Mixed pyogenic and tuberculous spinal epidural abscesses perforating the dura and extending into the subdural space: A case report and review of the literature

Fawaz S Almotairi; Alwaleed Abdulrahman Alsaleh; Ali A Basalamah; Mohannad M Mallat; Emad M Babateen; Ali Abdu; Saeed O Bahabri

doi:10.25259/SNI_536_2023

Mixed pyogenic and tuberculous spinal epidural abscesses perforating the dura and extending into the subdural space: A case report and review of the literature

Surg Neurol Int. 2023 Sep 8:14:315. doi: 10.25259/SNI_536_2023. eCollection 2023.

Authors

Fawaz S Almotairi¹, Alwaleed Abdulrahman Alsaleh², Ali A Basalamah³, Mohannad M Mallat⁴, Emad M Babateen⁵, Ali Abdu⁶, Saeed O Bahabri⁷

Affiliations

¹ Department of Neurosurgery, King Saud University Medical City, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
² Medical Intern, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
³ Department of Neurosurgery, King Saud University Medical City, Riyadh, Saudi Arabia.
⁴ Medical student, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
⁵ Medical student, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia.
⁶ Department of Radiology, King Saud University Medical City, Riyadh, Saudi Arabia.
⁷ Department of Pathology, King Saud University Medical City, Riyadh, Saudi Arabia.

Abstract

Background: Spinal infections are associated with a wide variety of clinical conditions, including osteomyelitis, spondylitis, diskitis, septic facet joints, and abscesses. Based on its anatomical relationship with the dura mater, the abscess can be epidural (extradural) or subdural (intrathecal). Subdural intramedullary abscesses of the lumbar spinal canal are more common than subdural extramedullary abscesses. Here, we present a rare case of a patient with a mixed pyogenic and tuberculous epidural abscess in the lumbar spine, which perforated the dura and extended to the subdural space.

Case description: A 29-year-old male presented with progressively worsening back pain and lower-limb weakness over a period of 3 months, with an associated inability to walk, intermittent radicular pain primarily on the left side, intermittent incontinence, and a history of low-grade fever and night sweats. The patient had a history of intravenous (IV) drug abuse and reported practicing unprotected sexual intercourse. Furthermore, the patient had recently came into contact with a person diagnosed with tuberculosis (TB). The patient was administered empirical broad-spectrum antibiotics and underwent emergent L4-L5 laminectomy and spinal abscess decompression. IV antibiotics were selected based on culture results, and anti-TB medications were started. Postoperatively, the patient demonstrated a remarkable lower-limb power improvement and radicular pain alleviation.

Conclusion: Spinal epidural abscess perforation of the dura and extension into the subdural space is extremely rare. Distinguishing between epidural and subdural abscesses radiologically is challenging. Multiple risk factors, such as unprotected sexual contact and IV drug misuse, may be associated with the development of polymicrobial abscesses in the lumbar spine. Careful anticipation, identification, and isolation of the causative micro-organisms can ensure effective antibacterial treatment. Early diagnosis, expeditious surgical decompression, and antibiotic treatment are associated with promising outcomes.

Keywords: Epidural abscess; Pyogenic spinal infection; Spinal infection; Spinal tuberculosis; Subdural abscess.

Publication types

Case Reports