Penetrating cervical spine injury and spinal cord intramedullary abscess

Abstract

Penetrating spinal injuries by wooden foreign body (WFB) is rare 1 . We present a 52 year-old man with a cervical spine injury by a WFB, identified 172 days after the accident, with an intramedullary abscess. Surgical intervention and antibiotic treatment led to neurological improvement. CASEA 52 year-old man had fallen from a horse on May 29, in 2008, with a penetrating injury from a piece of wood below the angle of the left mandible causing prompt change in sensibility and strength in his left side. He underwent a superficial exploration and suture in the local hospital. Neurological deficits evolved over time to loss of independent gait and severe functional limitations of the upper limbs, particularly the left.He was admitted on October 13, in 2008, without signs of inflammation, dehiscence, or cerebrospinal fluid (CSF) fistula in the neck. Neurological examination showed tetraparesis, predominantly on the left side, and hyperreflexia in lower limbs with preserved vibration and position sensation in all four limbs. He was only able to walk with great difficulty if supported by two helpers. Bladder and bowel functions were normal.The magnetic resonance image (MRI) revealed spinal cord edema and a heterogeneous intramedullary lesion at C4-C5 level, with ring like post-contrast enhancement, consistent with an abscess (Fig A and B). There was a hypointense linear image within the left C4-C5 intervertebral foramen with intramedullary extension and hyperdense on computed tomography, measuring 3.0 cm, consistent with a WFB. It transfixed the ipsilateral vertebral artery, which was obliterated (Fig C and D).The WFB was surgically removed (Fig E). Purulent matter was drained from location, where the WFB had been lodged. Lab work showed the presence of Staphilococcus epidermiditis, and the patient was treated with oxacillin. At the latest outpatient follow-up visit on January 18 th , 2011, he was independent for activities of daily living, walking without any aid, with intact sphincter control. DISCUSSIONNon-missile penetrating spinal injuries are more commonly caused by stabs 2 . WFB is rarely reported as the cause of this type of injury 1 . Since the wood is an optimal source of infection due its porous, soft, organic, and vegetable nature, spinal infectious complications are prone to occur 1,3 . Foreign body reaction, another inflammatory complication, may lead to long-term neurological worsening 1 .CT and MRI are essential to evaluate spinal cord and the presence of a foreign body in penetrating spinal injuries. The density of wood on CT is highly variable and depends on its type and hydration status, as well as on the length of stay in the body 4 . This latter factor may explain the increased density of the wooden fragment in this patient. MRI is mandatory in non-missile penetrating spinal injuries for the diagnosis of associated lesions 5 , whenever a metallic foreign body has been excluded or removed 2 . Even when CT is negative, MRI should be performed to exclude retained foreign bodies 1 .Treatment of penetra...

Spontaneous intramedullary abscesses caused by Streptococcus anginosus: two case reports and review of the literature

“…Intramedullary infections can be precipitated by several risk factors, including dermoid cysts [18]. intravenous drug use [6], genitourinary infections [1], osteomyelitis [19], penetrating or iatrogenic injuries to the spine [20], endocarditis [2], septic embolism [7], bacterial meningitis [8], and pre-existing spinal pathologies, including spinal tumors, AVMs or dural arteriovenous fistulas [21,22]. Of note, the patients reported here did not appear to have any of these predisposing conditions.…”

Recovery after inadvertent intramedullary microchip implantation at C1–C2 in a kitten

“…Abscess formation within the CNS is mostly described with foreign bodies of plant origin. 31 , 32 , 38 Sterile CNS foreign bodies like suture material, 30 cotton pledget 28 , 29 and bone wax 39 have been reported to cause late-onset clinical signs in humans due to granulomatous reactions that could potentially lead to complications in our cat in the future.…”

“…19,23 Although our cat demonstrated a favourable outcome with medical management, the clinician should be aware of late-onset complications in patients with central nervous system (CNS) foreign body diseases. Migration of foreign bodies, 13,24,25 inflammatory reactions like granuloma [26][27][28][29][30] and abscess formation, [31][32][33] myelitis, 34 arachnoiditis with and without subsequent subarachnoid diverticula or syrinx formation 35,36 and CSF leakage 37 have been reported in veterinary and human medicine. In our cat, some degree of migration of the microchip was identified on follow-up CT that might have occurred in the context of maturing of the spine.…”

Penetrating Sacral Injury with a Wooden Foreign Body

“…As a result of their organic nature, wooden objects are sources of infection and all wooden foreign bodies should be totally removed from the wound carefully [ 2 , 5 ]. The surgical management of these patients should include high volume irrigation.…”