J Neurosurg 76:307-311, 1992
Spinal subdural abscess Case report RONALD H. BARTELS, M.D., T. Ron DE JONG, M.D., AND J. ANDRI~ GROTENHUIS, M.D.
University Hospital Nijmegen, Department of Neurosurgery, Nijmegan, The Netherlands v, Only 44 cases of spinal subdural abscess have been reported to date. The authors present another case and review the relevant literature. The findings of intraspinal gassification on computerized tomography scans and Escherichia coli as the causative organism have not previously been described in relation to spinal subdural abscess. Most frequently, Staphylococcus aureus is the responsible organism. Hematogenous spread of infection from a distant source often takes place. In a surprising number of incidences, iatrogenic causes are the primary foci of spinal subdural abscess. Spinal subdural abscess is an unpredictable disease, with an unfavorable outcome if left untreated. If there is suspicion of a spinal subdural abscess, urgent radiological examination followed by immediate surgical drainage and appropriate antibiotic therapy is warranted. KEY WORDS
"
abscess
9 E s c h e r l c h i a coil
PINAL subdural abscesses are rare. Most neurosurgical textbooks omit the subject or mention it only briefly. Recent experience with a patient exhibiting this abscess stimulated us to conduct a search of the literature. Since the first description by Sittig 32 in 1927, only 44 such cases have been described. 1-16'18-35 These cases are reviewed and our case is presented. The need for proper diagnosis and prompt surgical intervention is stressed since treatment of spinal subdural abscess has a high probability of success, whereas the outcome of nonsurgically treated patients is bleak.
S
Case Report
This 55-year-old man with insulin-independent diabetes mellitus and moderate radicular pains in the left arm due to cervical spondylarthrosis was referred to our neurosurgical unit. The patient presented with progressive quadriplegia that was more pronounced on the left side, urinary incontinence, and sensory loss, particulady on the right side. These symptoms had developed within a 24-hour period. During the 2-week period before admission, he had suffered high fevers with chills and lancinating pains in all limbs. He had no history of instrumentation, such as catheterization or cystoscopy.
J. Neurosurg. / Volume 76 /February, 1992
9
intraspinal gassification
9 spinal lesion
Examination. On admission, the patient's general physical examination showed no abnormalities except for a fever of 38.4*C. There were no signs of peripheral infection. Neurological examination revealed spastic paresis below the C-6 level, particularly pronounced on the left side. The triceps reflex was absent on both sides, while the tendon jerks of the legs were hyperreactive with bilateral Babinski's sign. Sensation was diminished below the T- 1 level. A stiff neck was also noted. The patient's erythrocyte sedimentation rate was elevated (80 mm/hr; normal: < 5 m m in 1st hour), as were the number of leukocytes (l 3.2; normal < 10.0 x l0 -9) and the blood glucose level (18.6 mmol/liter; normal 3.5 to 6.5 retool/liter). All other specimen values fell within the normal ranges. Cultures of blood, urine, and sputum showed no growth. A computerized tomography scan disclosed air in the spinal canal from C-5 to C-7 on the left side (Fig. 1). Discrimination between epi- and subdural localization was not possible. Because a spinal abscess was suspected and therefore surgical intervention was warranted, no further radiological examination, such as myelography, was carried out. Operation. An emergency C5-7 laminectomy was performed. No epidural abscess was found. The strongly 307
R. H. Bartels, T. R. de Jong, and J. A. Grotenhuis
FIG. 1. Computerized tomography scan showing intraspinal air on the left side at the C-5 level.
tensed but nonpulsating dural sac was opened at the C6-7 level. The spinal cord was found to be enlarged, with an altered appearance. On the left side, a subdural empyema around the C6-7 roots was excised. To exclude intramedullary abscess formation, the spinal cord was punctured at the midline, where the swelling was most prominent; however, no pus could be aspirated. After closure of the dura, the wound was closed in layers. Postoperative Course. Cultures of the empyema were positive for Escherichia coli. Intravenous administration of co-trimoxazole (960 rag twice daily), metronidazole (500 mg three times a day), and cefuroxime (2.5 gm four times a day) was started. The patient's neurological condition gradually improved. Two weeks after surgery, the administration of metronidazole and co-trimoxazole was stopped but the cefuroxime was continued for 6 weeks. Four weeks after surgery, the patient was referred to a rehabilitation center. Five months later, although his gait was spastic, he could walk without assistance. The intrinsic musculature of the left hand was still severely paretic (1/5), while the strength of the musculature of the fight hand was nearly normal. He still complained of root pains in the left arm. Magnetic resonance imaging disclosed cervical spondylarthrosis with instability, a pathologically broadened myelin sheath from C-4 to T-l, and an abnormal signal intensity, interpreted as the result of an infectious process (Fig. 2). In cooperation with an orthopedic surgeon, an intercorporal spondylodesis was performed from C-4 to C-7. The cervical spine was immobilized by a Minerva brace for a period of 3 months. Postoperatively, 308
FIG. 2. Postoperative T~-weighted magnetic resonance image disclosing spondylarthrosis, a broadened myelin sheath extending from C-4 to T-I, and an abnormal signal intensity, interpreted as the result of an infectious process.
the patient's brachialgia disappeared. He has regained the ability to perform normal daily activities and to work full time at his former job.
Discussion Incidence of Spinal Subdural Abscess The exact incidence of spinal subdural abscess is unknown. Including our patient, only 45 cases have been reported, j-~6.~8-35The relative scarcity of reported cases of spinal in comparison with cranial subdural abscesses has been ascribed to the absence of sinuses in the spine, the width of the epidural spinal space acting TABLE 1 Initial versus late symptomsfor 45 patients with spinal subdural abscesses* Symptom
Onset of Symptoms
Initial Late fever 25 (55.6%) 39 (86.7%) spinal/limb pain 38 (84.4%) 38 (84.4%) motor deficit 4 (8.9%) 37 (82.2%) sensory loss 0 (0%) 26 (57.8%) sphincter dysfunction 0 (0%) 24 (53.3%) * Late symptomsare defined as those presentingjust prior to death or therapy. J. Neurosurg. / Volume 76/February, 1992
Spinal subduralabscess
FIG. 3. Graph showingage distribution of 44 patients with spinal subdural abscess. The age and sex of one patient are unknown. as a filter, and the centripetal direction of the spinal blood flow in contrast with the predominantly centrifugaUy oriented bloodstream in the head."'26 The male:female ratio of the cases reported was 1.1:1. The age of the patients at diagnosis ranged from 9 months to 77 years. In nearly 50% of the reported cases, the patients were between 49 and 70 years of age. Spinal subdural abscess occurred more frequently in men in the fifth and sixth decade of life, while women were more affected in the seventh decade (Fig. 3). Clinical Presentation The symptoms of spinal subdural abscess include fever, spinal or root pain, and neurological deficit, depending on the location (Table 1). In 55.6% of the cases, the initial symptom was fever, while 84.4% presented with spinal and/or radiating pain. A combination of fever and spinal and/or root pain was present in 37.8% of the cases. During the course of the disease, 82.2% of the patients developed motor deficit, 57.8% sensory loss, and 53.3% sphincter disturbances. Analogous to the stages of progression of symptoms proposed by HeusneP 7 for spinal epidural abscess, symptoms of spinal subdural abscess appear to occur in a certain sequence; Stage 1: fever, either in combination with or without spinal and/or root pain; Stage 2: motor deficit, sensory loss, and/or sphincter disturbances; and Stage 3: paralysis and complete sensory loss below the level of the lesion. In our case, symptoms developed in the order outlined above. The rate of progression from one stage to another is not predictable. The duration of symptoms from their onset until patient death or therapeutic intervention ranged from 1 day to approximately I year. A division between acute (duration _< 1 week), subacute (2 to 8 weeks), and chronic (> 8 weeks) spinal subdural abscess can be made. Most spinal subdural abscesses were subacute (28 cases), six were chronic, and five acute; in six cases, the duration was not known. The location of the spinal subdural abscesses, upon which the extent of symptoms is dependent, is illustrated in Fig. 4. J. Neurosurg. / Volume 76/February, 1992
FI6. 4. Diagram showing the location of spinal subdural abscess in 43 patients.
Differential diagnosis includes acute transverse myelitis, spinal epidural abscess, epidural hematoma, vertebral osteomyelitis, and intraspinal tumor. 2,7,9,24,26 Neuroradiographic Examination Myelographic studies may confirm the presence of an intraspinal space-occupying process. In 28 of the 30 cases in which myelography was performed, a blockage with or without intradural irregularities was found. The myelographic features are not as characteristic as some have described. 24'34 In the remaining two cases, only intradural irregularities were found. Computerized tomography was performed in only seven cases; in five, the scans revealed an intraspinal space-occupying lesion. Intraspinal gassification, as demonstrated in our case, has not been described before. Spinal subdural abscess was diagnosed using magnetic resonance imaging in only one case?~ Treatment In conformity with the old adage ubipus, ibi evacua, surgical drainage followed by appropriate antibiotic therapy is the optimum treatment (Table 2). In the surgically treated group, 32 (82.1%) of the 39 patients
TABLE 2 O~comefor44patientswith ~inalsubduralabscesses* Ou~ome complete recovery improved death total
Treatment Surgical 12 (27.3%) 20 (45.4%) 7 (15.9%) 39 (88.6%)
Conservative 0 (0%) 1 (2.3%) 4 (9.1%) 5 (11.4%)
Total 12 (27.3%) 21 (47.7%) 11 (25%) 44 (100%)
* The treatment in one patient was unknown.
309
R. H. Bartels, T. R. de Jong, and J. A. Grotenhuis TABLE 3
TABLE 4
Duration of symptoms and outcome in the 39 surgically treated patients wit,5 spinal subdural abscesses
Causative organisms for 45 patients with spinal subdural abscesses
Outcome
Duration of Symptoms*
Acute Subacute Chronic Unknown complete recovery 1 (25%) 8 (30.8%) 1 (16.7%) I (33.3%) improved 3 (75%) 13 (50.0%) 4 (66.6%) 2 (66.7%) death 0 5(19.2%) 1(16.7%) 0 total 4(100%) 26(100%) 6(100%) 3(100%) * Acute = duration _< 1 wk; subacute = duration 2 to 8 wk; chronic = duration > 8 wk.
survived; in contrast, one (20%) of five patients in the conservatively managed group survived. All surviving patients improved or completely recovered. In no patient did the symptoms worsen, and in none was the outcome affected by the duration of symptoms (Table 3). Therefore, we recommend immediate surgical decompression and drainage if a spinal abscess is suspected after clinical and neuroradiographic examination. Appropriate antibiotic therapy using susceptibility testing of the cultured organism should follow surgery. The issue of coexistent epi- and subdural abscesses should be addressed. If the dura is found to be tense but not pulsating after evacuation of an epidural abscess, intradural inspection is warranted. The consequences of ignoring a nonpulsating dura, including clinical deterioration and subsequent surgery, are well demonstrated by the case described by Sittig? 2 Frank pus, whether encapsulated or not, was most often encountered at surgery or autopsy (Fig. 5). The
FIG. 5. Graph showing the relationship between the duration of symptoms and the finding at surgery or autopsy in 41 patients. Acute = duration _< 1 week; subacute = duration 2 to 8 weeks; chronic = duration _> 8 weeks. 310
Causative Organism Staphylococcus aureus Staphylococcus epidermidis Pseudomonas aeruginosa Streptococcus milleri/Bacteroides corrodens Bacteroides melangolicus/Fusobacterium sp/ Streptococcus viridans Diplococeus pneumoniae haemolyticStreptococcus Peptococcus magnus Escherichia coli
sterile unknown total
No. of Cases 25 1 1 1
1 1 1 1 1
2 10 45
presence of frank pus in 62.5% of the chronic spinal subdural abscesses is remarkable. As expected, granulation tissue has not been found in patients with acute spinal subdural abscess. Pathogenesis
The causative agent was identified in all but 12 cases (Table 4). Staphylococcus aureus was the responsible organism in 25 cases; Escherichia coli had not been encountered as the causative organism before our case. Organisms producing spinal subdural abscess reach the subdural space via several routes. Most frequently, hematogenous spread from a distant focus takes place with peripheral infections such as furunculosis being the primary source (Fig. 6). Direct extension of a contiguous infection is a different but infrequent route. The number of patients with spinal subdural abscess related to iatrogenic causes, such as lumbar puncture, injection of a local anesthetic agent, and discography, J'3`s1~'22"23" 26.3.~ is striking. In 10 cases, accompanying factors or diseases that diminished the patient's resistance to infections were present. These are summarized in Table 5.
FIG. 6. Graph showing the foci in 45 patients with spinal subdural abscess. J. Neurosurg. / Volume 76 / February, 1992
Spinal subdural abscess TABLE 5 Accompanying diseases orfactors for 45 patients with spinal subdural abscesses Disease or Factor lues diabetes meUitus Crohn'sdisease rheumatoid arthritis intravenous drug abuse unknown none total
No. of Cases 1 6 1 1 1 1 34 45
Conclusions Spinal subdural abscess is a rare but treacherous disease. The rate of progression of symptoms is unpredictable and outcome may be unfavorable. Therefore, if a spinal subdural abscess is suspected (for example, as in the case of the febrile patient with spinal pain after a lumbar puncture), urgent radiological examination is warranted, followed by immediate surgical drainage and appropriate antibiotic therapy. The coexistence ofepi- and subdural abscesses should be noted. References 1. Abbott KH: Acute subdural spinal abscess. Report of case. Bull Los Angeles Neurol Soc 5:227-231, 1940 2. Abramovitz JN, Batson RA, Yablon JS: Vertebral osteomyelitis. The surgical management of neurologic complications. Spine 11:418-420, 1986 3. Arnett JH: Meningocoecic (later also staphylococcic) meningitis, low spinal subarachnoid block, abscess, laminectomy, recovery. Med Clin North Am 13:1051-1062, 1930 4. Bennett AE, Keegan J J: Circumscribed suppurations of the spinal cord and meninges. Report of a case of subdural abscess with functional recovery following operation. Arch Neurol Psychiatry 19:329-333, 1928 5. Butler EG, Dohrmann PJ, Stark RJ: Spinal subdural abscess. Clin Exp Neurol 25:67-70, 1988 6. Chi CY: Intraspinal subdural abscess. Chinese Med J 50: 921-926, 1936 7. Dacey RG, Winn HR, Jane JA, et al: Spinal subdural empyema: report of two cases. Nenrosurgery 3:400-403, 1978 8. Dfis V: Spinal peripachymeningitis (epidural abscess). Report of 8 cases. J Neurosurg 17:972-983, 1960 9. Fraser RAR, Ratzan K, Wolpert SM, et ah Spinal subdural empyema. Arch Neurol 28:235-238, 1973 10. Freedman H, Alpers BJ: Spinal subdural abscess. Arch Neurol Psychiatry 60:49-60, 1948 11. Grubel G: Bericht tiber ein spinales subdurales Empyem. Acta Neurochir 22:2 t 3-216, 1970 12, Hurries-Jones R, Hernandez-Bronchud M, Anslow P, et al: Meningitis and spinal subdural empyema as a complication of sinusitis. J Neurol Neurosnrg Psychiatry 53:441, 1990 (Letter) 13. Harris LF, Haws FP, Triplett JN Jr, et al: Subdural empyema and epidural abscess. Recent experience in a community hospital. South Med J 80:1254-1258, 1987 14. Heindel CC, Ferguson JP, Kumarasamy T: Spinal subdural empyema complicating pregnancy. Case report. J J. Neurosurg. / Volume 76 / February, 1992
Neurosurg 40:654-656, 1974 15. Hershkowitz S, Link R, Ravden M, et al: Spinal empyema in Crohn's disease. J Clin Gastroenterol 12:67-69, 1990 16. Hesketh KT: Sub-dural abscess of the lumbar cord. Report of a patient with recurring paraplegia. Paraplegia 3: 161-164, 1965 17. Heusner AP: Nontuberculous spinal epidural infections. N Engl J Med 239:845-854, 1948 18. Hirson C: Spinal subdural abscess. Lancet 2:1215-1217, 1965 19. Kumar S, Gulati DR: Spinal abscesses. A report on 22 cases. Neurol India 26:193-195, 1978 20. Kurokawa Y, Hashi K, Fujishige M, et al: [Spinal subdural empyema diagnosed by MRI and recovery by conservative treatment.] No To Shinkei 41:513-517, 1989 (Jpn) 21. Lomholdt Knudsen L, Voldby B, Stagaard M: Computed tomographic myelography in spinal subdural empyema. Neuroradiology 29:99, t987 22. Lownie SP, Ferguson GG: Spinal subdural empyema complicating cervical discography. Spine 14:1415-1417, 1989 23. Negrin J Jr, Clark RA Jr: Pyogenic subdural abscess of the spinal meninges. Report of two cases. J Nenrosurg 9: 95-100, 1952 24. Patronas NJ, Marx WJ, Ducla EE: Radiographic presentation of spinal abscess in the subdural space. AJR 132: 138-139, 1979 25. Penkert G, Fliedner E: Spinales subdurales Empyema nach Stromverletzung. Unfallheilknnde 85:473-477, 1982 26. Probst C, Wicki G: Spinale subdurale Empyeme und Abszesse. Schweiz Arch Neurol Neuroehir Psychiatr 134: 53-70, 1984 27. Raskind R, Weiss SR: Subdural and extradural abscess with unusual complication and complete recovery. Int Surg 52:440-443, 1969 28. Reddy DR, Rao GN, Krishnamurthy D: Pneumococcal spinal subdural abscess (a case report). J Postgrad Med 19:190-192, 1973 29. Schiller F, Shadle OW: Extrathecal and intrathecal suppuration. Report of two cases and discussion of the spinal subdural space. Arch Neurol 7:33-36, 1962 30. Schnegg JF, Glauser M, de Tribolet N: Infection of a lumbar dermoid cyst by an anaerobic peptococcus. Acta Neurochir 58:127-129, 1981 31. Scully RE, Mark EJ, McNeely BU: Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 47-1984. N Engl J Med 311: 1365-1370, 1984 32. Sittig O: Metastatischer Riickenmarksabscess bei septischem Abortus, Z Neurol Psyehiatr 107:146-151, 1927 33. Takenaka K, Kobayashi H, Niikawa S, et at: [Spinal subdural abscess - - report of a case and a review of the literature of 43 cases.] No To Shinkei 41:331-336, 1989 (Jpn) 34. Theodotou B, Woosley RE, Whaley RA: Spinal subdural empyema: diagnosis by spinal computed tomography. Surg Neurol 21:610-612, 1984 35. Walker AE, Bucy PC: Congenital dermal sinuses: a source of spinal meningeal infection and subdural abscesses. Brain 57:401-421, 1934 Manuscript received March 28, 1991. Accepted in final form July 16, 1991. Address reprint requests to: Ronald H. Bartels, M.D., Department of Neurosurgery, University Hospital Nijmegen, Reinier Postlaan 4, 6500 HB Nijmegen, The Netherlands. 311
Spinal subdural abscess Case report RONALD H. BARTELS, M.D., T. Ron DE JONG, M.D., AND J. ANDRI~ GROTENHUIS, M.D.
University Hospital Nijmegen, Department of Neurosurgery, Nijmegan, The Netherlands v, Only 44 cases of spinal subdural abscess have been reported to date. The authors present another case and review the relevant literature. The findings of intraspinal gassification on computerized tomography scans and Escherichia coli as the causative organism have not previously been described in relation to spinal subdural abscess. Most frequently, Staphylococcus aureus is the responsible organism. Hematogenous spread of infection from a distant source often takes place. In a surprising number of incidences, iatrogenic causes are the primary foci of spinal subdural abscess. Spinal subdural abscess is an unpredictable disease, with an unfavorable outcome if left untreated. If there is suspicion of a spinal subdural abscess, urgent radiological examination followed by immediate surgical drainage and appropriate antibiotic therapy is warranted. KEY WORDS
"
abscess
9 E s c h e r l c h i a coil
PINAL subdural abscesses are rare. Most neurosurgical textbooks omit the subject or mention it only briefly. Recent experience with a patient exhibiting this abscess stimulated us to conduct a search of the literature. Since the first description by Sittig 32 in 1927, only 44 such cases have been described. 1-16'18-35 These cases are reviewed and our case is presented. The need for proper diagnosis and prompt surgical intervention is stressed since treatment of spinal subdural abscess has a high probability of success, whereas the outcome of nonsurgically treated patients is bleak.
S
Case Report
This 55-year-old man with insulin-independent diabetes mellitus and moderate radicular pains in the left arm due to cervical spondylarthrosis was referred to our neurosurgical unit. The patient presented with progressive quadriplegia that was more pronounced on the left side, urinary incontinence, and sensory loss, particulady on the right side. These symptoms had developed within a 24-hour period. During the 2-week period before admission, he had suffered high fevers with chills and lancinating pains in all limbs. He had no history of instrumentation, such as catheterization or cystoscopy.
J. Neurosurg. / Volume 76 /February, 1992
9
intraspinal gassification
9 spinal lesion
Examination. On admission, the patient's general physical examination showed no abnormalities except for a fever of 38.4*C. There were no signs of peripheral infection. Neurological examination revealed spastic paresis below the C-6 level, particularly pronounced on the left side. The triceps reflex was absent on both sides, while the tendon jerks of the legs were hyperreactive with bilateral Babinski's sign. Sensation was diminished below the T- 1 level. A stiff neck was also noted. The patient's erythrocyte sedimentation rate was elevated (80 mm/hr; normal: < 5 m m in 1st hour), as were the number of leukocytes (l 3.2; normal < 10.0 x l0 -9) and the blood glucose level (18.6 mmol/liter; normal 3.5 to 6.5 retool/liter). All other specimen values fell within the normal ranges. Cultures of blood, urine, and sputum showed no growth. A computerized tomography scan disclosed air in the spinal canal from C-5 to C-7 on the left side (Fig. 1). Discrimination between epi- and subdural localization was not possible. Because a spinal abscess was suspected and therefore surgical intervention was warranted, no further radiological examination, such as myelography, was carried out. Operation. An emergency C5-7 laminectomy was performed. No epidural abscess was found. The strongly 307
R. H. Bartels, T. R. de Jong, and J. A. Grotenhuis
FIG. 1. Computerized tomography scan showing intraspinal air on the left side at the C-5 level.
tensed but nonpulsating dural sac was opened at the C6-7 level. The spinal cord was found to be enlarged, with an altered appearance. On the left side, a subdural empyema around the C6-7 roots was excised. To exclude intramedullary abscess formation, the spinal cord was punctured at the midline, where the swelling was most prominent; however, no pus could be aspirated. After closure of the dura, the wound was closed in layers. Postoperative Course. Cultures of the empyema were positive for Escherichia coli. Intravenous administration of co-trimoxazole (960 rag twice daily), metronidazole (500 mg three times a day), and cefuroxime (2.5 gm four times a day) was started. The patient's neurological condition gradually improved. Two weeks after surgery, the administration of metronidazole and co-trimoxazole was stopped but the cefuroxime was continued for 6 weeks. Four weeks after surgery, the patient was referred to a rehabilitation center. Five months later, although his gait was spastic, he could walk without assistance. The intrinsic musculature of the left hand was still severely paretic (1/5), while the strength of the musculature of the fight hand was nearly normal. He still complained of root pains in the left arm. Magnetic resonance imaging disclosed cervical spondylarthrosis with instability, a pathologically broadened myelin sheath from C-4 to T-l, and an abnormal signal intensity, interpreted as the result of an infectious process (Fig. 2). In cooperation with an orthopedic surgeon, an intercorporal spondylodesis was performed from C-4 to C-7. The cervical spine was immobilized by a Minerva brace for a period of 3 months. Postoperatively, 308
FIG. 2. Postoperative T~-weighted magnetic resonance image disclosing spondylarthrosis, a broadened myelin sheath extending from C-4 to T-I, and an abnormal signal intensity, interpreted as the result of an infectious process.
the patient's brachialgia disappeared. He has regained the ability to perform normal daily activities and to work full time at his former job.
Discussion Incidence of Spinal Subdural Abscess The exact incidence of spinal subdural abscess is unknown. Including our patient, only 45 cases have been reported, j-~6.~8-35The relative scarcity of reported cases of spinal in comparison with cranial subdural abscesses has been ascribed to the absence of sinuses in the spine, the width of the epidural spinal space acting TABLE 1 Initial versus late symptomsfor 45 patients with spinal subdural abscesses* Symptom
Onset of Symptoms
Initial Late fever 25 (55.6%) 39 (86.7%) spinal/limb pain 38 (84.4%) 38 (84.4%) motor deficit 4 (8.9%) 37 (82.2%) sensory loss 0 (0%) 26 (57.8%) sphincter dysfunction 0 (0%) 24 (53.3%) * Late symptomsare defined as those presentingjust prior to death or therapy. J. Neurosurg. / Volume 76/February, 1992
Spinal subduralabscess
FIG. 3. Graph showingage distribution of 44 patients with spinal subdural abscess. The age and sex of one patient are unknown. as a filter, and the centripetal direction of the spinal blood flow in contrast with the predominantly centrifugaUy oriented bloodstream in the head."'26 The male:female ratio of the cases reported was 1.1:1. The age of the patients at diagnosis ranged from 9 months to 77 years. In nearly 50% of the reported cases, the patients were between 49 and 70 years of age. Spinal subdural abscess occurred more frequently in men in the fifth and sixth decade of life, while women were more affected in the seventh decade (Fig. 3). Clinical Presentation The symptoms of spinal subdural abscess include fever, spinal or root pain, and neurological deficit, depending on the location (Table 1). In 55.6% of the cases, the initial symptom was fever, while 84.4% presented with spinal and/or radiating pain. A combination of fever and spinal and/or root pain was present in 37.8% of the cases. During the course of the disease, 82.2% of the patients developed motor deficit, 57.8% sensory loss, and 53.3% sphincter disturbances. Analogous to the stages of progression of symptoms proposed by HeusneP 7 for spinal epidural abscess, symptoms of spinal subdural abscess appear to occur in a certain sequence; Stage 1: fever, either in combination with or without spinal and/or root pain; Stage 2: motor deficit, sensory loss, and/or sphincter disturbances; and Stage 3: paralysis and complete sensory loss below the level of the lesion. In our case, symptoms developed in the order outlined above. The rate of progression from one stage to another is not predictable. The duration of symptoms from their onset until patient death or therapeutic intervention ranged from 1 day to approximately I year. A division between acute (duration _< 1 week), subacute (2 to 8 weeks), and chronic (> 8 weeks) spinal subdural abscess can be made. Most spinal subdural abscesses were subacute (28 cases), six were chronic, and five acute; in six cases, the duration was not known. The location of the spinal subdural abscesses, upon which the extent of symptoms is dependent, is illustrated in Fig. 4. J. Neurosurg. / Volume 76/February, 1992
FI6. 4. Diagram showing the location of spinal subdural abscess in 43 patients.
Differential diagnosis includes acute transverse myelitis, spinal epidural abscess, epidural hematoma, vertebral osteomyelitis, and intraspinal tumor. 2,7,9,24,26 Neuroradiographic Examination Myelographic studies may confirm the presence of an intraspinal space-occupying process. In 28 of the 30 cases in which myelography was performed, a blockage with or without intradural irregularities was found. The myelographic features are not as characteristic as some have described. 24'34 In the remaining two cases, only intradural irregularities were found. Computerized tomography was performed in only seven cases; in five, the scans revealed an intraspinal space-occupying lesion. Intraspinal gassification, as demonstrated in our case, has not been described before. Spinal subdural abscess was diagnosed using magnetic resonance imaging in only one case?~ Treatment In conformity with the old adage ubipus, ibi evacua, surgical drainage followed by appropriate antibiotic therapy is the optimum treatment (Table 2). In the surgically treated group, 32 (82.1%) of the 39 patients
TABLE 2 O~comefor44patientswith ~inalsubduralabscesses* Ou~ome complete recovery improved death total
Treatment Surgical 12 (27.3%) 20 (45.4%) 7 (15.9%) 39 (88.6%)
Conservative 0 (0%) 1 (2.3%) 4 (9.1%) 5 (11.4%)
Total 12 (27.3%) 21 (47.7%) 11 (25%) 44 (100%)
* The treatment in one patient was unknown.
309
R. H. Bartels, T. R. de Jong, and J. A. Grotenhuis TABLE 3
TABLE 4
Duration of symptoms and outcome in the 39 surgically treated patients wit,5 spinal subdural abscesses
Causative organisms for 45 patients with spinal subdural abscesses
Outcome
Duration of Symptoms*
Acute Subacute Chronic Unknown complete recovery 1 (25%) 8 (30.8%) 1 (16.7%) I (33.3%) improved 3 (75%) 13 (50.0%) 4 (66.6%) 2 (66.7%) death 0 5(19.2%) 1(16.7%) 0 total 4(100%) 26(100%) 6(100%) 3(100%) * Acute = duration _< 1 wk; subacute = duration 2 to 8 wk; chronic = duration > 8 wk.
survived; in contrast, one (20%) of five patients in the conservatively managed group survived. All surviving patients improved or completely recovered. In no patient did the symptoms worsen, and in none was the outcome affected by the duration of symptoms (Table 3). Therefore, we recommend immediate surgical decompression and drainage if a spinal abscess is suspected after clinical and neuroradiographic examination. Appropriate antibiotic therapy using susceptibility testing of the cultured organism should follow surgery. The issue of coexistent epi- and subdural abscesses should be addressed. If the dura is found to be tense but not pulsating after evacuation of an epidural abscess, intradural inspection is warranted. The consequences of ignoring a nonpulsating dura, including clinical deterioration and subsequent surgery, are well demonstrated by the case described by Sittig? 2 Frank pus, whether encapsulated or not, was most often encountered at surgery or autopsy (Fig. 5). The
FIG. 5. Graph showing the relationship between the duration of symptoms and the finding at surgery or autopsy in 41 patients. Acute = duration _< 1 week; subacute = duration 2 to 8 weeks; chronic = duration _> 8 weeks. 310
Causative Organism Staphylococcus aureus Staphylococcus epidermidis Pseudomonas aeruginosa Streptococcus milleri/Bacteroides corrodens Bacteroides melangolicus/Fusobacterium sp/ Streptococcus viridans Diplococeus pneumoniae haemolyticStreptococcus Peptococcus magnus Escherichia coli
sterile unknown total
No. of Cases 25 1 1 1
1 1 1 1 1
2 10 45
presence of frank pus in 62.5% of the chronic spinal subdural abscesses is remarkable. As expected, granulation tissue has not been found in patients with acute spinal subdural abscess. Pathogenesis
The causative agent was identified in all but 12 cases (Table 4). Staphylococcus aureus was the responsible organism in 25 cases; Escherichia coli had not been encountered as the causative organism before our case. Organisms producing spinal subdural abscess reach the subdural space via several routes. Most frequently, hematogenous spread from a distant focus takes place with peripheral infections such as furunculosis being the primary source (Fig. 6). Direct extension of a contiguous infection is a different but infrequent route. The number of patients with spinal subdural abscess related to iatrogenic causes, such as lumbar puncture, injection of a local anesthetic agent, and discography, J'3`s1~'22"23" 26.3.~ is striking. In 10 cases, accompanying factors or diseases that diminished the patient's resistance to infections were present. These are summarized in Table 5.
FIG. 6. Graph showing the foci in 45 patients with spinal subdural abscess. J. Neurosurg. / Volume 76 / February, 1992
Spinal subdural abscess TABLE 5 Accompanying diseases orfactors for 45 patients with spinal subdural abscesses Disease or Factor lues diabetes meUitus Crohn'sdisease rheumatoid arthritis intravenous drug abuse unknown none total
No. of Cases 1 6 1 1 1 1 34 45
Conclusions Spinal subdural abscess is a rare but treacherous disease. The rate of progression of symptoms is unpredictable and outcome may be unfavorable. Therefore, if a spinal subdural abscess is suspected (for example, as in the case of the febrile patient with spinal pain after a lumbar puncture), urgent radiological examination is warranted, followed by immediate surgical drainage and appropriate antibiotic therapy. The coexistence ofepi- and subdural abscesses should be noted. References 1. Abbott KH: Acute subdural spinal abscess. Report of case. Bull Los Angeles Neurol Soc 5:227-231, 1940 2. Abramovitz JN, Batson RA, Yablon JS: Vertebral osteomyelitis. The surgical management of neurologic complications. Spine 11:418-420, 1986 3. Arnett JH: Meningocoecic (later also staphylococcic) meningitis, low spinal subarachnoid block, abscess, laminectomy, recovery. Med Clin North Am 13:1051-1062, 1930 4. Bennett AE, Keegan J J: Circumscribed suppurations of the spinal cord and meninges. Report of a case of subdural abscess with functional recovery following operation. Arch Neurol Psychiatry 19:329-333, 1928 5. Butler EG, Dohrmann PJ, Stark RJ: Spinal subdural abscess. Clin Exp Neurol 25:67-70, 1988 6. Chi CY: Intraspinal subdural abscess. Chinese Med J 50: 921-926, 1936 7. Dacey RG, Winn HR, Jane JA, et al: Spinal subdural empyema: report of two cases. Nenrosurgery 3:400-403, 1978 8. Dfis V: Spinal peripachymeningitis (epidural abscess). Report of 8 cases. J Neurosurg 17:972-983, 1960 9. Fraser RAR, Ratzan K, Wolpert SM, et ah Spinal subdural empyema. Arch Neurol 28:235-238, 1973 10. Freedman H, Alpers BJ: Spinal subdural abscess. Arch Neurol Psychiatry 60:49-60, 1948 11. Grubel G: Bericht tiber ein spinales subdurales Empyem. Acta Neurochir 22:2 t 3-216, 1970 12, Hurries-Jones R, Hernandez-Bronchud M, Anslow P, et al: Meningitis and spinal subdural empyema as a complication of sinusitis. J Neurol Neurosnrg Psychiatry 53:441, 1990 (Letter) 13. Harris LF, Haws FP, Triplett JN Jr, et al: Subdural empyema and epidural abscess. Recent experience in a community hospital. South Med J 80:1254-1258, 1987 14. Heindel CC, Ferguson JP, Kumarasamy T: Spinal subdural empyema complicating pregnancy. Case report. J J. Neurosurg. / Volume 76 / February, 1992
Neurosurg 40:654-656, 1974 15. Hershkowitz S, Link R, Ravden M, et al: Spinal empyema in Crohn's disease. J Clin Gastroenterol 12:67-69, 1990 16. Hesketh KT: Sub-dural abscess of the lumbar cord. Report of a patient with recurring paraplegia. Paraplegia 3: 161-164, 1965 17. Heusner AP: Nontuberculous spinal epidural infections. N Engl J Med 239:845-854, 1948 18. Hirson C: Spinal subdural abscess. Lancet 2:1215-1217, 1965 19. Kumar S, Gulati DR: Spinal abscesses. A report on 22 cases. Neurol India 26:193-195, 1978 20. Kurokawa Y, Hashi K, Fujishige M, et al: [Spinal subdural empyema diagnosed by MRI and recovery by conservative treatment.] No To Shinkei 41:513-517, 1989 (Jpn) 21. Lomholdt Knudsen L, Voldby B, Stagaard M: Computed tomographic myelography in spinal subdural empyema. Neuroradiology 29:99, t987 22. Lownie SP, Ferguson GG: Spinal subdural empyema complicating cervical discography. Spine 14:1415-1417, 1989 23. Negrin J Jr, Clark RA Jr: Pyogenic subdural abscess of the spinal meninges. Report of two cases. J Nenrosurg 9: 95-100, 1952 24. Patronas NJ, Marx WJ, Ducla EE: Radiographic presentation of spinal abscess in the subdural space. AJR 132: 138-139, 1979 25. Penkert G, Fliedner E: Spinales subdurales Empyema nach Stromverletzung. Unfallheilknnde 85:473-477, 1982 26. Probst C, Wicki G: Spinale subdurale Empyeme und Abszesse. Schweiz Arch Neurol Neuroehir Psychiatr 134: 53-70, 1984 27. Raskind R, Weiss SR: Subdural and extradural abscess with unusual complication and complete recovery. Int Surg 52:440-443, 1969 28. Reddy DR, Rao GN, Krishnamurthy D: Pneumococcal spinal subdural abscess (a case report). J Postgrad Med 19:190-192, 1973 29. Schiller F, Shadle OW: Extrathecal and intrathecal suppuration. Report of two cases and discussion of the spinal subdural space. Arch Neurol 7:33-36, 1962 30. Schnegg JF, Glauser M, de Tribolet N: Infection of a lumbar dermoid cyst by an anaerobic peptococcus. Acta Neurochir 58:127-129, 1981 31. Scully RE, Mark EJ, McNeely BU: Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 47-1984. N Engl J Med 311: 1365-1370, 1984 32. Sittig O: Metastatischer Riickenmarksabscess bei septischem Abortus, Z Neurol Psyehiatr 107:146-151, 1927 33. Takenaka K, Kobayashi H, Niikawa S, et at: [Spinal subdural abscess - - report of a case and a review of the literature of 43 cases.] No To Shinkei 41:331-336, 1989 (Jpn) 34. Theodotou B, Woosley RE, Whaley RA: Spinal subdural empyema: diagnosis by spinal computed tomography. Surg Neurol 21:610-612, 1984 35. Walker AE, Bucy PC: Congenital dermal sinuses: a source of spinal meningeal infection and subdural abscesses. Brain 57:401-421, 1934 Manuscript received March 28, 1991. Accepted in final form July 16, 1991. Address reprint requests to: Ronald H. Bartels, M.D., Department of Neurosurgery, University Hospital Nijmegen, Reinier Postlaan 4, 6500 HB Nijmegen, The Netherlands. 311
