Postoperative quadriplegia following cervical epidural abscess evacuation: the role of mechanical instability and hemodynamic support

Cervical epidural abscess (CEA) with concurrent vertebral osteomyelitis represents a challenging surgical problem combining infectious destruction, structural instability, and proximity to the spinal cord. This case illustrates how intraoperative discovery of bone necrosis can unmask acute cervical instability, precipitating postoperative neurological deterioration despite uneventful initial hemodynamic management. We describe a 35-year-old male with MRSA bacteremia complicated by C4-C5 osteomyelitis/discitis, pathologic fracture, and retropharyngeal/epidural abscess who developed acute quadriplegia in the post-anesthesia care unit (PACU) following anterior abscess evacuation. IONM was employed during the second combined procedure and confirmed no additional intraoperative neurological worsening. Neurological deterioration occurred at a mean arterial pressure (MAP) of 85 mmHg; augmentation to supranormal MAP was associated with partial recovery of left upper extremity motor function. Emergent MRI demonstrated bony spinal cord compression (SCC) from displaced necrotic vertebral elements. The patient underwent urgent combined anterior cervical decompression at C4-C5 and posterior C2-C7 decompressive laminectomies and instrumented fusion (C2-C6), achieving near-complete neurological recovery. He was neurologically intact at 5-month follow-up. Postoperative neurological deterioration following CEA evacuation may arise primarily from mechanical SCC due to intraoperatively destabilized necrotic bone. MAP augmentation may serve as an adjunctive neuroprotective measure supporting cord perfusion while awaiting urgent surgical decompression, but cannot substitute for definitive stabilization. This case underscores the need to anticipate occult structural instability in vertebral osteomyelitis, and readiness for urgent reoperation.