Spinal subdural empyema: report of two cases

Intradural Staphylococcus aureus Abscess of the Cauda Equina in an Otherwise Healthy Patient

Abscesses involving the spine are usually located in the epidural space. In rare circumstances, intradural spinal abscesses can occur, typically in the setting of tuberculosis or other predisposing systemic conditions. In this illustrated case report, we discuss the imaging and intraoperative findings of an otherwise healthy patient with an intradural abscess of the cauda equina caused by Staphylococcus aureus. Although rare, intradural spinal abscesses can occur in the absence of typical “red flags” for infection, and a bacterial abscess should be considered in the differential diagnosis of intradural spinal cystic enhancing lesions.

Spinal Subdural Abscess Following Laminectomy for Symptomatic Stenosis: A Report of 2 Cases and Review of the Literature

BACKGROUND Spinal subdural abscesses, also known as empyemas, are rare infectious lesions, the exact incidence of which is unknown. Presentation is typically dramatic, with back pain, fever, motor, and sensory deficits. Rapid identification and surgical intervention with laminectomy, durotomy, and washout provides the best outcomes. While hematogenous spread of an extra-spinal infection is the most common cause of this condition, a significant number of cases result from iatrogenic mechanisms, including lumbar punctures, epidural injections, and surgery. CASE REPORT Here we present 2 cases: 1) an 87-year-old man with type 2 diabetes, schizophrenia, mild cognitive impairment, and symptomatic lumbar spinal stenosis and 2) a 62-year-old man with a prior L3-4 spinal fusion with symptomatic lumbar spinal stenosis. In both cases, patients underwent laminectomy for spinal stenosis and developed epidural abscess. Following successful drainage of the epidural abscess, they continued to be symptomatic, and repeat imaging revealed the presence of a subdural abscess that was subsequently evacuated. Case 1 had significant improvement with residual lower-extremity weakness, while Case 2 made a complete neurological recovery. CONCLUSIONS These cases illustrate patients at increased risk for developing this rare spinal infection, and demonstrate that rapid recognition and surgical treatment is key to cure and recovery. Review of the literature highlights pertinent risk factors and demonstrates nearly one-third of reported cases have an iatrogenic etiology. The cases presented here demonstrate that a subdural process should be suspected in any patient with intractable pain following treatment of an epidural abscess.

Pyogenic Intradural Abscess of Lumbar Spine: A Case Report

We report a case of spinal intradural abscess which shows serial changes on magnetic resonance imaging (MRI). Well-encapsulated, rim-enhancing lesion with mass effect was visualized at ventral side of lumbar spinal canal on 17 days after initial negative MRI, which was thought to be epidural abscess. It was revealed to be intradural in location on operation and successfully treated by drainage and antibiotics. Follow-up MRI showed resolution of abscess. Clinical significance and pathogenesis of this case was briefly discussed.

Infections of the spinal subdural space in children: a series of 11 contemporary cases and review of all published reports. A multinational collaborative effort

INTRODUCTION

Positioned anatomically between the spinal epidural space and the intramedullary compartment, the spinal subdural space remains the least common area of localized infection in the central nervous system. Infectious processes of the subdural spinal space include subdural spinal empyema, subdural spinal abscess, infected spinal subdural cyst, and infectious spinal subdural cyst. To date, there has been no systematic review of these entities in children, with the cumulative knowledge of the pathophysiologic, microbiologic, and demographic characteristics of these infections relegated solely to few small series and case reports.

METHODS

A series of 11 recent cases culled from the collaboration of international authors are presented. In addition, an exhaustive MEDLINE search and manual review of the international literature was performed, identifying a total of 73 cases of spinal subdural infections in patients under the age of 21. Data of interest include the age, sex, signs, and symptoms at presentation, spinal location of infection, presence of spinal dysraphism, and other comorbidities, offending organism, treatment, outcome, and follow-up.

RESULTS

Patients ages ranged from 4 weeks to 20 years (mean, 6.5 years). Males outnumbered females by a ratio of 2:1. Over half (53 %) of spinal subdural infections in children were associated with spinal dysraphism or other congenital abnormalities of the spine. The commonest organism to infect the spinal subdural space in children is mycobacterium tuberculosis and the thoracic spinal region was most commonly infected.

CONCLUSIONS

The disease is usually treated surgically, although a more expectant approach consisting of antibiotics and observation has also been proposed.

Cervical subdural empyema following acupuncture

A review of the literature reveals only a few cases of spinal subdural empyema. Etiologies of spinal subdural empyema include hematogenous spread from skin lesions, systemic sepsis, direct spread from spinal osteomyelitis and complications of discography. However, in this report, we describe a patient who developed spinal subdural empyema following several cervical acupuncture sessions. Operative treatment with adequate laminectomy, removal of abscess, and copious irrigation resulted in good recovery. Microbiologic culture study of pus obtained at surgery was positive for Staphylococcus aureus. The need for sterilization procedures for acupuncture is emphasized and a brief review of the relevant literature is presented.

Pyogenic abscess of the filum terminale. Case report

Intradural spinal abscesses are rare. They are predominantly encountered as intramedullary abscesses of the spinal cord and infrequently as subdural lesions. To their knowledge, the authors report the first case of a chronic pyogenic abscess of the terminal filum in an adult woman with kyphoscoliosis who presented with lumbar radiculopathies. Magnetic resonance imaging revealed a partly cystic intradural L3-4 mass that markedly enhanced after contrast administration. Laboratory signs of infection were absent. Intraoperatively a lobulated lesion observed within the terminal filum was tightly attached to neighboring nerve roots by fibrosis. On opening the cyst wall pus was revealed. Histological examination confirmed the diagnosis of a chronic abscess. Microbiological culture detected Staphylococcus aureus. Antibiotic therapy resulted in an uneventful postoperative course, with complete resolution of symptoms and radiologically demonstrated disappearance of the lesion. The pathogenesis and radiological features of the lesion are discussed. Although extremely rare, a pyogenic abscess should be considered in the differential diagnosis of mass lesions of the cauda equina, especially in patients with preexisting spinal abnormalities. Surgical exposure, including drainage and biopsy sampling to rule out underlying tumor, combined with antibiotic treatment result in a favorable outcome.

Spinal subdural abscess: successful treatment with limited drainage and antibiotics in a patient with AIDS

The authors present a case of Staphylococcus aureus spinal subdural abscess in a patient with AIDS. Although complete surgical drainage has been strongly advocated in the literature, this patient made a complete neurologic and symptomatic recovery and radiographically demonstrated resolution of the abscess with only limited surgical drainage and parenteral antibiotics. Magnetic resonance imaging findings of this unusual lesion are discussed. Relevant literature in the management of spinal subdural abscesses is reviewed.

Subdural empyema of the cervical spine: clinicopathological correlates and magnetic resonance imaging. Report of three cases

A paucity of formally described information is available in the scientific literature regarding spinal subdural empyema. Patients presenting with neurological deterioration associated with subdural empyema are rarely identified, and treatment is often based upon anecdotal cases. The authors contribute three cases of primary cervical spinal subdural empyema and review the seven found in the literature. All patients had clinical evidence of neurological compromise, cervical tenderness, cervical pain, and leukocytosis upon admission. Cervical involvement ranged from C-2 to C-7. All patients underwent laminectomy with durotomy and drainage. The authors recommend prompt surgical decompressive laminectomy, copious irrigation, and drainage, followed with appropriate adjunctive antibiotic therapy for treatment of these patients.

Nontraumatic spinal cord compression

Nontraumatic spinal cord compression can have very dramatic clinical presentations with rapid onset of symptoms and quickly ensuing paralysis. The manifestations may be much more subtle. This text will discuss the four most common causes of myelopathy, including spinal canal hemorrhage, spinal abscess, compression by tumor, and skeletal disease. Compressive lesions to the spinal cord from other than these etiologies are rare.

Spinal subdural abscess

✓ Only 44 cases of spinal subdural abscess have been reported to date. The authors present another case and review the relevant literature. The findings of intraspinal gassification on computerized tomography scans and Escherichia coli as the causative organism have not previously been described in relation to spinal subdural abscess. Most frequently, Staphylococcus aureus is the responsible organism. Hematogenous spread of infection from a distant source often takes place. In a surprising number of incidences, iatrogenic causes are the primary foci of spinal subdural abscess.

Spinal subdural abscess is an unpredictable disease, with an unfavorable outcome if left untreated. If there is suspicion of a spinal subdural abscess, urgent radiological examination followed by immediate surgical drainage and appropriate antibiotic therapy is warranted.

Meningitis and spinal subdural empyema as a complication of sinusitis

Images

Subdural empyema and cranial epidural abscess

Subdural empyema and cranial epidural abscess are life-threatening infections that require a combined medical and surgical approach for proper management. The pathophysiology, clinical presentation, diagnosis, and treatment of these conditions are discussed.

Spinal subdural empyema: diagnosis by spinal computed tomography

The authors describe the use of metrizamide spinal computed tomography scan to delineate the surgical extent of spinal subdural empyema in a 65-year-old diabetic female.