A 28-year-old woman, gravida 1 para 1, comes to the office for follow-up 10 days after cesarean delivery. Her pregnancy was uneventful; she went into labor spontaneously at full term but underwent cesarean section due to failure to progress. The patient received epidural analgesia during labor and general anesthesia during surgery. She notes that she still has some lower back discomfort. In addition, her legs feel weaker, and she has been experiencing tingling and numbness in the lower extremities. The patient reports malaise but has had no significant pain or discharge from the surgical wound or vaginal bleeding. She has no other significant medical issues, and her only medication is a daily multivitamin. Temperature is 38.2 C (100.8 F), blood pressure is 110/70 mm Hg, and pulse is 94/min. Physical examination shows clear lungs; normal heart sounds; well-healing surgical incision with no surrounding erythema or discharge; and nontender uterus. Back examination reveals moderate tenderness over the lumbar region. Neurological examination shows weakness of left quadriceps and decreased left knee reflex. Sensation to light touch is decreased over bilateral dorsa of the feet. Which of the following is the most appropriate management for this patient's current symptoms?

Question

A 28-year-old woman, gravida 1 para 1, comes to the office for follow-up 10 days after cesarean delivery.  Her pregnancy was uneventful; she went into labor spontaneously at full term but underwent cesarean section due to failure to progress.  The patient received epidural analgesia during labor and general anesthesia during surgery.  She notes that she still has some lower back discomfort.  In addition, her legs feel weaker, and she has been experiencing tingling and numbness in the lower extremities.  The patient reports malaise but has had no significant pain or discharge from the surgical wound or vaginal bleeding.  She has no other significant medical issues, and her only medication is a daily multivitamin.  Temperature is 38.2 C (100.8 F), blood pressure is 110/70 mm Hg, and pulse is 94/min.  Physical examination shows clear lungs; normal heart sounds; well-healing surgical incision with no surrounding erythema or discharge; and nontender uterus.  Back examination reveals moderate tenderness over the lumbar region.  Neurological examination shows weakness of left quadriceps and decreased left knee reflex.  Sensation to light touch is decreased over bilateral dorsa of the feet.  Which of the following is the most appropriate management for this patient's current symptoms?

Quizplus · Accepted Answer

11ec25c8_d897_64f3_bc81_37c8ef76feb0_MD0003_00 This patient underwent epidural anesthesia 10 days ago and now has lumbar back pain, low-grade fever, and lower-extremity neurologic symptoms (eg, weakness, tingling, numbness), raising strong suspicion for spinal epidural abscess. Most cases arise via hematogenous spread of a distant infection, contiguous spread from an adjacent infection (eg, vertebral osteomyelitis), or following direct inoculation during spinal/epidural anesthesia. The epidural space is a vertical, contiguous area that contains fat, arteries, and a venous plexus; infections tend to affect multiple spinal levels and cause progressive neurologic impairment due to direct spinal cord compression, thrombophlebitis of the draining venous plexus, and/or interruption of the arterial blood supply. Although patients classically have the triad of fever, spinal pain, and neurologic symptoms, all 3 are present in a minority of cases. Most patients have fever, malaise, and neurologic symptoms that typically progress in the following fashion (due to worsening spinal cord compression): Focal back pain →Nerve root pain (eg, shooting, electric-shock sensation) →Motor weakness, sensory changes, bowel/bladder dysregulation →Paralysis Focal back pain → Focal back pain → Nerve root pain (eg, shooting, electric-shock sensation) → Nerve root pain (eg, shooting, electric-shock sensation) → Motor weakness, sensory changes, bowel/bladder dysregulation → Motor weakness, sensory changes, bowel/bladder dysregulation → Paralysis Paralysis Early diagnosis is crucial to prevent paralysis and death; MRI of the affected spinal area is the test of choice because it is positive early in the disease course and provides excellent visualization of the extent of infection. Surgical drainage plus antibiotic therapy is generally required for treatment. (Choice A) Nonsteroidal anti-inflammatory drugs and early physical activity are important components of treating lumbosacral radiculopathy, which usually presents with back pain radiating along the affected dermatome. Although motor and sensory impairment can occur, fever is atypical. (Choice B) Lower-extremity peripheral nerve injury is a relatively common obstetric complication due to nerve compression or vascular compromise during labor. However, it rarely causes fever. (Choice D) Reassurance would be inappropriate because abscess progression could cause paralysis and death. (Choice E) This patient with fever and neurologic symptoms on examination is unlikely to have somatic symptoms of depression. Given recent epidural anesthesia, she requires MRI of the spine to evaluate for epidural abscess. Educational objective: Spinal epidural abscess often presents with several days/weeks of fever, malaise, and the following progressive neurologic symptoms: focal back pain → nerve root pain → motor weakness, sensory changes, and bowel/bladder dysregulation → paralysis. Suspected cases require urgent MRI spine; treatment generally includes surgical decompression and antibiotics. Epidural anesthesia is a common triggering event (due to direct inoculation).

A 28-Year-Old Woman, Gravida 1 Para 1, Comes to the Office