Case Report: A case of cervical spinal epidural abscess combined with cervical paravertebral soft tissue abscess

Abstract

Background
Spinal epidural abscess (SEA) is a rare purulent infection of the central nervous system. Abscesses confined to the spinal canal can compress the spinal cord, causing nerve damage and even death in severe cases (1). Prompt diagnosis and treatment can relieve symptoms and prevent complications. To increase awareness of this rare disease, we report a case of a 58-year-old man with a cervical spinal epidural abscess combined with a soft tissue abscess in the neck and describe its clinical course, imaging feature, pathology, treatment, and patient prognosis.Case descriptionA 58-year-old male Chinese patient was admitted to our hospital because of neck pain for 2 months, which worsened for 4 days. On the third day of admission, the muscle strength of the limbs decreased, and MRI of the spinal cord showed abnormal signal shadows in the spinal canal at the C1-C7 level and in the surrounding soft tissue on the right side of spine, suggesting the possibility of inflammatory lesions with local abscess formation. We immediately performed decompression of the spinal canal on the patient and performed incision and drainage of the cervical abscess. During the operation, we found a large amount of pus in the epidural space of the spinal canal, and there was a fistula between the cervical abscess and the epidural abscess of the spinal canal. The patient underwent continuous drainage and anti-infective treatment with sensitive antibiotics after operation. No recurrence of the abscess was observed and the patient recovered well.Conclusion
Early diagnosis is the key to the treatment of SEA, so radiologists and neurosurgeons need to strengthen their understanding of this rare disease to avoid misdiagnosis. For SEA with definite diagnosis, decompression surgery should be performed in a timely manner when symptoms of nerve compression occur, continuous drainage should be performed after surgery, and sensitive antibiotics should be used for anti-infective treatment.

Full text

EDITED BY
J. M. Zuidam,
Erasmus Medical Center, Netherlands
REVIEWED BY
Nguyen Minh Duc,
Pham Ngoc Thach University of Medicine,
Vietnam
Bipin Chaurasia,
Neurosurgery Clinic, Nepal
Paolo Palmisciano,
University of Cincinnati, United States
*CORRESPONDENCE
Xuefei Shao
drshao@163.com
Jun Cao
caojun13651611423@126.com
Jincheng Fang
jinchengfang@foxmail.com
†
These authors have contributed equally to this
work and share first authorship
SPECIALTY SECTION
This article was submitted to Neurosurgery, a
section of the journal Frontiers in Surgery
RECEIVED 13 June 2022
ACCEPTED 23 August 2022
PUBLISHED 05 October 2022
CITATION
Cao J, Fang J, Shao X, Shen J and Jiang X
(2022) Case Report: A case of cervical spinal
epidural abscess combined with cervical
paravertebral soft tissue abscess.
Front. Surg. 9:967806.
doi: 10.3389/fsurg.2022.967806
COPYRIGHT
© 2022 Cao, Fang, shao, Shen and Jiang. This is
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terms of the Creative Commons Attribution
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terms.
Case Report: A case of cervical
spinal epidural abscess
combined with cervical
paravertebral soft tissue abscess
Jun Cao*†, Jincheng Fang*†, Xuefei Shao*, Jun Shen
and Xiaochun Jiang
Department of Neurosurgery, The First Affiliated Hospital of Wannan Medical College (Yijishan
Hospital of Wannan Medical College), Wuhu, China
Background: Spinal epidural abscess (SEA) is a rare purulent infection of the
central nervous system. Abscesses confined to the spinal canal can
compress the spinal cord, causing nerve damage and even death in severe
cases (1). Prompt diagnosis and treatment can relieve symptoms and prevent
complications. To increase awareness of this rare disease, we report a case
of a 58-year-old man with a cervical spinal epidural abscess combined with
a soft tissue abscess in the neck and describe its clinical course, imaging
feature, pathology, treatment, and patient prognosis.
Case description: A 58-year-old male Chinese patient was admitted to our
hospital because of neck pain for 2 months, which worsened for 4 days. On
the third day of admission, the muscle strength of the limbs decreased, and
MRI of the spinal cord showed abnormal signal shadows in the spinal canal
at the C1-C7 level and in the surrounding soft tissue on the right side of
spine, suggesting the possibility of inflammatory lesions with local abscess
formation. We immediately performed decompression of the spinal canal on
the patient and performed incision and drainage of the cervical abscess.
During the operation, we found a large amount of pus in the epidural space
of the spinal canal, and there was a fistula between the cervical abscess and
the epidural abscess of the spinal canal. The patient underwent continuous
drainage and anti-infective treatment with sensitive antibiotics after
operation. No recurrence of the abscess was observed and the patient
recovered well.
Conclusion: Early diagnosis is the key to the treatment of SEA, so
radiologists and neurosurgeons need to strengthen their understanding of
this rare disease to avoid misdiagnosis. For SEA with definite diagnosis,
decompression surgery should be performed in a timely manner when
symptoms of nerve compression occur, continuous drainage should
be performed after surgery, and sensitive antibiotics should be used for
anti-infective treatment.
KEYWORDS
spinal epidural abscess, decompression, surgery, treatment, case report
TYPE Case Report
PUBLISHED 05 October 2022
|
DOI 10.3389/fsurg.2022.967806
Frontiers in Surgery 01 frontiersin.org

Introduction
Spinal epidural abscess (SEA) is a rare purulent infection of
the epidural space (1). Due to the accumulation of a large
amount of pus and the proliferation of granulation tissue, the
spinal cord is compressed and has a high disability rate. After
the onset of the disease, the patient’s condition develops
rapidly, and a large amount of pus can accumulate in the
epidural space in a short period of time, which can cause the
spinal cord to be compressed, resulting in neurological
dysfunction and even paraplegia (1,2). Currently, the main
treatment options for spinal epidural abscesses are sensitive
antibiotic therapy or open surgery with laminectomy for
decompression, removal of pus, and continuous drainage (3).
Spinal epidural abscesses are more common in the
thoracolumbar spinal cord and less common in the cervical
spinal cord. Recently, a patient with cervical spinal epidural
abscess combined with cervical soft tissue abscess was treated
in our hospital, and the treatment effect was satisfactory. The
report is as follows.
Case description
The patient, a 58-year-old Chinese male, was admitted to
the hospital with a 2-month history of neck pain that
worsened for 4 days. In the past two months, the patient
often developed neck pain without obvious cause,
accompanied by radiating pain in both upper limbs and
shoulders. He had been treated in a local hospital and was
considered as having “cervical spondylosis”. 14 days before
admission, he received neck acupuncture treatment at the
local hospital, but the neck pain did not improve significantly.
4 days before admission, she developed redness, swelling and
pain in her neck, and fever appeared. The highest temperature
reached 38.6°C in the afternoon. After admission, a neck B-
ultrasound showed an abnormal echo mass in the deep soft
tissue of the right posterior neck. On the third day of
admission, the muscle strength of the limbs decreased, and
the decrease of the muscle strength of the lower limbs was
particularly obvious. Physical examination showed extensive
percussion pain in the spinous process of the neck with
radiating pain in both upper limbs. The left biceps muscle
strength was grade 3, the right biceps muscle strength was
grade 2, the quadriceps muscle strength of both lower limbs
was grade 2, the left foot dorsiflexor muscle strength was
grade 2, the right foot dorsiflexor muscle strength was grade
0, and the anal sphincter muscle strength was grade 0. MRI of
the cervical and thoracic vertebrae was immediately
performed, showing abnormal signal shadow of dorsal spinal
cord in the spinal canal at C1–C7 level, inflammatory lesions
with the possibility of local abscess formation, posterior
herniation of the C5/6 disc, and compression of the
surrounding dura and spinal cord (Figure 1). The patient had
a history of hypertension for 7 years, with normal blood
pressure control, and denied the history of diabetes and other
diseases.
Considering that the patient had developed neurological
symptoms and was at risk of respiratory failure at any time
due to cervical spinal cord compression, the patient was
immediately treated with “cervical spinal epidural abscess
removal + spinal canal decompression + neck abscess incision
and drainage”under general anesthesia. The C4 spinous
process was used as the center to mark a straight incision
with a length of 8 cm in the posterior midline of the neck.
The incision was made layer by layer, and the bilateral
paraspinal muscles were dissected to the lateral edge of the
lamina under the periosteum. During the operation, an
abscess fistula was seen in the right paravertebral muscle,
connecting the soft tissue abscess of the neck to the spinal
canal. A large amount of dark yellow epidural pus spilled
when the C3–C5 lamina was opened (Figure 2). The pus was
collected for bacterial culture and drug sensitivity test. Part of
ligamentum flavum was resected and sent for pathological
examination. During the operation to remove the pus in the
spinal canal, it is necessary to decompress the spinal canal
thoroughly, but also to protect the dura mater to prevent pus
from breaking into the subarachnoid space and causing
subarachnoid space infection. After complete decompression,
the spinal canal was rinsed with iodophor solution, hydrogen
peroxide and a large amount of normal saline, and the spinal
cord was found to be pulsating well without obvious spinal
cord compression. One negative pressure drainage tube was
indwelled and the incision was closed successively. Further
incision and drainage were performed for the abscess in the
deep neck. A vertical incision of 4.5 cm was made about 3 cm
beside the midline of the posterior neck. The skin and
subcutaneous tissue were cut layer by layer, and the abscess
cavity was observed in the depth of the neck. The pus in the
cavity was sucked out, and a negative pressure drainage tube
was placed and sutured successively to close the incision.
After surgery, the patient was transferred to neurosurgical
intensive care unit for observation, assisted breathing by
ventilator, anti-inflammatory treatment was performed by
intravenous infusion of vancomycin, symptomatic treatment
was performed by nutritive nerve drugs, and continuous
drainage was performed by negative pressure drainage tube.
On day 2 after surgery, the muscle strength of the patient’s
left biceps muscle was grade 4, the muscle strength of the
right biceps muscle was grade 3, the muscle strength of the
quadriceps femoris muscle of both lower limbs was grade 4,
and the muscle strength of the anal sphincter muscle was
grade 4. The patient was able to control urination and remove
the catheter 5 days after surgery. Bacterial culture and drug
sensitivity test showed Staphylococcus aureus (susceptible to
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FIGURE 1
(A) MRI T1-weighted image shows a long strip of isointense lesions on the dorsal side of the spinal cord in the C1–C7 spinal canal. Also see C5/6
intervertebral disc herniation, and the corresponding dura and spinal cord are compressed. (B) T2-weighted image shows hyperintensity of the
lesion. (C) T1-enhanced image showed annular enhancement of the lesion, no obvious internal enhancement, and spinal cord compression at
the corresponding level. (D) Axial T1-enhanced image showed a large range of irregular non-enhanced areas in the soft tissue of the right
posterior side of the cervical spine, and a ring-enhancing lesion in the right posterior part of the spinal cord in the spinal canal, with no obvious
internal enhancement. (E) Coronal T1-enhanced image shows a slightly hypointense lesion on the right side of the spinal cord in the cervical
spinal canal and (F) a honeycomb-like non-enhancing area in the soft tissue on the right side of the spinal canal.
FIGURE 2
(A) during the operation, a fistula was seen in the right posterior side of the spinal canal, connecting the paravertebral abscess and the spinal epidural
abscess.The arrow points to the location of the fistula. (B) After opening the lamina, a large amount of pus was seen in the spinal canal, and the pus
was mainly located in the back of the spinal cord and the right side of the spinal cord. The arrow points to the pus on the side of the spinal cord.
(C) The surgical incision and drainage tube for the spinal abscess are shown on the left, and the surgical incision and drainage tube for the
paravertebral soft tissue abscess in the neck are shown on the left.
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vancomycin, levofloxacin and ceftriaxone), and pathological
results showed inflammatory reactions (Figure 3). Drainage
tube was removed 10 days after surgery and vancomycin was
replaced with ceftriaxone (continued for 5 weeks). Twenty
days after surgery, the patient got out of bed with a neck
brace and moved autonomously. MRI of the cervical spine 21
days after the operation showed that the abscess signal in the
spinal canal disappeared completely (Figure 3). After 6
months of follow-up, the patient had grade 5 muscle strength,
no sensory disturbance, and no recurrence of abscess.
Discussion
The infection of spinal epidural abscess is mainly through the
following three ways (3): (1) Blood and lymphatic system
infection; (2) Direct spread of local infection; (3) Invasive
surgical procedures such as the placement of epidural catheter,
result in bacterial invasion of the spinal canal. Among them,
the placement of epidural catheter is an important risk factor
for SEA. Some studies (4,5) reported that the incidence of
epidural abscess after the placement of epidural catheter is
0.5%∼3.0%. Other possible risk factors include diabetes, human
immunodeficiency virus (HIV) infection, trauma, tattooing,
acupuncture, and infection of adjacent bone or soft tissue. In
this case, combined with the intraoperative findings, the
infection route was considered to be the spread of the cervical
paravertebral soft tissue abscess into the spinal canal. This
patient denied the history of diabetes mellitus and other
diseases, but had received neck acupuncture treatment before
the onset of the disease. It cannot be ruled out that acupuncture
treatment was the cause of the disease.
The common pathogenic bacteria of SEA are Staphylococcus
aureus, while Escherichia coli and Streptococcus pneumoniae are
rare (6–8). The mechanism of spinal cord injury caused by
abscess diffusion in epidural space is as follows (3): (1) Direct
compression of spinal cord; (2) Thrombosis and
thrombophlebitis of adjacent veins; (3) Interruption of arterial
blood supply; (4) Bacterial toxins and inflammatory mediators.
When the infection occurs in the epidural space, the abscess
can spread longitudinally to 3–5 spinal segments, and in severe
cases it can spread to the entire spine (9). However, even small
SEA can cause severe neurological symptoms and sequelae, and
neurological impairment is the most serious complication of
spinal epidural abscess (10).
SEA is more common in the thoracolumbar spine, an area
where the epidural space is larger and contains more fatty
tissue that is susceptible to infection (10). Most of the SEA is
located in the posterior part of the spinal canal, and if it
occurs in the anterior part, it is usually located below L1.
The epidural space is a vertical sheath-like structure, and
an abscess that begins at one segment often expands to
multiple segments (3). Our case is unique in that the SEA
occurred at almost the entire cervical vertebra segment,
forming neurological symptoms with obvious spinal cord
compression.
The initial manifestations of SEA are usually non-specific,
and the classical triad with diagnostic significance is fever,
spinal pain and neurological dysfunction (11). However, only
a few patients have all three manifestations at the time of
diagnosis. When the patient has severe localized neck and
back pain and fever, the diagnosis can be considered as SEA
or spinal osteomyelitis. However, when a patient seeks a
doctor only for neck pain, SEA is rarely considered, and it is
easy to miss the diagnosis. When SEA is combined with
paravertebral abscess, it can also manifest as inflammatory
manifestations of redness, swelling, heat, and pain in the
paravertebral soft tissue.
FIGURE 3
(A) microscopic examination of the sample tissue with HE staining revealed fibrous adipose tissue, in which a large number of acute and chronic
inflammatory cell infiltrates with abscess formation, and vascular dilatation and hyperemia were observed. Picture was taken at 100 magnification.
(B) T1-weighted image of the cervical spine 21 days after the operation showed that the abscess signal in the spinal canal disappeared. (C) T2-
weighted image of the cervical spine 21 days after the operation.
Cao et al. 10.3389/fsurg.2022.967806
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Once SEA is suspected, imaging should be performed as
soon as possible. MRI examination can show the location
and extent of intraspinal lesions, and can even show
fistulas between abscesses, which is the preferred examination
method (12). In the acute phase, SEA manifests as low signal
intensity or iso-intensity on T1WI and high signal intensity
on T2WI. As the disease progresses, it will show iso-intensity
on T1WI and T2WI, and the abscess wall will be significantly
enhanced on enhanced scan, but there is no enhancement in
the abscess cavity. MRI can help differentiate SEA from
intraspinal hematoma and spinal epidural tumor. Intraspinal
hematoma is mainly iso-intensity and highintensity on
T1WI, and slightly high-intensity or high-intensity on T2WI,
mixed with a little low-intensity. Enhanced scan shows the
enhancement of the hematoma wall. Epidural tumors show
isointensity on T1WI, slightly hyperintensity or isointensity
on T2WI, and obvious homogeneous enhancement on
enhanced scan (13). Contrast-enhanced CT scans can be used
if MRI cannot be performed immediately or if there are
contraindications (14). X-ray examination has little diagnostic
value for SEA, and myelography has been basically eliminated.
In recent years, there have been many debates on how to
treat spinal epidural abscesses. Some scholars advocate the use
of sensitive antibiotics alone, while others believe that open
surgery assisted by sensitive antibiotics is more reliable.
Suppiah et al. (15) believed that open surgery assisted with
sensitive antibiotic therapy is the best treatment method. If
the neurological function is intact, conservative antibiotic
treatment can be given first, but close neurological function
monitoring is required. Patients with suspected spinal epidural
abscess should be closely monitored for neurological function.
Tuchman et al. (16) believed that patients should be clear
about delayed neurological damage that may occur at any
time when they are treated with antibiotics alone for SEA
patients without neurological symptoms, but because the
irreversible time point of spinal nerve damage is still unclear,
the first recommended treatment is surgical treatment.
Shweikeh et al. (17) regard the occurrence of nerve damage as
the key factor for surgical treatment, and the timing of
surgical treatment should be within 36∼72 h after the
occurrence of nerve dysfunction. The timing of surgery
should also be determined by the patient’s age, complications
(diabetes, cardiovascular disease, renal insufficiency) and other
specific conditions (18).
In this case, MRI examination was performed immediately
after the onset of neurological symptoms and decompression
of the spinal canal was performed in time, which is the key to
the good prognosis of the patient. After surgery, vancomycin
was used empirically for anti-inflammatory treatment. The
postoperative drug sensitivity test showed that the bacteria
were sensitive to vancomycin, levofloxacin and ceftriaxone.
After the drainage tube was removed, vancomycin was
replaced with ceftriaxone to continue treatment for 5 weeks.
Follow-up MRI re-examination showed that the epidural
abscess disappeared and the compression was relieved. In this
case, only spinal canal decompression was performed, and
internal fixators were not used. The main considerations were
as follows: (1) The pathogenic bacteria were not clear, and the
use of internal fixators might increase the risk of infection; (2)
No stability structures such as articular processes were
destroyed during operation, and postoperative spinal stability
was not affected.
Conclusion
Early diagnosis is the key to the treatment of SEA. Patients
without neurological symptoms can be treated with effective
antibiotics in early, sufficient and timely manner. If
neurological symptoms worsen, MRI examination should be
performed in time. For SEA with definite diagnosis,
decompression surgery should be performed in time when
symptoms of nerve compression occur, and continuous
drainage and anti-infection treatment with sensitive antibiotics
should be selected after surgery.
Data availability statement
The original contributions presented in the study are
included in the article/Supplementary Material, further
inquiries can be directed to the corresponding author/s.
Ethics statement
The studies involving human participants were reviewed
and approved by The studies involving human participants
were reviewed and approved by the Ethics Committee of the
First Affiliated Hospital of Wannan Medical College (Yijishan
Hospital of Wannan Medical College). The patients/
participants provided their written informed consent to
participate in this study. Written informed consent was
obtained from the individual(s) for the publication of any
potentially identifiable images or data included in this article.
Author contributions
JC analyzed the data and wrote the first draft. XS, JS and
JC performed the surgery. JF and XS revised the article
critically for important intellectual content. Professor XJ is
directly responsible for the manuscript. All authors
substantially contributed to the conception and design of this
article and gave final approval for the version for publication
and agree to be accountable for all aspects of the work. All
Cao et al. 10.3389/fsurg.2022.967806
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authors contributed to the article and approved the
submitted version.
Funding
This work was supported by the “Peak”Training Program
for Scientific Research of Yijishan Hospital (grant number
PF2019003), and Domestic Visiting Scholar Program for
Excellent Young Talents in Colleges and Universities of Anhui
Province (grant number gxgnfx2021125).
Acknowledgments
We thank the patient and his family for participating in this
study.
Conflict of interest
The authors declare that the research was conducted
in the absence of any commercial or financial
relationships that could be construed as a potential conflict
of interest.
Publisher’s note
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authors and do not necessarily represent those of their
affiliated organizations, or those of the publisher, the editors
and the reviewers. Any product that may be evaluated in this
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