A 66-year-old man comes to the emergency department with progressive lower back pain, urinary incontinence, and decreased appetite for the past 2 days. He was recently diagnosed with L4-L5 disc herniation and received an epidural injection for radicular pain 2 weeks ago. His other medical problems include type 2 diabetes mellitus and hypertension. Temperature is 38.3 C (100.9 F), blood pressure is 136/88 mm Hg, pulse is 96/min, and respirations are 14/min. The patient is alert and oriented. Physical examination shows poor dentition, tenderness on palpation of the lumbar spine, and absent deep-tendon reflexes in both lower extremities. Rectal examination shows decreased rectal sphincter tone and an enlarged, smooth prostate. Laboratory results are as follows: Which of the following is the most appropriate next step in management of this patient?

Question

A 66-year-old man comes to the emergency department with progressive lower back pain, urinary incontinence, and decreased appetite for the past 2 days.  He was recently diagnosed with L4-L5 disc herniation and received an epidural injection for radicular pain 2 weeks ago.  His other medical problems include type 2 diabetes mellitus and hypertension.  Temperature is 38.3 C (100.9 F), blood pressure is 136/88 mm Hg, pulse is 96/min, and respirations are 14/min.  The patient is alert and oriented.  Physical examination shows poor dentition, tenderness on palpation of the lumbar spine, and absent deep-tendon reflexes in both lower extremities.  Rectal examination shows decreased rectal sphincter tone and an enlarged, smooth prostate.  Laboratory results are as follows:  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bff3_0d63_8f63_65327d3a607d_MD0005_00 This patient's presentation suggests spinal epidural abscess (SEA) and possible cord compression. SEA is more common than intracranial epidural abscess and is caused by hematogenous spread of bacteria from a distant source, contiguous tissue infection (eg, vertebral body osteomyelitis), or direct inoculation (eg, steroid injections, epidural anesthesia). Other risk factors for SEA include intravenous drug use and immunocompromised states such as diabetes mellitus, alcoholism, and HIV. Staphylococcus aureus accounts for about 60% of infections caused by pyogenic bacteria. spinal epidural abscess (SEA) The classic triad of symptoms includes fever (may not be present), severe focal spinal pain, and neurologic deficits. As symptoms progress, patients may develop radiculopathy, motor and sensory deficits, bowel or bladder dysfunction, and eventual paralysis. Initial evaluation includes complete blood count, inflammatory markers (erythrocyte sedimentation rate, and C-reactive protein), blood cultures, and urgent magnetic resonance imaging of the spine with gadolinium (preferred) or computed tomography (CT) with intravenous contrast. Once the diagnosis of SEA is confirmed on imaging, CT-guided aspiration and culture are needed to guide antibiotic therapy. Most patients are treated with immediate surgical decompression (preferably within 24 hours) to avoid complications of cord compression or cauda equina syndrome. magnetic resonance imaging of the spine with gadolinium (Choice A) Intravenous glucocorticoids are indicated for spinal cord compression or cauda equina syndrome due to metastatic malignancy/traumatic injury. They are NOT recommended empirically for patients with fever, back pain, and possible epidural abscess. (Choice B) Lumbar puncture is not recommended for the diagnosis of epidural abscess due to low diagnostic yield (<25% positive cerebral spinal fluid cultures). There is also risk of subdural spread of infection from the procedure. (Choice D) Serum prostate-specific antigen and bone scan are indicated in diagnosing metastatic prostate cancer. However, this patient's prostate examination is normal (no asymmetry or frank nodules). (Choice E) Tagged white blood cell scan is useful for detection of occult infections when preliminary studies fail to localize the source (eg, persistent bacteremia with no identifiable source). This procedure is time-consuming and is not indicated in this patient. Educational objective: Epidural abscess presents with fever, focal spinal tenderness/back pain, and neurologic dysfunction. Evaluation includes urgent magnetic resonance imaging, blood cultures, inflammatory markers (erythrocyte sedimentation rate and C-reactive protein), computed tomography-guided aspiration and culture, and antibiotics. Emergency surgical decompression and drainage of the abscess are recommended for most patients. References: Iatrogenic (para-) spinal abscesses and meningitis following injection therapy for low back pain (http://www.ncbi.nlm.nih.gov/pubmed/15979793) Spinal epidural abscess: a ten-year perspective (http://www.ncbi.nlm.nih.gov/pubmed/2385333)

A 66-Year-Old Man Comes to the Emergency Department with Progressive