Spinal subdural empyema: A two-dimensional illustrative operative video.

Background: Spinal subdural empyema rarely involves the spinal cord and may result in devastating neurological deficits. These lesions typically require prompt diagnosis, surgical evacuation, and antibiotic therapy. Here, we present the clinical course, imaging, and narrated operative video of a thoracic spinal subdural empyema initially diagnosed as an intramedullary neoplasm.

Case description: A 73-year-old female presented with a 6-month history of worsening thoracic myelopathy; over the last few weeks, she rapidly developed paraplegia. She was initially diagnosed with an enlarging thoracic intramedullary mass. A spinal biopsy was performed for the presumptive diagnosis of primary intramedullary central nervous system lymphoma. However, at surgery, the thoracic lesion proved to be a chronic subdural empyema (i.e., surrounded by arachnoid granulations and soft-purulent tissue). Interestingly, the operative specimen failed to grow any specific organism.

Conclusion: Spinal subdural empyema should be one of the differential diagnoses considered for patients presenting with intradural spinal cord lesions.