A 33-year-old female with a past medical history of anxiety presented to the emergency department complaining of back pain and right lower extremity weakness. The patient denied any recent illnesses, nausea, vomiting, fevers, or chills but reported three days of low back pain, recent onset of right lower extremity weakness, numbness, and tingling. She said that the weakness began suddenly, approximately 20 hours prior to ED arrival.
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On arrival, her temperature was 97.9°F, pulse 109 bpm, respiratory rate 20, blood pressure 130/90, and oxygen saturation 98 percent on room air. The physical exam revealed a nonambulatory alert and oriented, well-developed, well-appearing, anxious woman in no acute distress. The patient’s musculoskeletal exam was positive for midline tenderness on the lumbar spine located in the L4, L5 region. Neurologically, she had decreased strength (1/5) in the right lower extremity, with decreased sensation down her right lower extremity as well as diminished deep tendon reflexes. The left lower extremity was normal.
Upon further questioning, the patient reported an inability to void for 24 hours. A bedside ultrasound of her bladder demonstrated significant bladder distention. A Foley catheter was placed, and 1 L of urine promptly drained.
The patient was undressed for a detailed integumentary system exam, which did not reveal any insects, insect bites, or rash. All laboratory work was unremarkable and within normal limits. Neurology and neurosurgery were emergently consulted, and the patient was taken for immediate MRI without contrast of the brain, cervical spine, thoracic spine, and lumbar spine.
The MRI demonstrated expansion of the spinal cord, starting at C5 and extending to the T9–T10 level (see Figure 1). The MRI showed areas of hemorrhage in the spinal cord most prominent at the T2 level, with multiple serpentine structures consistent with a spinal cord vascular malformation (sAVM) (see Figure 2). The cord edema and expansion presumably reflected venous congestion/hypertension (see Figure 3). A neurosurgery consultation was obtained, and a catheter angiography was performed, localizing the lesion. At the choice of the patient and her family, the patient elected to transfer to another hospital.