Presentation
Acute worsening of low back pain, altered mental status, and fever with worsening weakness of extremities and incontinence.
Patient Data
There is an extensive epidural collection along the anterior aspect of the spinal canal from the T3-4 level through the L5-S1 level. Mild degrees of posterior extension at T5-T7 as well at T12.
Fluid signal within the L4-5 and L5-S1 disc spaces. No evidence of associated enhancement. Fluid signal within the bilateral L4-5 facet joints with extensive left greater than right adjacent inflammatory changes in the paraspinal musculature. Grade 1 spondylolisthesis L4 on L5 of 6 mm.
Severe spinal canal narrowing L4-5 related to the grade 1 spondylolisthesis, facet DJD, inflammatory changes, and epidural collection.
Case Discussion
The patient presented initially with a concerning combination of acute on chronic lower back pain, altered mental status and fever with worsening weakness in the extremities and new onset incontinence. The neurosurgeon, after evaluating the MRI and discussing with the patient's family, opted for conservative non-operative management, and it was decided not to aspirate the facet.
The patient was found to be positive for MSSA bacteremia. The patient was started on broad-spectrum antibiotics with CNS penetration and followed by the infectious diseases unit. A peripherally inserted central catheter (PICC) line was placed for long-term antibiotic therapy. Additional specialists were consulted for the patient's other medical issues, and she eventually improved and was discharged to acute inpatient rehab for continued recovery. The patient regained normal neurologic function.
Epidural abscesses can result in significant neurological deficits if not treated promptly. Management generally consists of antibiotics and surgical decompression, but conservative non-operative management may be considered in select cases. The decision for non-operative management, in this case, was made likely due to the extensive nature of the epidural abscess occupying the majority of the length of the spinal canal. In a complex case like this, surgical intervention may pose significant challenges and carry an elevated risk of spinal cord injury.
Co-author: Habib Zahir DO