Epidural abscess of the cervical spine with atypical manifestations: A report of two cases

Background: Epidural abscess of the cervical spine is a medical and surgical emergency, especially when it is located at cervical area, considering this critical anatomic location. Although there is the so-called triad of epidural abscess (fever, local pain, and neurologic deficits), these are not sensitive enough to detect spinal abscess early and prevent significant morbidity and mortality. Review Summary: We report 2 fatal cases of cervical spine epidural abscess with atypical manifestations. Patient I presented as an ascending paraparesis without signs of upper motor neuron involvement. The initial presentation was only lumbago and paraparesis. Patient 2 presented as a pure motor monoparesis of the lower limbs with lumbago. However, both had no neck pain or percussion tenderness initially. There was also no fever in patient 1. The diagnosis was made on the fourth and eighth days, respectively. They both had longstanding diabetes mellitus (DM) and presumably were not well controlled. Diabetic neuropathy and an immunocompromised status resulted in delayed diagnosis. Neither received surgical intervention. Both patients died despite correct empiric antibiotic therapy. Conclusion: A high index of suspicion is most important in making a rapid, correct diagnosis of spinal epidural abscess (SEA) when a patient presents with local spinal pain and has risk factors like DM. The classic symptom triad of SEA is not sensitive enough for early detection, so a erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) and CRP can be used to improve the accurate diagnosis. Spinal MRI should be performed as soon as possible. When patients present with neurologic deficits, surgical intervention is essential if there is no contraindication.