From the Department of Neurology (G.K.H., A.S.A., S.B.), Brigham and Women's Hospital, Boston, MA; and Department of Neurology (A.L.B.), University of California, San Francisco, CA.
Neurology. 2023 Aug 22;101(8):e836-e844. doi: 10.1212/WNL.0000000000207515. Epub 2023 Jul 3.
Intramedullary spinal cord abscess (ISCA) was described 200 years ago but remains poorly understood and is often mistaken for immune-mediated or neoplastic processes. We present a systematic review of ISCA in adults, describing the clinical presentation, diagnostic features, treatment strategies, and outcomes.
Database searches for intramedullary abscess were performed on April 15, 2019, and repeated on February 9, 2022, using PubMed and EMBASE with 2 unpublished cases also included. Publications were independently reviewed for inclusion by 2 authors followed by adjudication. Data were abstracted using an online form and then analyzed for predictors of disability.
A total of 202 cases were included (median age 45 years [interquartile range 31-58]; 70% male). Thirty-one percent of those affected had no identified predisposing condition. The most common symptom was weakness (97%), and the median symptom duration before presentation was 10 days (interquartile range 5-42). An MRI showed restricted diffusion in 100% of 8 cases where performed and enhancement in 99% of 153 cases where performed. The most common organisms were (29%), sp. (13%), and sp. (10%). All patients received antimicrobial therapy; surgical drainage was performed in 65%. At follow-up (median 6 months), 12% had died, 69% were ambulatory, and 77% had improved compared with clinical nadir. Of those who underwent operative intervention, surgery within 24 hours of diagnosis was associated with an increased likelihood of being ambulatory at follow-up compared with surgery after 24 hours (odds ratio 4.44; 95% CI 1.26-15.61; = 0.020).
ISCA is important to consider in any patient presenting with acute-to-subacute, progressive myelopathy. Immunocompromise and typical signs of infection (e.g., fever) are often absent. Diffusion restriction and gadolinium enhancement on MRI seem to be sensitive. Antimicrobial therapy with surgical drainage is the most common therapeutic approach, but morbidity remains substantial. If performed, urgent surgery may be more beneficial.
髓内脊髓脓肿（ISCA）在 200 年前被描述，但目前仍了解甚少，常被误诊为免疫介导或肿瘤过程。我们对成人 ISCA 进行了系统综述，描述了其临床表现、诊断特征、治疗策略和结局。
我们于 2019 年 4 月 15 日和 2022 年 2 月 9 日在 PubMed 和 EMBASE 数据库中进行了髓内脓肿的检索，并纳入了 2 篇未发表的病例，由 2 位作者独立进行纳入审查，然后进行裁决。使用在线表格提取数据，并分析残疾的预测因素。
共纳入 202 例（中位年龄 45 岁[四分位间距 31-58]；70%为男性）。31%的患者无明确的易患因素。最常见的症状是无力（97%），就诊前中位症状持续时间为 10 天（四分位间距 5-42）。在 8 例进行弥散受限检查的病例中，100%存在弥散受限，在 153 例进行增强检查的病例中，99%存在增强。最常见的病原体为金黄色葡萄球菌（29%）、凝固酶阴性葡萄球菌（13%）和链球菌（10%）。所有患者均接受了抗菌治疗；65%的患者进行了手术引流。在随访（中位时间 6 个月）时，12%的患者死亡，69%的患者能够行走，77%的患者与临床最低点相比有所改善。在接受手术干预的患者中，与 24 小时后手术相比，24 小时内手术与随访时更有可能能够行走（比值比 4.44；95%CI 1.26-15.61；P=0.020）。
对于任何表现为急性至亚急性、进行性脊髓病的患者，都应考虑 ISCA。免疫抑制和感染的典型体征（如发热）通常不存在。磁共振成像上的弥散受限和钆增强似乎具有较高的敏感性。最常见的治疗方法是抗菌治疗加手术引流，但发病率仍然较高。如果进行手术，紧急手术可能更有益。
