Sudden Onset of Paraplegia: T2 and T3 Collapse with Abscess

History

The patient is a 60-year-old female with sudden onset of paraplegia for the last 2 days. She has a previous history of low-grade neck and upper back pain for the last 6 months.

She’s not on any medications, and she has no co-morbid disorders and is medically fit.

Examination

Lower limbs power: Gr 0
Upper limbs power: Normal 

Low limbs reflexes: Brisk
Upper limbs reflexes: Normal

Hypesthesia below T9-T10

She does not have complete control of her bladder.

Pre-treatment Images

Figure 1: Sagittal MRI showing high intensity signal and T2 and T3.

Figure 2: Sagittal MRI showing T2 and T3 collapse with epidural abscess.

Figure 3: Axial MRI of T2 showing collection on the left side.

Figure 4: Axial MRI of T3 showing paravertebral and prevertebral collection and compression in the epidural space.

Figure 5: Sagittal CT scan showing C2 and C3 destruction on the left side.

Figure 6: Axial CT of T2 showing destruction on the left side.

Figure 7: Coronal CT showing T2 and T3 collapse.

Diagnosis

At this juncture, the most likely diagnosis was tuberculosis.  The biopsy later revealed that it was tuberculosis.

Selected Treatment

Because the patient was 60-years-old and had experienced a rapid onset of paraplegia, surgery was preferred.

Given her age and frailty, the transthoracic approach was not chosen. We performed an anterior sternotomy. The medial end of the clavicle was resected for bone graft.

A corpectomy of T2 and T3 was done, and the abscess was drained. The tissue was sent for biopsy and culture.

The defect was reconstructed with a Pyramesh cage filled with the morselized clavicle graft. A plate was used spanning T1 to T4. Since the bone was of good quality, posterior stabilization was not needed.

Post-treatment Images

Figure 8: Sagittal CT scan showing cage placement with adequate restoration of kyphosis. This image also shows the plate from T1 to T4.

Figure 9: Coronal CT scan showing the placement of the cage with the corpectomy at T2 and T3.

Figure 10: AP chest x-ray showing the plate centrally placed.

Outcome

The patient is recovering from her paraplegia. At 1-month follow-up, she had regained bladder control and has grade 2 power in her lower limbs with reduction of spasticity.

Case Discussion

Paraplegia secondary to just vertebral destruction, kyphosis, and epidural abscess is typically best treated through surgical means assuming that the patient can tolerate the procedure and is hemodynamically stable. Given the fact that this patient had an incomplete lesion (although her motor strength was 0 out of 5), she had sensation present in the lower extremities. I agree that urgent/emergent surgical intervention would provide the patient with the best likelihood of any meaningful neurological recovery.

I think in this case, the pathology could have been addressed through an anterior approach (as was done by Dr. Arbatti), a circumferential approach, or an all-posterior approach.

In general, my preference is to address problems of this sort through an all-posterior approach with a lateral extracavitary resection of the vertebral bodies, discs, and an infected material/abscess.

An all-posterior approach avoids the morbidity of a transthoracic/anterior approach. This is particularly beneficial in older patients and those with pulmonary and/or cardiac compromise. In this case, I would have likely performed a posterior spinal fusion with instrumentation from C7 to T6 with a lateral extracavitary resection of T2 and T3 and anterior reconstruction using a titanium cage filled with iliac crest bone graft.

I would have performed the procedure through a left-sided approach given the fact that the majority of the abscess and collection is present on the left side. Having said that, the approach employed by Dr. Arbatti is perfectly reasonable and carries with it the advantage that it allows direct decompression of the pathology. Dr. Arbatti is to be commended for achieving such a good surgical result given the severity of the patient’s neurological deficit and the degree of spinal canal compression and bony destruction.