E. coli) and M. tuberculosis. In the 2nd case, the pathogen was non-tuberculosis mycobacterium in the extramedullary abscess. In the 44th postoperative month, she underwent surgery for intramedullary abscess. The causative pathogen was E. coli. Except for 1 male adolescent who presented with severe clinical status (paraplegic), the improvement was observed in all patients at their last follow-up after 50.3 ± 43.5 months of average.

CONCLUSIONS

Drainage followed by appropriate antibiotics is the optimal treatment for SSAs. Early diagnosis and urgent surgical treatment are essential for a good prognosis. All surgically treated SSA patients with neurological deficits were rehabilitated with physical therapy postoperatively.

Pediatric spinal infections-a review of non-tuberculous infections

Pediatric spinal infection includes spinal epidural abscess, spondylodiscitis and intradural (extramedullary and intramedullary) spinal infections. However, these entities are extremely rare and no clear guidelines exist for their management. Pertinent literature was searched and a detailed narrative review of this topic is presented.

Chronic thoracolumbar subdural empyema: Case report and surgical management

BACKGROUND

Spinal cord abscesses and spinal subdural empyemas are rare and difficult to treat.

CASE DESCRIPTION

A 35-year-old male presented to an outside institution with 2 months of progressive low back pain, weakness, and bowel incontinence; he was diagnosed with an L4 epidural abscess that was poorly managed. When the patient presented to our institution, magnetic resonance imaging (MRI) revealed a well-organized chronic subdural abscess at the thoracolumbar junction. Following resection, his back pain resolved but he was left with a residual paraparesis.

CONCLUSION

Subdural abscesses are rare and should be considered among the differential diagnoses for intraspinal mass lesions. Treatment should include prompt surgical exploration and decompression combined with appropriate prolonged antibiotic treatment.

Spinal subdural abscess following repeat lumbar microdiscectomy: A case report of imaging findings for a rare infection

Spinal subdural abscess is a rare central nervous system infection with just over a hundred cases reported. It is much less common than spinal epidural abscess. While most case reports have focused on route of infection and treatment options, there have not been any reports that focused on the unique MRI findings of spinal subdural abscess. We describe a case of spinal subdural abscess diagnosed by MRI in a 33-year-old male who presented with headaches after undergoing a microdiscectomy procedure, and review the underlying anatomic features of the spinal meninges which produce the appearance of a spinal subdural abscess.

Spinal Subdural Abscess Following Laminectomy for Symptomatic Stenosis: A Report of 2 Cases and Review of the Literature

BACKGROUND Spinal subdural abscesses, also known as empyemas, are rare infectious lesions, the exact incidence of which is unknown. Presentation is typically dramatic, with back pain, fever, motor, and sensory deficits. Rapid identification and surgical intervention with laminectomy, durotomy, and washout provides the best outcomes. While hematogenous spread of an extra-spinal infection is the most common cause of this condition, a significant number of cases result from iatrogenic mechanisms, including lumbar punctures, epidural injections, and surgery. CASE REPORT Here we present 2 cases: 1) an 87-year-old man with type 2 diabetes, schizophrenia, mild cognitive impairment, and symptomatic lumbar spinal stenosis and 2) a 62-year-old man with a prior L3-4 spinal fusion with symptomatic lumbar spinal stenosis. In both cases, patients underwent laminectomy for spinal stenosis and developed epidural abscess. Following successful drainage of the epidural abscess, they continued to be symptomatic, and repeat imaging revealed the presence of a subdural abscess that was subsequently evacuated. Case 1 had significant improvement with residual lower-extremity weakness, while Case 2 made a complete neurological recovery. CONCLUSIONS These cases illustrate patients at increased risk for developing this rare spinal infection, and demonstrate that rapid recognition and surgical treatment is key to cure and recovery. Review of the literature highlights pertinent risk factors and demonstrates nearly one-third of reported cases have an iatrogenic etiology. The cases presented here demonstrate that a subdural process should be suspected in any patient with intractable pain following treatment of an epidural abscess.

Concomitant epidural and subdural spinal abscess: a case report

BACKGROUND CONTEXT

Spinal subdural abscess (SSA) is a rare occurrence for which the management typically involves open surgical removal and washout.

PURPOSE

This case report aims to review the literature and discuss the management of patients with SSA.

STUDY DESIGN

We present a case of a 33-year-old female who presented with a spinal epidural abscess and concurrent SSA. She presented in the context of intravenous (IV) drug use, back pain, and generalized lower extremity weakness.

METHODS

The literature was reviewed with a focus on modern treatment options for SSA. Our patient was managed with IV antibiotics, and separate laminectomies and washouts for both lesions.

RESULTS

The patient recovered well with return of neurologic function and normalization of infection markers. The review of the literature resulted in a management flowchart that will help direct treatment of SSA.

CONCLUSIONS

The literature suggests that in a patient with a definitive diagnosis of SSA, limited surgical management and IV antibiotics are the mainstay of treatment in a patient with a decline in neurologic function. There may be a role for expectant management in the absence of diagnostic imaging or the neurologically stable patient.

Intradural Extension of a Pyogenic Epidural Abscess: A Case Report

CASE

Few cases of spinal epidural abscess involving an extradural abscess with an intradural extension have been reported. A unique complication with extension of pus from the epidural space through multiple perforations into the dura is described. Due to a proximal meningeal inflammatory reaction, which served as a proximal plug, no cerebrospinal fluid leak was encountered.

CONCLUSION

Intradural extension of pus through multiple dural perforations is a rare complication of spinal epidural abscess and a treatment challenge. Early diagnosis enabling prompt surgical decompression, along with subsequent aggressive debridements and prolonged intravenous antibiotic treatment, can lead to a favorable outcome.

Spinal subdural abscess following epidural steroid injection

The authors report the case of a 58-year-old man who presented with a cervicothoracolumbosacral spinal subdural abscess about a month after receiving an epidural steroid injection for management of low-back pain due to L5-S1 disc herniation. Although he presented with symptoms concerning for a spinal etiology, the subdural empyema was not evident on the initial MRI study and was observed on imaging 5 days later. This patient was successfully managed with surgical intervention and antibiotic treatment, and he is doing well more than 21 months after the operation. It is possible that a prior history of disc herniation or other spinal abnormality may increase a patient's risk of developing spinal subdural empyema. This case illustrates the risk of infection following spinal epidural steroid injections and the importance of early recognition and intervention to successfully treat an extensive subdural abscess.

Spinal subdural abscess: a rare complication of decubitus ulcer

Spinal subdural abscess (SSA) is an uncommon entity. The exact incidence is unknown, with very few cases reported in the literature. This condition may result in spinal cord compression, thus constituting a medical and neurosurgical emergency. The pathogenesis of SSA is not well-described, and the available knowledge is based on case observations only. There is only one case report that describes direct seeding from decubitus ulcers as a possible mechanism for development of SSA. We report a case of subacute onset of quadriplegia in a male patient, age 55 years, due to spinal cord compression from SSA and superimposed spinal subdural hematoma. The direct seeding from decubitus ulcers is thought to be the cause of infection in our patient. We present this case of SSA to elucidate and review the predisposing factors, pathogenesis, clinical presentation, diagnostic modalities, and treatment regarding management of this rare disorder.

Thoracolumbosacral spinal subdural abscess: magnetic resonance imaging appearance and limited surgical management

STUDY DESIGN

Case report and review of relevant literature.

OBJECTIVE

To report a rare case of a thoracolumbosacral spinal subdural abscess (SSA) and highlight the magnetic resonance imaging (MRI) appearance and surgical management.

SUMMARY OF BACKGROUND DATA

SSA is rare, as most intraspinal abscesses are epidural in location. Extensive thoracolumbosacral SSA has only rarely been reported. The MRI features and options for limited surgical management are not well described.

METHODS

A case report of SSA is presented and relevant literature is reviewed.

RESULTS

An elderly female presented with worsening back pain and sepsis. MRI demonstrated an extensive intraspinal abscess, extending from the upper thoracic spine to the sacrum. Both axial and sagittal images demonstrated a subdural location of the collection, with preservation of the dorsal epidural fat and mass effect on the spinal cord. Cord compression was most marked at the T8 level. Limited midthoracic laminectomies were performed. The epidural space seemed normal intraoperatively. A limited longitudinal durotomy yielded purulent fluid. After intraoperative irrigation, primary dural repair was performed. At 2-year follow-up, the patient had no clinical, radiographical, or laboratory evidence of residual or recurrent spinal infection.

CONCLUSION

Careful review of MRI can localize an intraspinal abscess to the subdural space. Even for extensive subdural collections, limited operative management can achieve excellent clinical outcome.

LEVEL OF EVIDENCE

N/A.

Chronic spinal subdural abscess mimicking an intradural-extramedullary tumor

Spinal subdural abscesses (SSA) are very rare disease. The etiologies of SSA are hematogenous spread, iatrogenic contamination, and local extension. Elevated WBC counts, ESR, and C-reactive protein are usually found in laboratory tests. But they are not sensitive indicators of SSA, especially chronic abscesses patient tend to have a less specific characteristic. We report the case of a healthy man with chronic subdural abscess referred to our hospital as an intradural-extramedullary (IDEM) tumor. The patient presented with voiding difficulty and pain in the back and left leg. In a contrast MRI scan, a rim-enhanced mass-like lesion was seen at the L5/S1 level. But adjacent ill-defined epidural fat enhancement that are unusual imaging manifestation for IDEM tumors was seen. He had no fever and normal WBC, ESR, and CRP. In addition, the patient had no previous infection history or other disease, but he did have an epidural block for back pain at another hospital 2 years previously. So, we repeated the MRI with a high-resolution 3-T scanner. The newly taken MR images in our hospital revealed a clear enlargement of lesion size compared to the previous MRI taken 1 week before in other hospital. We suspected a chronic spinal subdural abscess with recent aggravation and immediately performed surgical evacuation. In the surgical field, tensed dura was observed and pus was identified after opening the abscess capsule. Because chronic spinal subdural abscesses are difficult to diagnose, we could differentiate with IDEM tumor exactly and an exact history taking, contrast MRI are required.

Infections of the spinal subdural space in children: a series of 11 contemporary cases and review of all published reports. A multinational collaborative effort

INTRODUCTION

Positioned anatomically between the spinal epidural space and the intramedullary compartment, the spinal subdural space remains the least common area of localized infection in the central nervous system. Infectious processes of the subdural spinal space include subdural spinal empyema, subdural spinal abscess, infected spinal subdural cyst, and infectious spinal subdural cyst. To date, there has been no systematic review of these entities in children, with the cumulative knowledge of the pathophysiologic, microbiologic, and demographic characteristics of these infections relegated solely to few small series and case reports.

METHODS

A series of 11 recent cases culled from the collaboration of international authors are presented. In addition, an exhaustive MEDLINE search and manual review of the international literature was performed, identifying a total of 73 cases of spinal subdural infections in patients under the age of 21. Data of interest include the age, sex, signs, and symptoms at presentation, spinal location of infection, presence of spinal dysraphism, and other comorbidities, offending organism, treatment, outcome, and follow-up.

RESULTS

Patients ages ranged from 4 weeks to 20 years (mean, 6.5 years). Males outnumbered females by a ratio of 2:1. Over half (53 %) of spinal subdural infections in children were associated with spinal dysraphism or other congenital abnormalities of the spine. The commonest organism to infect the spinal subdural space in children is mycobacterium tuberculosis and the thoracic spinal region was most commonly infected.

CONCLUSIONS

The disease is usually treated surgically, although a more expectant approach consisting of antibiotics and observation has also been proposed.

Spinal Subdural Staphylococcus Aureus Abscess: case report and review of the literature

Background

Only 65 cases (including our case) of spinal subdural abscesses have been reported to the literature, mostly to the lumbar spine. Staphylococcus aureus is the most common bacterial. The symptoms are not caracteristic and contrast – enhanced magnetic resonance imaging scan (MRI) is the imaging method of choice. The early diagnosis is crucial for the prognosis of the patient.

Case presentation

We present a patient 75 years old who had a history of diabetes and suffered acute low back pain in the region of the lumbar spine for the last 4 days before his admission to the hospital. He also experienced lower leg weakness, fever and neck stiffness. After having a brain CT scan and a lumbar puncture the patient hospitalized with the diagnosis of meningitis. Five days after his admission the diagnosis of subdural abscess secured with contrast – enhanced MRI but meanwhile the condition of the patient impaired with respiratory failure and quadriplegia and he was admitted to the ICU. A laminectomy was performed eight days after his admission into the hospital but unfortunately the patient died.

Conclusion

Early diagnosis and treatment are very important for the good outcome in patients with subdural abscess. Although morbidity and mortality are very high, surgical and antibiotic treatment should be established as soon as possible after the diagnosis has secured.