Cover letter
Dear Sirs
I kindly presenting to you my article as a case study “Spinal Epidural Abscess Mimicking
Lumbar Disc Herniation” .Not only I’ve not resubmitted my paper to another journal nor
I’ve published any related articles.
Sincerely yours
Ghavam Tavallaee, Neurosurgeon
2
Title page
Spinal Epidural Abscess Mimicking Lumbar Disc Herniation
Ghavam Tavallaee MD
Neurosurgeon
Social security organization - Salman Farsi hospital of Boushehr, Neurosurgery department,
Bushehr – Iran
Tel: +98 771 4542824
Fax: +98 771 4542836
Email: Tavallaee@sums.ac.ir
www.dr-tavallaee.com
3
Abstract
Key words: Epidural abscess- staphylococci -diagnosis
Epidural abscess of the spinal column is a rare condition that can be fatal if left untreated.
Risk factors for epidural abscess include immunocompromised states such as diabetes
mellitus, alcoholism, cancer, and acquired immunodeficiency syndrome, as well as spinal
procedures including epidural anesthesia and spinal surgery.
A patient with left side radicular pain in lower extremity and claudication and a disc free
fragment in L4-L5 space is presented. But final diagnosis was lumbar epidural abscess. Gram
stains of samples revealed many WBC and culture contained gram positive staphylococci
growth. CT and MR could not identify the lesion during initial evaluations. In this patient, risk
factors for spinal epidural abscess seem to be steroid consumption. Neurologic dysfunction is
often disproportionate to the observed degree of compression
4
A case report
Spinal Epidural Abscess Mimicking Lumbar Disc Herniation
Key words: Epidural abscess- staphylococci -Discopathy
Introduction
Epidural abscess of the spinal column is a rare condition that can be fatal if left untreated.
Risk factors for epidural abscess include immunocompromised states such as diabetes
mellitus, alcoholism, cancer, and acquired immunodeficiency syndrome, as well as spinal
procedures including epidural anesthesia and spinal surgery (1). No predisposing condition
can be found in 20 percent of patients with spinal epidural abscess, and the condition has
been reported in patients with no predisposing risk factors.(2) The signs and symptoms of
epidural abscess are nonspecific and can range from low back pain to sepsis. The treatment of
choice in most patients is surgical decompression followed by four to six weeks of antibiotic
therapy. Nonsurgical treatment may be appropriate in selected patients. The most common
causative organism in spinal epidural abscess is Staphylococcus aureus. Spinal epidural
abscess involving actinomycosis is rare.
Spinal epidural abscess has an estimated incidence rate of 0.2 to 2.8 cases per 10,000 per
year, with the peak incidence occurring in people who are in their 60s and 70s. The most
common causative agent is Staphylococcus aureus (2). Epidural abscess caused by
actinomycosis is rare; fewer than 80 cases have been reported since the organism was
identified in 1878(3, 4).
I present a patient with left side radicular pain in lower extremity and claudication.Normal
physical exam rather than positive Lt. SLR.A free fragment in L4-L5 space was seen. During
laminectomy frank pus was released. After antibiotic therapy he was discharged and returned
to his daily activities very well.
The patient is a 40 years old man with left side lower extremity radicular pain and
claudication since 3 months ago and exacerbation since 2 weeks before admission. His
significant prior medical history included Multiple sclerosis since 6 years ago, which it seems
not to be controlled very well. Inappropriate steroid consumption and interferon injections are
5
seen in his past medical history. The patient was alert and oriented, and had stable vital signs.
Positive physical findings included mild tenderness on palpation of the lower thoracic spine
and upper lumbar region with no external evidence of injury and positive Left sided SLR.
Pain corresponding to the lumbosacral vertebrae, which had branched to the postero-medial
gluteal region, posterior-tibial area, and plantar face of the left foot. DTR was present
bilaterally in lower extremities. He had a mid to high socio-economical level. There was not
any history for illegal drug iv injection. We requested lumbosacral MRI and his MRI
revealed an extruded disc in L4-L5 space which with compression effect over Dural sac and
left side L5 root (figure 1). Initial laboratory investigation showed no leukocytosis, however
no any inflammatory indices were checked before surgery by a classic skin incision, L4-L5
bilateral laminectomy was done.
Figure 1-1
6
Figure 1-2
During retraction of root shoulder for removing fragment suddenly frank pus was evacuated.
Samples were taken for gram stain/culture and abscess wall for pathology. After the operation
he was pain free. I asked the infectious medicine specialist to exam the patient for probable
site of infectious origion.No gross site was observed but back skin was covered by a few skin
acnes. Gram stains revealed many WBC and culture contained gram positive staphylococci
growth. No acid fast bacilli were seen. Culture was resistance to Erythromicin,
nitrofurantoine, nalidixic acid, amikacin and intermediate sensitivity to Gentamicine and
ciprofluxacine. In pathology, fragments of fibroconnective tissue with acute and chronic
inflammation and granulation tissue suggestive of wall of abscess formation were reported.
multiple parental antibiotics were prescribed, but he didn't accept to complete his drug course
and left hospital. About 40 days later he returned by severe low back pain and cludication and
difficulty to straighten up and walk. He was mildly febrile.
in his lab data in second admission high ESR (78), CRP( +++) and WBC>25000 was
observed. Second MRI with contrast was done which showed L4/L5 end plates enhancement
without any collection around dural sac. In this case we started proper antibiotics regard to
previous culture. He was hospitalized for 6 weeks. During this period of time all of
inflammatory indices got normal and he was pain free. He was advised to wear a hard brace
7
for about 3 months and with oral antibiotics was discharged. During the first year after
operation, he was followed monthly and he had no any signs or symptoms regarding disease.
The MS is under controlled by a neurologist.
Conclusion
In this paper, I reported a case of a patient with spinal epidural abscess, who was formerly
suggested for surgery after the diagnosis of a lumbar disk herniation. Although CT and MR
could not identify the lesion during initial evaluations. In this patient, risk factors for spinal
epidural abscess seems to be steroid consumption. Most epidural abscesses are located
posteriorly in the thoracic or lumbar spine . Most posterior spinal epidural abscesses are
thought to originate from a distant focus such as a skin infection, pharyngitis, or dental
abscess.(5,6) Anterior epidural abscesses are commonly associated with discitis or vertebral
osteomyelitis.(2) Although cord and nerve root compression from the extradural mass within
the rigid spinal canal might appear to be the obvious explanation, neurologic dysfunction is
often disproportionate to the observed degree of compression(7).Many authors have
postulated that the edema and inflammation in the epidural space may involve the epidural
venous plexus, which may compromise circulation and result in cord ischemia(8) . A
combination of compressive and ischemic effects may act in synergy to produce the
disastrous sequelae of epidural abscess
REFERENCES
1. Colle I, Peeters P, Le Roy I, Diltoer M, D'Haens J. Epidural abscess: case report and
review of the literature. Acta Clin Belg. 1996;51:412–6.
2. Vilke GM, Honingford EA. Cervical spine epidural abscess in a patient with no
predisposing risk factors. Ann Emerg Med. 1996;27:777–80.
3. Martin RJ, Yuan HA. Neurosurgical care of spinal epidural, subdural, and intramedullary
abscesses and arachnoiditis. Orthop Clin North Am. 1996;27:125–36
4. Mackenzie AR, Laing RB, Smith CC, Kaar GF, Smith FW. Spinal epidural abscess: the
.importance of early diagnosis and treatment. J Neurol Neurosurg Psychiatry. 1998;65:209–3
3. Oruckaptan HH, Senmevsim O, Soylemezoglu F, Ozgen T. Cervical actinomycosis
causing spinal cord compression and multisegmental root fail ure: case report and review of
the literature. Neurosurgery. 1998;43:937–40.
8
4.Kannangara DW, Tanaka T, Thadepalli H. Spinal epidural abscess due to Actinomyces
israelii. Neurology. 1981;31:202–4
5.Lane T, Goings S, Fraser DW, Ries K, Pettrozzi J, Abrutyn E. Disseminated actinomycosis
with spinal cord compression: report of two cases. Neurology. 1979;29:890–3
6. Baker AS, Ojemann RG, Swartz MN, Richardson EP. Spinal epidural abscess. N Engl J
Med. 1975;293:463–8
7.Verner EF, Musher DM. Spinal epidural abscess. Med Clin North Am. 1985;69:375–847.
8. Danner RL, Hartman BJ. Update on spinal epidural abscess: 35 cases and review of the lit
erature. Rev Infect Dis. 1987;9:265–74
9. Hlavin ML, Kaminski HJ, Ross JS, Ganz E. Spinal epidural abscess: a ten-year
perspective. Neurosurgery. 1990;27:177–84