History
Menezes and VanGilder have classified patients by the duration of symptoms into acute, subacute, and chronic categories. [6] In one study, the average time from the onset of symptoms to diagnosis was 46 days, with a range of 0-540 days.
Patients in the acute category present with symptoms lasting less than 1 week. Patients who present acutely have a clinical picture of transverse myelitis (with rapid onset of motor and sensory loss) and sphincter disturbances. Pain is common, and fever with signs of concomitant infection typically is present.
Patients in the subacute category present with symptoms that are 1-6 weeks old. The clinical picture resembles that of a chronic presentation.
Those in the chronic category present with symptoms of greater than 6 weeks' duration. Patients with chronic spinal cord abscesses present with signs and symptoms that are more consistent with an intramedullary tumor (ie, with a slowly progressive and stuttering neurologic deficit). Patients may complain of a radicular-type pain and are frequently afebrile.
Radiculopathic pain can present in the back, neck, extremities, or, occasionally, as abdominal or chest pain of undetermined origin. At least one reported case exists in which abdominal surgery was performed and later diagnosis proved intramedullary abscess of the spinal cord to be the origin of the problem.
A review of 25 patients, published in 1998, revealed fever in 40%, back or radicular pain in 60%, and a triad of fever, pain, and neurologic deficits in 24%. [2]
Physical
A thorough physical examination to determine the extent of the motor and sensory deficit and its levels is of primary importance to guide diagnostic modalities later. Examine the cervical, dorsal, and lumbar regions carefully looking for dermal sinuses, suggestive lesions, and signs of local infection.
First findings of intramedullary spinal cord abscess include fever (in acute forms), radiculopathic pain, and neurologic deficit. [7]
Root pain can present along a well-defined dermatome or, occasionally, as abdominal or chest pain of undetermined origin.
Palpation of the spinous processes or straight-leg raising is unlikely to elicit pain on examination.
Motor deficit usually progresses from slight paresis of one or more limbs to a flaccid paraplegia or tetraplegia with sensory loss below the level of the lesion and eventual sphincter disturbances (urinary retention or incontinence and/or loss of rectal tone).
A review of 25 patients, published in 1998, revealed the following: [2]
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Motor deficits only (24%)
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Sensory deficits only (4%)
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Motor and sensory deficits (68%)
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Brainstem dysfunction (4%)
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Urinary incontinence (56%)
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Meningismus (12%)
Causes
Presence of spinal dysraphism (congenital midline neuroectodermal defects) with persistent dermal sinus can lead to development of an intramedullary abscess by contiguity. These abscesses usually are observed early in life. In a review of 25 patients, 36% had spinal dysraphisms. [2] Tethered cord syndrome can lend itself to iatrogenic spinal cord infection and damage via a lumbar puncture. [8]
The existence of chronic conditions (eg, alcoholism, diabetes, intravenous drug use) can predispose patients to the development of this rare pathology of intramedullary abscess.
Immunosuppression (eg, AIDS) alters the bacteriology of spinal abscesses.
Organisms also can cause spinal cord infections.
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Graph showing age distribution of 91 patients with intramedullary spinal cord abscess. The age or gender of 14 patients is unknown.
