| disease | Thoracic Tuberculosis with Paravertebral Abscess Penetrating into the Thoracic Cavity |
Spinal cold abscesses can locally infiltrate or directly rupture into adjacent organs, most commonly the lungs, while penetration into the esophagus or colon is rare. Rupture into the thoracic cavity may also occur. They are often confused with medical subcutaneous exudative pleurisy. Although the disease causes are the same, their origins differ, and the treatment approaches vary. With the widespread application of thoracic lesion clearance in treating spinal cold abscesses, there has been further understanding of this condition, hence the discussion.
bubble_chart Clinical Manifestations
The disease can occur in both children and the elderly, but is most common in young and middle-aged adults. Lesions in the thoracic spine are most frequently found between T6 and T10. Paravertebral abscesses often rupture into the right thoracic cavity, accounting for about two-thirds of cases. Approximately half of the cases are complicated by paraplegia, and occasionally, abscesses may simultaneously penetrate the lungs, making the condition generally more severe.
Most patients already have encapsulated effusion or empyema at the time of consultation. A few may experience sudden fever (38–40°C), chest pain, cough, and shortness of breath during hospitalization. When thoracic spinal subcutaneous nodular fistula disease is diagnosed, the presentation resembles that of common medical exudative pleuritis, often leading to misdiagnosis.
The rupture sites of paravertebral abscesses vary in size, ranging from as small as a grain of rice or sieve-like perforations to larger openings about 0.5–1 cm in diameter.
The pleural effusion (or pus) typically amounts to several hundred milliliters, with some cases exceeding 100 mL.
bubble_chart Auxiliary ExaminationX-ray imaging: Apart from pleuritis or encapsulated effusion, and the faintly visible enlarged paravertebral shadows in the mediastinum, there are no active subcutaneous nodule lesions in either lung field or the mediastinum. Anteroposterior X-ray views of the thoracic spine, especially anteroposterior tomograms, show indistinct boundaries of the paravertebral shadows on the same side as the pleuritis, connected to or even disappearing with the pleuritis.
The diagnosis can be made based on medical history, clinical manifestations, and X-ray imaging.
bubble_chart Treatment Measures
1. For cases where abscess rupture leads to chronic encapsulated empyema, after anti-subcutaneous node drug treatment and general improvement, elective surgery should be performed for decortication of the encapsulated empyema and clearance of thoracic vertebral lesions. Due to the significant surgical trauma, special attention is required.
2. The treatment principles for acute subcutaneous node exudative pleuritis include anti-subcutaneous node drug therapy and drainage of effusion, supplemented with corticosteroids.
For patients with high fever and toxic symptoms, a combination of 3–4 anti-subcutaneous node drugs should be administered before and after surgery, along with prednisone 20–30 mg/day for 4–6 weeks.
3. If bronchopleural fistula is present, preoperative closed thoracic drainage should be performed to control secondary infection and prevent bronchial dissemination.
4. Surgical Treatment
1. **Anesthesia**: Surgery is performed under general anesthesia with double-lumen endotracheal intubation.
2. **Positioning**: The patient is placed in a lateral decubitus position, with the side of the thoracic encapsulated empyema undergoing surgery.
3. **Operative Steps**
(1) **Incision**: A posterolateral thoracic incision is made, considering both the thoracic vertebral lesions and the extent of the encapsulated empyema to determine the appropriate level.
(2) **Procedure**: Decortication of the encapsulated empyema is performed, aiming to completely remove the encapsulated pus, including the parietal and visceral fibrous membranes of the abscess cavity, ensuring full lung re-expansion and avoiding residual cavities. Otherwise, thoracoplasty is performed either concurrently or at an intermediate stage (second stage). For acute ruptures into the pleural cavity occurring within one week, if conditions permit, intrathoracic lesion clearance may also be performed. In such cases, the procedure is relatively simple, involving the removal of deposited fibrin and caseous masses from the pleural cavity and interlobar spaces to fully re-expand the lung. Subsequently, the thoracic vertebral subcutaneous node lesions are cleared using the same method as described earlier.
(3) **Postoperative Management**: Similar to that for paravertebral abscesses rupturing into the lung.
Combined bronchopleural membrane fistula.
In internal medicine, the presence of subcutaneous nodules on the same side of the chest as pleuritis is often seen with pulmonary subcutaneous nodules, which serves as a basis for differential diagnosis.
