Epidural Abscess: A Cause of Back Pain That Must Not Be Missed

Abstract

Low back and cervical pain are common emergency department complaints. Most cases represent low-risk pathologies but in rare cases, it can be a symptom of a serious underlying disease and the distinction can be challenging. A case is reported of a 58-year-old male with recurrent cervical pain requiring several emergency department visits. He eventually presented with intense cervical and low back pain, tetraparesis, and dyspnea. His condition deteriorated in less than 24 hours, evolving with fever, shock, and respiratory insufficiency and was admitted to the Intensive Care Unit for aminergic support, invasive mechanical ventilation and started on empiric antibiotics. Investigations revealed raised inflammatory markers and a cervical pre-vertebral purulent collection associated with an epidural collection at the level of C2 to C5 with spinal cord compression. The patient underwent transoral drainage and removal of the posterior C1 arch along with C2-C3-C4-C5 laminectomy. Staphylococcus aureus was isolated in the blood, pus, and bone. Reintervention was required due to persistent pre-vertebral abscesses with clinical improvement thereafter. Eight weeks of antibiotic treatment were completed in total. The patient was discharged after 72 days of hospitalization with significant improvement in force and autonomy. Epidural abscess is a rare finding that can cause rapid irreversible neurological deterioration. Clinical suspicion must be high for an early diagnosis and treatment, essential for a better prognosis.

Methicillin-Resistant Staphylococcus aureus Spinal Epidural Abscess: Local and Systemic Case Management

“…As previously indicated, SEA is a rare condition with variable and complex etiology and mechanism of disease [ 6 , 10 ]. If diagnosis is delayed or missed altogether, SEA can progress to severe permanent defects in nervous structures [ 2 , 11 , 12 ]. Idiopathic back pain has historically been a cause for suspicion of spinal involvement when weakness and/or pain in the extremities present without acute injury or known chronic conditions [ 3 , 12 ].…”

Cervical Epidural Abscess

“…Mortality in cases of cervical epidural abscess can be up to 25% and mortality and neurological outcomes are worse when compared with other types of spinal epidural abscess 2,4,8,9 . This is thought to be due in part to the smaller epidural space to accommodate the space-occupying and inflammatory effects of an abscess 2,10 …”

“…2,4,8,9 This is thought to be due in part to the smaller epidural space to accommodate the space-occupying and inflammatory effects of an abscess. 2,10 The classic presentation of spinal epidural abscess is the triad of spinal pain, fever, and neurological deficit; however, diagnosis may be difficult because only 8% to 15% of patients present with the full triad. 3,5 Diagnosis must be made as early as possible as delayed management and increased neurological symptoms are associated with lower success of interventions.…”