Keyhole decompression surgery for holospinal epidural abscess: a novel approach for spinal stability preservation

Spinal epidural abscesses are rare yet serious conditions, often necessitating emergency surgical intervention. Holospinal epidural abscesses (HEA) extending from the cervical to the lumbosacral spine are even rarer and present significant challenges in management. This report aims to describe a case of HEA with both ventrally-located cervical and dorsally-located thoracolumbar epidural abscesses treated with a combination of anterior keyhole decompression and posterior skip decompression surgeries.

A 73-year-old woman with diabetes and hypertension presented with severe neck and back pain, fever, and a marked increase in leukocytes (29980/µL) and C-reactive protein (CRP; 24.26 mg/dL) levels. Magnetic resonance imaging revealed epidural abscesses extending from the cervical to lumbar spine, confirming the diagnosis of HEA. At the cervical lesion, spinal cord was compressed by ventrally-located epidural abscess. Due to the patient's poor general condition, conservative treatment was initially pursued, followed by surgical intervention targeting the most severely compressed spinal segments. Managing ventrally-located epidural abscesses poses greater challenges. In this patient, a novel anterior keyhole decompression surgery was employed to evacuate the ventrally-located cervical epidural abscess while preserving intervertebral discs and endplates.

Posterior skip decompression surgery was performed, successfully reducing thoracolumbar epidural abscesses. Subsequently, anterior keyhole decompression was performed to evacuate ventrally-located epidural abscess, preserving intervertebral discs and endplates. Postoperatively, the patient's symptoms improved, and leukocyte count and CRP gradually normalized. Follow-up imaging showed resolution of the abscesses and bone remodeling within the keyhole without evidence of spinal instability and postoperative kyphosis.

Management of HEA poses significant challenges, particularly in cases with ventrally-located cervical epidural abscesses. Our case highlights the efficacy of a combined surgical approach involving anterior keyhole decompression and posterior skip decompression in achieving abscess drainage and preserving spinal stability. This novel technique offers advantages over existing methods by preserving intervertebral motion and minimizing the risk of postoperative kyphosis. Further studies are warranted to validate the long-term outcomes and generalizability of this approach.