Presentation
Presented with back pain and high-grade fever associated with upper limb weakness and tingling worse on the right side.
Patient Data
MRI C-Spine showing fluid signal within the disc and bone marrow edema at the level of C6/C7 and to a lesser extent at the level of C4/C5 and C5/C6 in-keeping with spondylodiscitis. Also showing an epidural abscess extending from the level of C4 to C7 (measuring 4.3 x 0.7 x 1.8 cm), widest at C4/C5 level showing evidence of cord compression. There is also evidence of a pre-vertebral abscess (measuring 5.8 x 0.7 x 3.0 cm) at the level of C3.
X-ray C-spine showing changes following C4/C5 anterior cervical discectomy and fusion (ACDF) a few days post-operatively. Surgical skin clips can be appreciated over the anterior aspect of the neck.
CT C-spine showing changes following C4/C5 ACDF, as well as, progressive kyphosis from erosion of C6/C7.
X-ray C-spine taken 3 weeks post-operatively, showing changes following C4/C5 ACDF and progressive kyphosis.
X-ray C-spine showing post-operative changes following C6 and C7 corpectomy and posterior stabilization. Previous C4/C5 ACDF changes can also be appreciated. Surgical skin clips are still in situ over the anterior and posterior aspects of the neck.
Case Discussion
The patient is a known intravenous drug user. This gentleman was also being treated with long-term oral prednisolone in view of uveitis at the time of presentation, for which he missed follow-up appointments and continued taking high-dose steroids for 3 months.
Blood cultures revealed methicillin-resistant Staphylococcus aureus (MRSA) septicemia, with elevated white cell count and X-rays of the cervical spine showed widening of the prevertebral soft tissues throughout.
The patient developed sudden onset weakness in both upper limbs and lower limbs. On examination he was found to have a rigid neck with range of movement (ROM) significantly limited in view of pain, reduced power throughout all 4 limbs bilaterally, positive Hoffman sign bilaterally, hyperreflexia in both lower limbs with positive clonus and upgoing plantars.
An MRI spine revealed multilevel spondylodiscitis and an epidural abscess extending from the level of C4 to C7 with evidence of spinal cord compression.
The patient underwent emergency anterior cervical discectomy and fusion (ACDF) at C4/C5 and evacuation of epidural abscess. Operation findings included pus under the prevertebral fascia, pus in the disc space and pus in the epidural space. Post-operatively with intensive physiotherapy and subsequent antibiotic therapy, the patient was able to make a full recovery and be able to mobilize independently with resolution of symptoms.
Follow up X rays showed progression of kyphosis from erosion of C6/C7. He subsequently had a C6 and C7 corpectomy and posterior stabilization.
The development of spinal epidural abscesses often takes an insidious course, typically presenting with back pain, neurological deficits and fever 1. A high index of suspicion is required in order to make the diagnosis. This should always be kept in mind for patients with high risk of disseminated infection, such as IVDUs, patients on long-term steroid therapy and uncontrolled diabetics 2.
The most cultured organism in such cases is Staphylococcus aureus, with an ever-increasing rate of cases being due to MRSA 1,2 and has been quoted to account for around 60-90% of cases. Blood investigations may show evidence of ongoing infection with raised white cell counts and inflammatory markers. Blood cultures may be positive for the causative organism as was the case with the case described above. This is likely to be related to the fact that hematogenous spread is a common source of spread in such infections. In the spine, pathogens may travel through the vertebral venous plexus called Batson plexus. In the healthy individual, this acts as a reservoir to control intracranial pressures and thus does not contain valves, further facilitating microbial spread 3.
Prompt diagnosis is essential and MRI imaging with and without contrast is the optimal choice in suspected epidural abscesses. CT with contrast is an alternative, however, one should keep in mind that this modality of imaging is much less sensitive for detection of epidural abscesses 1,3.
With regards to management, if cases are diagnosed promptly and prior to spinal cord involvement, conservative management with aggressive antibiotic therapy which is directed against the causative organism through blood cultures or otherwise, for a period of 4-16 weeks is often acceptable. Those with signs of acute cord compression need urgent decompression and evacuation of the abscess 4.
Case courtesy of Mr Shawn Agius (Consultant Neurosurgeon) who also acted as a co-author for this case.
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