# Pan Spinal Epidural Abscess in a Young Healthy Male:  A Case Report

Authors: Linqiu Zhou; Alan Turtz; Galit Levy
Journal: Scholarly Research Exchange
 (2008)

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## Abstract

Pan spinal epidural abscess is rare in a young healthy adult and may lead to permanent neurological deficits and meningitis if not treated promptly. A case is described of a pan spinal epidural abscess, from C1 to S1, in a young, healthy adult without risk factors that presented with ascending back pain and no fever. The abscess was diagnosed with MRI and treated with hemilaminotomies, surgical drainage, and antibiotics with a satisfactory outcome.  The literature is reviewed herein.


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## Body

## 1. Introduction

Spinal epidural abscess (SEA) is a rare condition with potentially devastating
consequences. Many SEA patients have a direct
source of infection such as epidural injections or spinal injury [1–7]. Conditions that are usually associated with
SEA include diabetes mellitus, cancer, AIDS, IV drug abuse, alcoholism, steroid
treatment, chronic renal failure, herpes zoster, and reflex sympathetic
dystrophy [1, 2, 3, 8, 9]. SEA occurs
commonly in short segments of the spinal cord. Although multiple or solitary abscesses with
cervicolumbar extension have been described previously [10, 11], Pan spinal
epidural abscess (C1-S1) in a young healthy adult with no predisposing factors has
never been described in the literature with Medline and Pubmed.


## 2. Case Report

A 23-year-old male manual laborer presented with sudden onset low back pain. He was diagnosed with lumbar muscle spasm and
treated with an NSAID by his family doctor. The pain progressively worsened and ascended. Two weeks later, he developed severe
worsening of his low back pain with radiating left anterior thigh pain. He visited the emergency room twice for
severe pain and was diagnosed with an L3-L4 disc herniation and given Naproxen
and Oxycodone/acetminophen for analgesia. On the day of his admission, the patient was awoken by excruciating back
and neck pain refractory to analgesics. He presented to the emergency room where a lumbar CT scan was performed
and revealed questionable epidural and paraspinal abscesses. The patient was then transferred to our
hospital.The patient denied fever, headache, sore throat, cough, dysuria, illicit drug use,
or any past medical history. He recalled
a tick bite to his left anterior thigh one month earlier, with no apparent skin
reaction.On physical exam, he was a5′11′′, 95 kg, well-educated male in mild distress. Temperature was 36.5°C, with a blood
pressure 140/77 mmHg, heart rate 110/min, and a respiratory rate of 24/min. There was no palpable superficial
adenopathy. He had slight neck stiffness
and moderate cervical tenderness. There
was diffuse tenderness along the thoracic and lumbar spine and L3 paraspinal
muscle tenderness. Neurologically, the
patient had a normal level of consciousness and mental status with a mild
decrease of left hip flexor muscle strength and no sensory deficit. There was 1.0×1.5 cm pigmented area on the
left anterior thigh that was nontender and without other signs of inflammation. WBC was 37,900 with 35 bands and both ESR and
CRP were elevated. An MRI of the lumbar
spine demonstrated an epidural abscess extending from T1-S1 (Figure 1) with a
collection in the paraspinal muscles to the left of L3. The patient refused additional imaging.Preoperative T1 weighted MRI scans with contrast of lumbar spine
in (a) sagital  and (b) axial  planes demonstrating the ring
enhancing epidural collection (arrows) with mass effect.
(a)(b)The patient was taken directly to the operating room from the emergency department,
where he underwent a T12-L1 partial hemilaminotomy on the right side. A large amount of liquid pus drained from the
epidural space which was gently irrigated followed by placement of a
Jackson-Pratt drain. Simultaneously, the
L3 paraspinal abscess was debrided and irrigated. There was no connection between the
paraspinal abscess and the epidural abscess that could be identified at the
time of surgery. Subsequently, the
patient was admitted to the surgical ICU, with antibiotic and steroid
therapy. By post-op day 1, the patient's
lower back pain significantly decreased and his left hip flexor muscle strength
returned to normal. However, he still
complained of neck pain and mild stiffness. An MRI of the cervical and thoracic spine was performed which showed a
C1-T12 epidural abscess (Figures2 and 3). A C6-C7 right hemilaminotomy was performed
and the abscess drained. The patient's
neck and low back pain subsided after surgery. Each JP drain (T12-L1 and C6-7) was
removed on post-op day 2. The cultures
from the cervical, lumbar, and L3 paraspinal specimens all grew β-hemolytic
group A Streptococci. The AFB and fungal
cultures were negative. Multiple blood
and urine cultures were negative. An
MRI of the head was normal. Chest,
abdominal, and pelvic CT scans did not show any other collections. An HIV test was negative. Vancomycin had been
given initially. Then, the antibiotic therapy was tailored based on culture and
sensitivity. On hospital day 4, the
patient was discharged home with an additional 6 weeks of antibiotic
therapy. A CBC, ESR, and MRI (Figures 4
and 5) were normal on follow-up at day 9. The patient returned to normal life with complete recovery and no
neurological deficits.T1 sagital MRI of cervical spine demonstrating ring enhancing epidural collection (arrows).
(a)(b)(a) Preoperative T2 sagital MRI scans of cervical, (b) thoracic,
and  (c) lumbar spine demonstrating a low to mixed signal intensity collection in
the epidural space (arrows).
(a)(b)(c)(a) Postoperative T2 sagital MRI scans of cervical, (b) thoracic,
and (c) lumbar spine demonstrating postoperative changes
(arrows) and evacuation of the epidural abscess.
(a)(b)(c)T1 weighted MRI scans with contrast of lumbar spine in (a) sagital  and (b) axial  planes 9 days
after surgery demonstrating adequate decompression.
(a)(b)


## 3. Discussion

The etiology of this patient's SEA is unknown. An epidural hematoma caused by epidural analgesic injections or trauma
(injury or surgery) may later become the focus of bacterial colonization by hematogenous
dissemination from a cutaneous or mucosal source, or infection can occur from direct
seeding from the invasive procedure itself [5–7]. Epidural abscess may also result from the
direct spread of infection into the epidural space from a source adjacent to
the spine such as spondylodiscitis, paraspinal abscess, or vertebral
osteomyelitis [7, 12]. Systemic illness,
such as diabetes mellitus, immune deficiency states, such as AIDS or cancer,
renal failure, IV drug abuse, and steroid therapy contribute to this process [1–8]. SEA in young healthy patients without any
risk factors is extremely rare. Pan spinal
epidural abscess (C3-S1) was reported previously in an infant with a congenital
spinal malformation [12]. In our
patient, there was no significant focal infection. The only potential infectious source we could
identify was the left anterior thigh tick bite without any reported signs of
inflammation which occurred one month earlier.The valveless, low
pressure vertebral venous system is a possible route for infectious metastasis
[13] and the fatty tissue in the epidural space makes the epidural abscess
easily expandable. Staphylococcus aureas
is the most common micro-organism found in an epidural abscess. Streptococcus pyogenes species (β-hemolytic
group A) is uncommon [8, 9]. It produces
streptokinases, deoxyribonucleases, and hyaluronidase,
which hydrolyze the ground substance of connective tissue and aid in the spread
of infection.SEA is a rare condition
that can be easily misdiagnosed. There
is no specific clinical manifestation. The most common symptoms include back pain, fever, and neurological
deficits. Leukocytosis may or may not be
present. However, in severe ascending
back pain, even without fever or major neurological compromise, SEA must be
suspected. SEA may present as meningitis
with fever, neck stiffness, and neurological deficit [5, 8, 9].Imaging studies play a key role in diagnosing SEA. Although CT myelogram yields high specificity, MRI is considered the first
line imaging modality since it is noninvasive [1, 2, 9, 14, 15]. Tung et al. classified epidural inflammation
into phlegmon and abscess based on contrast-enhanced MRI images [14]. Phlegmonous tissue is characterized by
homogenous contrast enhancement that consists of vascularized granular tissue
with microabscesses but little or no drainable pus. In comparison, a peripheral pattern of
contrast enhancement is consistent with a frank abscess containing a liquefied,
purulent core. Clinically, surgically
treated patients with pustular abscesses had better outcomes than patients with
granular tissue or granular tissue plus pus [4]. Even with a delayed diagnosis of 3 weeks and
a long segment abscess (extending through the whole spine), as seen in our
patient, there was an excellent outcome without any complications. The length of the abscess and degree of
neural compression did not negatively impact the outcome of our patient. Incomplete recovery of neurological deficit
is seen in 40% of cases due to delayed diagnosis of SEA [5, 8], therefore early
diagnosis and treatment is crucial for decreasing mortality and morbidity [15]. In the past two decades, the mortality rate
has been improving due to improved antibiotic therapy and advanced neuroimaging
[2]. Early decompressive laminectomy
with antibiotic treatment is the gold standard for SEA [7–9]. However, caution should be used in pediatric
patients given that multiple segment laminectomies in a child can cause spinal
malformation with growth [6]. If an MRI
shows a peripheral pattern of enhancement consistent with liquefied pus, hemilaminotomies
with drainage may be adequate, as it proved to be with our patient. Kindler et al. reported that epidural needle
drainage with antibiotic therapy yielded satisfactory results [2]. Du Pen et al. reported using antibiotics only for epidural
abscess with good results [4]. However,
continued vigilance is required with medical therapy alone given the consequences
of progressive spinal cord compression.


## 4. Conclusion

We have reported a
rare case of pan spinal epidural abscess in a young, healthy adult. SEA should
be considered in a patient with severe ascending back pain even in the absence
of risk factors, fever, or major neurologic deficit. MRI is the diagnostic method of choice, and early
diagnosis, adequate surgical decompression, and antibiotic therapy can result
in an excellent outcome.



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