Tuberculous lumbar spinal epidural abscess in a young adult (case report)

Subcutaneous and paraspinal tuberculous abscesses in a patient with Crohn's disease

This case involves a man with longstanding Crohn's disease on azathioprine therapy who developed a rare manifestation of tuberculosis, presenting as a subcutaneous tuberculous abscess and tuberculous spondylitis. The patient's immunocompromised state due to azathioprine raised the risk for opportunistic infections. The unique aspects include the absence of disseminated tuberculosis and the development of tuberculous paraspinal and subcutaneous abscesses in a patient with Crohn's disease. The case underscores the importance of vigilance for rare infections in immunosuppressed individuals and highlights the need for tuberculosis screening before initiating immunosuppressive therapies. The patient was successfully treated with antituberculous medication, emphasising the importance of a tailored approach in managing such cases.

A Rare Case of Thoracolumbar Epidural Abscess with Tuberculous Etiology in an Adolescent Male with Neurological Deficit

Introduction

Spinal epidural abscess (SEA) refers to collection of infection of the epidural space due to various etiologies. Tuberculosis (TB) of the spine is one of the important causes of SEA. Patient with SEA usually presents with history of fever, back pain, difficulty in walking, and neurological weakness. Magnetic resonance imaging (MRI) is the initial modality for diagnosis and it can be confirmed by examination of abscess for microorganism growth. It can be treated by laminectomy and decompression which helps to drain out the pus and relive the compression on the cord.

Case Report

A 16-year-old male, student by profession, presented with a history of low back pain and progressive difficulty in walking for the past 12 days and lower limb weakness for the past 8 days associated with fever, generalized weakness, and malaise. Computed tomography brain and whole spine showed no significant changes MRI left facetal joint of L3 L4 vertebrae infective arthritis with abnormal soft-tissue collection in the posterior epidural region extending from D11-L5 vertebrae causing compression on the thecal sac, cauda equine nerve roots, and represents infective abscess with abnormal soft-tissue collection in the posterior paraspinal region and left psoas muscles representing infective abscess. Patient was taken for emergency decompression with clearance of abscess through posterior approach. Laminectomy was done extending from D11 TO L5 vertebrae and thick pus was drained through multiple pockets. Samples pus and soft tissue were sent for investigation. Pus culture ZN and Gram's stain did not show growth of any organism, but GeneXpert was positive for growth of Mycobacterium tuberculosis. Patient was registered under RNTCP program and anti TB drugs were started as per the weight scale. Sutures were removed on post-operative day 12 and neurological evaluation was done for any signs of improvement. Patient showed improvement of power in both lower limb; power 5/5 on the right lower limb whereas 4/5 in the left lower limb. Patient also had improvements in other symptoms and has no complaints of back ache and malaise at discharge.

Conclusion

Tuberculous thoracolumbar epidural abscess is a rare disease with potential to cause lifelong vegetative state if diagnosis and treatment is not done promptly. Surgical decompression by unilateral laminectomy and evacuation of collection is both diagnostic and therapeutic.

Evaluation of functional outcome and neurological recovery pattern in patients with retro-thecal tubercular epidural abscess managed at a tertiary center

We performed a retrospective observational study to analyze the neurological recovery pattern in patients with a sub-laminar retro-thecal epidural abscess managed at our tertiary apex center from 2014 to 2020. We evaluated the Maximal Spinal Cord Compression (MSCC) ratio on Magnetic Resonance Imaging (MRI), the time interval between the appearance of neurological deficit and the initiation of management, spasticity as per Modified Ashworth Scale, presence of drug resistance, and the Lower Extremity Motor Score (LEMS). All patients were given anti-tubercular chemotherapy. We surgically managed 8 patients of which 6 required decompression alone, while 2 patients required additional instrumentation. 2 patients were managed conservatively of which 1 responded favorably to conservative treatment while the other patient showed a worsening of neurology following the detection of drug resistance and abrupt discontinuation of chemotherapy. The mean LEMS on admission was 20.2, which improved to 38.5 at the end of 1 year (p-value <0.05). The patients in whom the time interval between the onset of neurological deficit and the initiation of management was fewer than 6 weeks showed better LEMS and milder or absent spasticity at follow-up (p-value <0.05). The MSCC ratio did not have a significant correlation with the LEMS (p-value >0.05).

Disorders of the Cauda Equina

PURPOSE OF REVIEW

Cauda equina dysfunction (often referred to as cauda equina syndrome) is caused by a diverse group of disorders that affect the lumbosacral nerve roots. It is important to recognize dysfunction of the cauda equina quickly to minimize diagnostic delay and lasting neurologic symptoms. This article describes cauda equina anatomy and the clinical features, differential diagnosis, and management of cauda equina disorders.

RECENT FINDINGS

The diagnosis of disorders of the cauda equina continues to be a challenge. If a compressive etiology is seen, urgent neurosurgical intervention is recommended. However, many people with clinical features of cauda equina dysfunction will have negative diagnostic studies. If the MRI is negative, it is important to understand the diagnostic evaluation and differential diagnosis so that less common etiologies are not missed.

SUMMARY

Cauda equina dysfunction most often occurs due to lumbosacral disk herniation. Nondiskogenic causes include vascular, infectious, inflammatory, traumatic, and neoplastic etiologies. Urgent evaluation and surgical intervention are recommended in most cases of compressive cauda equina syndrome. Other types of treatment may also be indicated depending on the etiology.