Spinal Subdural Abscess: A Rare Complication of Decubitus Ulcer

Abstract

A male patient, aged 55 years, presented to the emergency room with complaints of bilateral upper extremity weakness. His past medical history was significant for paraplegia and neurogenic bladder from a spinal cord injury, complicated with decubitus ulcers and end-stage renal disease secondary to type II diabetes mellitus. His past surgical history was significant for posterior spine fusion with Harrington rod instrumentation at the level of T10. He developed subacute onset of bilateral upper extremity weakness and paresthesias on the day of presentation. He reported a 2-day history of neck and back pain that he initially contributed to his bedridden state. The patient denied fever, recent infections, or trauma. His vital signs were unremarkable. Physical examination revealed quadriparesis, absence of deep tendon reflexes, hypoesthesia, and decubitus ulcers (figure 1). He had a normal leukocyte count and elevated C-reactive protein. Blood cultures and cultures from the ulcers were obtained. With the concern of spinal cord compression based on presentation, intravenous corticosteroids and broad spectrum antibiotics were initiated. A magnetic resonance imaging (MRI) scan of the spine (figure 2) revealed large elongated epidural collection posteriorly within the cervical spine, extending into the thoracic spine and inferiorly. Spinal cord compression was prominent in the narrowed areas of disc-osteophyte complexes at the levels of C3-4 and C5-6, where the spinal cord was compressed between these disc-osteophyte complexes and the posterior epidural collection, with some mildly increased signal intensity within the cord. The lumbosacral spine was not well imaged due to artifacts of spinal hardware. Emergent drainage of the collection was indicated, but the patient declined. Per the patient's wishes, palliative care was initiated on the day Spinal subdural abscess (SSA) is an uncommon entity. The exact incidence is unknown, with very few cases reported in the literature. This condition may result in spinal cord compression, thus constituting a medical and neurosurgical emergency. The pathogenesis of SSA is not welldescribed, and the available knowledge is based on case observations only. There is only one case report that describes direct seeding from decubitus ulcers as a possible mechanism for development of SSA. We report a case of subacute onset of quadriplegia in a male patient, age 55 years, due to spinal cord compression from SSA and superimposed spinal subdural hematoma. The direct seeding from decubitus ulcers is thought to be the cause of infection in our patient. We present this case of SSA to elucidate and review the predisposing factors, pathogenesis, clinical presentation, diagnostic modalities, and treatment regarding management of this rare disorder.

Isolated Spinal Subdural Empyema: A Case Report & Review of the Literature

“…The presentation of spinal subdural empyema has been described in 3 separate stages which often, but not always, progress in chronologic order at unpredictable rates [4] [7]. Most commonly, the presenting signs and symptoms are fever, back/neck pain, and radicular pain referred to affected nerve roots.…”

“…While populations likely to develop spinal epidural abscess (SEA) such as those with chronic sinus infections or conditions promoting immunosuppression, such as diabetes mellitus, systemic malignancies, use of immunosuppressive drugs, or intravenous drug abuse are likely the most at risk patient populations to also develop SSE, this has yet to be delineated given the rarity of the pathology. The reported outcomes are varied in the literature [1] [2] [3] [4].…”

Meningioma mimicker: non-tubercular intradural abscess

“…It very uncommonly localizes as a central nervous system infection that may occur secondary to a systemic infection or surgery. 2 It has been observed that Staphylococcus aureus is the most frequent causative agent and the lumbar region the most frequent site of the SSA. The common age of presentation is between 60 and 70 years.…”

Spinal subdural abscess caused by Sthaphylococcus aureus

“…El diagnóstico necesita de pruebas de imagen donde el patrón de oro es la resonancia magnética nuclear (RMN) con gadolinio para la evaluación de las infecciones vertebrales y paravertebrales pues permite localizar [5][6][7] y determinar la extensión de la lesión, valorar la compresión medular y guiar la conducta quirúrgica . Una técnica con valor agregado a la RMN convencional es la imagen de resonancia con difusión ponderada, que otorga las ventajas de poder realizarse en pacientes en falla renal con restricción para el uso de gadolinio y permite discriminar colecciones de pus de otras patologías como ser aquellas postquirúrgicas, tumores 1 quísticos o hematomas .…”

“…El procedimiento de elección es la laminectomía que dependiendo de la extensión será a uno o a varios niveles con desbridamiento de todo 6 tejido infectado. Esto debe ser realizado rápidamente puesto que constituye una emergencia neuroquirúrgica .…”