The Spine Journal 14 (2014) 3054–3055
Latent spinal epidural abscess revealed 4 months after esophageal perforation A 37-year-old man presented with mild fever and progressively worsening midthoracic back pain for over 3 months. During the last weeks, he also noted progressive weakness in his lower extremities that affected his gait, truncal paresthesias, and urinary retention. Neurologic examination revealed localized spinal pain at the level of Th4–Th6 vertebrae, sensory disturbance below the Th5 dermatome, and muscular weakness in his lower extremities (muscular strength of 2/5 on the right and 3/5 on the left). Relevant laboratory investigations included mild leukocytosis and an elevated erythrocyte sedimentation rate.
A computed tomography scan revealed a needle-shaped high density structure anterior to the Th4 vertebra (Figure, arrows), most consistent with a foreign body. Local softtissue infiltration (Figure, arrowheads) with apparent erosions of Th4–Th5 vertebral bodies and associated narrowing of the Th4–Th5 disc space was indicative of a local inflammatory process spreading to the adjacent vertebrae and Th4–Th5 intervertebral disc. On further questioning, it was established that the patient inadvertently swallowed a sharp needle-shaped bone during his meal about 4 months earlier. At that time, he had significant discomfort and the feeling of a bone stuck in his esophagus; however, his condition gradually improved. Given these findings and worsening neurologic status, the patient underwent Th4–Th6 meningolysis and decompressive Th4–Th6 laminectomy. The foreign body was removed and the cavity was drained, followed by the
Figure. Computed tomography images showing a needle-shaped foreign body anterior to the Th4 vertebra (arrows). Local soft tissue infiltration (arrowheads) with apparent erosions of Th4–Th5 vertebral bodies can also be noted. (A) Axial view, (B) sagittal view, (C) coronal view, and (D) volumerendered image. http://dx.doi.org/10.1016/j.spinee.2014.07.012 1529-9430/Ó 2014 Elsevier Inc. All rights reserved.
E. Condrea et al. / The Spine Journal 14 (2014) 3054–3055
administration of broad spectrum antibiotics. Subsequently, the patient gradually recovered and was discharged. Spinal infections secondary to esophageal perforation are rare and usually develop at an earlier stage [1]. A delayed spinal epidural abscess, occurring years after spinal instrumentation has been previously reported [2]. Our case shows that latent spinal epidural abscess may also develop months after esophageal perforation. Early diagnosis is a key factor to avoid neurologic sequelae and high mortality related to esophageal perforation [1,3]. In cases of suspected acute epidural abscess, the whole spine is frequently scanned to exclude the possibility of multilevel involvement [4,5]. Surgical drainage together with antimicrobial therapy remains the treatment of choice [3–5]. References [1] Chen Y, Kim BJ, Lee SH, Hu SS. High thoracic spinal infection following upper gastrointestinal work-up. J Clin Neurosci 2007;14:1132–5. [2] Choma T, Burke M, Kim C, Kakarlapudi R. Epidural abscess as a delayed complication of spinal instrumentation in scoliosis surgery: a case of progressive neurologic dysfunction with complete recovery. Spine 2008;33:E76–80. [3] Darouiche RO, Hamill RJ, Greenberg SB, Weathers SW, Musher DM. Bacterial spinal epidural abscess. Review of 43 cases and literature survey. Medicine (Baltimore) 1992;71:369–85. [4] Panagiotopoulos V, Konstantinou D, Solomou E, Panagiotopoulos E, Marangos M, Maraziotis T. Extended cervicolumbar spinal epidural
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abscess associated with paraparesis successfully decompressed using a minimally invasive technique. Spine 2004;29:E300–3. [5] Urrutia J, Rojas C. Extensive epidural abscess with surgical treatment and long term follow up. Spine J 2007;7:708–11.
Eugen Condrea, MDa Dan Lisii, MDa Valery Timirgaz, MD, DSca Ion Codreanu, MD, PhDb Natalia Rotaru, MD, PhDb a Department of Neurosurgery Institute of Neurology and Neurosurgery State University of Medicine and Pharmacy ‘‘Nicolae Testemitanu’’ 2 Korolenko str, Chisinau, MD 2028, Republic of Moldova b Department of Radiology Medpark International Hospital State University of Medicine and Pharmacy ‘‘Nicolae Testemitanu’’ 24 Andrei Doga str, Chisinau, MD 2024, Republic of Moldova FDA device/drug status: Not applicable. Author disclosures: EC: Nothing to disclose. DL: Nothing to disclose. VT: Nothing to disclose. IC: Nothing to disclose. NR: Nothing to disclose. Disclosures: None. The authors report no conflict of interest.
Latent spinal epidural abscess revealed 4 months after esophageal perforation A 37-year-old man presented with mild fever and progressively worsening midthoracic back pain for over 3 months. During the last weeks, he also noted progressive weakness in his lower extremities that affected his gait, truncal paresthesias, and urinary retention. Neurologic examination revealed localized spinal pain at the level of Th4–Th6 vertebrae, sensory disturbance below the Th5 dermatome, and muscular weakness in his lower extremities (muscular strength of 2/5 on the right and 3/5 on the left). Relevant laboratory investigations included mild leukocytosis and an elevated erythrocyte sedimentation rate.
A computed tomography scan revealed a needle-shaped high density structure anterior to the Th4 vertebra (Figure, arrows), most consistent with a foreign body. Local softtissue infiltration (Figure, arrowheads) with apparent erosions of Th4–Th5 vertebral bodies and associated narrowing of the Th4–Th5 disc space was indicative of a local inflammatory process spreading to the adjacent vertebrae and Th4–Th5 intervertebral disc. On further questioning, it was established that the patient inadvertently swallowed a sharp needle-shaped bone during his meal about 4 months earlier. At that time, he had significant discomfort and the feeling of a bone stuck in his esophagus; however, his condition gradually improved. Given these findings and worsening neurologic status, the patient underwent Th4–Th6 meningolysis and decompressive Th4–Th6 laminectomy. The foreign body was removed and the cavity was drained, followed by the
Figure. Computed tomography images showing a needle-shaped foreign body anterior to the Th4 vertebra (arrows). Local soft tissue infiltration (arrowheads) with apparent erosions of Th4–Th5 vertebral bodies can also be noted. (A) Axial view, (B) sagittal view, (C) coronal view, and (D) volumerendered image. http://dx.doi.org/10.1016/j.spinee.2014.07.012 1529-9430/Ó 2014 Elsevier Inc. All rights reserved.
E. Condrea et al. / The Spine Journal 14 (2014) 3054–3055
administration of broad spectrum antibiotics. Subsequently, the patient gradually recovered and was discharged. Spinal infections secondary to esophageal perforation are rare and usually develop at an earlier stage [1]. A delayed spinal epidural abscess, occurring years after spinal instrumentation has been previously reported [2]. Our case shows that latent spinal epidural abscess may also develop months after esophageal perforation. Early diagnosis is a key factor to avoid neurologic sequelae and high mortality related to esophageal perforation [1,3]. In cases of suspected acute epidural abscess, the whole spine is frequently scanned to exclude the possibility of multilevel involvement [4,5]. Surgical drainage together with antimicrobial therapy remains the treatment of choice [3–5]. References [1] Chen Y, Kim BJ, Lee SH, Hu SS. High thoracic spinal infection following upper gastrointestinal work-up. J Clin Neurosci 2007;14:1132–5. [2] Choma T, Burke M, Kim C, Kakarlapudi R. Epidural abscess as a delayed complication of spinal instrumentation in scoliosis surgery: a case of progressive neurologic dysfunction with complete recovery. Spine 2008;33:E76–80. [3] Darouiche RO, Hamill RJ, Greenberg SB, Weathers SW, Musher DM. Bacterial spinal epidural abscess. Review of 43 cases and literature survey. Medicine (Baltimore) 1992;71:369–85. [4] Panagiotopoulos V, Konstantinou D, Solomou E, Panagiotopoulos E, Marangos M, Maraziotis T. Extended cervicolumbar spinal epidural
3055
abscess associated with paraparesis successfully decompressed using a minimally invasive technique. Spine 2004;29:E300–3. [5] Urrutia J, Rojas C. Extensive epidural abscess with surgical treatment and long term follow up. Spine J 2007;7:708–11.
Eugen Condrea, MDa Dan Lisii, MDa Valery Timirgaz, MD, DSca Ion Codreanu, MD, PhDb Natalia Rotaru, MD, PhDb a Department of Neurosurgery Institute of Neurology and Neurosurgery State University of Medicine and Pharmacy ‘‘Nicolae Testemitanu’’ 2 Korolenko str, Chisinau, MD 2028, Republic of Moldova b Department of Radiology Medpark International Hospital State University of Medicine and Pharmacy ‘‘Nicolae Testemitanu’’ 24 Andrei Doga str, Chisinau, MD 2024, Republic of Moldova FDA device/drug status: Not applicable. Author disclosures: EC: Nothing to disclose. DL: Nothing to disclose. VT: Nothing to disclose. IC: Nothing to disclose. NR: Nothing to disclose. Disclosures: None. The authors report no conflict of interest.
