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Background: Despite technological advances in medical treatment, the prognosis of the rarely reported spinal subdural abscesses (SSAs) has remained a serious entity largely unaffected, especially when they are diagnosed late. In this study, the authors aimed to present the surgical outcomes of 3 consecutive pediatric patients with SSA. Materials and Methods: We retrospectively reviewed the medical records of pediatric patients with spinal lesions who underwent surgery at 2 neurosurgical centers spanning 7 years, from 2012 to 2019. All pediatric patients who were diagnosed with SSA (n = 3) were selected as the core sample for this study. Results: Three pediatric patients (2 females and 1 male) with SSA were surgically treated. Holocord SSA was observed in 1 patient. The mean age was 7.1 ± 7.7 years. The most common presenting symptoms were gait disturbance and weakness of lower extremities (100%). The mean preoperative course was 5.7 ± 4.0 weeks. The causative pathogens were Escherichia coli (E. coli) and M. tuberculosis. In the 2nd case, the pathogen was non-tuberculosis mycobacterium in the extramedullary abscess. In the 44th postoperative month, she underwent surgery for intramedullary abscess. The causative pathogen was E. coli. Except for 1 male adolescent who presented with severe clinical status (paraplegic), the improvement was observed in all patients at their last follow-up after 50.3 ± 43.5 months of average. Conclusions: Drainage followed by appropriate antibiotics is the optimal treatment for SSAs. Early diagnosis and urgent surgical treatment are essential for a good prognosis. All surgically treated SSA patients with neurological deficits were rehabilitated with physical therapy postoperatively.

Purpose Congenital dermal sinuses are a rare form of spinal dysraphism. The developmental defects are located along the midline neuroaxis, with sinuses in the cervical region being the least common. Congenital dermal sinuses can be associated with intraspinal infection as they act as a direct route from the skin and subcutaneous tissues into the spinal cord. Methods The authors present two cases of cervical dermal sinuses complicated by intramedullary abscess. Both children presented with neurological decline and febrile illness. MRI showed intraspinal abscess. Both underwent prompt surgical excision of the sinus tract, exploration of the cord and intravenous antibiotics. Results Both patients demonstrated excellent neurological recovery. Conclusions Complete surgical excision of the sinus and tract in addition to long-term antimicrobials can yield excellent neurological outcomes. At surgery, do not expect to find pus when exploring the intramedullary component. Long-term follow-up is advocated due to potential late recurrence.

Intramedullary spinal cord abscess (ISCA) is a rare infection of the central nervous system. Untreated, it may result in significant morbidity and mortality. We describe the case of a 34-year-old man, who initially was admitted for bacterial meningitis. 3 days after initiation of antibiotic therapy, a gradually and progressive weakness appeared on the left side of his body with numbness on the contralateral side. MRI of the spine demonstrated an ISCA at level of C4. A myelotomy and surgical drainage was performed. Postoperatively, the patient had improved significantly his neurological deficit. ISCA is still a life-threatening condition, we point out that the diagnosis should be highly suspected, if a cystic spinal cord lesion is surrounded by significant medullar edema associated with fast onset of symptoms, especially in a context of sepsis or acuate meningitis. Prompt surgical evacuation followed by adequate antibiotic therapy, are the mainstays of treatment.

BACKGROUNDThe purpose of the present case report is to highlight the presentation, workup, clinical decision making, and operative intervention for a 68-year-old woman who developed rapidly progressive myelopathy secondary to idiopathic cervical intramedullary abscess.OBSERVATIONSThe patient underwent laminectomy and aspiration/biopsy of the lesion. Intraoperatively, division of the posterior median sulcus released a large volume of purulent material growing the oral pathogens Eikenella corrodens and Gemella morbillorum. Broad-spectrum antibiotics were initiated postoperatively. At the 6-month follow-up, the patient had almost completely recovered with some persistent hand dysesthesia. Complete infectious workup, including full dental assessment and an echocardiogram, failed to reveal the source of her infection.LESSONSThe authors report the first case of cryptogenic spinal intramedullary abscess secondary to Eikenella spp. and Gemella spp. coinfection. Intramedullary abscesses are exceptionally rare and most commonly develop in children with dermal sinus malformations or in the context of immunosuppression. In adults without risk factors, they can readily be mistaken for more common pathologies in this age group, such as intramedullary neoplasms or demyelinating disease. Prompt diagnosis and management based on rapidly progressive myelopathy, assessment of infectious risk factors and/or symptoms, and targeted imaging are critical to avoid potentially devastating neurological sequelae.

Spinal infection (SI) is defined as an infectious disease affecting the vertebral body, the intervertebral disc, and/or adjacent paraspinal tissue and represents 2–7% of all musculoskeletal infections. There are numerous factors, which may facilitate the development of SI including not only advanced patient age and comorbidities but also spinal surgery. Due to the low specificity of signs, the delay in diagnosis of SI remains an important issue and poor outcome is frequently seen. Diagnosis should always be supported by clinical, laboratory, and imaging findings, magnetic resonance imaging (MRI) remaining the most reliable method. Management of SI depends on the location of the infection (i.e., intraspinal, intervertebral, paraspinal), on the disease progression, and of course on the patient’s general condition, considering age and comorbidities. Conservative treatment mostly is reasonable in early stages with no or minor neurologic deficits and in case of severe comorbidities, which limit surgical options. Nevertheless, solely medical treatment often fails. Therefore, in case of doubt, surgical treatment should be considered. The final result in conservative as well as in surgical treatment always is bony fusion. Furthermore, both options require a concomitant antimicrobial therapy, initially applied intravenously and administered orally thereafter. The optimal duration of antibiotic therapy remains controversial, but should never undercut 6 weeks. Due to a heterogeneous and often comorbid patient population and the wide variety of treatment options, no generally applicable guidelines for SI exist and management remains a challenge. Thus, future prospective randomized trials are necessary to substantiate treatment strategies.

Cervical intramedullary spinal cord abscess is an extremely rare entity. We present a case of a 53-year-old male with a cervical intramedullary spinal cord abscess caused by Streptococcus viridians that presented with 4 days of neck pain and progressive left upper extremity numbness and weakness. The patient was managed with a cervical myelotomy and adjunctive antibiotic treatment.

La tuberculose du système nerveux central est une affection rare. Elle se présente sous plusieurs formes mais l'association d'un abcès intra médullaire et un pott multifocal est exceptionnelle. Nous rapportons le cas d'une patiente âgée de 23 ans chez qui le diagnostic d'un pott multifocal L2-L3 et L4-L5 a été posé sur la tomodensitométrie (TDM) du rachis. Elle a été mise sous traitement anti tuberculeux et devant l'installation d'un tableau de compression médullaire deux mois après le début du traitement, une imagerie par résonance magnétique (IRM) médullaire a été réalisée objectivant une image d'abcès intra médullaire à hauteur de T4. Elle a été opérée bénéficiant dans le même temps opératoire du drainage de l'abcès intra médullaire et de la stabilisation du rachis. L'évolution a été favorable, la patiente a été suivie pendant 12 mois. L'association d'un abcès intra médullaire et un pott multifocal est exceptionnelle. Le traitement repose sur les antituberculeux et la chirurgie pour lever la compression médullaire et ou stabiliser le rachis le cas échéant.

Spinal intramedullary abscesses are rare and potentially devastating lesions. Infection is mostly caused by staphylococci. Anaerobes are rare and often polymicrobial. We report an unusual case of spinal cord intramedullary abscess in a 7-month-old infant with monomicrobial infection due to Finegoldia magna. She was found to have a missed congenital thoracic dermal sinus. The patient was treated with metronidazole and ceftriaxone for 8 weeks, and improvement of the infection was documented. Clinical awareness of patients at risk is crucial for early diagnosis and intervention. As detection methods continue to improve for Finegoldia magna, it is important to increase awareness of the pathogenic role of this organism.

Background Intramedullary abscess of the spinal cord (IASC) symptoms are often nonspecific with the diagnosis rarely considered on the initial differential. This can delay surgical management and may lead to permanent neurological deficits or mortality. Additionally, many organisms are implicated in IASC, leading to uncertainty in empiric antimicrobial therapy. Methods This case report follows a patient with IASC due to Streptococcus anginosus group (SAG). We also review a 25-case meta-analysis of IASC and 5 cases of SAG IASC. Results A 65-year-old woman with an unremarkable past medical history presented with 2 weeks of neck pain and paresthesias. She was afebrile with no systemic signs of infection or abnormal laboratory markers. MRI revealed an 8mm lesion at C4-C5 with edema C1-T1 and she received high-dose steroids for suspected malignancy. Follow-up MRI 4 days later revealed rapid progression of the lesion to 14mm, consistent with an infectious process (Figure 1). The patient received empiric therapy with ceftriaxone, vancomycin, and metronidazole. She underwent a C2-C7 laminectomy with midline myelotomy for evacuation of the abscess. Due to clinical and radiographic progression she required a second surgical wash-out 4 days later. Her intraoperative cultures grew SAG and her regimen was changed to penicillin and vancomycin. Her course was complicated by eosinophilia requiring meropenem and later linezolid to complete a 6-week course, during which she improved clinically and neurologically. Our review demonstrated that 40% of cases presented with fever. The majority of cases were idiopathic with the organisms known in 70% of cases. Surgery and IV antibiotics were used in 83% of cases and one case required a second surgery. A wide range of antibiotic regimens were reported with no consensus on how to best preserve neurological function. Conclusion This case highlights the complexities in diagnosing and managing IASC. We suspect that due to the protected nature of the intramedullary space, the infection may not trigger constitutional symptoms or a systemic inflammatory response. In patients who present with significant neurological deficits, MRI may reveal IASC and this should prompt immediate initiation of antibiotics that penetrate the blood–brain barrier and surgical intervention. Disclosures All authors: No reported disclosures.

Intramedullary spinal cord abscesses are uncommon lesions. Forty percent of all such abscesses occur before 20 yr of age. Patients with acute onset of symptoms and signs have a graver prognosis. This generally occurs in the setting of systemic bacteremia. A case of large intramedullary spinal cord abscess extending up to the terminal spinal canal in a 6-month-old male baby who developed flaccid paraplegia without an evidence of systemic infection or septicemia or anatomical defect is reported. The possibility of infection of an epidermoid in such cases cannot ruled out.

Congenital dermal sinus (CDS) is a type of occult spinal dysraphism characterized by a midline skin dimple. A 12-month-old girl presented with fever and ascending quadriparesis. She had a midline skin dimple in the upper sacral area that had been discovered in her neonatal period. Imaging studies revealed a holocord intramedullary abscess and CDS. Overlooking CDS or misdiagnosing it as benign sacrococcygeal dimple may lead to catastrophic infection and cause serious neurological deficits. Therefore, further imaging work-up or consultation with a pediatric neurosurgeon is recommended following discovery of any atypical-looking dimples in the midline.

Spinal abscess in pediatric age group is a rare entity. Tubercular type is even rarer and it has been found to be associated with patent dermal sinus. Very few cases have been reported so far.We present a 2-month-old baby with gradually progressing paraparesis. There was a small dermal sinus in the lower area of right buttock which was discharging pus. MRI was done which showed intramedullary fluid collection at the level of lower lumbar and sacral spine suggesting abscess formation. Patient party was suggested for surgical exploration and histopathological evaluation. However, they denied and thus baby was put on steroid therapy. The baby gradually improved. However he started having paraparesis again and even worse than before. Repeat MRI showed intramedullary collection more than the previous MRI. Again surgical option was given and finally surgery done. Right hemilaminectomy was done from L3-4-5-S1and dura exposed. Dura was incised and spinal cord, conus and cauda equina exposed which were swollen and congested. Midline myelotomy was done opening the intramedullary. Free flow of thick pus was observed. Dermal sinus was excised and closed.Pus and small pieces of granulation tissue was sent for culture and cytological examination which showed features of tuberculosis. Antitubercular treatment was started and the baby became much better.Nepal Journal of Neuroscience 12:43-45, 2015

Intramedullary spinal cord abscesses are rare and potentially devastating lesions usually associated with other infective processes such as bacterial endocarditis, or pulmonary or urogenital infection. We describe a 2-year-old girl who presented with an infected dermal sinus leading to an intraspinal abscess. This abscess eventually spread and involved the entire neural axis leaving her quadriparetic. Drainage of the abscess resulted in recovery and the child regained normal function of her limbs. To our knowledge this is the first documented case of an intramedullary abscess involving the entire neural axis.

Intramedullary abscess is a rare condition with high rate of mortality and morbidity. We are presenting a case of delayed intramedullary abscess in an operated case of spinal lipoma, after 2 years of primary surgery. To best of our knowledge this only second case of intramedullary abscess in a case of spinal lipoma without dermal sinus.

Although lumbar puncture (LP) is a relatively straightforward procedure and is usually associated with low morbidity, rare and significant neurological complications can occur. Intramedullary spinal cord abscess (ISCA) after lumbar puncture is one of these serious complications; however, this complication has not yet been reported in children.After 27 days in another medical facility, a 1-year-old girl was admitted to our hospital with a diagnosis of fever of unknown origin. Prior to the second admission, she had undergone multiple traumatic LP attempts. The patient was referred to our institution with progressive and ascending weakness. Three days later, this weakness involved all of the patient's four limbs. A LP was performed and showed purulent cerebrospinal fluid (CSF). An emergent spinal magnetic resonance imaging was performed and revealed an intramedullary lesion extending from the T2 to L3 level. Broad-spectrum antibiotics and steroids were administered to the patient, and a T2-L3 laminectomy was performed. The postoperative course was uneventful, but a neurologic deficit, including lower limb paralysis, remained.The index of suspicion for a pyogenic infection of the intramedullary space should be higher if progressive flaccid paralysis develops within a few days after a lumbar procedure. Nevertheless, the diagnosis may be challenging due to the rarity of this condition. Any misdiagnosis or delay of adequate treatment may lead to unfavorable outcomes.

A spinal intramedullary abscess secondary to an infected dermoid cyst is rare, and it has a poor prognosis, unless diagnosed and treated promptly. We report a 12-month-old patient with a spinal intramedullary abscess with secondary to a dermoid cyst resulting from a dermal sinus, despite a clearly defined opening at the lower back with discharge of a purulent material from a dermal sinus tract seen on the lower back before the patient had become symptomatic and showed meningeal signs. The patient was managed as a case of meningitis until he had complications that endangered his life, and then further radiological evaluation was done to delineate the underlying pathology. This case illustrates the importance of the recognition and evaluation of skin markers because of the potential for intradural extension and a frequent association with other dysraphic abnormalities. It also emphasizes the importance of early diagnosis and treatment of spinal intramedullary abscess.

Summary Intramedullary spinal cord abscess (ISCA) is a rare entity in the central nervous system, especially in patients without meningitis. It is often difficult to promptly establish the diagnosis. In this report, we describe the case of a woman 52 years of age who presented with progressive neck pain that was followed by rapidly worsening quadriparesis. The cervical spine magnetic resonance imaging revealed an ovoid lesion at the level of C2-C4 with a gadolinium contrast ring enhancement. Because ISCA was suspected, we performed surgery to decompress the cervical spinal cord. The bacterial culture of the cystic content revealed the growth of two bacteria, Fusobacterium nucleatum and Peptoniphilus asaccharolyticus, which have rarely been observed. The patient's postoperative course was uneventful and her outcome was excellent on discharge. Antibiotics were prescribed for 6 weeks. We further report the result of a literature review on the management of ISCA. The surgical indications for ISCA are controversial, but early surgery to decompress the spinal cord and confirm bacterial growth is recommended in rapidly worsening cases.

Spinal congenital dermal sinus is a rare entity. Still rarer is its location over the thoracic and cervical spine. Secondary to congenital dermal sinus, intramedullary abscesses of the spinal cord are uncommon. Only few cases of such an association have been reported in the literature. We report such an interesting case of thoracic spinal congenital dermal sinus associated with intramedullary abscess in an 18-month-old boy who presented with a diagnostic conundrum. The pathogenesis, clinical presentation, neuroimaging and management of such cases are discussed. Awareness, detection, timely referral and definitive operative intervention for a better neurological outcome are emphasized.

SUMMARY Dorsal dermal sinus, a congenital abnormality associated with spinal dysraphism, can serve as a path for spread of infection inside the spinal thecal sac with its sequelae. Intramedullary abscess formation is an uncommon complication and only about 20 cases have been reported in the English literature. We report MR appearances of three new cases.

✓ An intramedullary abscess of the spinal cord (IASC) represents a rare disease associated with a potentially devastating outcome. Few cases involving children suffering from an IASC have been reported in the neurosurgical literature. In the majority of the reported pediatric cases there were either congenital abnormalities, such as a dermal sinus, or signs of local infections leading to a secondary hemopoietic spread. The authors report the case of an 18-month-old girl with an extensive IASC associated with an epidermoid cyst extending from T-11 to S-2 without evidence of a dermal sinus or history of clinically apparent systemic infection. To their knowledge, this is the first case report of an IASC without a condition facilitating either direct contamination via a dermal sinus or hemopoietic spread from an infectious focus outside the central nervous system. Signs and symptoms, the clinical course, and imaging features are discussed and the relevant literature is reviewed.