An unusual rectal fistula: Extradural abscess discharging per rectum

Abstract

A paraspinal abscess extending through a sacral foramen has not, to our knowledge, been reported previously. Paraspinal abscesses occur primarily in the midthoracic region and below the second lumbar vertebra. The organisms responsible reach the epidural space via the blood stream or by local implantation. Neurological signs appear when the abscess is small and result from cord a n d root compression o r thrombosis of spinal vessels. Large abscesses are rare, though spread along the whole length of the vertebral canal has been reported'. Early diagnosis and prompt surgical treatment of paraspinal abscesses has been stressed recently'. Waldeyer's fascia would be expected t o prevent extradural pus tracking into the pelvis, but this barrier was evidently insufficient in this case. Case reportA 35-year-old woman was admitted with a 5 month history of back pain, a 2 week history of mild weakness and paraesthesiae of the left leg, and difficulty voiding urine. Five years previously osteomyelitis of her right femur had been treated by sequestrectomy and antibiotics. Staphylococci, enterococci and Klebsiella had been cultured but no primary source of the infection had been found. Apart from a uterine myomectomy performed 2 years previously, she had undergone no surgery and had had no serious illnesses. There were no symptoms of gastrointestinal or gynaecological disease.Examination revealed pyrexia (38.5 "C), slight neck stiffness, mild tenderness over the lumbar spine and a positive Kernig's sign. Ankle jerks were absent but there was no sensory loss. Rectal examination was normal.On admission her haemoglobin was 12.0 g/dl and WCC 19.7 x 109/l. Lumbar puncture revealed turbid CSF with 103 x lo6 WCC/I (100 per cent lymphocytes) together with a raised protein and low sugar. Later Staphylococcus pyogenes was cultured from both CSF and blood. Myelography showed extradural compression of the lower part of the cauda equina which was therefore promptly explored through a laminectomy. A surprisingly large volume of pus (40 ml) was found in the extradural space and it was noted that pus reappeared in the spinal canal after it had been cleared suggesting the presence of an external reservoir. The area was drained by total laminectomy of L4 and L5 and de-roofing of the sacrum to S.4. No attempt was made to explore the spinal canal either anteriorly or laterally. Two irrigation catheters were left in the extradural space. S. pyogenes was again grown from the pus. No source of infection was found.Postoperatively her general condition improved slightly but she remained pyrexial and on the sixth postoperative day developed diarrhoea. On the tenth day the wound broke down and discharged Short notes and case reports faecal fluid from which Escherichia coli and Bacteroides fragilis were cultured. Rectal examination revealed a tender indurated area on the left side of the pelvis at 10 cm but sigmoidoscopy did not show any breach of the mucosa or intrinsic bowel disease. A plain X-ray of the pelvis showed a gas shadow extending out of the...

Spinal epidural abscess: a meta-analysis of 915 patients

“…Sources of infection near the vertebral canal include paraspinal abscess (14 of 854 cases), retropharyngeal abscess (five of 854), and psoas abscess (four of 854) ( Table 1). In these cases, the colonization of the spinal epidural space occurred by contiguous spread [46,61,71,133,168,188,294,321,372].…”

Emergency surgery for epidural abcess secondary to sacral fistula after laparoscopic proctectomy

“…In our case, as in the M.H. Jamison's case report in 1984, a defunctionning pelvic loop colostomy was necessary [ 3 ]. An appendectomy was necessary with a drainage of the collection for the case of Carter et al .…”

“…However, there are no studies dealing with a presacral fistula between a chronic presacral collection and spinal canal after of laparoscopic proctectomy for tubulo-villous resection of rectum with osteitis and arachnoiditis. It was sometimes necessary to realize intervertebral disc biopsy [ 1 ], bacteriological fluid drainage [ 2 ], parasitological examination of stools [ 3 ] and lumbar puncture [ 4 ]. The variation of symptoms depended on neurological involvement and the importance of the fistula.…”