JOURNAL OF NEUROSCIENCE AND NEUROSURGERY (ISSN:2517-7400)

We present a case of acute hydrocephalus secondary to a cervical, pyogenic spinal epidural abscess in a patient with a history of polysubstance abuse. A 53-year-old female with history of intravenous (IV) substance abuse presented to the hospital with abdominal pain, fever, and chills. On hospital day 2 her mental status deteriorated rapidly and she became acutely quadriplegic. An MRI of the spine revealed a new cervical epidural abscess with cervical cord compression and developing hydrocephalus. External ventriculostomy drainage was immediately performed at bedside with some improvement in her mental status. Hydrocephalus due to spinal cord pathology is a rare entity which has been reported in the literature in cases of trauma and malignancy but not related to an epidural abscess. Acute hydrocephalus although uncommon, should be considered in cases of acute neurological deterioration with known spinal cord pathology.

Spinal subdural abscess; Cervical myelopathy induced hydrocephalus; Autonomic dysfunction. 

Running title: cervical epidural abscess induced hydrocephalus

A 53-year-female visited the emergency department (ED) with abdominal pain, fevers and chills. Her blood cultures were positive for Staphylococcus aureus. She was started on broad-spectrum antibiotics. A urine Drug screen was tested on admission and was positive for cocaine and opiates. The initial MRI of her cervical and thoracic spine revealed no epidural abscess or paraspinal abscess. She had an elevated white count and elevated lactate levels that went up from 3.4 to 5.3 in 24 hours. She developed worsening mental status on the floor and was transferred to the ICU. She was given narcan 0.4mg and intubated. Her mental status continued to deteriorate and she became hemodynamically unstable. Her head CT revealed no intracranial pathology, but significant edema within the posterior musculature of the neck thought to be due to anasarca. She was obtunded with pin point pupils with sluggish reaction to light and her motor exam was 0/5 in bilateral arms and 1/5 in bilateral legs. Her leg weakness was thought possible to be due to Guillan Barre versus critical care myopathy/neuropathy, although infectious pathology was also highly considered. Her altered mental status was thought to be due to “infectious encephalopathy”. She could not undergo immediate repeat imaging due to profound autonomic disturbance ranging from bradycardia to PEA, requiring multiple codes and pacer pads to be placed. Once she was hemodynamically stable, a repeat MRI of the cervical spine revealed multiple new abscesses in the posterior, paraspinal soft tissues, with the largest at C2-C4 with extension into the spinal canal (Figure 1).

The MRI of her thoracic and lumbar was unremarkable. Due to continued autonomic instability, laminectomy with the patient prone was not advised and she underwent percutaneous cervical epidural abscess drainage. Her exam did not improve after this. In addition, her mental status deteriorated to coma. A repeat head CT showed acute hydrocephalus (Figure 2). An external ventricular drain (EVD) was placed bedside at a right frontal approach. A repeat head CT showed improvement in hydrocephalus and anterior displacement of the poorly seen upper cervical cord and medulla.

Despite maximal treatment, her neurological exam deteriorated with loss of brain stem reflexes and brain death. A neuropathologic evaluation revealed evidence of an extensive purulent inflammation involving the spinal epidural space from the cervical to sacral levels, extending to subdural and parenchymal areas, with total infarction the cord. There was no evidence of an inflammatory process involving the brainstem, cerebellum or the cerebrum.