Name: Endoscopic Infection Management for Cervical Spondylodiscitis With Epidural Abscess
Uploaded: 2026-09-16T07:53:00Z
Channel: Arthrex
Description: Vincent Hagel, MD (Lindau, Germany), presents a case highlighting the use of endoscopic techniques to manage a multilevel cervical epidural abscess associated with spondylodiscitis in a 57-year-old male patient.

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<p>Vincent Hagel, MD (Lindau, Germany), presents a case highlighting the use of endoscopic techniques to manage a multilevel cervical epidural abscess associated with spondylodiscitis in a 57-year-old male patient.</p>

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VID1-009761-en-US | A | Endoscopic Infection Management for Cervical Spondylodiscitis With Epidural Abscess

Vincent Hagel, MD

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Endoscopic Infection Management for Cervical Spondylodiscitis With Epidural Abscess

Speaker  Hi, I'm Vincent Hagle, a neurosurgeon from Lindau, Germany. I'd like to present to you a case of a cervical spondylodiscitis with an associated multisegmental epidural abscess. It's the case of a 57 year old male patient who experienced two weeks of progressive neck pain after about one week. He additionally noticed a weakness of his left upper extremity. Also, he mentioned about one week of intermittent fever. Once he presented, he denied any sensory deficit, gait disturbance, or bladder bowel dysfunction. Also, he does not have any risk factors for developing a spinal infection. Physical examination showed a severe weakness of his proximal left arm, especially deltoid function was significantly impaired as well as his arm flexion. Also, there was mild weakness of his left hand. He did not show any sensory deficits. Beyond that, he showed a mild neck stiffness and also infection parameters were increased. White blood cell count was slightly increased up to 11,700 per microliter CRP was significantly increased. These are examples of the pre-op MRI. We see sagittal T1 contrast enhanced views were. On the one hand, we see a spondylodiscitis at the level C5 six, but also a long distance epidural abscess reaching all the way up to the skull base. These are two examples of axial cuts. Also T1 contrast enhanced. On the left side, at the level three four, where we see a significant accumulation of that abscess, especially in the left side of the canal, thereby compressing and deviating the spinal cord to the right side. On the right hand side, we see the level of Spondylodiscitis c5 six, where we also have a significant abscess formation in the canal circumferentially located and thereby compressing the spinal cord. Speaker  Why surgery? Well, spinal epidural abscesses by themselves can rapidly develop into a life threatening condition. But in this very specific case, we obviously had a severe neurological deficit, which is usually reason enough to do surgery. Beyond that, it's epidural abscess was obviously extending all the way up to the skull base, making it therefore very dangerous to extend all the way into the brain. Now, there is no gold standard in treating these kind of conditions surgically. However, any traditional approach is usually associated with, quite often approach damage. There is a possibility of an anterior approach or a posterior approach, or even a combination of it. However, all of these approaches have advantages and disadvantages. Doing an anterior approach would definitely effectively address that spondylodiscitis, but on the other hand have very limited ability to address that long distance epidural abscess. Posterior approaches, on the other hand, can, by multilevel decompressions, effectively address that whole extent of that epidural abscess, but then again, have limited access to that discitis as seen on pre-op MRI. Most abscess was located at the level C3 four on the left hand side, which in our opinion was also the reason for causing the severe neurological deficit. So focus of our surgical approach was to perform an effective drainage of that abscess, especially at the level three four, but then also, of course address other levels to overall get a reduction of that abscess over the full extent all the way from the skull base down to C6. Speaker  That's why we decided to go with a posterior rather than an anterior approach, primarily. Now, traditional posterior approaches, as we also know from degenerative pathologies are usually quite invasive to where the patients experience long term neck pain. Post-operatively. Therefore, we decided to perform this posterior approach in a minimally invasive endoscopic way. So we took the most affected levels, which was C3, C4, and c5, C6, and performed an endoscopic approach at those two levels. Here is a short, intraoperative sequence of the level three four, where, after performing a bony decompression yellow ligament was removed and then again by just carefully manipulating membranes were opened and abscess started to drain. However, a lot of that abscess was already solid to where I had to additionally carefully dissect that abscess formation off of the dura and remove it, always keeping in mind to keep the risk for a dural tear as little as possible. At some point, the exiting route appeared. However, I had to additionally remove more of that abscess material centrally, which was then step by step exposing that thecal sac, which was, as you just saw, pulsating as a good indirect sign of a sufficient decompression at that level. This is a short intraoperative sequence of the level c5-c6, where I also, in the first step, performed the bony decompression on the ipsilateral side and thereby widely exposing that yellow ligament underneath before removing it. Speaker  I additionally did a contralateral bony decompression. After having performed that bony decompression, I started removing yellow ligament from midline over to the ipsilateral side, thereby also training and removing this layer of abscess posteriorly. Additionally, since that was the level of the discitis, I did enter the disc space and carefully removed some of that infected disc material. Now after having removed some of these parts of the disc material. This is the final view where you see down at 6:00 the ipsilateral exiting route. And now you see the central part of the thecal sac, which is fully decompressed bilaterally, with only a small layer of hyperemic vessels remaining, but no abscess left there. Here you can appreciate the ultra minimal invasive approach to very small skin incisions to train this abscess in the postoperative period, no complication, especially no new neurological deficit was observed. Also, the preoperative severe neck pain was significantly reduced in the post-operative period. Microbiological workup could prove a cutibacterium as the reason for this infection. Based on this. Iv antibiotics were recommended for three weeks before authorizing. Here we see a pre and post-operative MRI image sagittal view T1 contrast enhanced. Where? On the right hand side, on the first post-op day, you see a significant reduction of that abscess over the whole distance from the skull base all the way down to C6. Despite having only performed two ultra minimal invasive approaches, obviously the abscess is reduced over the whole distance all the way from the skull base down to C6. Speaker  Now, these two posterior approaches primarily addressed that epidural abscess. However, we could not effectively treat the discitis with this posterior approach. That's why we added an acdf on the fourth post-op day. This is a post-op X-ray showing the discectomy and cage placement. After three weeks of IV antibiotics, the patient was discharged. I did see him for the first time after that, after six weeks where he did report to not have experienced any pain again, and his neurological deficits were already significantly reduced by then. Beyond that, infection parameters return to normal values. Now that's a short video of his ability of already moving his arm, his left arm much better than Preoperatively, where again, we had the M1 two paresis of his deltoid and biceps. Here we see pre-operative and post-operative MRI image. On the left hand side. We see again the preoperative image with a long distance epidural abscess. In the center we see the same sequence T1 contrast enhancement after six weeks, where we see a complete disappearance of that abscess and also of the spondylitis with the discitis treated by the cage. On the right hand side, we see a T2 image of that same MRI six weeks after the surgery, also indicating a complete disappearance of that long distance epidural abscess. And also the spondylitis disappeared. Here we have two examples of axial views of that six weeks post op MRI also. T1 with contrast enhancement where we also see the complete disappearance of that abscess, especially on the pre-op image at the level 3.4. Speaker  We did see on the left side of the canal a significant accumulation of abscess compressing and deviating that spinal cord. Here you see CSF circumferentially surrounding that spinal cord again, and it's back in its original place in the center of the canal. I did see that patient again six months after the surgery, and by then his neurological deficits completely resolved. He mentioned that he does not feel any difference between his right and left arm anymore, to where he regained full strength in his left upper extremity. Now, spinal epidural infections are rare, but if they appear, they are a serious pathology with mortality up to 25%. There is no gold standard in treating these kind of multisegmental epidural abscesses in the cervical spine. Traditional techniques usually include quite a bit of approach damage. Therefore, the question is if these minimal, invasive and ultra minimal invasive approaches are an effective alternative to our best knowledge, there is only this one study describing the full endoscopic treatment of a cervical epidural abscess. Obviously, in our case, this was also an adequate treatment to where we removed the full extent of that epidural abscess by only performing two ultra minimal invasive approaches from posterior in the cervical spine. However, we will definitely need more high quality literature to expand the application of this endoscopic technique in order to safely and effectively treat spinal infections, especially multisegmental epidural abscesses. Thank you.

Endoscopic Infection Management for Cervical Spondylodiscitis With Epidural Abscess

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