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Journal of Peking University (Health Sciences) ›› 2020, Vol. 52 ›› Issue (2): 275-280. doi: 10.19723/j.issn.1671-167X.2020.02.013

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Diagnosis and treatment of primary intraspinal abscess

Chang-cheng MA,Zhen-yu WANG(),Guo-zhong LIN   

  1. Department of Neurosurgery, Peking University Third Hospital, Beijing, 100191, China
  • Received:2018-04-03 Online:2020-04-18 Published:2020-04-18
  • Contact: Zhen-yu WANG E-mail:wzyu502@hotmail.com
  • Supported by:
    Supported by the Capital Foundation for Clinical Characteristics and Application Research(Z171100001017120)

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Abstract:

Objective: To summarize the feature and treatment of the primary intraspinal abscess in order to improve the prognosis.Methods: In the study, 13 cases of primary intraspinal abscess of the recent 20 years were retrospectively analyzed. The history, etiology, pathogen, surgical methods and prognosis were summarized.Results: The course of the illness ranged from 7 days to 6 months. All the cases began with pain. Of the 13 patients, 10 had limb weakness. Five had a fever and 8 had increased white blood cells. As for distribution, 1 was in cervical vertebra, 1 in cervicothoracic junction, 1 in thoracic vertebra, 4 in thoracolumbar junction, and 6 in lumbosacral segment. The results of bacterial culture were positive in 4 cases, 3 cases were diagnosed as tuberculosis by pathological examination, and 1 case was recognized as infection of Brucella melitensis bacteria because of prior brucellosis. The pathogen of the remaining cases were unclear. All the cases received surgical treatment and pathology examination. The surgical aim was mainly removal of the lesion, decompression and drainage. Postoperatively anti-infection and glucocorticoid therapy were performed according to the pathogeny results and clinical experience. Incision abscesses were seen in 2 cases and reoperations including debridement and repair with transferred muscle flap were performed. Postoperative follow-up ranged from 6 months to 3 years (mean 1.8 years). One case suffered postoperative recurrence and the abscess spread along the vertebral canal. Reoperation was performed. Infections of all the cases were recovered completely and the nervous system signs were all improved in different degrees.Conclusion: The onset of primary intraspinal abscess is relatively urgent, mainly with pain. The lumbar and sacral vertebra is the predilection site. The bacterial culture is mostly negative. Early operation and use of sufficient amount of broad-spectrum antibiotic are recommended. If the incision abscess forms after the operation, it is advisable to transfer the muscle flap to repair the coloboma on the basis of debridement. In order to relieve edema of spinal cord and nerve root, the glucocorticoid can be used in the escort of antibiotics.

Key words: Intraspinal abscess, Surgery, Antibiotics, Glucocorticoid, Muscle flap

CLC Number: 

  • R632.5

Table 1

General information of patients"

Case Gender Age Predisposing factor Course/d Onset symptom Temperature Neurological signs
1 Female 13 Diabetes mellitus 30 Low back pain and lower extremity pain Normal Weakness of lower limb and loss of lower limb tendon reflex
2 Female 15 None 180 Right upper limb pain Normal Weakness and hypoesthesia in the right upper limb
3 Male 18 Malignancy 7 Low back pain and lower extremity pain Fever Local tenderness, hypoesthesia between T10 to L1 and hyperesthesia between L2-L5
4 Female 24 Long term use of glucocorticoid 7 Low back pain Fever Weakness of lower limb, hypoesthesia below T12, hyporeflexiaof lower limb tendon reflex and relaxation of anal sphincter
5 Male 30 History of brucellosis 20 Neck pain Normal Weakness of right limb, positive right Babinski's sign and hypoesthesia at C2
6 Female 34 None 180 Low back pain Fever Local tenderness, hypoesthesia of right lower limb, weakness of lower limb, hyporeflexia of lower limb tendon reflex and meningeal irritation sign
7 Female 46 Malignancy, Diabetes mellitus 18 Low back pain Normal Weakness of lower limb and hyporeflexia of lower limb tendon reflex
8 Female 51 Local dermal sinus 15 Low back pain Normal Weakness of lower limb, hyperreflexia of lower limb tendon reflex, hypermyotonia and hyperesthesia of lower limb
9 Male 54 Local dermal sinus 10 Low back pain Normal Weakness of lower limb, hyperreflexia of lower limb tendon reflex, hypermyotonia and hyperesthesia of lower limb
10 Male 56 None 14 Low back pain Fever Local tenderness, weakness of lower limb and meningeal irritation sign
11 Female 58 None 20 Chest back pain Normal Weakness of lower limb, hyperreflexia of lower limb tendon reflex, pathological signs and hypoesthesia below T6
12 Female 64 None 30 Lumbosacral pain Fever Local tenderness, weakness of lower limb and hyporeflexia of lower limb tendon reflex
13 Male 68 Adjacent skin infection 7 Low back pain Normal Paralysis of lower limbs and relaxation of anal sphincter

Table 2

Preoperative adjuvant examination"

Case Inflammatory markers MRI
WBC ESR CRP
1 Normal High NA Subdural lesion between L4-S1 with significant enhancement
2 Normal High NA Epidural lesion between C7-T3 with area of cystoid variation and necrosis and significant enhancement of solid area
3 High NA NA Epidural lesion in the thoraco-lumbo-sacral spinal canal with posterior vertical spine muscle strip enhancement, posterior lamellar muscle enhancement
4 High NA NA Epidural cystic lesion between T12-L2 with enhancement of cyst wall
5 Normal Normal High Epidural lesion ventral to spinal cord between C2-C4 with significant homogeneous enhancement and edema of corresponding spinal cord
6 Normal NA NA Multiple subdural lesions between T12-L3 with significant homogeneous enhancement
7 Normal High NA Intraspinal cystic lesion between T8-L2 with ring enhancement of cyst wall
8 High NA NA Intramedullary abnormal signal between L2-L3 with ring enhancement, dermal sinus at L4-L5 connected to the spinal canal with tethered cord
9 High NA NA Intramedullary abnormal signal between L2-L3 with ring enhancement, dermal sinus at L2-L3 connected to the spinal canal
10 High NA NA Intraspinal lesion between L3-L5 with ring enhancement
11 High NA NA Extramedullary epidural lesion between T4-T5 with ring enhancement
12 High High High Multiple intraspinal and paravertebral cystic lesions between S1-S3 with ring enhancement
13 High NA NA Epidural cystic lesions between T9-L1 with ring enhancement

Figure 1

Preoperative MRI in a patient with thoracolumbar epidural abscess The sagittal (A) and axial (B) T2WI MRI showed a highsignal lesion in the epidural space, and the dural sac was obviously pressed. The sagittal (C) and axial (D) enhanced MRI showed a ring-enhancement lesion which extended to the intervertebral foramen, and the corresponding dura was thickened."

Table 3

Treatment and intraoperative findings"

Case Treatment Location Abscess character
Surgery Antibacterials Glucocorticoid Mannitol
1 Yes Yes(anti-TB) No No L4-S1, epidural, ventral Gelatinous and caseous
2 Yes Yes(anti-TB) No No C7-T3, epidural Thinning pus and gray granuloma
3 Yes Yes No No L4-S1, epidural Yellowish-white thinning pus
4 Yes Yes Yes No T12-L2, epidural Beige pus
5 Yes Yes Yes Yes C3-C7, epidural, ventral Purple-red granuloma
6 Yes Yes No No T12-L3,intra-extramedullary Yellow sticky pus and granuloma
7 Yes Yes Yes No T8-L2, epidural Much yellow pus with granuloma
8 Yes Yes Yes Yes L2-L3,intra-extramedullary Yellowish-white pus with much pus mosses
9 Yes Yes Yes Yes L2-L3,subdural Yellowish-white pus
10 Yes Yes No No L3-L5, epi-subdural Yellowish-white pus with pus mosses and granuloma
11 Yes Yes Yes Yes T4-T5, intramedullary Yellowish-white pus
12 Yes Yes No No S1-S3, epi-subdural and paravertebral Yellowish-white pus with pale yellow granuloma
13 Yes Yes No No T9-L1, epidural Beige pus with little granuloma and much pus mosses

Table 4

Postoperative situation"

NA, not applicable.
Case Pyoculture Blood culture Pathology Possible way Outcome
1 Negative Negative Tuberculosis Hematogenous Complete recovery
2 Negative NA Tuberculosis Hematogenous Complete recovery
3 Negative NA NA Hematogenous Complete recovery
4 Staphylococcus aureus NA Pus Hematogenous No abscess or pain, light hypoesthesia, muscle strength grade IV, occasional urine incontinence
5 NA NA NA Hematogenous No abscess or pain, euesthesia, muscle strength grade Ⅳ
6 Negative NA Pus Hematogenous Recurrence 1 year later, complete recovery finally
7 Negative NA Tuberculosis Hematogenous No abscess or pain, euesthesia, muscle strength grade Ⅳ
8 Enterococcus faecalis NA Dermal sinus, necrosis
and granulation tissue		 Direct spread Complete recovery
9 Escherichia coli NA Dermal sinus Direct spread Complete recovery
10 Negative NA Pus Hematogenous No abscess or pain, euesthesia, muscle strength grade Ⅳ
11 Negative NA Pus Hematogenous No abscess or pain, hypoesthesia, no provement in muscle strength
12 Negative Negative Pus Hematogenous Wound abscess which restored after debridement and repair with muscle flap, complete recovery finally
13 Staphylococcus aureus NA Pus Hematogenous Wound abscess which restored after debridement and repair with muscle flap. No abscess or pain, hypoesthesia, muscle strength grade Ⅳ, occasional urine incontinence finally

Figure 2

Postoperative MRI in a patient with a thoracolumbar epidural abscess The sagittal T1WI(A) and sagittal T2WI(B) MRI showed that the abscess was cleared after the operation and the corresponding dural sac was relieved. The axial T2WI(C) MRI showed that the subarachnoid cavity was unblocked."

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