Management of Posterior Cervical Epidural Abscess Complicated by Non-Communicating Tetra-Ventricular Hydrocephalus: A Case Report and Review of the Literature

Abstract

Background Spinal epidural abscess (SEA) is an uncommon condition, especially in children. Its occurrence in the cervical spine, particularly without significant osseous involvement, is exceedingly rare. We report a case of non-communicating tetra-ventricular hydrocephalus associated with a posterior cervical epidural abscess. The condition was managed with surgical drainage, specific antibiotics, and ventriculoperitoneal shunting.

Case Description A 15-year-old female presented with a history of posterior cervical abscess drainage. Bacteriological findings revealed two microorganisms (Staphylococcus epidermidis and tuberculosis) despite initial improvement following surgical intervention and antibiotic therapy, the patient experienced a recurrence of symptoms, including fever and deterioration in consciousness. Imaging revealed a tetra ventricular hydrocephalus, prompting urgent ventriculoperitoneal shunt placement. Subsequent treatment with anti-tuberculous therapy and vancomycin led to favorable outcomes.

Conclusion SEA poses diagnostic and management challenges, particularly in resource-limited settings. Prompt recognition, appropriate antimicrobial therapy, and surgical intervention are crucial for favorable outcomes. Consideration of tuberculous and S. epidermidis etiology, even in atypical presentations, is essential.

Keywords

spinal epidural abscess - hydrocephalus - ventriculoperitoneal shunt - cervical spine - tuberculous etiology - Staphylococcus epidermidis

Introduction

Exploring rare cases in neurosurgery is crucial to enhancing understanding and improving the management of these uncommon but serious conditions. Spinal epidural abscesses (SEA) are rare clinical entities, with cervical localization accounting for approximately 15% of cases. Their global incidence is estimated at 0.2 to 1.2 per 10,000 hospital admissions and is reportedly increasing due to improved diagnostic tools and greater awareness. Common risk factors include diabetes, intravenous drug use, chronic renal failure, and alcoholism, often associated with a state of immunosuppression.[1]

SEA classically presents with severe, localized back pain, tenderness to percussion, and progressive neurological deficits such as radiculopathy followed by spinal cord involvement. However, atypical presentations, such as the absence of fever or leukocytosis, can delay diagnosis. Pathophysiologically, spinal cord dysfunction may result from compressive mechanisms or vascular compromise, including venous compression and spinal infarction.[1]

This study focuses on a rare case of a posterior cervical epidural abscess complicated by non-communicating tetra-ventricular hydrocephalus. The condition was successfully managed through surgical drainage of the cervical abscess and ventriculoperitoneal shunt placement. In addition to a detailed case analysis, this article explores the epidemiological aspects, associated comorbidities, and pathophysiology of SEA and hydrocephalus, drawing on the current literature. This work contributes to the enrichment of the medical literature by providing a rare yet informative clinical case with successful management.

Case Presentation

A 15-year-old female, a right-handed student in the third grade of general education, presented to our institution with a history of superficial posterior cervical abscess (soft tissues). With an unknown vaccination history, there was a history of living in crowded conditions. She was admitted to the neurosurgery department for posterior cervical suppuration in a febrile context associated with reactive torticollis. The initial clinical examination revealed general deterioration with important body loss of about 15%, GCS score of 15/15, fever of 39°C, and a dressing soiled with pus, no deficit was found.

An emergency cervical spine CT scan with injection of contrast was performed, showing hypodensity of the posterior cervical peri vertebral areas C1 to C5, measuring 67.3 mm × 44.8 mm in axial section, with erosion of the posterior arch and spinous process of C1 associated with enhancement of soft and epidural tissues. ([Fig. 1]).

Fig. 1 Initial emergency cervical spine CT scan with injection of contrast.

The diagnosis of extensive cervical abscess was made, and the laboratory findings showed an inflammatory syndrome with a positive CRP of 59.69 mg/L. The acid-fast bacilli stain for tuberculosis was negative. Neurosurgical intervention was indicated due to the significant volume of the abscess, multiple septations, and extension to the posterior arch of C1. The patient underwent cervical posterior approach surgery with intraoperative sampling, aspiration drainage, and abundant irrigation of the white caseous-smelling abscess. A bacteriological study identified a pyogenic organism (Staphylococcus epidermidis), justifying the initiation of parenteral antibiotic therapy with Vancomycin (1 g/12 H for 7 days) and metronidazole (400 mg/8 H for 10 days), followed by oral antibiotic therapy with amoxicillin/clavulanic acid (1 g × 3/day for 2 weeks).

The clinical course initially improved transiently, then deteriorated, marked by the recurrence of fever at 39°C and deterioration in general condition 3 weeks after the operation. Cerebro-cervical spine control CT scan with contrast enhancement was performed, revealing an abscess collection of 22 ml with internal calcifications in the retro-cervical soft tissues at the level of C1 to C2, along with adjacent epidural inflammation and osteitis of the posterior arch of C1 and A presence of two other collected abscesses in the retro and para-cervical soft tissues measuring 4.5 and 14.2 mL respectively. She complained of fever, headaches, and vomiting in the context of altered consciousness (Glasgow coma scale [GCS] 13/15); the diagnoses of hydrocephalus and cerebral thrombophlebitis were considered; a contrast-enhanced cerebral CT scan with contrast enhancement was performed, along with blood electrolyte levels and a complete blood count, showing respectively ([Fig. 2]):

Fig. 2 Follow-up contrast-enhanced cerebral CT scan, 3 weeks postsurgery.

• Tetra ventricular hydrocephalus with subependymal resorption.

• Hyponatremia at 118.9 mEq/L, hypochloremia at 97.6 mEq/L, and hypocalcemia at 1.08 mg/dL

• Mild anemia at 10.5 g/L microcytic normochromic without leukocytosis.

After correction of these biological and biochemical abnormalities, a depletive lumbar puncture of approximately 30 to 50 mL was performed with cerebrospinal fluid (CSF) analysis and confirmed the absence of meningitis. The patient underwent surgery for a ventriculoperitoneal shunt. The analysis of CSF suggests indirect signs of tuberculosis (glucose = 0.73 g/L, chlore 110,6 mmol/L, protein = 0.09 g/L), prompting initiation of anti-tuberculous therapy with a combination of rifampicin–isoniazid–ethambutol–pyrazinamide (one tablet each at 5 am) with a favorable progressive evolution without neurological deficit allowing the patient's discharge 2 weeks later. She has completely recovered clinically from her symptoms, and the parents no longer have the funds for imaging follow-up. The 1-year postoperative phone follow-up did not mention any complaints, and there were no disruptions in academic results. ([Fig. 3])

Fig. 3 Follow-up cerebral CT scan at 1 year postop, without hydrocephalus.

Discussion

The SEA is a rare entity, especially without significant osseous involvement, and cervical spine EDAs are less common than those in the lumbar or thoracic spine. We could hypothesize that this particularity is probably linked to immunosuppression (malnutrition) in addition to an unknown vaccination history or the spread of an undiagnosed remote infection that went unnoticed. Contrary to Voelker et al[2] who reported a case of posttraumatic SEA (involved in a fight 5 weeks prior) where the cause was evident. The fact that the abscesses were drained multiple times in vain certainly indicates the non-identification of the causative microorganism, the patient's non-compliance with treatment (due to lack of financial means or lack of therapeutic education), and likely advanced osseous extension of this abscess.

The initial clinical presentation of our patient (severe, rapidly progressive neck pain and nuchal rigidity) aligns well with the literature regarding SEA, although they are not specific to it. Manoharan et al[3] this variation in the initial presentation of her case, which presented difficulty in walking with an unsteady gait and a 3-month history of progressive weakness in both her arms, with the right side more affected than the left. This alternating presentation may lead us, to consider certain differential diagnoses such as meningitis, transverse myelitis, or spinal tumor.

Due to insufficient financial resources, we were unable to obtain an MRI with Gadolinium, which is the imaging modality of choice in these contexts. However, the cervical computed tomography showed an extensive heterogeneous posterior peri vertebral collection from C1 to C5 with erosion of the posterior arch and spinous process of C1. As mentioned earlier, it is certainly this secondary osseous involvement that perpetuated the recurrence of abscesses in the adolescent.

The pathophysiology in our case remains highly debated. Although antitubercular treatment worked for this adolescent, we believe that the osseous involvement and the formation of the EA were secondary to cervical soft tissue abscesses (contiguity) and not hematogenous tuberculous dissemination.[4]

The extension of paravertebral soft tissue abscesses into the epidural space is not an uncommon event, as most patients are typically diagnosed and treated after meningeal extension, either because they were seen too late or lacked the necessary financial means. Like our patient, Houston et al,[5] Ran et al,[6] and Voelker et al[2] all presented with involvement of the paravertebral soft tissues in association with SEA (thus indicating direct extension).

Regarding the challenges we faced in managing this case, two issues arise: limited financial resources and difficulty in identifying the causative agent. While the identification is sometimes straightforward, as described in the literature, it was more challenging in our case to identify the causative agent responsible for the SEA. Likely due to the multiple drainages and antibiotics she received until she arrived at our hospital.

Although the soft tissue abscess was caused by Staphylococcus (which we treated medically and surgically with favorable outcomes initially), the patient experienced a subsequent phase of unfavorable evolution 1 month postoperatively, presenting with Quadri-ventricular hydrocephalus. CSF analysis revealed clear fluid with 52 red blood cells/mm³, less than 1 leukocyte/mm³, normal glucose levels, decreased protein levels, and low chloride levels, with a negative culture result. This could be explained by the likelihood of an extensive epidural abscess with multiple organisms, including tuberculosis, given the patient's location (sub-Saharan Africa) and living conditions. This justifies the success of our ventriculoperitoneal shunt placement along with the therapeutic trial of antitubercular medications.

Conclusion

SEA is a rare condition, occurring less frequently in children than in adults. Its clinical presentation varies, and a high clinical suspicion is necessary to establish a precise diagnosis in time, to avoid possible permanent and devastating neurological deficits. Identifying the causative agent is particularly challenging, especially in patients who have already received antibiotics or those with limited financial resources. Sometimes, no specific infectious source is identified, and the possibility of involvement of multiple organisms exists. Especially in sub-Saharan Africa, it is important to consider a tuberculous etiology, even in the absence of typical clinical manifestations. Early recognition, prompt intervention, and appropriate antimicrobial therapy are crucial for achieving favorable outcomes in patients with SEA.

Conflict of Interest

None declared.

• References

• 1 Greenberg MS. Handbook of Neurosurgery. 10th ed.. New York: Thieme; 2022: 381-385
• 2 Voelker A, von der Hoeh NH, Gulow J, Heyde CE. Cervical spondylodiscitis with epidural abscess after knife stab wounds to the neck: a case report. Injury 2015; 46 (08) 1684-1688
• 3 Manoharan SR, Leitao J, Emberton P, Quraishi NA. A large tuberculosis abscess causing spinal cord compression of the cervico-thoracic region in a young child. Eur Spine J 2013; 22 (07) 1459-1463
• 4 Ambulgekar RK, Iqbal Z, Masne P. A rare case of thoracolumbar epidural abscess with tuberculous etiology in an adolescent male with neurological deficit. J Orthop Case Rep 2022; 12 (09) 98-101
• 5 Houston R, Gagliardo C, Vassallo S, Wynne PJ, Mazzola CA. Spinal epidural abscess in children: case report and review of the literature. World Neurosurg 2019; 126: 453-460
• 6 Ran B, Chen X, Zhong Q, Fu M, Wei J. CT-guided minimally invasive treatment for an extensive spinal epidural abscess: a case report and literature review. Eur Spine J 2018; 27 (Suppl. 03) 380-385

Publikationsverlauf

Eingereicht: 10. Dezember 2024

Angenommen: 27. Januar 2025

Accepted Manuscript online:
30. Januar 2025

Artikel online veröffentlicht:
28. Februar 2025