18 July 2018 VA MR Team 3 Brennan Ochoa MD Case CC 56 yr old male presents complaining of 2d history of neck pain HPI Two days after returning from a trip to Florida he developed worsening anterior left sided neck pain He has never had this pain before He describes the pain as ID: 762521
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18 July 2018 VA MR – Team 3 Brennan Ochoa, MD
Case CC: 56 yr old male presents complaining of 2d history of neck pain HPI: Two days after returning from a trip to Florida he developed worsening anterior left sided neck pain. He has never had this pain before. He describes the pain as achey . No radiation. Exacerbated by movement of his head. He has tried OTC pain meds, without relief. He also endorses associated headache and weakness of his upper extremities, but denies photophobia or mental status changes.
Review of Systems +Neck pain +Headache +Upper extremity weakness Per wife:+ Rigors+ Fever (-) Mental status changes (-) Cough (-) Photophobia (-) N/V/D (-) Abd pain (-) Changes in urine (-) Rashes (-) Chest pain
History Past medical history Alcoholic cirrhosis (MELD 30) CKD-3Gout HTN Epilepsy HypothyroidLow back painStrongyloidiasisPast surgical historyNoneAllergiesNoneFamily historyFather with early MIMother with CAD Medications Lasix 40mg/day Lactulose 10gm BID Keppra 250 BID Lisinopril 20mg Methocarbamol 750mg Oxycodone 5mg Pantoprazole 40mg Rifaximin 500 TID Ambien 10mg Social history Quit drinking ~10 years ago Monogamous with wife Pets: 2 dogs and a cat Has travelled all over the world while in military No h/o IV drug use
Differential
Objective Vitals T: 101.3 P: 110RR: 18BP: 153/81O2: 95% RA Physical Exam: General: Hispanic mildly jaundiced middle aged male, in moderate discomfortEars/Eyes: Scleral icterus present, EOMI Neck: left anterior neck muscles are tender to palpation, Restricted ROM in all planes 2/2 painCardiac: Tachycardic rate, regular rhythm, no murmursLungs: CTABAbd: Soft, nontender, non-distended, no fluid waveExtremities: Terry’s nails present, good distal pulses, painful passive ROM of knees bilaterally when attempting Kernig’s sign , No edema Neuro : A+Ox4, speech is intact without slurring, no asterixis , negative Kernig’s , 5/5 strength of extensor muscle groups of upper and lower extremities, 4/5 strength in flexors of upper and lower, grip strength is 4/5 , Cranial nerves intact, normal sensation throughout
Labs/Imaging CXR : No acute CT Head w/o : No acuteCT neck w/o: No abnormal neck mass or drainable fluid collection visualized 11 111 35 9 129 103 34 16 6.1 2.40 142 106 23 59 1.3 3.9 5.4 2.4
Hospital course: HD 0: IV Ceftriaxone initiated HD 1: Continued to feverWorsening weakness Coverage expanded: Vanc /Ceftriaxone/AmpicillinBlood cultures return positive 2/2: GPCHD 2:Continues to decline – motor weakness and worsening painTransfer to BSW for MRI w/ contrastBlood cultures return positive 2/2: MSSA
MRI
Spinal Epidural Abscess Pathophysiology: Bacteria gain access to epidural space: Hematogenously Direct extension of contiguous infected tissue (vertebral body or psoas muscle)Direct inoculation into spinal canal during procedure Pyogenic inflammation progresses: Abscess extends longitudinally: Interrupting blood supplyCausing compressionThrombosis/thrombophlebitis of nearby veins
Spinal Epidural Abscess: Epidemiology
Spinal Epidural Abscess: Epidemiology/Microbiology
Diagnosis MRI with contrast is preferred test Often positive early in course of infection. Provides best visualization of location and extent of inflammation. Can do CT w/ contrast if MRI is not immediately available or is contraindicated. LP for CSF is often not performed. Low diagnostic yield Risk of introducing infection into CNS if needle goes through infection CSF gram stain usually negative, cultures rarely positive.
Treatment Empiri c therapy : Vancomycin - MRSA +Ceftriaxone/Cefotaxime/ - MSSA Cefepime / Ceftazidime +Surgical drainage/decompression
Take away: 1. Consider epidural abscess in patient with focal, severe back pain. Back pain -> nerve pain -> motor weakness/sensory/bowel/bladder dysfct -> paralysis2. Once epidural abscess is seriously considered, imaging is imperative.MRI w/ contrast
References: Arko , Leopold, et al. “Medical and Surgical Management of Spinal Epidural Abscess: a Systematic Review.” Neurosurgical Focus , vol. 37, no. 2, 2014, doi:10.3171/2014.6.focus14127.Sexton, DJ, et al. Spinal Epidural Abscess. In: UpToDate, Thorner, AR, UpToDate, Waltham, MA. 2018.