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Neuroradiology Case of the Week

Case 229

Ravinder Sidhu MD, Ajay Malhotra MD, Sudhir Kathuria MD,
Sven Ekholm MD, PhD, and PL Westesson MD, PhD, DDS

Clinical Presentation: A 13-year old child presented with a seven day history of fever and spine tenderness.

Imaging Findings: MR lumbar spine showed an epidural abscess at T8-10 level. Patient underwent emergent thoracotomy. Causative organism was staphylococcus aureus  

Diagnosis: Spontaneous epidural abscess in a child

Discussion: Spinal epidural abscess, although rare is associated with high rates of morbidity and mortality.  The incidence of spinal epidural abscess is 2 per 10,000 hospital admissions and of spontaneous spinal epidural abscess is 0.2 to 1.3 per 10,000 hospital admissions. The risk factors are diabetes mellitus, IV drug abuse, chronic renal failure, alcohol abuse, altered immune status, malignancy, traumatic and iatrogenic.  Hematogenous spread from an intercurrent pyrexial illness, such as tonsillitis, pharyngitis, pneumonia, acute otitis media, and neonatal skin sepsis, is the favored route of infection. Staphylococcus aureus is the most common causative agent
     Spontaneous epidural abscess is an under recognized entity. Clinical presentation is variable. Triad of pain, fever, and neurological deficits is seen in a minority of patients; hence, the diagnosis may be delayed in a large percentage of patients. Most cases of spontaneous epidural abscess occur in patients aged between 30 and 60 years of age, but the youngest patient reported was only 10 days old and the oldest was 87 year old.
     MR displays the greatest diagnostic accuracy and is the method of first choice in diagnostic process. It offers superior resolution of anatomical detail of spinal cord compression, and adjacent soft tissue in paravertebral region. CT is helpful in evaluation of associated osseous abnormality.
     Immediate surgical decompression followed by antibiotic treatment offers good prognosis for cases presenting with cord compression.

References:

1. Reihsaus E, Waldbaur H, Seeling W. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev. 2000 Dec;23(4):175-204; discussion 205. [Medline]
2. Tang K, Xenos C, Sgouros S. Spontaneous spinal epidural abscess in a neonate. With a review of the literature. Childs Nerv Syst. 2001 Oct;17(10):629-31. [Medline]