Case of unilateral biportal endoscopic management of multilevel thoracic spinal epidural abscess with acute paraplegia

Abstract

Background:

Spinal epidural abscess (SEA) may cause rapidly progressive neurological deterioration and requires urgent decompression when severe spinal cord compression is present. Unilateral biportal endoscopy (UBE) has been increasingly applied to spinal infection, but its use for extensive thoracic SEA has rarely been reported.

Case Description:

A 49-year-old female with poorly controlled type 2 diabetes mellitus presented with severe thoracic back pain and the acute onset of paraplegia. Thoracic magnetic resonance demonstrated a posterior epidural abscess extending from T7 to T11 resulting in severe thoracic spinal cord compression. Urgent decompression and abscess evacuation were performed using UBE without conversion to open surgery. Postoperative imaging demonstrated near-complete evacuation of the collection, while motor strength progressively improved to Medical Research Council grade 4/5 in both lower extremities.

Conclusion:

UBE may provide effective decompression and abscess evacuation in carefully selected patients with multilevel posterior thoracic SEA.

INTRODUCTION

Minimally invasive endoscopic techniques have emerged as alternatives for selected spinal infections, but experience with unilateral biportal endoscopy (UBE) for multilevel thoracic spinal epidural abscess (SEA) remains limited.[4-6] Here, we report a 49-year-old woman with acute paraplegia secondary to an extensive T7–T11 posterior SEA successfully managed with urgent UBE decompression and drainage followed by neurological recovery.

CASE PRESENTATION

A 49-year-old female with poorly controlled type 2 diabetes mellitus presented with severe mid-thoracic back pain and the rapid onset of bilateral lower-extremity paralysis (0/5 motor strength and complete loss of sensory function below the lower thoracic level). Laboratory studies were consistent with a spinal infection. A STAT thoracic magnetic resonance documented an extensive T7-T11 posterior SEA compressing the cord [Figure 1].

Figure 1:

Preoperative magnetic resonance imaging demonstrating an extensive posterior thoracic spinal epidural abscess extending from T7 to T11 with severe spinal cord compression.

UBE surgery for a T7-T11 thoracic abscess

Emergently, the abscess was evacuated under direct UBE visualization using suction, dissectors, and continuous irrigation [Figure 2a-f]. First, fluoroscopy was used to localize the affected thoracic levels [Figure 3a-c]. A viewing portal and a working portal were established.[8] A limited laminotomy was performed using a high-speed drill and Kerrison rongeurs to expose the ligamentum flavum. After flavectomy, purulent epidural material was encountered, and specimens were obtained before irrigation [Figure 2b]. A feeding tube was then advanced cranially within the epidural space to facilitate drainage of the more rostral collection [Figure 2c and d]. Decompression was continued until the dural sac and neural elements were freely visualized without residual purulent material [Figure 2e-f]. The procedure was completed without conversion to open surgery.

Figure 2:

Demonstration of the unilateral biportal endoscopic surgical technique. (a) Hemilaminectomy utilized a high-speed drill, exposing the ligamentum flavum beneath the lamina. (b) Release of purulent epidural material immediately following flavectomy. (c) Cranial epidural advancement of a feeding tube with Rhoton dissector. (d) Evacuation of epidural abscess using gentle suction with the feeding tube. (e) Complete decompression of the thoracic cord. (f) Final endoscopic view demonstrating adequate decompression of thoracic foramen.

Figure 3:

Intraoperative fluoroscopic localization and skin marking for unilateral biportal endoscopic portal placement. (a) Preoperative skin planning with fluoroscopic localization of the surgical levels and portal marking (b) Lateral fluoroscopic view demonstrating identification of the T9–T10 interlaminar space. (c) Anteroposterior fluoroscopic view illustrating the trajectory and depth of the endoscopic instruments within the T9–T10 interlaminar space.

Postoperative course

The early postoperative course was favorable, with progressive neurological improvement. Intraoperative bacterial and fungal cultures remained negative. Intravenous antimicrobial therapy was discontinued after 48 h because the patient elected to leave the hospital against medical advice. A thoracic magnetic resonance imaging obtained 10 days after surgery demonstrated near-complete resolution of the epidural collection with satisfactory spinal cord decompression [Figure 4]. At 3- and 6-month follow-up, neurological recovery was sustained, with bilateral lower-extremity motor strength of 4/5.

Figure 4:

Postoperative magnetic resonance imaging demonstrating near-complete evacuation of the epidural collection with satisfactory spinal cord decompression.

DISCUSSION

Multilevel thoracic SEA causing severe neurological deterioration requires prompt decompression and source control, often necessitating exposure across several thoracic levels.[1,2,7,10,11] Here, the posterior location of the abscess, absence of radiographic instability, and the surgical team’s experience with biportal endoscopy favored a UBE approach. UBE provided direct visualization of the epidural space, allowed evacuation of purulent material, and achieved satisfactory spinal cord decompression without conversion to open surgery.

Literature regarding UBE

Published experience with endoscopic treatment of multilevel thoracic spinal infections remains limited, with most reports focusing on lumbar spondylodiscitis.[2-6,9] Nevertheless, previous studies have shown that endoscopic debridement can provide adequate visualization, tissue sampling, and drainage in selected spinal infections.[4-6,8] An advantage of endoscopic debridement for spinal infections is the ability to obtain tissue and fluid specimens under direct visualization. Certainly, adequate microbiological sampling is essential to identify the causative organism and guide targeted antimicrobial therapy.[4,5] In this case, the biportal configuration allowed for independent visualization and manipulation of conventional instruments, while continuous irrigation facilitated clearance of inflammatory material. The studies referenced in this discussion are summarized in Table 1. Cranial advancement of a feeding tube within the epidural space also permitted drainage of the more rostral component of the collection through a limited operative corridor. However, this strategy should be reserved for carefully selected posterior collections without significant vertebral destruction or instability and should not replace open decompression when extensive reconstruction, stabilization, or circumferential access is required.[4,5,8]

Table 1:

Summary of the literature on spinal epidural abscess and endoscopic management.

CONCLUSION

UBE provided effective decompression and abscess evacuation in this carefully selected patient who presented with the acute onset of paraplegia attributed to a multilevel T7-T11 posterior thoracic SEA.

Ethical approval:

The Institutional Review Board approval is not required.

Declaration of patient consent:

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for their images and other clinical information to be reported in the journal. The patient understands that the patient’s names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation:

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Disclaimer

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