Critical Cases - Epidural Abscess Emergency!
CC: Back pain
HPI: 61 yo M with PMHx DM, HTN, HCV c/o lower back pain x 2 days. The pain is located bilat but L>R and radiates down his LLE. Described as 9/10 and sharp/shooting. Seen two days ago and had CT T and L spine that showed herniated discs and neural foraminal stenosis. Taking acetaminophen without relief. Denies F/C/N/V/D/CP/SOB or upper back pain. . Pain is better when laying flat. Denies saddle paresthesias, leg numbness/weakness, difficulty urinating, urinary or fecal incontinence. Denies recent infection, no hx of cancer, and no IVDU. In 2006 he suffered a severe back injury after falling in a hole- was diagnosed with herniated discs at that time. Works as a trash collector.
VS: BP 149/107 | Pulse 134 | Temp 99.5 °F (37.5 °C) (Oral) | Resp 18 | SpO2 97%
Cardiovascular: Reg rhythm, tachycardic, no murmur.
Abdominal: Soft and nontender
Musculoskeletal:+b/l T anbd L paraspinal TTP
Rectal: normal rectal tone, no prostate tenderness
Neurological: He exhibits normal muscle tone. 5/5 strength BLE but severe pain with movement of LLE and +straight leg raise test.
- Sciatica secondary to known herniated discs
- Spinal stenosis
- Osteomyelitis/discitis/epidural abscess
- Epidural hematoma
- Pathologic fracture
- Consider: AAA/dissection (HTN, smoker, male), nephrolithiasis/pyelonephritis
- CBC/chem/ua all unremarkable
- CT a/p to assess for ureterolithiasis: negative
- Rpt vitals: T 102.1F HR 120s
- MRI of his T and L spine: Epidural abscess T11/T12
- Neurosurg consult: to OR for decompressive hemilaminectomy
- Cultures grew MSSA
- Back pain usually benign, until it is not
- Beware bouncebacks: intensify workup on second visit, consider consultation and/or admission
- Spinal epidural abscesses most common complaints in decreasing order: back pain > fever > focal neuro deficit; triad only in 8-37% of patients
- MRI is the study of choice for high clinical suspicion
- TIME IS OF THE ESSENCE → neuro outcome is correlated with degree of deficit prior to NSG intervention
Reference: Tanski ME and Ma OJ. Central Nervous System and Spinal Infections. In: Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill.