A spinal cord abscesses is an extremely rare form of suppurative central nervous system infection and may resemble a spinal cord neoplasm 1.
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Epidemiology
Spinal cord abscesses most commonly occur in the thoracic and lumbar spine among individuals with congenital midline defects or anatomical abnormalities. There is a bimodal age distribution, with the majority of reported cases affecting individuals younger than 25 years or older than 50 years 2.
Clinical presentation
Spinal cord abscesses often exhibit a rapid progression of symptoms. Initially, patients commonly experience progressive back pain accompanied by fever. Subsequently, neurological deficits become evident. In certain instances, the abscess may give rise to acute neurological deficits resembling episodes of transverse myelitis. It is important to recognize that the classic triad of fever, pain, and neurological deficits may be absent in individuals with subacute or chronic spinal cord abscesses 5.
Pathology
Spinal cord abscesses typically develop in patients with systemic conditions that predispose to infection such as immunosuppression and diabetes mellitus. Other predisposing factors include drug abuse, previous surgical history, meningitis, and congenital midline defects (e.g. myelomeningocele) and anatomical abnormalities of the spinal cord.
In the past, hematogenous spread accounted for nearly half of the cases, with approximately 25% of them associated with suppurative lung disease 3. In the modern era, the majority of cases have an unknown origin, and less than 10% of cases are attributed to hematogenous spread from an infection outside the spine.
The most common organisms responsible for spinal cord abscesses are Staphylococcus spp., followed by Streptococcus spp. However, other organisms such as Mycobacterium tuberculosis, Escherichia coli, Proteus spp., Listeria spp., Bacteroides spp., and Pseudomonas spp. can also be involved 4.
Radiologic features
MRI
MRI is the preferred imaging modality for assessing the location and extent of spinal cord lesions.
T1: hypointense
T2: central hyperintensity with a hypointense rim
T1 C+: peripheral enhancement
DWI/ADC: high signal intensity on DWI and low ADC values compared to the surrounding spinal cord 7
As the infection resolves after treatment, the hyperintensity on T2-weighted images gradually subsides. Abscess features on MRI include a well-demarcated and hyperintense lesion on sagittal T2-weighted images, with well-defined rim enhancement and a central non-enhancing area on sagittal T1-weighted post-contrast images. The rim of the lesion often demonstrates hypointensity on T2-weighted images. Occasionally, enhancement may extend to the adjacent dura or epidural space, which can be a helpful imaging feature of infection 7.
DWI is recommended as a more sensitive and specific method for differentiating abscesses from cystic or necrotic tumors, as the latter present with low signal intensity and increased ADC values 7.
Treatment and prognosis
The recommended treatment for spinal cord abscesses is a combination of antibiotics and surgical drainage procedures such as laminectomy and myelotomy. However, there have been reported cases of successful non-surgical treatment when the abscess is not extensive (less than 2.2 vertebral bodies) 6. It is noteworthy that spinal cord abscess carries a poor prognosis and a high mortality rate, even with appropriate treatment 6.
History and etymology
Spinal cord abscess was first described by Hart in Ireland in 1830 8.
Differential diagnosis
primary spinal cord tumor with central necrosis
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