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 Table of Contents  
CASE REPORTS
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 260-264

Single-stage decompression of C1–D9 anterior epidural abscess by a gas-producing enteric pathogen


Department of Orthopaedics and Traumatology, Meenakshi Mission Hospital & Research Centre, Madurai, Tamil Nadu, India

Date of Submission27-Oct-2020
Date of Decision12-May-2021
Date of Acceptance22-May-2021
Date of Web Publication16-Jul-2021

Correspondence Address:
M Atharsh Chander
Department of Orthopaedics and Traumatology, Meenakshi Mission Hospital and Research Centre, Madurai 625107, Tamil Nadu.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ISJ.ISJ_85_20

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  Abstract 

Multilevel pyogenic spinal epidural abscess is a rare presentation, and there are only a few documented cases. This is a case report of a cervicothoracic epidural abscess (C1–D9) presenting with sepsis and neurological impairment due to a gas-producing enteric organism that was managed by surgical decompression. The abscess was drained in a single-stage multilevel procedure. The patient recovered gradually in the postoperative period clinically and neurologically and is on follow-up for two years. The peculiarity of this case is the absence of any vertebral or disc involvement in the presence of such an extensive anterior epidural abscess.

Keywords: Cervicothoracic epidural abscess, E. coli epidural abscess, epidural abscess, epidural abscess with gas, Escherichia coli


How to cite this article:
Nallathambi V, Chander M A. Single-stage decompression of C1–D9 anterior epidural abscess by a gas-producing enteric pathogen. Indian Spine J 2021;4:260-4

How to cite this URL:
Nallathambi V, Chander M A. Single-stage decompression of C1–D9 anterior epidural abscess by a gas-producing enteric pathogen. Indian Spine J [serial online] 2021 [cited 2021 Dec 4];4:260-4. Available from: https://www.isjonline.com/text.asp?2021/4/2/260/321585




  Introduction Top


Pyogenic spinal infection is a significant disease occurring in patients with comorbidities like diabetes mellitus, obesity, immunodeficiency, sepsis, intravenous drug abuse.[1] Epidural abscesses are especially high-risk infections because neurological deterioration can occur. The etiology of pyogenic epidural abscess is mostly hematogenous seeding, 10%–20% from osteomyelitis, hematoma, or soft-tissue infection, and 20% iatrogenic.[1] Symptoms include a triad of fever, back pain, progressive neurological worsening[1]; however, 50% of patients present with only back pain or other nonspecific complaints.[2],[3] Historically, spinal epidural abscess (SEA) is associated with high morbidity and mortality rates.[3] Targeted antibiotic therapy, surgical intervention, and supportive care have improved patients’ outcome.[4],[5]

SEA occurring in contiguous cervical, thoracic, lumbar, and even sacral regions is extremely rare, but when encountered represents a particularly challenging treatment dilemma requiring more extensive decompression in the form of multilevel laminectomies. But this may not be ideal for a number of reasons, including the risk of mechanical instability, longer surgical duration and high-operative blood loss.[6],[7],[8]

In this case report, we enumerate a single-stage surgical intervention of an extensive multilevel anterior epidural abscess presenting with compressive myelopathy and sepsis caused by a gas-producing organism—Escherichia coli without vertebral/disc involvement.


  Case Report Top


A 45-year-old lady came to the casualty with complaints of diffuse backache and vomiting for the past four days. She was a diabetic patient on irregular treatment. The patient had sustained a trivial fall one week before and since then had become bedridden because of pain and weakness.

On examination, she was anemic, febrile (100°F), and had blood pressure of 160/100 mmHg, heart rate of 120/min, SpO2 of 97% on room air. Her motor power was 3/5 in all limbs with brisk biceps reflex, and lower limb reflexes were absent. Her Hoffman sign was positive, Kernig sign was positive, and she had decreased sensation below C5 dermatome up to L1 and hyperesthesia below L1 level. On investigation, total white blood cell (WBC) count was 26,900 cells/cu·mm, erythrocyte sedimentation rate (ESR): 95 mm/hr, CRP: 9.05 mg/L, urea: 58 mg/dL, creatinine: 2.2 mg/dL, eGFR: 24 mL/min/1.73 m2, random blood sugar: 218 mg/dL, HbA1c: 11.3%. Magnetic resonance imaging (MRI) of the spine [Figure 1][Figure 2][Figure 3] revealed a large epidural abscess involving anterior aspect of spinal cord extending from C1 to D9 levels compressing the spinal cord, with another small epidural abscess in the posterior aspect at D10–D11 levels(sacralized L5) without the involvement of vertebral elements or disc. The patient also had right renal pyelonephritis with an abscess.
Figure 1: Sagittal T2W image of cervical spine showing extensive anterior epidural abscess (arrows) extending from C1 vertebra. Note the air pocket seen as hypointense patch

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Figure 2: Sagittal T2W image of dorsolumbar spine showing anterior epidural abscess (arrows) extending up to D9 and posterior collection of abscess at D10–D11. Air pockets are seen, which signify a gas-producing organism

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Figure 3: Axial T2W image showing cord compression by the anterior epidural abscess

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The patient was planned for emergency single-stage decompression of the anterior cervicothoracic epidural abscess by C6 corpectomy and D10 laminectomy for the posterior epidural abscess. C6 was chosen for corpectomy as we thought it would be easier for surgically approaching and stabilizing the vertebra, also since it was closer to cervicothoracic junction it would facilitate the decompression of abscess from both cervical and thoracic levels.

Preoperatively, the patient was placed in a supine position, and C6 corpectomy was done through the Southwick-Robinson approach, and an intact posterior longitudinal ligament (PLL) visualized. Once the PLL was incised, frank pus gushed out of the epidural space (about 30 mL) [Figure 4], and samples were sent for bacterial culture sensitivity(C/S), fungal C/S, and tuberculosis-polymerase chain reaction (TB-PCR). Then, a 7-Fr infant feeding tube was passed cranially up to C2 vertebral level and successively caudally up to D9 level, confirming its position with radio-opaque dye under C-arm guidance, and thorough irrigation of epidural space was performed from C2 level up to D9 level [Figure 5]A–C. The residual abscess collected in the epidural space in these levels was washed out and subsequently diluted 5% Povidone-Iodine solution, and plenty of normal saline was used for irrigation. Tricortical bone graft harvested from the iliac crest was placed and stabilized using anterior cervical plate.
Figure 4: Abscess draining from cervical epidural region after corpectomy with Caspar retractor and Langenbeck retractors in place

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Figure 5: A–C: Confirming the level of irrigation of epidural space from C2 to D9 with radio-opaque dye injection under C-arm guidance

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The patient was then positioned prone, D10 laminectomy done, and about 5 mL abscess drained which was sent for bacterial culture and sensitivity.

Double-J stenting of the right ureter was done by a urologist for drainage of the right renal abscess.

Bacterial cultures grew Escherichia coli in samples from blood, urine, epidural abscesses drained at both cervical and dorsal levels. Fungal culture grew Candida krusei in the epidural abscess sample. TB-PCR was reported as negative.

The patient was started on culture-sensitive antibacterial meropenem (minimum inhibitory concentration (MIC) ≤ 0.25 μg/mL) and antifungal voriconazole (MIC ≤ 0.12 μg/mL). Her clinical condition improved, and gradual mobilization, physiotherapy, and rehabilitation were instituted.

On follow-up, her inflammatory markers returned to normal, and MRI showed complete abscess resolution [Figure 6]A and B. After six-week antibiotic therapy, the patient was comfortably ambulant without support. For the past two years, she continues to be on regular follow-up without any complaints.
Figure 6: A, B: Sagittal T2W images taken preoperatively and one week postopertatively showing the decompressed cord and anterior fallback with complete abscess clearance

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  Discussion Top


SEA was first reported by Morgagni in 1761 and represents 1 of 10,000 hospital admissions annually in the United States.[3],[9] Known risk factors for SEA in adults include diabetes mellitus, intravenous drug abuse, immunosuppression (Crohn’s disease, malignancy, steroid use, cirrhosis, and hepatitis), and pregnancy.[10] Blood cultures are essential in early pathogen identification and are positive in up to 60% of cases.[11] SEA is most commonly associated with S. aureus with no predisposition for age and immunocompromised state.

Diagnosis is made with MRI as they play a critical role in the diagnosis of the condition and associated paraspinal, abdominal infections. The use of MRI is essential for delineating phlegmon from liquid pus prior to determining a surgical approach as phlegmon-type abscess will require extensive laminectomy for removal. Homogeneous enhancement on T1-weighted sequences obtained with gadolinium, and hyperintensity throughout the lesion on T2-weighted sequences is more consistent with phlegmon, whereas bright rim enhancement with a hypointense core on T1-weighted images is suggestive of liquid pus.[12],[13]

SEA is a surgical emergency in a neurologically deteriorating patient. The pathophysiology behind neurological worsening was suggested to be direct focal cord compression based on rabbit model studies[14] and hematogenous spread leading to arteritis, venous thrombosis, septic thrombophlebitis causing spinal infarction resulting in neurological worsening according to Baker, et al.[15] The goals of surgical intervention are always to decompress the neural elements, evacuate infection, identify the pathogen, and stabilize the spine (if needed) with minimal instrumentation, which can be achieved easily in focal epidural abscesses. Since our case presented with neurological worsening and myelopathy, we had planned for surgical decompression, but the involvement of multiple levels anteriorly warranted a specific approach for this case. There are only a few case reports on extensive SEA covering more than five vertebral levels,[16] and none of these cases have had extensive anterior abscess without vertebral/disc involvement.

In a relatively large series of eight cases with holospinal posterior epidural abscess reported by Bridges and Than,[17] skip laminectomies had a similar outcome to panspinal laminectomies. Schultz, et al.[16] reported selective laminectomies at the ends of the posterior epidural abscess and using Fogarty catheters to mechanically drain the abscess, with an associated risk of very high hydraulic pressures on the spinal cord. Abd-El-Barr, et al.[1] suggested laminectomies at natural apices of the spine, namely mid-cervical, mid-thoracic, and mid-lumbar levels for maximum accessibility cranially and caudally from the apex, for drainage and irrigation of epidural abscess. Further, they used an infant feeding tube (5-Fr) in place of a Fogarty catheter, which is semirigid but flexible and gives good tactile feedback without coiling. They also advocated that since the holes are in the side rather than at the end, irrigation directed sideways maximizes abscess drainage, although this technique has been tried successfully in the setting of liquid pus presentation only as suggested by MRI.

In our case with the presentation of anterior epidural abscess from C1 to D9 levels and posterior epidural abscess at D10–D11 levels without any vertebral body or disc involvement with MRI features suggestive of liquid pus, we planned for decompression by irrigation at the most apical part by C6 corpectomy. The presence of dentate ligament on either side of the cord prevents the anterior abscess from being drained posteriorly. Adequate drainage of pus from C2 to D9 was possible by irrigation using an infant feeding tube. In MRI, the gas bubbles had occupied a relatively higher position to the abscess (the MRI being taken with the patient in a supine position and the gas bubbles were accumulated in the cervical region alone in the whole cervicothoracic abscess), indicating liquid pus. This further reassured us in using this technique. Epidural space was cleared of pus and irrigated from C2 to D9 level with an infant feeding tube under radiographic guidance. The same procedure might not be beneficial if the pus was of organized phlegmatic type.

No previous case reports have mentioned such an extensive anterior epidural abscess without vertebral/disc involvement, and this is the first such report with the management of such a scenario.

A case report of Escherichia coli causing cervical osteomyelitis with epidural abscess secondary to urinary tract infection has been reported by Moustafa, et al.[18] But this was a localized collection treated by surgical decompression and antibiotics.

In our case, bacterial culture reports suggested gas-producing Escherichia coli, which was secondary to pyelonephritis of the kidney. The patient was given a six-week course of antibiotics.


  Conclusion Top


We describe the management of a rare presentation of an epidural abscess. The drainage of an extensive anterior epidural abscess can be safely achieved by the method described above. The rarity of this case is the anterior presentation of an extensive epidural abscess without a disc or vertebral pathology. The causative organism Escherichia coli for such an extensive anterior abscess presentation has not been reported in the literature previously.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Abd-El-Barr MM, Bi WL, Bahluyen B, Rodriguez ST, Groff MW, Chi JH. Extensive spinal epidural abscess treated with “apical laminectomies” and irrigation of the epidural space: Report of 2 cases. J Neurosurg Spine 2015;22:318-23.  Back to cited text no. 1
    
2.
Curry WT Jr, Hoh BL, Amin-Hanjani S, Eskandar EN. Spinal epidural abscess: Clinical presentation, management, and outcome. Surg Neurol 2005;63:364-71; discussion 371.  Back to cited text no. 2
    
3.
Reihsaus E, Waldbaur H, Seeling W. Spinal epidural abscess: A meta-analysis of 915 patients. Neurosurg Rev 2000;23:175-204; discussion 205.  Back to cited text no. 3
    
4.
Grieve JP, Ashwood N, O’Neill KS, Moore AJ. A retrospective study of surgical and conservative treatment for spinal extradural abscess. Eur Spine J 2000;9:67-71.  Back to cited text no. 4
    
5.
Karikari IO, Powers CJ, Reynolds RM, Mehta AI, Isaacs RE. Management of a spontaneous spinal epidural abscess: A single-center 10-year experience. Neurosurgery 2009;65:919-23; discussion 923-4.  Back to cited text no. 5
    
6.
Martin-Benlloch JA, Maruenda-Paulino JI, Barra-Pla A, Laguia-Garzaran M. Expansive laminoplasty as a method for managing cervical multilevel spondylotic myelopathy. Spine (Phila Pa 1976) 2003;28:680-4.  Back to cited text no. 6
    
7.
Oda I, Abumi K, Lü D, Shono Y, Kaneda K. Biomechanical role of the posterior elements, costovertebral joints, and rib cage in the stability of the thoracic spine. Spine (Phila Pa 1976) 1996;21:1423-9.  Back to cited text no. 7
    
8.
Tai CL, Hsieh PH, Chen WP, Chen LH, Chen WJ, Lai PL. Biomechanical comparison of lumbar spine instability between laminectomy and bilateral laminotomy for spinal stenosis syndrome—An experimental study in porcine model. BMC Musculoskelet Disord 2008;9:84.  Back to cited text no. 8
    
9.
Chen WC, Wang JL, Wang JT, Chen YC, Chang SC. Spinal epidural abscess due to Staphylococcus aureus: Clinical manifestations and outcomes. J Microbiol Immunol Infect 2008;41:215-21.  Back to cited text no. 9
    
10.
Elsamaloty H, Elzawawi M, Abduljabar A. A rare case of extensive spinal epidural abscess in a diabetic patient. Spine (Phila Pa 1976) 2010;35:E53-6.  Back to cited text no. 10
    
11.
Pereira CE, Lynch JC. Spinal epidural abscess: An analysis of 24 cases. Surg Neurol 2005;63(Suppl 1):S26-9.  Back to cited text no. 11
    
12.
Adogwa O, Karikari IO, Carr KR, Krucoff M, Ajay D, Fatemi P, et al. Spontaneous spinal epidural abscess in patients 50 years of age and older: A 15-year institutional perspective and review of the literature. J Neurosurg Spine 2014;20:344-9.  Back to cited text no. 12
    
13.
Shoakazemi A, Amit A, Nooralam N, Abouharb A, Gormley M, McKinstry S. Panspinal epidural and psoas abscess with secondary cervical disc space infection. Ulster Med J 2013;82:23-5.  Back to cited text no. 13
    
14.
Feldenzer JA, McKeever PE, Schaberg DR, Campbell JA, Hoff JT. Experimental spinal epidural abscess: A pathophysiological model in the rabbit. Neurosurgery 1987;20:859-67.  Back to cited text no. 14
    
15.
Baker AS, Ojemann RG, Swartz MN, Richardson EP Jr. Spinal epidural abscess. N Engl J Med 1975;293:463-8.  Back to cited text no. 15
    
16.
Schultz KD Jr, Comey CH, Haid RW Jr. Pyogenic spinal epidural abscess: A minimally invasive technique for multisegmental decompression. Clin Spine Surg 2001;14:546-9.  Back to cited text no. 16
    
17.
Bridges KJ, Than KD. Holospinal epidural abscesses—Institutional experience. J Clin Neurosci 2018;48:18-27.  Back to cited text no. 17
    
18.
Moustafa A, Kheireldine R, Khan Z, Alim H, Khan MS, Alsamman MA, et al. Cervical spinal osteomyelitis with epidural abscess following an Escherichia coli urinary tract infection in an immunocompetent host. Case Rep Infect Dis 2019;2019:5286726.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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