Topics in Neurology
Thoracic Spondylodiscitis Epidural Abscess in an Afebrile Navy Veteran: A Case Report

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Abstract

Objective

The purpose of this case study was to describe the differential diagnosis of a thoracic epidural abscess in a Navy veteran who presented to a chiropractic clinic for evaluation and management with acupuncture within a Veterans Affairs Medical Center.

Clinical Features

An afebrile 59-year-old man with acute thoracic spine pain and chronic low back pain presented to the chiropractic clinic at a Veterans Affairs Medical Center for consideration for acupuncture treatment.

Intervention and Outcome

The veteran elected to trial acupuncture once per week for 4 weeks. A routine thoracic magnetic resonance imaging scan without gadolinium detected a space-occupying lesion after the patient failed to attain 50% reduction of pain within 2 weeks with conservative care. The patient was diagnosed with a multilevel thoracic spondylodiscitis epidural abscess and was treated same day with emergency debridement and laminectomy of T7-8 with a T6-9 fusion. The patient had complete recovery without neurological compromise and completed an antibiotic regimen for 6 weeks.

Conclusion

A Navy veteran with acute thoracic spine and chronic low back pain appeared to respond initially but failed to achieve clinically meaningful outcomes. Follow-up advanced imaging detected a thoracic spondylodiscitis epidural abscess. Early diagnosis and immediate intervention are important to preserving neurological function and limiting morbidity in cases of spondylodiscitis epidural abscess.

Introduction

Back and neck pain are leading global causes of disability.1 Back pain caused by serious underlying pathology accounts for less than 3% of all back pain.2 A spinal epidural abscess (SEA) is a rare, life-threatening infection, with the incidence on the rise in recent decades. The rate of SEA in 1975 was 0.2 to 2.0 cases per 10 000.3 In a study of tertiary referral centers in 1999, 12.5 cases per 10 000 were reported.4 Early diagnosis is paramount to mitigate neurological compromise and limit morbidity. A history of diabetes mellitus (21%-38% of cases), intravenous (IV) drug use, end-stage renal disease, human immunodeficiency virus (HIV), or immunosuppressant use and iatrogenic causes, such as epidural spinal procedures, increase the risk of SEA.5, 6, 7

Cases of SEA have been documented as presenting to chiropractic offices often masquerading as non-specific neck or back pain.8, 9, 10 The classic clinical triad of back pain, fever, and neurological deficits is observed in only ~10% of cases.11 Clinical progression of SEA has been observed to comprise four phases: (1) spinal ache, (2) root pain, (3) weakness of voluntary muscles and sphincters, followed by (4) paralysis.12

Because of the pervasive nature of neck and back pain, misdiagnosis of SEA on initial presentation is noteworthy, with estimates ranging from 11% to 75%.7, 13 A SEA, on average, crosses 3.85 vertebral levels and is reported in the thoracic (15%-39.1%), lumbosacral (30%-54.7%), and cervical (9%-35.9%) regions.6, 7, 14, 15 Magnetic resonance imaging (MRI) examination with and without gadolinium of the entire spine is the gold standard, as it differentiates SEA from other space-occupying lesions and malignancy. A computed tomography (CT) myelogram should be obtained when MRI is unavailable or is contraindicated because of an implanted electrical device (eg, pacemaker, spinal stimulator).5, 11, 15 The infectious agent causing SEA is most commonly of bacterial origin and overwhelmingly either methicillin-sensitive or methicillin-resistant Staphylococcus aureus.7, 13 Once patients are diagnosed with SEA, best outcomes are achieved with rapid surgical intervention, abscess drainage, and concomitant antibiotic treatment. When monitored closely for clinical deterioration, there are select cases with limited neurological deficit that may be managed with antibiotic therapy only.11, 13

Multiple published SEA cases have suggested acupuncture to be the causative route of infection.16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31 In this report, we describe a case of SEA in a man who presented to a chiropractic office for acupuncture at a Veterans Affairs Medical Center. The purpose of this case study is to describe the differential diagnosis of a thoracic epidural abscess in a Navy veteran who presented to a chiropractic clinic for evaluation and management with acupuncture within a Veterans Affairs Medical Center.

Section snippets

Case Report

A 59-year-old man with chronic low back pain and left leg pain below the knee was referred by his primary care physician (PCP) to a chiropractor for evaluation and consideration for acupuncture. The patient developed acute, non-traumatic left-sided thoracic pain 8 days prior to his initial appointment. He reported his thoracic spine pain was significantly relieved following a bowel movement the day prior, yet remained more prominent than low back and left leg pain.

The patient had Minor’s sign

Discussion

Acupuncture is commonly used to treat back, neck, and joint pain. Since 1982, there have been at least 16 reports in the English literature of SEA secondary to acupuncture treatment.16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31 It has been proposed that poorly controlled hygiene in acupuncture practice might lead to epidural infections.17, 18, 19, 22, 25 All invasive procedures that break the skin carry the risk of infection. Appropriate clean needle technique is required to

Conclusion

A Navy veteran with acute thoracic spine and chronic low back pain appeared to initially respond to acupuncture, but failed to achieve a clinically meaningful outcome. Follow-up advanced imaging revealed a thoracic SEA, despite no elevation in temperature on multiple occasions or neurological deterioration. The spine practitioner is reminded that early diagnosis and immediate intervention are important to preserving neurological function and limiting morbidity in cases of SEA.

Funding Sources and Conflicts of Interest

This work was conducted at and supported by VA Butler Healthcare. No conflicts of interest were reported for this study.

Contributorship Information

Concept development (provided idea for the research): Z.A.C., M.T.A.

Design (planned the methods to generate the results): Z.A.C., M.T.A.

Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): Z.A.C.

Data collection/processing (responsible for experiments, patient management, organization, or reporting data): Z.A.C., T.J.S.

Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): Z.A.C.,

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