A typical presentation of a not so rare condition.

1. PARAPLEGIA
A TEXTBOOK CASE
Chair:- Prof. Dr. Baby Paul
Presenter: Dr.Shybin Usman

2. STRIKE ONE
 Mr. Gopakumar, 28 years from Neyyatinkara.
 Working in the BSF & posted in Bengal.
 Developed a nagging backache.
 Admitted in a local hospital near his base on
17/10/07.
 D/D on 20/10/07 as he was better.

3. STRIKE TWO
 Backache was back by 23/10/07.
 Shooting pain radiating from back to
umbilicus.
 Noticed gradually developing weakness of
both lower limbs.
 Admitted from 23/10/07 to 31/10/07.
 Symptoms grew worse and he got on the next
train home.

4. STRIKE THREE
 Reached here on 3/11/07.
 Weakness of lower limbs was complete.
 Had lost all sensation in both lower limbs.
 In the final day of journey high grade fever set
in.
 Backache was very severe with difficulty in
lying on his back.

5. SNIPPETS
 No significant medical past history.
 H/o haemorrhoidectomy 7 years ago.
 Occasional alcoholic.
 Non smoker.

6. PRESENTING PICTURE
 Moderately built and nourished.
 Concious and oriented.
 Febrile.
 No PICCLE, conjunctival congestion.
 Chest – Clear.
 CVS – WNL.
 Abdomen – Bladder distended.
 Spine - Tenderness at D12 spine.

7. NEUROLOGIC DEFICITS
 Grade 0 power both LL.
 Reflexes totally absent below the level of
umbilicus.
 Sensations totally absent below the level of
umbilicus.
 Bladder was distended.
 Rest of the nervous system examination was
normal.

8. INVESTIGATIONS
 Hb-11.4, TC-22700, N82 P15 E3, ESR-76.
 RBS-113.
 B.Urea- 62, S.Creat- 0.9
 Na⁺- 139, K⁺-3.9
 Bili- 1.4(T)/0.5(D),
 SGOT- 112, SGPT- 222, ALP-156
 Prot- 6.0, S.Alb- 2.6
 APTT- 31 sec, INR- 1.2

9. PRIMA FACIE
ACUTE TRANSVERSE
MYELOPATHY
with
SPINAL SHOCK

10. SUSPECTS
 Pott’s spine
 Spinal extradural tumour with bleed
 Transverse myelitis
 Epidural abscess
 IVDP

11. M SP
RI INE

12.  Diffuse posterior dorsal epidural abscess with
spinal cord compression.
 Altered spinal cord signal intensity s/o edema.
 Multiple vertebral body (D12,L4,L5,S1)
destruction with involvement of posterior
elements & abscess formation.
 Extensive paravertebral & iliopsoas abscess
formation.

13. FINAL DIAGNOSIS
SPINAL EPIDURAL ABSCESS

14. EPILOGUE
Patient was handed over to the NS1 unit of the
Dept.of Neurosurgery for further
management on 6/11/07.
He underwent posterior decompression with
abscess evacuation on 13/11/07.

15. INNARDS
Histopathology report:-
Section shows fragments of a lesion composed of
numerous granulomas composed of epitheloid
cells, multinucleated giant cells of Langhans
type & inflammatory cells composed of mainly
lymphocytes & also neutrophils. Areas show
extensive caseation necrosis. The inflammatory
infiltrate seems to invade the adjacent adipose
tissue.
Caseating granulomatous inflammatory lesion
consistent with Tuberculosis.

16. FOOTNOTE
Patient was put on daily regimen of ATT.
He bettered during the rest of his hospital stay.
He was discharged on 21/11/07 with grade 1+
power in both LL.

17. SPINAL EPIDURAL ABSCESS
AN OVERVIEW

18. Remains a challenging problem that often
eludes diagnosis and receives suboptimal
treatment.
Vague symptomatology & non-specific clinical
findings in the early stages can make diagnosis
difficult.

19. AETIOLOGY
 Predisposing factors:-
• Underlying disease (DM, alcoholism, HIV, etc)
• Spinal abnormality/intervention (Joint degeneration, Sx)
• Source of infection- local/systemic
 Mode of spread:-
• Hematogenous- 50% cases
• Contiguous- 33% cases
• Rest- unknown
• Abscess can spread locally or via bloodstream

20. ORGANISMS
 Staph. aureus- 67%
 MRSA on the increase
 S.epidermidis (invasive procedure)
 E.coli (UTI)
 P.aeruginosa (iv drug abuse)
 Rare- Actinomycetes, Nocardia, Mycobacteria,
Fungi.

21. COURSE OF DISEASE
 STAGE I- Pain @ affected spine(s)
 STAGE II- Nerve root pain from involved area
 STAGE III- Motor weakness, sensory deficit,
bowel & bladder dysfunction.
 STAGE IV- Paralysis

22. CLINICAL FEATURES
 CLASSIC TRIAD (infrequently seen):-
• Back pain- 75% pts
• Fever- 50% pts
• Neurologic deficit- 33% pts (pattern depends on site)
 Duration & progression of symptoms vary widely
 Source of infection may be identifiable

23. SITES
 More in infection-prone fat & larger epidural
spaces
 Posterior > Anterior
 Thoracolumbar > Cervical
 Usually span 3-4 vertebrae
 Can involve the whole spine- Panspinal
infection

24. DIAGNOSIS
 Clinical features + clinical findings + lab data +
investigation + high degree of suspicion
 Lab data (not specific):-
• Leukocytosis- 66%
• CRP & ESR increased- almost 100%
• Bacterimia- 60%
• CSF (mostly)- Protein ↑, Glucose N
Leukocytosis (neutro+lympho)
Gram stain- neg
 Culture- CSF +ve 25% (= Blood +ve 100%)

25. INVESTIGATIONS
 LP to be avoided:-
 Not much helpful
 Meningitis
 Subdural infection
 Neurologic deterioration if below complete block
 X-ray spine-
 Narrowed disc space
 Bone lysis
 CT myelography- 90% specific, but unadvisable

26. IMAGING MODALITY OF CHOICE
MRI + Gadolinium (best)
Less invasive
Delineates lesion best
Diff b/w infection & tumours

27. DIFFERENTIALS
 Meningitis
 Transverse myelitis
 Spinal tumour
 Spinal hematoma
 Osteomyelitis of vertebrae
 Diskitis
 IVDP
 Degenerative joint disease
 Demyelinating illness
 Sepsis

28. TREATMENT
 Surgical- Decompression laminectomy and
debridement. (Rate of progress of symptoms cannot be
predicted. Sx as early as possible)
 Appropriate systemic antibiotics (min 6
weeks)
 Emperical- Vancomycin + 3rd /4th gen Cephalosporin
MSSA- Cefazolin/Naficillin

29. MONITORING
 Neurological status (esp. antibiotic only)-
 Deterioration – Extension/incomplete evacuation
 Signs of sepsis
 Repeat imaging (esp. antibiotic only)

30. PROGNOSIS
 Best predictor of post-op final neurologic
outcome is pre-op neurologic status.
 Paralysis of <24-36 hrs= better prognosis.
 Recovery can continue till about 1 year.

31. COMPLICATIONS
 Irreversible paralysis
 Bladder dysfunction
 Decubiti
 Supine hypertension
 Recurrent sepsis

33. THANK YOU