Spontaneous spinal epidural abscess in pregnancy: a case series

Abstract

INTRODUCTION: Spontaneous spinal epidural abscess (SEA) is a rare diagnosis; only eight cases have been reported during pregnancy. Diagnosis of SEA can be difficult, especially when the classic triad of fever, back pain, and neurologic deficits are not present. Early diagnosis and treatment are necessary to reduce potential morbidity and mortality. CASE PRESENTATIONS: We report two separate cases of SEA in pregnancy and summarize the existing literature. Case 1: A 20year-old G1P0 presented at 35-week gestation with low back pain and lower extremity (LE) weakness. Magnetic resonance imaging (MRI) revealed thoracic SEA. The patient underwent cesarian delivery followed by posterior thoracic laminectomy and fusion (T9-11), abscess decompression, and antibiotic therapy. Unfortunately, there was a recurrence of her infection requiring a second irrigation and debridement 1 month after index procedure. At final follow-up, the patient had complete neurologic recovery. Case 2: A 38-year-old G10P0 presented at 36-week gestation in labor with LE weakness and difficulty ambulating. After delivery, she had significant LE neurologic deficits. MRI demonstrated thoracic osteodiscitis with associated epidural abscess. She underwent thoracic laminectomy and fusion (T7-12), abscess decompression, and antibiotic therapy. Unfortunately, despite aggressive treatment, she has persistent LE neurologic deficits. DISCUSSION: Pregnancy complicates the diagnosis and treatment strategies of SEA: back pain is very commonly underestimated, especially in the absence of fever and gross neurologic deficits. Prompt diagnosis and treatment are paramount to prevent neurologic decline and facilitate recovery. It is important to perform a focused physical exam noting motor strength, sensation, and reflexes. Coordinated management between the Emergency Department, OB-GYN, and spinal surgery team is required for best possible patient outcomes. Typically, management consists of aggressive surgical decompression and antibiotic therapy.

Compressive Myelopathy, Spinal Shock, and a Complicated Neurological Exam

“…No deficits in sensory or vibratory senses were clearly documented and anterior column localization seemed clear in many of these cases where the spinal epidural abscess affected the ventral cord. Alternatively, in a case report by Daniel Robinson, a patient with posteriorly located T8-T12 epidural abscess was documented as having predominantly sensory loss below the right knee and diminished sensation to light tough up to the thighs bilaterally [8]. Although particular spinal cord injuries have known syndromic presentations, the neurological exam can vary greatly depending on degree of compression of the lesion.…”

Neurologic Emergencies in Pregnancy

“…However, more recent data suggest that it could be as high as 1 in 1,000, and rates are increasing. [60][61][62] Spinal epidural abscess can be with neuraxial anesthesia and can occur from hematologic or direct extension from an overlying skin infection, recent surgery, or trauma. Although there are no official guidelines on neuraxial anesthesia placement in patients with suspected intraamniotic infection and the risk of spinal epidural abscess, there is a theoretical risk of seeding the space.…”