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Case reports
9 Springer-Verlag 1992 Child's Nerv Syst (1992) 8:290-291
Intramedullary spinal cord abscess: a case report M.K. Tewari 1, B. Indira Devi 1, R. C. Thakur 1, A. Pathak 1 N. Khandelwal 2, and V.K. Kak 1 1 Department of Neurosurgery and 2 Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh- 160 012, India Received April 30, 1991
Abstract. A n 11-year-old b o y p r e s e n t e d with p a i n in the b a c k , u r i n a r y retention, p a r a p l e g i a a n d loss of sensations b e l o w L1. I n v e s t i g a t i o n s r e v e a l e d a n i n t r a m e d u l l a r y lesion. A n i n t r a m e d u l l a r y spinal c o r d abscess was f o u n d at surgery. T h e pus was e v a c u a t e d a n d abscess was excised. M i n i m a l r e c o v e r y was seen following surgery. E a r l y interv e n t i o n a n d a high index of s u s p i c i o n is r e q u i r e d in such cases.
Key words: Abscess i n t r a m e d u l l a r y - Abscess spinal c o r d
I n t r a m e d u l l a r y spinal c o r d abscess ( I M S C A ) is a rare c o n d i t i o n which in the p r e - a n t i b i o t i c e r a used to have a fatal o u t c o m e . T h e scene has c h a n g e d , however, with the a d v e n t of a n t i b i o t i c s [9]. A n a w a r e n e s s of this c o n d i t i o n is essential for early d i a g n o s i s a n d m a n a g e m e n t . O n e such case is discussed in the p r e s e n t c o m m u n i c a t i o n .
Fig. 1. Iohexol myelogram suggestive of an intramedullary spaceoccupying lesion at the T12-L1 level
Case report An 11-year-old boy presented with non-radiating pain in the dorsolumbar region of 40 days' duration, which used to increase on lying down. He also had retention of urine with overflow for 1 month and rapidly progressive weakness of both lower limbs for 20 days leading to paraplegia in 5 days. There was history of moderate grade fever for 4 days prior to the onset of pain. There was no history of trauma, tuberculosis, or an immunocompromised status. Clinical examination revealed a young boy with normal findings for general physical condition, higher mental functions, cranial nerves and upper limbs. There was flaccid paraplegia: knee and ankle jerks were absent on either side, plantar flexors were mute and superficial abdominal reflexes could not be elicited. Sensory examination revealed hypoaesthesia over TI1-L1 dermatomes and total anaesthesia below the L1 level with sacral sparing. Bladder sensations were absent. There was no spinal tenderness. The haematological findings, urinalysis and plain X-rays of the dorsal spine were normal. Iohexol myelography showed a complete intramedullary block at the L1 level. CT scanning following myelography confirmed the same findings (Figs. 1, 2). Correspondence to; V.K. Kak
Fig. 2. Iohexol CT of the dorso-lumbar region showing an intramedullary space-occupying lesion
291 At surgery a T8-LI laminectomy was done. The dura mater was bulging. After opening of the dura, dull yellow arachnoid was seen with underlying pus in the lower part of the operative field. Seven milliliters of yellow-coloured, non-foul-smelling pus was aspirated. After performance of a longitudinal myelotomy over the conus, a 2 cmx 0.5 em abscess cavity was excised. Histopathological examination showed inflammatory granulation tissue comprising vascular proliferation, chronic inflammatory cells and hyalinised fibrous tissue forming the external layer. Collection of macrophages (gitter cells) and possibly haemosiderin pigment was seen in the centre. No granuloma were noticed. Gram staining as well as staining for acid-fast bacilli did not reveal any organisms. The pus was sterile after 24 h incubation. The patient showed some improvement in sensations following surgery, though his motor power and bladder function remained unchanged.
Discussion The first report of I M S C A was published by H a r t in 1830 [5, 8], and to date a little over 75 cases have been reported [1, 5-71. I M S C A can be acute, subacute or chronic, depending on the duration of illness, solitary or multiple, and primary or secondary [2, 9]. It is commonly seen in the dorsal region, although it can occur anywhere from the cervical to the l u m b a r region [3, 8, 9]. Patients with acute abscesses present with local pain, dysaesthesias, urinary incontinence, fever, signs of infection and nuchal rigidity without meningeal involvement. A partial or complete transverse myelitis m a y be gradual or sudden in onset. Patients with subacute or chronic abscesses present with symptoms and signs mimicking those of intramedullary tumours [8]. Peripheral leucocyte count and CSF findings are usually inconclusive in these patients. Skeletal abnormalities are rarely seen in primary 1MSCAs, but radiological changes usually demonstrate the primary pathology in cases of secondary IMSCAs, e.g. intramedullary tumours, spinal dysraphisms or osteomyelitis [8]. Myelography usually indicates widening of the spinal cord, with or without a block. Hoche [4] demonstrated that metastatic abscesses in the spinal cord are a sequel to infection in an area of infarction. Due to low pressure in the vertebral venous plexus and backflow from intrathoracic and intraabdominal pressure, blood remains pooled, thus enabling organisms from a distance to enter the spinal cord. The subarachnoid space is also connected with the abdominal cavity, retroperitoneal space and mediastinum by lymphatics along the spinal nerves [8]. Of late some cases of I M S C A have been reported in drug addicts and patients with i m m u n o c o m p r o m i s e d status due to H I V infection [6]. C o m m o n organisms in these cases have been staphylococci, streptococci and gramnegative organisms, although in a significant n u m b e r of cases no organisms were shown [8]. An intramedullary abscess caused by Pseudomonas cepacia has also been reported [6]. The treatment of I M S C A consists of surgical evacuation of pus combined with the use of appropriate antibiotics and steroids to reduce oedema. The advent of antibiotics has resulted in reduced morbidity [8].
Acute abscesses have a poorer prognosis than subacute and chronic ones and earlier intervention gives better results.
References 1. Arzt PK (1944) Abscess within the spinal cord: review of literature and report of three cases. Arch Neurol Psychiatry 51: 533543 2. Bell WE, Menezes AH (1980) Focal suppurative diseases of the central nervous system. In: Kelley VC (ed) Practice of paediatries. Harper & Row, Hagerstown, Md, pp 1-28 3. Blalock JB, Hood TW, Maxwell RE (1982) Intramedullary spinal cord abscess: case report. J Neurosurg 57:270-273 4. Hoche A (1899) Experimentelle Beitrfige zur Pathologic des Rfickenmarkes. Arch Psychiatr Nervenkr 32:975-1008 5. Kak VK, Gulati DR, Chander K (1972) Spinal suppurations. Neurology (India) 20 [Suppl II]: 334-338 6. Koppel BS, Daras H, Duffy KR (1990) Intramedullary spinal cord abscess. Neurosurgery 26:145-146 7. Marwaha RK (1985) Intramedullary spinal cord abscess. Ind Pediatr 22:71-74 8. Menezes AH, VanGilder JC (1985) Spinal cord abscess. In: Wilkins RH, Rengachary SS (eds) Neurosurgery, vol 3. McGraw-Hill, New York, pp 1969-1972 9. Menezes AH, Graf CJ, Perret GE (1977) Spinal cord abscess: a review. Surg Neurol 8:461 467
Geographic editor's comment Intramedullary spinal cord abscess is an entity that one has to bear in mind when a patient develops a precipitous or rapidly progressive spinal lesion, especially when associated with fever and severe backache. It m a y not be associated with root pains, which are characteristically seen with an acute epidural abscess. The infection is usually blood-borne and the abscess is c o m m o n l y located in the region of the conus. M R I would be an ideal m o d e of investigation of these lesions. Besides showing the extent of the lesion, it would suggest its nature as well. If well formed, the capsule would show up with contrast medium. If the abscess were secondary to a primary pathology like a dermoid, this would be shown by MRI. The possibility of a tubercular abscess or granuloma should also be borne in mind in countries where neurotuberculosis is prevalent. N o t infrequently, associated small tubercles m a y be seen on the surface of the cord. Examination of the pus shows tubercle bacilli. It is not necessary to excise the lesion totally unless this can be done safely, as antitubercular drugs can resolve the lesion completely. The pyogenic abscess m a y be excised totally provided it has a well-formed capsule. Aspiration of the abscess, its marsupialisation, and vigorous antibiotic treatment would otherwise be the best way of treating it. The prognosis would be p o o r in the case of an abscess with precipitous onset due to vascular involvement. S.N. Bhagwati
Case reports
9 Springer-Verlag 1992 Child's Nerv Syst (1992) 8:290-291
Intramedullary spinal cord abscess: a case report M.K. Tewari 1, B. Indira Devi 1, R. C. Thakur 1, A. Pathak 1 N. Khandelwal 2, and V.K. Kak 1 1 Department of Neurosurgery and 2 Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh- 160 012, India Received April 30, 1991
Abstract. A n 11-year-old b o y p r e s e n t e d with p a i n in the b a c k , u r i n a r y retention, p a r a p l e g i a a n d loss of sensations b e l o w L1. I n v e s t i g a t i o n s r e v e a l e d a n i n t r a m e d u l l a r y lesion. A n i n t r a m e d u l l a r y spinal c o r d abscess was f o u n d at surgery. T h e pus was e v a c u a t e d a n d abscess was excised. M i n i m a l r e c o v e r y was seen following surgery. E a r l y interv e n t i o n a n d a high index of s u s p i c i o n is r e q u i r e d in such cases.
Key words: Abscess i n t r a m e d u l l a r y - Abscess spinal c o r d
I n t r a m e d u l l a r y spinal c o r d abscess ( I M S C A ) is a rare c o n d i t i o n which in the p r e - a n t i b i o t i c e r a used to have a fatal o u t c o m e . T h e scene has c h a n g e d , however, with the a d v e n t of a n t i b i o t i c s [9]. A n a w a r e n e s s of this c o n d i t i o n is essential for early d i a g n o s i s a n d m a n a g e m e n t . O n e such case is discussed in the p r e s e n t c o m m u n i c a t i o n .
Fig. 1. Iohexol myelogram suggestive of an intramedullary spaceoccupying lesion at the T12-L1 level
Case report An 11-year-old boy presented with non-radiating pain in the dorsolumbar region of 40 days' duration, which used to increase on lying down. He also had retention of urine with overflow for 1 month and rapidly progressive weakness of both lower limbs for 20 days leading to paraplegia in 5 days. There was history of moderate grade fever for 4 days prior to the onset of pain. There was no history of trauma, tuberculosis, or an immunocompromised status. Clinical examination revealed a young boy with normal findings for general physical condition, higher mental functions, cranial nerves and upper limbs. There was flaccid paraplegia: knee and ankle jerks were absent on either side, plantar flexors were mute and superficial abdominal reflexes could not be elicited. Sensory examination revealed hypoaesthesia over TI1-L1 dermatomes and total anaesthesia below the L1 level with sacral sparing. Bladder sensations were absent. There was no spinal tenderness. The haematological findings, urinalysis and plain X-rays of the dorsal spine were normal. Iohexol myelography showed a complete intramedullary block at the L1 level. CT scanning following myelography confirmed the same findings (Figs. 1, 2). Correspondence to; V.K. Kak
Fig. 2. Iohexol CT of the dorso-lumbar region showing an intramedullary space-occupying lesion
291 At surgery a T8-LI laminectomy was done. The dura mater was bulging. After opening of the dura, dull yellow arachnoid was seen with underlying pus in the lower part of the operative field. Seven milliliters of yellow-coloured, non-foul-smelling pus was aspirated. After performance of a longitudinal myelotomy over the conus, a 2 cmx 0.5 em abscess cavity was excised. Histopathological examination showed inflammatory granulation tissue comprising vascular proliferation, chronic inflammatory cells and hyalinised fibrous tissue forming the external layer. Collection of macrophages (gitter cells) and possibly haemosiderin pigment was seen in the centre. No granuloma were noticed. Gram staining as well as staining for acid-fast bacilli did not reveal any organisms. The pus was sterile after 24 h incubation. The patient showed some improvement in sensations following surgery, though his motor power and bladder function remained unchanged.
Discussion The first report of I M S C A was published by H a r t in 1830 [5, 8], and to date a little over 75 cases have been reported [1, 5-71. I M S C A can be acute, subacute or chronic, depending on the duration of illness, solitary or multiple, and primary or secondary [2, 9]. It is commonly seen in the dorsal region, although it can occur anywhere from the cervical to the l u m b a r region [3, 8, 9]. Patients with acute abscesses present with local pain, dysaesthesias, urinary incontinence, fever, signs of infection and nuchal rigidity without meningeal involvement. A partial or complete transverse myelitis m a y be gradual or sudden in onset. Patients with subacute or chronic abscesses present with symptoms and signs mimicking those of intramedullary tumours [8]. Peripheral leucocyte count and CSF findings are usually inconclusive in these patients. Skeletal abnormalities are rarely seen in primary 1MSCAs, but radiological changes usually demonstrate the primary pathology in cases of secondary IMSCAs, e.g. intramedullary tumours, spinal dysraphisms or osteomyelitis [8]. Myelography usually indicates widening of the spinal cord, with or without a block. Hoche [4] demonstrated that metastatic abscesses in the spinal cord are a sequel to infection in an area of infarction. Due to low pressure in the vertebral venous plexus and backflow from intrathoracic and intraabdominal pressure, blood remains pooled, thus enabling organisms from a distance to enter the spinal cord. The subarachnoid space is also connected with the abdominal cavity, retroperitoneal space and mediastinum by lymphatics along the spinal nerves [8]. Of late some cases of I M S C A have been reported in drug addicts and patients with i m m u n o c o m p r o m i s e d status due to H I V infection [6]. C o m m o n organisms in these cases have been staphylococci, streptococci and gramnegative organisms, although in a significant n u m b e r of cases no organisms were shown [8]. An intramedullary abscess caused by Pseudomonas cepacia has also been reported [6]. The treatment of I M S C A consists of surgical evacuation of pus combined with the use of appropriate antibiotics and steroids to reduce oedema. The advent of antibiotics has resulted in reduced morbidity [8].
Acute abscesses have a poorer prognosis than subacute and chronic ones and earlier intervention gives better results.
References 1. Arzt PK (1944) Abscess within the spinal cord: review of literature and report of three cases. Arch Neurol Psychiatry 51: 533543 2. Bell WE, Menezes AH (1980) Focal suppurative diseases of the central nervous system. In: Kelley VC (ed) Practice of paediatries. Harper & Row, Hagerstown, Md, pp 1-28 3. Blalock JB, Hood TW, Maxwell RE (1982) Intramedullary spinal cord abscess: case report. J Neurosurg 57:270-273 4. Hoche A (1899) Experimentelle Beitrfige zur Pathologic des Rfickenmarkes. Arch Psychiatr Nervenkr 32:975-1008 5. Kak VK, Gulati DR, Chander K (1972) Spinal suppurations. Neurology (India) 20 [Suppl II]: 334-338 6. Koppel BS, Daras H, Duffy KR (1990) Intramedullary spinal cord abscess. Neurosurgery 26:145-146 7. Marwaha RK (1985) Intramedullary spinal cord abscess. Ind Pediatr 22:71-74 8. Menezes AH, VanGilder JC (1985) Spinal cord abscess. In: Wilkins RH, Rengachary SS (eds) Neurosurgery, vol 3. McGraw-Hill, New York, pp 1969-1972 9. Menezes AH, Graf CJ, Perret GE (1977) Spinal cord abscess: a review. Surg Neurol 8:461 467
Geographic editor's comment Intramedullary spinal cord abscess is an entity that one has to bear in mind when a patient develops a precipitous or rapidly progressive spinal lesion, especially when associated with fever and severe backache. It m a y not be associated with root pains, which are characteristically seen with an acute epidural abscess. The infection is usually blood-borne and the abscess is c o m m o n l y located in the region of the conus. M R I would be an ideal m o d e of investigation of these lesions. Besides showing the extent of the lesion, it would suggest its nature as well. If well formed, the capsule would show up with contrast medium. If the abscess were secondary to a primary pathology like a dermoid, this would be shown by MRI. The possibility of a tubercular abscess or granuloma should also be borne in mind in countries where neurotuberculosis is prevalent. N o t infrequently, associated small tubercles m a y be seen on the surface of the cord. Examination of the pus shows tubercle bacilli. It is not necessary to excise the lesion totally unless this can be done safely, as antitubercular drugs can resolve the lesion completely. The pyogenic abscess m a y be excised totally provided it has a well-formed capsule. Aspiration of the abscess, its marsupialisation, and vigorous antibiotic treatment would otherwise be the best way of treating it. The prognosis would be p o o r in the case of an abscess with precipitous onset due to vascular involvement. S.N. Bhagwati
