INTRODUCTION
Spinal infections encompass a broad spectrum of pathological entities, ranging from spondylodiscitis and epidural abscesses to the exceptionally rare subdural abscess [1,2]. Among these, holospinal subdural abscesses, extending throughout the spinal canal, represent an exceedingly uncommon and often life-threatening condition. Rapid neurological deterioration may occur due to circumferential compression of the spinal cord and cauda equina, making prompt recognition and decompression essential for favorable outcomes [3].
The diagnosis of a spinal subdural abscess (SSA) is often challenging because its clinical presentation can mimic epidural abscesses, meningitis, or intramedullary pathologies. Magnetic resonance imaging (MRI) remains the gold standard for early identification, delineating the extent of infection and guiding surgical strategy [4].
Traditional management involves extensive multilevel laminectomies for evacuation and decompression. However, such wide exposures increase the risk of postoperative instability, prolonged recovery, and blood loss. In contrast, a minimally invasive, skip-laminectomy approach allows targeted access for drainage and irrigation while preserving posterior elements and stability [5].
We present a rare case of a holospinal subdural abscess in a previously healthy patient with no predisposing factors, successfully treated through multilevel limited decompression and subdural irrigation using an external ventricular drainage (EVD) catheter. This report highlights a practical, tissue-sparing technique for achieving effective decompression in extensive spinal infections.
CASE REPORT
A 54-year-old male patient presented with acute onset of severe back pain, progressive bilateral lower limb weakness, and urinary retention over 48 hours. He had no history of diabetes, immunosuppression, spinal surgery, trauma, or invasive procedures. On neurological examination, bilateral lower extremity muscle strength was graded as 2/5, with hypoesthesia below the T10 level and urinary retention requiring catheterization.
Laboratory tests showed leukocytosis (14,800/µL) and elevated C-reactive protein (14.6 mg/dL). Blood cultures were negative. Whole-spine MRI demonstrated a circumferential subdural fluid collection extending from the cervical to the lumbosacral levels, causing diffuse spinal cord compression. The lesion was hypointense on T1-weighted and hyperintense on T2-weighted sequences, with rim enhancement after gadolinium administration—findings consistent with a holospinal subdural abscess (Figure 1).
After obtaining written informed consent, the patient underwent urgent decompression under general anesthesia. Through two limited midline incisions at T2–3 and L4–5, skip-laminectomies were performed to minimize tissue damage. Upon durotomy, thick yellow purulent material was identified in the subdural space and gently aspirated. The abscess cavity was irrigated using an EVD catheter, advanced cranially and caudally under direct vision to ensure complete clearance. The dura was closed primarily after confirming unobstructed cerebrospinal fluid flow.
No intraoperative or postoperative complications occurred. Intravenous ceftriaxone (2 g twice daily) was administered for six weeks under infectious disease consultation. The patient’s neurological function progressively improved; muscle strength increased to 4/5 within 3 weeks, and bladder control was fully restored. At 2 months, follow-up MRI confirmed complete resolution of the subdural abscess and restoration of normal spinal canal dimensions (Figure 2A and B). At one-year follow-up, the patient remained neurologically intact without recurrence, and MRI showed preserved spinal alignment and no residual enhancement (Figure 2C and D). Written informed consent was obtained from the patient for both treatment and publication.
DISCUSSION
SSA is an exceptionally rare infection of the central nervous system, accounting for less than 1% of all spinal infections [1,2]. Unlike epidural abscesses, which arise from hematogenous spread or contiguous infection, SSAs develop within the subdural space between the dura mater and arachnoid membrane, leading to rapid and diffuse neurological decline. The pathogenesis remains unclear in most cases, especially when no predisposing factors are identified. Reported etiologies include bacteremia, postoperative contamination, penetrating trauma, or hematogenous seeding following distant infection [3,4].
The holospinal form, in which the purulent collection extends through the entire spinal canal, is exceedingly uncommon and associated with a high risk of mortality and permanent neurological deficits [5,6]. Early diagnosis using MRI is essential, as the radiological features—T2 hyperintensity, rim enhancement, and circumferential compression—guide the differentiation from epidural abscess, arachnoid cyst, or intramedullary lesions [4,7]. In our case, prompt MRI of the entire spine enabled rapid surgical planning and likely prevented irreversible damage.
Traditionally, treatment involves extensive multilevel laminectomies for decompression and abscess evacuation. However, this approach carries substantial risks, including postoperative instability, prolonged hospital stay, and delayed rehabilitation. Several authors have advocated limited, multilevel, or skip-laminectomies combined with catheter-based irrigation to achieve adequate drainage while minimizing tissue destruction [8,9]. Our technique—performing limited laminectomies at the upper thoracic and lower lumbar levels, followed by subdural irrigation using an EVD catheter—allowed complete evacuation with preservation of spinal integrity.
This approach aligns with the growing trend toward minimally invasive infection control in spine surgery, which prioritizes adequate decompression, microbial eradication, and preservation of stability [5,10]. Our patient’s neurological recovery and absence of recurrence at one-year follow-up confirm the effectiveness of this strategy. To our knowledge, holospinal subdural abscess successfully treated with a dual-level skip-laminectomy and EVD-based subdural irrigation has been very rarely reported.
Early diagnosis, prompt limited decompression, and targeted antibiotic therapy remain the cornerstones of management. A multidisciplinary approach involving neurosurgery, infectious disease, and radiology teams is essential for optimizing outcomes.
CONCLUSION
Holospinal subdural abscess is an exceptionally rare but life-threatening condition that requires urgent surgical intervention. A limited skip-laminectomy with catheter-assisted subdural irrigation provides effective decompression while minimizing surgical morbidity. Early recognition, minimally invasive strategy, and long-term follow-up are key factors for achieving favorable neurological recovery without recurrence.
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