- Department of Orthopaedics, Khoula Hospital, Muscat, Oman.
DOI:10.25259/SNI_306_2019Copyright: © 2019 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Sam Supreeth, Khalifa Al Ghafri. Ventral holocord spinal epidural abscess managed surgically in a critical setting. 13-Dec-2019;10:248
How to cite this URL: Sam Supreeth, Khalifa Al Ghafri. Ventral holocord spinal epidural abscess managed surgically in a critical setting. 13-Dec-2019;10:248. Available from: https://surgicalneurologyint.com/surgicalint-articles/9798/
Background: Extensive epidural abscess is an uncommon entity which is increasing in the aging population. Its prevalence is also greater among those with diabetes mellitus and in those who are immunocompromised. Here, a 59-year-old female presented with a spinal epidural abscess (SEA) warranting operative intervention.
Case Description: A 59-year-old female with a history of diabetes and hypertension, presented with the acute onset of a high-grade fever, generalized back pain, and an evolving quadriparesis. Preliminary laboratory studies revealed elevated inflammatory markers. The magnetic resonance scan showed a ventral epidural abscess extending from C1-2 to the L5 level. She underwent urgent surgical decompression using a Nelaton catheter placed through an L4-L5 hemilaminectomy and threaded cephalad (40 cm); this resulted in a complete recovery.
Conclusion: This case study underscores a unique way of managing an anterior holospinal SEA extending from the C1-2 through the L5 spinal levels.
Keywords: Cervicolumbar, Critical, Hemilaminectomy, Holocord, Nelaton, Spinal epidural abscess, Ventral
Spinal epidural abscess (SEA) occurs in approximately 0.2–2 case/10,000 admissions.[
Treatment of SEA is a two-staged process that includes (1) antibiotics for treating the systemic manifestations versus (2) surgery with additional appropriate antibiotic therapy. Here, we report the case of a ventrally located SEA extending from the C1-2 through L5 level treated successfully utilizing a minimally invasive catheter technique (Nelaton catheter: 40 cm long) introduced through a hemilaminectomy at the L4-L5 level.
A 59-year-old female with diabetes and hypertension presented with low back pain, electric shock- like sensations, and a progressive quadriparesis of 10 days duration. For the past 2 days, she had a high-grade fever with chills. Her neurological examination revealed diffuse hyperreflexia 3–4+ accompanied by bilateral Hoffman’s sign, clonus, and Babinski responses.
Preliminary laboratory tests revealed markedly elevated C-reactive protein (CRP: 447 mg/l), a high erythrocytes sedimentation rate (ESR: 119 mm/h), an increased white blood cell count (WBC: 25 × 103/µl), and abnormal serum urea level (11.69 mmol/l).
Magnetic resonance imaging (MRI) [
Treatment of SEA
At surgery, the right paraspinal abscess at the L4-5 level was filled with frank pus and was appropriately drained. Next, the patient underwent L4-5 right side hemilaminectomy allowing for drainage of pus from the ventral spinal canal; tilting the operating table (reverse Trendelenburg) further facilitated such drainage from more cephalad levels. Next, a Nelaton catheter (size 14 gauge and 40 cm long) was gently and gradually guided cephalad along the ventral epidural space. This allowed for further washout of pus and accompanying infectious debris. Once instilled irrigation drained clear fluid, the catheter was then withdrawn, and the wound was closed. Over the next 4 postoperative months, the patient improved dramatically as did the inflammatory markers.
Intraoperative cultures of the ventral pus and blood culture yielded Streptococcus pneumoniae. It was appropriately treated with ceftriaxone (2 g once a day) and vancomycin (1 g twice a day) for 6 weeks intravenously, followed by oral cefuroxime (500 mg twice a day) for an additional 6 weeks on discharge. An incidental finding was an infection involving the right knee requiring arthroscopic washout at both 1 week and 3 weeks after the spine surgery.
The 1-month postoperative MRI [
Location of SEA
SEA most typically appear in the lumbar level (48%) followed by thoracic (31%) and then cervical (21%) levels.[
Five similar holocord SEAs
Five similar cases of holocord SEA have previously been reported. One study included three pockets of SEA located at C7-T5 ventrally, and T5-11, and L1-5 dorsally.[
Operative techniques for holocord SEA
Different techniques for treating holocord SEA are described ranging from; open decompression/late closure, multilevel decompression, limited decompression (one-level laminectomy or hemilaminectomy with Fogarty embolectomy catheter use), percutaneous CT-guided needle aspiration, and limited laminectomies (e.g., using a silicon catheter epidurally).[
In this case, we utilized a Nelaton catheter (size 14; 40 cm long) introduced through a right-sided L4-L5 hemilaminectomy to successfully drain a holocord ventral SEA extending from the C1-C2 through the L5.
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