Adolescence spinal epidural abscess with neurological symptoms: case report, a lesson to be re-learnt
A 15 year old boy presented to orthopedic clinic with a 2 week history of urinary retention, back pain, bilateral leg numbness and weakness, lumbar pain exacerbated by movement, sweat and fever. He had received conservative medical treatment with a diagnosis of low back pain but there was no response to analgesic and medical treatment. He had also referred to urologist due to his urinary retention. Ultra-sonograohy of bladder and kidneys detected no abnormal finding. He was then discharged after urinary catheterization with an unexplained diagnosis of urinary retention. His lower back pain was exacerbated and severe neurological deficit was also added to his clinical picture. He also developed difficulty in weight bearing and walking. His past medical history was not significant. He denied any previous trauma, spinal surgery, or immunodeficiency. He was not taking any medication. In physical examination, he presented with blood pressure of 100/80 mmHg, pulse rate of 100 pulse/minute and a body temperature of 38.5º C. Hematologic examination revealed a white blood cell count of 18600 /µl (neutrophil 70%), an erythrocyte sedimentation rate (ESR) of 68 mm/hr and a C reactive protein 3-plus positive.\nOn physical examination, there was a tenderness over the left side of lumbar vertebrae and on the left and right sides of para-lumbar region. Neurological examination showed hyperactive deep tendon reflexes, muscle weakness (3/5), and decreased pin prick sensation in the right leg. Rectal tone and sensation were normal but there was a perineal numbness.\nRadiologic imaging showed no significant evidence (). On magnetic resonance imaging (MRI) scan that were taken at the time of admission there were abnormal signal intensity at right paraspinal muscles of L2 and L3 level. The lesion was extended to the posterior aspect of thecal sac and its extra-dural mass effect caused canal stenosis and cauda equina compression to anterior wall of the canal. Radiologist recommended emergent laminectomy and debulking of the canal (, ).\nImmediately the patient underwent surgical operation. Abscess drainage and L2 and L3 laminectomy were done under microscopic surgery. Surgical finding was a yellow colored abscess-like fluid under yellow ligament. Culture testwas positive for Staphylococcus aurous. Following the operation, all the symptoms disappeared and neurological deficit were resolved.\nIntravenous antibiotic (cefazolin 1gr) was administered for two postoperative weeks then oral antibiotic (cephalexin 500 mg every 6 hours) were continued for 4 weeks. After 6 weeks from the time of operation, white blood cell (WBC) counts, ESR and CRP were all found to be normal. On a three month follow-up period there was no recurrence and the patient was returned to his normal life.